Sun exposure practices, attitudes and knowledge among students and teachers at a University School of Health Sciences in Ecuador

Skin cancer incidence is increasing worldwide. Late adolescence and young adulthood are fundamental stages of life to acquire good sun exposure practices, regarding both personal involvement in skin cancer prevention and being a role model for others, especially in a health education environment. This descriptive cross-sectional study is based on the validated CHACES questionnaire to study sun exposure and photoprotection behavior among students and teachers at the School of Health Sciences in the National University of Chimborazo, Riobamba (Ecuador). University members (814 students (89.8 %) and 93 teachers (10.2 %)) were studied, with a predominance of females and light-skin phototypes in both groups. Similar results were obtained regarding sun exposure, with higher recreative exposure in the teachers' group and higher occupational exposure in students. However, students significantly showed lower avoiding midday sun (41.9 % vs 60.9 %), and lower use of sunglasses (10.1 % vs. 41.6 %). Attitudes towards the sun and photoprotection knowledge issues were also equivalent between students and teachers (6.1/10 vs 6.2/10). Students' sunburn rate last year reaches 88.4 % and 52.7 % in teachers (p < 0.001). Using a multivariable logistic regression model, we identified risk factors associated with a greater risk of sunburn in our population. This study highlights areas to be improved regarding knowledge, attitudes and, especially, practices of photoprotection, among students and teachers at the University of Chimborazo. These results point out that awareness-raising campaigns should be implemented to reduce sunburns, morbidity and mortality of skin cancer in this environment.

[Patient participation through active listening. About the remodeling of an extractions service]

BACKGROUND AND OBJECTIVE

From listening to patients there arises the possibility of improving both the care and the health infrastructure that users frequent. Our purpose of study was to explore the perception of users about the means and the care received involved in a hospital service through active listening, and to evaluate the satisfaction perceived after the opening of the renovated area.

METHODS

A mixed methodology evaluative investigation was carried out within the context of the Extraction Service of the Costa del Sol Hospital, using qualitative methodology to assess the perception of users, and quantitative methodology through a satisfaction survey to identify the change after remodeling of the area.

RESULTS

Through a qualitative approach, improvements have been identified in terms of the internal and external infrastructure of the center, highlighting the need to personalize spaces depending on the profile of the patient attended. In evaluating the impact after remodeling the area, patients have a higher overall satisfaction both from the healthcare professionals who attend them and from the healthcare center.

CONCLUSIONS

Through the use of a mixed methodology, useful information has been incorporated for a project to improve a hospital infrastructure, and a subsequent evaluation of the positive impact on the satisfaction perceived by users after remodeling.

Efficacy and safety of selexipag in real-life in patients with pulmonary arterial hypertension: early results of RAMPHA study

Background

Pulmonary arterial hypertension (PAH) is a syndrome characterized by marked remodeling of the pulmonary vasculature and leading to right heart failure and death. Selexipag, an oral prostacyclin IP receptor agonist, has been shown to decrease morbidity and mortality compared to patients treated with placebo.

Purpose

Our aim was to evaluate the efficacy and safety of Selexipag in patients with PAH in real-life.

Methods

The RAMPHA study was a multicenter, observational and retrospective trial of patients who had PAH and began taking Selexipag between 2017–2021. We analyzed baseline characteristics, risk profiles, clinical assessments that were used for risk stratification and events in follow-up time.

Results

29 patients aged 48±14 were initially studied. 23 (79%) were women. Within the pulmonary hypertension-classification, 10 (34,5%) had PAH associated-congenital heart disease, 9 (31%) had idiopathic HAP, 7 (24,1%) had PAH associated with connective tissue disease, 1 had PAH associated to HIV and 2 heritable PAH. The time from PAH diagnoses to the beginning of Selexipag treatment was 54 months (IQR 89).

