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Animut Y, Assefa AT, Lemma DG. Blood pressure control status and associated factors among adult hypertensive patients on outpatient follow-up at University of Gondar Referral Hospital, northwest Ethiopia: a retrospective follow-up study. Integr Blood Press Control 2018; 11:37-46. [PMID: 29720880 PMCID: PMC5918628 DOI: 10.2147/ibpc.s150628] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Large segments of the hypertensive population in the world are either untreated or inadequately treated. The incidence of heart failure and mortality from cardiovascular complications of hypertension is high among patients with uncontrolled blood pressure (BP). But BP control status of hypertensive patients has not been investigated in the study area. The study aimed to assess BP control status and determinant factors among adult hypertensive patients on antihypertensive medication attending outpatient follow-up at University of Gondar Referral Hospital, northwest Ethiopia. Methods An institution-based retrospective follow-up study was conducted from September 2015 to April 2016. Data were collected using a structured and pretested questionnaire adopted from the World Health Organization STEPwise approach. BP records of 6 months were used, and patients were classified as having controlled BP if their BP readings were <140/90 mmHg for all adults ≥18 years of age and <150/90 mmHg for adults aged ≥60 years. A generalized estimating equation was fitted, and the odds ratio with a 95% confidence level was used to determine the effect of covariates on BP control status. Results Among 395 participants, 50.4% (95% CI: 45–55) of them controlled their BP in the last 6 months of the survey. Physical activity (adjusted odds ratio [AOR]=1.95, 95% CI: 1.41–2.68), duration on antihypertensive drugs of 2–4 years (AOR=1.70, 95% CI: 1.13–2.56) and 5 years or more (AOR=1.96, 95% CI: 1.32–2.92), and high adherence (AOR=2.18, 95% CI: 1.14–4.15) to antihypertensive drugs were positively associated with BP control, while salt intake (AOR=0.67, 95% CI: 0.49–0.93), overweight (AOR=0.50, 95% CI: 0.36–0.68), and obesity (AOR=0.56, 95% CI: 0.36–0.87) were inversely associated with BP control. Conclusion In this study, only half of the hypertensive patients controlled their BP. Thus, health care providers need to be made aware about the importance of counseling hypertensive patients on drug adherence, moderate physical activity, and salt restriction to improve BP control.
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Affiliation(s)
- Yaregal Animut
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Alemu Takele Assefa
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Dereseh Gezie Lemma
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Pérez-Manchón D, Álvarez-García GM, González-López E. [Perception of cardiovascular risk in an outpatient population of the Madrid Community]. HIPERTENSION Y RIESGO VASCULAR 2015; 32:100-4. [PMID: 26180033 DOI: 10.1016/j.hipert.2014.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 07/31/2014] [Accepted: 09/19/2014] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Cardiovascular diseases are responsible for the largest burden of global mortality. The study of the degree of knowledge of their population risk factors and cardiovascular risk is a priority preventive strategy. MATERIAL AND METHODS A cross-sectional study with 369 people was performed. The sociodemographic variables were cardiovascular risk and perception as well as physical and anthropometric factors. The risk was stratified with the SCORE table. RESULTS A total of 49.6% were men and 50.4% were women. The proportion of diagnosis was 23.8% in HTA, 39% in hypercholesterolemia, 31.4% in smoking, 26.3% in obesity and 4.6% in diabetes. Concordance between perceived and real cardiovascular risk was very weak. DISCUSSION The population has good knowledge about diabetes and acceptable knowledge about hypertension, and hypercholesterolemia but knowledge in prediabetic states and perception of the associated cardiovascular risk is low.