89,7% (26) were in treatment with doubled combination therapy with PDE5i+ARE; Sildenafil was the most widely used PDE5i and bosentan (37,9%) the most used ARE. No patients were under treatment with intravenous prostacyclin analogue, but 3 were with Treprostinil (1 of them subcutaneous and 2 inhaled) and 2 patients with iloprost.

Most patients were categorized in intermediate risk profile (figure 1), using the risk stratification strategy of ESC/ERS PH guidelines. In the approach of risk assessment before start with Selexipag, clinical, functional, exercise (with 6MWT) and echocardiographic variables were used in all the patients. Biochemical variables with NT-proBNP were used in 93% of the patients. Only 15 patients had a right catheterization to get haemodynamic parameters before the treatment.

At follow up, 11 patients (38%) improved functional class, only 1 patient got worst (p=0,001). 3 patients improved risk-profile in the exercise test and, in the others, a quantitative improvement was found. NT-proBNP levels were not significant better (924ng/l IQR 1209 vs 760ng/l IQR 1397). There were not changes in RV function in the echocardiographic parameters.

Selexipag was well-tolerated, 86% of the patients experienced side effects, but none had to discountinue the treatment. The most common side effect was headache. The titration lasted 68 days (IQR 72) and 38% of the patients got maximum doses.

At the medium-term follow-up of 52 months, the free-event survival (worsening of PAH that resulted in hospitalization; initiation of parenteral prostanoid therapy or death to PAH; or any cause) was 80% (Figure 2).

Conclusion

Selexipag, added as triple combination therapy in patients with PAH intermediate risk, improved risk variables, was well tolerated and achieved a medium-long-term free-event survival greater than 80%.

Funding Acknowledgement

Type of funding sources: None.

Sun exposure and protection habits in transplant athletes: An international survey

BACKGROUND

Transplant recipients are particularly prone to the development of skin cancer, and overexposure to UV radiation during outdoor activities increases the risk of carcinogenesis.

OBJECTIVE

The aim of this study was to analyze sun-related behaviors and knowledge in transplant athletes, examine the frequency of sunburns, and explore associations with a history of skin cancer.

MATERIALS AND METHODS

Cross-sectional descriptive study. Participants (n = 170) in the XXI World Transplant Games from >50 countries completed a questionnaire on sun protection habits and knowledge, type of transplant, immunosuppressive therapy, and personal history of skin cancer.

RESULTS

The most common transplanted organs were the kidney (n = 79), the liver (n = 33), and the heart (n = 31). Overall, 61.3% of athletes had been doing sport for >15 years and 79.5% spent >1-2 h a day outdoors. Fifteen % of athletes had a history of skin cancer. The prevalence of sunburn in the previous year was 28.9%, higher in athletes aged <50 years (37.2%); without a primary school education (58.3%), not taking cyclosporin (32.6%), and athletes who played basketball (75%). The main sun protection measures used were sunscreen (68.9%) and sunglasses (67.3%). Use of a hat or cap was the only measure significantly associated with a reduced prevalence of sunburn.

CONCLUSIONS

Despite high awareness that sun exposure increases the risk of skin cancer, sunburn was common in transplant athletes. Efforts should be made to strengthen multidisciplinary sun protection education strategies and ensure periodic dermatologic follow-up to prevent sun-induced skin cancer in this population.

Photoprotection habits, attitudes and knowledge among school communities in the Costa del sol (Spain)

BACKGROUND

Scholar photoprotection campaigns are among the most effective strategies for preventing skin cancer. Analysis of the target population constitutes a valuable starting point for the implementation of primary prevention strategies. Our aim is to study photoprotection habits, attitudes and knowledge among a Spanish school community.

METHODS

Descriptive cross-sectional study targeting schoolchildren, parents and teachers at 20 schools in the area of the Costa del Sol Health Agency in southern Spain. Two population-specific, validated questionnaires were used: the CHRESI (for children aged 0-10 years) and CHACES Questionnaire(for adults and adolescents aged > 11 years). We collected demographic data, skin colour, skin phototype, sunburn episodes, sun exposure and photoprotection practices, attitudes and knowledge.

RESULTS

1728 questionnaires were analyzed (22% parents, 14.5% teachers, 44.8% adolescents and 18.6% children). The average ages were 8 years (children), 16 years (adolescents), 39 years (teachers) and 42 years (parents). Globally, the predominant features were: male sex (52%), Spanish nationality (92%) and phototypes II-III (61%). Children, followed by adolescents, reported the highest exposure to the sun, both in frequency and in duration. Adolescents had the higher rate of sunburn (75%), followed by parents/teachers (54.1%) and children (44.1%). Children and their parents were the most likely to adopt photoprotection measures, while adolescents presented more risky attitudes. Knowledge regarding photoprotection was acceptable (6.9/10).

CONCLUSIONS

This study highlights the need to improve photoprotection knowledge, habits and attitudes among our target population. Scholars, parents and teachers in our area should be addressed in campaigns to promote healthy sun exposure habits, thus reducing skin cancer-related morbidity and mortality in this region.

Real-life cost-effectiveness of benralizumab in patients with severe asthma

BACKGROUND

Availability of clinically effective and cost-effective treatments for severe asthma would be beneficial to patients and national healthcare systems. The aim of this study was to evaluate clinical outcomes and healthcare expenditure after incorporating benralizumab into the standard treatment of refractory eosinophilic asthma.

METHODS

This was a cross-sectional multicentre study of consecutive patients with refractory eosinophilic asthma who received treatment with benralizumab during at least 12 months. Patient follow-up was performed in specialised severe asthma units. The main effectiveness parameters measured were: the avoidance of one asthma exacerbation, a 3-point increase in the asthma control test (ACT) score, and the difference in utility scores (health-related quality of life) between a 1-year baseline treatment and 1-year benralizumab treatment. The health economic evaluation included direct costs and incremental cost-effectiveness ratios (ICERs).

RESULTS

After 1 year of treatment with benralizumab, patients with refractory eosinophilic asthma showed an improvement in all the effectiveness parameters analysed: improvement of asthma control and lung function, and decrease in the number of exacerbations, oral corticosteroid (both as corticosteroid courses and maintenance therapy), and inhaled corticosteroid use. The total annual cost per patient for the baseline and benralizumab treatment periods were €11,544 and €14,043, respectively, reflecting an increase in costs due to the price of the biological agent but a decrease in costs for the remaining parameters. The ICER was €602 per avoided exacerbation and €983.86 for every 3-point increase in the ACT score.

CONCLUSIONS

All the pharmacoeconomic parameters analysed show that treatment with benralizumab is a cost-effective option as an add-on therapy in patients with refractory eosinophilic asthma.

[How does one die from SARS-CoV-2 infection? Analysis of the death process in patients admitted to an acute hospital]

INTRODUCTION

The SARS-CoV-2 pandemic has generated a mortality rate 10times higher than normal influenza according to the World Health Organization (WHO), yet they do not mention palliative care in their action guidelines on maintaining essential health services during this crisis. The aim of this study was to analyse the death process of patients who died from SARS-CoV-2 at the Hospital Costa del Sol.

MATERIAL AND METHODS

Descriptive cross-sectional study of the period in which all patients who died of SARS-CoV-2 from February to April 2020 were analysed. Sociodemographic characteristics, sample characterization and a set of variables related to the death process were collected in the death event.

RESULTS

A total of 16 deaths were recorded out of a total of 103 admissions positive for SARS-CoV-2. Limitation of therapeutic effort was decided in 68.8% of the patients, and admission to the intensive care unit was refused in 56.3%. Support devices had not been removed in any of the cases on the day of death, 43.8% had palliative sedation, and 18.8% were in induced coma.

CONCLUSIONS

Quality standards were maintained in the death process in patients who died from SARS-CoV-2, although there were aspects that could be improved. Palliative care is an essential component of the response to SARS-CoV-2 that must be incorporated into all health care settings.