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Affiliation(s)
- D Pérez-Manchón
- Consultorio de Brunete, Centro de Salud Universitario Villanueva de la Cañada, Dirección asistencial noroeste del Servicio Madrileño de Salud (SERMAS), Madrid, España.
| | - G M Álvarez-García
- Centro de Salud Universitario Cerro del Aire, Dirección asistencial noroeste del Servicio Madrileño de Salud (SERMAS), Majadahonda, Madrid, España
| | - E González-López
- Centro de Salud Universitario Villanueva de la Cañada, Dirección asistencial noroeste del Servicio Madrileño de Salud (SERMAS), Facultad de Medicina de la Universidad Autónoma de Madrid, Villanueva de la Cañada, Madrid, España
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Márquez-Hernández VV, Granados Gámez G, Roales-Nieto JG. [In Process Citation]. Aten Primaria 2015; 47:83-9. [PMID: 24889381 PMCID: PMC6985635 DOI: 10.1016/j.aprim.2014.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 02/27/2014] [Accepted: 03/18/2014] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To test the effectiveness of a program to improve treatment adherence in new onset hypertensive patients. DESIGN This is a quasi-experimental study. LOCATION Four health centers in Almeria. PARTICIPANTS A total of 120 subjects between 18 and 65 years, diagnosed with hypertension within the previous 12 months. MAIN MEASUREMENTS The participants were divided into three groups: intervention group A, which received educational instruction, intervention group B, educational instruction and feedback process, and the control group C, received usual care. Adherence was determined by lifestyle (diet, physical activity, smoking, alcohol) and drug treatment. RESULTS As regards diet and physical activity, there were significant differences between performance groups after intervention (p<0,05), with better adherence levels being found in group B subjects for these variables. Better adherence to pharmacological treatment was also observed in these patients. No significant results were found regarding alcohol and smoking. CONCLUSIONS In the study population, patients undergoing educational instruction and feedback had better adherence levels than those who received only instruction or usual treatment.
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Affiliation(s)
| | - Genoveva Granados Gámez
- Departamento de Enfermería, Fisioterapia y Medicina, Universidad de Almería, Almería, España
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Adebolu FA, Naidoo M. Blood pressure control amongst patients living with hypertension presenting to an urban district hospital outpatient clinic in Kwazulu-Natal. Afr J Prim Health Care Fam Med 2014; 6:E1-6. [PMID: 26245402 PMCID: PMC4502887 DOI: 10.4102/phcfm.v6i1.572] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 02/28/2014] [Accepted: 11/13/2013] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The prevalence of hypertension in South Africa has been estimated to be 20% of the adult population with over six million people being affected. Poor adherence to treatment plans lead to inadequate blood pressure control and high morbidity. Many studies have looked at factors contributing to poor blood pressure control in South Africa but few studies actually focus on district hospitals in Kwazulu-Natal in particular, despite the fact that the province has the most heterogeneous population in South Africa. METHOD The study was a descriptive cross-sectional study conducted at the chronic out patient clinic of an urban district hospital involving 370 participants aged 18-90 years. RESULT The study showed poorly controlled blood pressure in 58% of the participants. Only 35% knew their blood pressure results on the day of interview and 19.2% were aware of their target blood pressure. Good adherence was self-reported by 95% of the participants, whist 51.4% reported significant side-effects to medication. CONCLUSION The majority of patients had poor knowledge about blood pressure and little awareness of their blood pressure reading. These may be precursors to poor blood pressure control and this needs further investigation. A high level of self-reported adherence to medication did not translate into effective blood pressure control. A significant number reported medication side-effects which may have contributed to the poor blood pressure control. The high adherence rate may therefore have been over reported. An objective way tomeasure adherence will be necessary for future research.
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Affiliation(s)
| | - Mergan Naidoo
- Department of Family Medicine, University of Kwazulu-Natal.
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Barrios V, Escobar C, Calderón A, Moreno FJA, Pallarés V, Galgo A. Clinical profile and blood pressure control in patients managed in primary care in Spain: are there any differences between the young and the old? REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2014; 66:824-5. [PMID: 24773867 DOI: 10.1016/j.rec.2013.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Vivencio Barrios
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - Carlos Escobar
- Servicio de Cardiología, Hospital Universitario La Paz, Madrid, Spain
| | - Alberto Calderón
- Centro de Salud Rosa de Luxemburgo, San Sebastián de los Reyes, Madrid, Spain
| | | | - Vicente Pallarés
- Unidad de Vigilancia de la Salud, Unión de Mutuas, Castellón, Spain
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Demografía y características clínicas de la hipertensión resistente en 6.292 pacientes en atención primaria. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.09.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Gijón-Conde T, Graciani A, Banegas JR. Resistant hypertension: demography and clinical characteristics in 6,292 patients in a primary health care setting. ACTA ACUST UNITED AC 2014; 67:270-6. [PMID: 24774589 DOI: 10.1016/j.rec.2013.09.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 09/10/2013] [Indexed: 11/17/2022]
Abstract
INTRODUCTION AND OBJECTIVES The prevalence of resistant hypertension has recently been reported, but there are no studies on its demography. This study aimed to examine the demography and clinical characteristics of resistant hypertension in a large sample of primary care patients. METHODS A cross-sectional study was performed of all computerized medical records of hypertensive patients in Health Area 6 of Madrid (Spain). Of 63 167 hypertensive patients, we selected 48 744 with prescription of antihypertensive medication; of these, we selected those who met the American Heart Association criteria for resistant hypertension. RESULTS A total of 6292 patients had resistant hypertension, representing 9.9% of all hypertensive patients and 12.9% of those treated. A total of 5.5% were < 50 years (8.5% men and 3.2% women) and 24.7% were > 80 years (15.8% men and 31.4% women) (P < .001). In patients < 50 years, resistant hypertension was associated with male sex (odds ratio female/male = 0.006; 95% confidence interval, 0.000-0.042; P < .001), systolic blood pressure, obesity, stroke, and chronic kidney disease (P < .001). In those > 80 years, resistant hypertension was associated with female sex (odds ratio female/male = 1.27; 95% confidence interval, 1.08-1,10; P = .004), systolic blood pressure, diabetes mellitus, obesity, chronic kidney disease, coronary heart disease, and atrial fibrillation (P < .001). More than 50% of patients > 80 years with resistant hypertension had cardiovascular disease. CONCLUSIONS One in 4 patients with resistant hypertension is > 80 years. Resistant hypertension is associated with cardiovascular disease, age < 50 years in men and age > 80 years in women. There is a high proportion of cardiovascular disease in elderly patients with resistant hypertension.
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Affiliation(s)
- Teresa Gijón-Conde
- Centro de Salud Universitario Cerro del Aire, Dirección Asistencial Noroeste, Majadahonda, Madrid, Spain; Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid/IdiPaz, CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.
| | - Auxiliadora Graciani
- Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid/IdiPaz, CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - José R Banegas
- Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid/IdiPaz, CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
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Perfil clínico y grado de control de la presión arterial de la población hipertensa asistida en atención primaria en España: ¿hay diferencias entre la población joven y la más mayor? Rev Esp Cardiol 2013. [DOI: 10.1016/j.recesp.2013.04.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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[Resting heart rate and cardiovascular disease]. Med Clin (Barc) 2013; 143:34-8. [PMID: 23937816 DOI: 10.1016/j.medcli.2013.05.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 05/28/2013] [Accepted: 05/30/2013] [Indexed: 01/29/2023]
Abstract
Heart rate reflects autonomic nervous system activity. Numerous studies have demonstrated that an increased heart rate at rest is associated with cardiovascular morbidity and mortality as an independent risk factor. It has been shown a link between cardiac autonomic balance and inflammation. Thus, an elevated heart rate produces a micro-inflammatory response and is involved in the pathogenesis of endothelial dysfunction. In turn, decrease in heart rate produces benefits in congestive heart failure, myocardial infarction, atrial fibrillation, obesity, hyperinsulinemia, insulin resistance, and atherosclerosis. Alteration of other heart rate-related parameters, such as their variability and recovery after exercise, is associated with risk of cardiovascular events. Drugs reducing the heart rate (beta-blockers, calcium antagonists and inhibitors of If channels) have the potential to reduce cardiovascular events. Although not recommended in healthy subjects, interventions for reducing heart rate constitute a reasonable therapeutic goal in certain pathologies.