Lymphogranuloma Venereum in a Public Health Service Hospital in Southern Spain: A Clinical and Epidemiologic Study

Lymphogranuloma venereum (LGV) is an emerging disease in men who have sex with men (MSM): the incidence was 1.15 cases per 100,000 population in Spain in 2017. Patients with LGV characteristically have severe proctitis that can cause abscesses, fistulas, and anal stenosis. Genital ulcers and inflammatory inguinal adenopathy may occasionally be present. The aim of this study was to describe a series of patients with LGV treated in a public health service hospital in Andalusia, Spain.

MATERIAL AND METHODS

Retrospective, observational description of a series of patients diagnosed with LGV. We gathered epidemiologic, clinical, microbiologic, and treatment data. Patients' sexual behaviors were also noted.

RESULTS

We found 17 cases of LGV diagnosed in MSM between October 2016 and May 2019. Twelve of the patients were also infected with the human immunodeficiency virus, and 13 had severe proctitis with ulcers in the anal canal and rectum. Four patients had genital or inguinal manifestations. The following high-risk sexual behaviors were on record: a high number of sexual partners, receptive anal sex with strangers and without a condom, seeking sexual partners online, participation in group sex, and sex with partners from outside Andalusia. Chlamydia trachomatis serovar L2 was identified in all cases, and the infection responded well to oral doxycycline. Two patients with the most characteristic form of LGV required longer treatment cycles. Three required surgery.

CONCLUSIONS

When symptomatic proctitis is found in MSM who engage in high-risk sex, the LGV exudate should be sampled and the C trachomatis serovar identified. Genital ulcers or inguinal buboes are also highly suggestive of LGV. Clinical suspicion and early treatment are the keys to preventing complications and disease transmission.

Real-life experience with benralizumab during 6 months

BACKGROUND

Benralizumab is a monoclonal antibody that binds to the human interleukin-5 (IL-5) receptor (IL-5R), thereby preventing IL-5 from binding to its receptor and inhibiting differentiation and maturation of eosinophils in the bone marrow. Because of its recent marketing approval, sufficient real-life evidence is lacking to confirm the efficacy and safety data from clinical trials. The purpose of this study was to evaluate the efficacy and safety of benralizumab for the treatment of severe refractory eosinophilic asthma in a real-world cohort of patients.

METHODS

This was a cross-sectional multicentre study of consecutive patients with severe refractory eosinophilic asthma who received treatment with benralizumab during at least 6 months. Patient follow-up was performed in specialised severe asthma units.

RESULTS

A total of 42 patients were enrolled and treated with benralizumab. Asthma control, as measured by the asthma control test (ACT), improved in all patients both at 3 months of treatment compared with baseline (13.9 ± 4 vs 20.1 ± 3.7, p < 0.001) and at 6 months of treatment compared with the results obtained at 3 months (20.1 ± 3.7 vs 21 ± 2.7, p = 0.037). Similarly, the number of emergency department visits decreased both at 3 months compared with baseline (1 [IR:0.7] vs 0 [IR:0.75], p < 0.001) and at 6 months compared with the results at 3 months (0 [IR:0.75] vs 0 [IR:0], p = 0.012). Reductions in the number of oral corticosteroid cycles, percentage of corticosteroid-dependent patients, and mean daily dose of oral or inhaled corticosteroid were also evidenced. Finally, mean lung function improvement was 291 mL (p < 0.001), and FEV1% improved both at 3 months compared with baseline (64.4 ± 9.3 vs 73.1 ± 9.1, p < 0.001) and at 6 months compared to 3 months (73.1 ± 9.1 vs 76.1 ± 12, p = 0.002). Side effects were mild and did not lead to treatment discontinuation.

CONCLUSIONS

This study confirms the efficacy and safety of benralizumab in a real-life setting with improved asthma control and lung function, and a reduced oral and inhaled corticosteroid use as well as fewer emergency department visits. In addition to a rapid initial improvement, it appears that patients continue to improve during the first 6 months of treatment.

Is the bone tissue of the femoral neck demineralised in patients with hip fracture?