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Asociación entre presión arterial y mortalidad en una cohorte de individuos de edad igual o superior a 65 años de España: un modelo dinámico. Rev Esp Cardiol 2013. [DOI: 10.1016/j.recesp.2012.11.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Gutiérrez-Misis A, Sánchez-Santos MT, Banegas JR, Zunzunegui MV, Sánchez-Martinez M, Castell MV, Otero A. Association between blood pressure and mortality in a Spanish cohort of persons aged 65 years or over: a dynamic model. ACTA ACUST UNITED AC 2013; 66:464-71. [PMID: 24776049 DOI: 10.1016/j.rec.2012.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Accepted: 11/12/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND OBJECTIVES Few studies have used time-dependent correction to analyze the relationship between blood pressure and all-cause mortality, and to our knowledge none has been performed in older people from the Mediterranean area. This study aimed to estimate the relationship between baseline blood pressure and blood pressure as a time-dependent covariate with the risk of all-cause mortality in a population cohort of persons aged 65 or older in Spain. METHODS Data were taken from the population-based study "Aging in Leganés" with 17 years of follow-up, launched in 1993 in a random sample (n=1560) of persons aged ≥65 years. Mortality was assessed in 2010. Cox proportional hazards models were fitted to examine the effects on mortality of blood pressure at baseline and of blood pressure as a time-dependent covariate. RESULTS The lowest mortality was observed at baseline systolic blood pressure of 136 mmHg and time-dependent covariate value of 147 mmHg. The highest risk of mortality for time-dependent covariates occurred with systolic blood pressure <115 mmHg and >93 mmHg and diastolic blood pressure <80 mmHg. Diastolic blood pressure over 85 mmHg did not increase the risk of death. CONCLUSIONS Based on the dynamic association between blood pressure and mortality, a U-shaped relationship was found for systolic blood pressure and a negative relationship for diastolic blood pressure and all-cause mortality. The lowest mortality corresponded to a systolic blood pressure level slightly over the diagnostic hypertension value and suggests that a value of 140 mmHg is not adequate as a diagnostic and therapeutic threshold in an elderly population.
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Affiliation(s)
- Alicia Gutiérrez-Misis
- Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Salud Dr. Castroviejo, Atención Primaria, IdiPAZ, Madrid, Spain.
| | - María T Sánchez-Santos
- Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid, Madrid, Spain; Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid (UAM), Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
| | - José R Banegas
- Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid, Madrid, Spain; IdiPAZ, CIBER de Epidemiología y Salud Pública, Madrid, Spain
| | - María V Zunzunegui
- Département de Médecine Sociale et Préventive, Université de Montréal, Montreal, Québec, Canada
| | | | - María V Castell
- Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Salud Dr. Castroviejo, Atención Primaria, IdiPAZ, Madrid, Spain
| | - Angel Otero
- Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid, Madrid, Spain; Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid (UAM), Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
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Marrodán Serrano MD, Cabañas Armesilla MD, Carmenate Moreno MM, González-Montero de Espinosa M, López-Ejeda N, Martínez Álvarez JR, Prado Martínez C, Romero-Collazos JF. Asociación entre adiposidad corporal y presión arterial entre los 6 y los 16 años. Análisis en una población escolar madrileña. Rev Esp Cardiol 2013. [DOI: 10.1016/j.recesp.2012.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Galve E, Castro A, Cordero A, Dalmau R, Fácila L, García-Romero A, Mazón P, Sanmartín M, Alonso García A. Update in cardiology: Vascular risk and cardiac rehabilitation. ACTA ACUST UNITED AC 2013; 66:124-30. [PMID: 24775386 DOI: 10.1016/j.rec.2012.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 10/08/2012] [Indexed: 11/17/2022]
Abstract
Atherosclerotic cardiovascular disease remains the major cause of premature death in developed and developing countries. Nevertheless, surveys show that most patients still do not achieve the lifestyles, risk factor levels, and therapeutic targets recommended in primary and secondary prevention. The present update reflects the most recent novelties in risk classification and estimation of risk and documents the latest changes in fields such as smoking, diet and nutrition, physical activity, lipids, hypertension, diabetes, and cardiovascular rehabilitation, based on experimental trials and population-based observational studies.
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Affiliation(s)
- Enrique Galve
- Servicio de Cardiología, Hospital Vall d'Hebron, Barcelona, Spain.
| | | | - Alberto Cordero
- Departamento de Cardiología, Hospital de San Juan, San Juan de Alicante, Alicante, Spain
| | - Regina Dalmau
- Servicio de Cardiología, Hospital La Paz, Madrid, Spain
| | - Lorenzo Fácila
- Departamento de Cardiología, Hospital General de Valencia, Valencia, Spain
| | | | - Pilar Mazón
- Servicio de Cardiología, Hospital de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
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Marrodán Serrano MD, Cabañas Armesilla MD, Carmenate Moreno MM, González-Montero de Espinosa M, López-Ejeda N, Martínez Álvarez JR, Prado Martínez C, Romero-Collazos JF. Association between adiposity and blood pressure levels between the ages of 6 and 16 years. Analysis in a student population from Madrid, Spain. ACTA ACUST UNITED AC 2012; 66:110-5. [PMID: 24775384 DOI: 10.1016/j.rec.2012.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 08/17/2012] [Indexed: 12/31/2022]
Abstract
INTRODUCTION AND OBJECTIVES The increase in the incidence of hypertension in children can be attributed to the rising prevalence of obesity. The objective is to analyze the impact of overweight and the degree or distribution of adiposity on blood pressure levels in a population of Spanish schoolchildren. METHODS A cross-sectional study was carried out in 1511 schoolchildren between 6 years and 16 years of age. We measured weight, height, waist circumference, subcutaneous skinfolds, and blood pressure. Nutritional categories were established on the basis of body mass index, waist-to-height ratio, and percent body fat. According to the National High Blood Pressure Education Program Working Group, subjects whose blood pressure was above the 90th percentile of the standard normal distribution were considered to have high blood pressure. RESULTS In all, 3.17% of the boys and 3.05% of the girls had high blood pressure. According to odds ratio analysis, the risk of high blood pressure increased in individuals with a body mass index indicative of obesity (7.87-fold in boys, 12.32-fold in girls), with a percent body fat>97th percentile (6.98-fold in boys, 18.51-fold in girls), or with a waist-to-height ratio ≥0.5 (10.56-fold in boys, 7.82-fold in girls). CONCLUSIONS Overweight and obesity increase the risk of high blood pressure in children between 6 years and 16 years of age, although the risk level varies depending on the amount and distribution of adipose tissue. Anthropometric indicators of relative adiposity and fat distribution are especially useful in the identification of children and adolescents with high blood pressure.
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Affiliation(s)
- M Dolores Marrodán Serrano
- Grupo de Investigación EPINUT-UCM, Madrid, Spain; Sociedad Española de Dietética y Ciencias de la Alimentación (SEDCA), Madrid, Spain.
| | | | | | | | | | - Jesús R Martínez Álvarez
- Grupo de Investigación EPINUT-UCM, Madrid, Spain; Sociedad Española de Dietética y Ciencias de la Alimentación (SEDCA), Madrid, Spain
| | - Consuelo Prado Martínez
- Departamento de Biología, Facultad de Ciencias, Universidad Autónoma de Madrid, Madrid, Spain
| | - Juan F Romero-Collazos
- Grupo de Investigación EPINUT-UCM, Madrid, Spain; Departamento de Biología, Facultad de Ciencias, Universidad Autónoma de Madrid, Madrid, Spain; DeporClinic, Clínica de Medicina Deportiva y Fisioterapia, Coslada, Madrid, Spain
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