The aim of this study is to establish the falsifiability of the "osteoporotic hypothesis" for hip fracture, according to which the bone density and mineral composition of bone tissue in patients with hip fracture is poorer than when no such fracture is present, and that this circumstance is relevant to the occurrence of a fracture. The study population consisted of forty patients treated with arthroplasty. Twenty patients with femoral neck fracture and another twenty with hip osteoarthritis received the same diagnostic protocol and the same antibiotic, anaesthetic, surgical and antithrombotic prophylaxis. Levels of calcium (Ca), phosphorus (P) and vitamin D in blood, amongst other values, were determined, and five samples of bone tissue from the proximal femoral metaphysis were obtained and characterised by optical microscopy and microanalytical analysis. No statistically significant differences were observed between the two groups with respect to the trabecular number, area or thickness, or inter-trabecular distance. However, there were differences in the length of the trabeculae, which was greater in the patients with hip osteoarthritis (p = 0.002), but not when the groups were compared by gender. When compared by age, a greater inter-trabecular distance was observed in the patients aged over 75 years (p = 0.036) but there were no differences in the remaining parameters. Serum levels of Ca (p = 0.03), P (p < 0.01) and vitamin D (p < 0.01) were lower in the fracture group. In the quantitative microanalytical analysis, no significant differences were observed in bone levels of Ca or P or in the Ca/P index, nor was there any correlation between serum and levels of bone Ca or P (Ca-0.197:p = 0.314;P-0.274:p = 0.158).Multiple linear regression revealed no correlation between the diagnoses, vitamin D and bone levels of Ca or P. Despite the reduced serum levels of Ca and P in the patients with hip fracture, no correlation was observed with bone levels of Ca and P,which were similar in both groups. There were differences in the organic bone structure, in terms of length and inter-trabecular distance. For patients with osteoporosis, treatment should be aimed at increasing the synthesis of bone trabeculae to reinforce their structure. Nevertheless, no such treatment can prevent falls, and therefore no reduction in hip fractures amongst this population can be assured.

Validation of the PROFUND index to predict early post-hospital discharge mortality

BACKGROUND

The PROFUND index (PI) is a prognostic scale for polypathological patients at 12 months. The objective of the study was to validate the PI as a predictor of 1-year mortality in a current cohort of polypathological patients and analyse its prognostic usefulness in the short-term (1 month and 3 months) after discharge from Internal Medicine.

DESIGN

We conducted a prospective observational study and all polypathological patients discharged from an Internal Medicine Department between 01 March 2016 and 28 February 2017 were enrolled.

METHODS

The variables recorded for each patient were age, sex, diseases and diagnostic categories defining patients as polypathological patients, PI at discharge, number of hospital admissions, length of stay, vital status at 1 year, and date and place of death if applicable. Follow-up lasted 1 year from the time of enrolment.

RESULTS

Six hundred and ten polypathological patients were enrolled. Mortality was 41% and the patients who died were older, their length of stay was longer and their PI was higher compared with those who survived. The discrimination of the PI for predicting mortality was good, with a C-statistic of 0.718 [95% confidence interval (CI) 0.67-0.76]. In addition, a subgroup of patients with early mortality after discharge was identified, with a C-statistic of 0.74 (95% CI 0.67-0.80) at 30 days and 0.73 (95% CI 0.68-0.78) at 90 days.

CONCLUSIONS

The PI is a valid tool for predicting early and 1-year mortality in polypathological patients after discharge from Internal Medicine.

Factors associated with bronchiectasis in patients with uncontrolled asthma; the NOPES score: a study in 398 patients

Background

Some studies have reported a high prevalence of bronchiectasis in patients with uncontrolled asthma, but the factors associated with this condition are unknown. The objective of this study was to determine the prevalence of bronchiectasis in uncontrolled moderate-to-severe asthma and to identify risk factors and their correlation with bronchiectasis in these patients.

Methods

This is a prospective study of data from consecutive patients with uncontrolled moderate-to-severe asthma. Diagnosis of bronchiectasis was based on high-resolution computed tomography. A prognostic score was developed using a logistic regression model, which was used to determine the factors associated with bronchiectasis.

Results

A total of 398 patients (60% with severe asthma) were included. The prevalence of bronchiectasis was 28.4%. The presence of bronchiectasis was associated with a higher frequency of chronic expectoration (OR, 2.95; 95% CI, 1.49–5.84; p = 0.002), greater severity of asthma (OR, 2.43; 95% CI, 1.29–4.57; p = 0.006), at least one previous episode of pneumonia (OR, 2.42; 95% CI, 1.03–5.69; p = 0.044), and lower levels of FeNO (OR, 0.98; 95% CI, 0.97–0.99; p = 0.016). The NOPES score was developed on the basis of these variables (FeNO[cut off point 20.5 ppb], Pneumonia, Expectoration and asthma Severity), and it ranges from 0 to 4 points, where 0 means “no risk” and 4 corresponds to “high risk”. The NOPES score yielded an AUC-ROC of 70% for the diagnosis of bronchiectasis, with a specificity of 95%.

Conclusions

Almost a third of the patients with uncontrolled moderate-to-severe asthma had bronchiectasis. Bronchiectasis was related to the severity of asthma, the presence of chronic expectoration, a previous history of pneumonia, and lower levels of FeNO. The NOPES score is an easy-to-use scoring system with a high prognostic value for bronchiectasis in patients with uncontrolled moderate-to-severe asthma.

[Clinical governance and patient safety culture in clinical laboratories in the Spanish National Health System]

AIM

To conduct a situational analysis of patient safety culture in public laboratories in the Spanish National Health System and to determine the clinical governance variables that most strongly influence patient safety.

METHOD

A descriptive cross-sectional study was carried out, in which a Survey of Patient Safety in Clinical Laboratories was addressed to workers in 26 participating laboratories. In this survey, which consisted of 45 items grouped into 6 areas, scores were assigned on a scale from 0 to 100 (where 0 is the lowest perception of patient safety). Laboratory managers were asked specific questions about quality management systems and technology.

RESULTS

The mean scores for the 26 participating hospitals were evaluated, and the following results observed: in 4of the 6areas, the mean score was higher than 70 points. In the third area (equipment and resources) and the fourth area (working conditions), the scores were lower than 60 points. Every hospital had a digital medical record system. This 100% level of provision was followed by that of an electronic request management system, which was implemented in 82.6% of the hospitals.

CONCLUSIONS

The results obtained show that the culture of security is homogeneous and of high quality in health service laboratories, probably due to the steady improvement observed. However, in terms of clinical governance, there is still some way to go, as shown by the presence of weaknesses in crucial dimensions of safety culture, together with variable levels of implementation of fail-safe technologies and quality management systems.

Usefulness of High-Frequency Ultrasound in the Classification of Histologic Subtypes of Primary Basal Cell Carcinoma

INTRODUCTION

Incisional biopsy may not always provide a correct classification of histologic subtypes of basal cell carcinoma (BCC). High-frequency ultrasound (HFUS) imaging of the skin is useful for the diagnosis and management of this tumor.

OBJECTIVES

The main aim of this study was to compare the diagnostic value of HFUS compared with punch biopsy for the correct classification of histologic subtypes of primary BCC. We also analyzed the influence of tumor size and histologic subtype (single subtype vs. mixed) on the diagnostic yield of HFUS and punch biopsy.

METHODS

Retrospective observational study of primary BCCs treated by the Dermatology Department of Hospital Costa del Sol in Marbella, Spain, between october 2013 and may 2014. Surgical excision was preceded by HFUS imaging (Dermascan C^©, 20-MHz linear probe) and a punch biopsy in all cases. We compared the overall diagnostic yield and accuracy (sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) of HFUS and punch biopsy against the gold standard (excisional biopsy with serial sections) for overall and subgroup results.

RESULTS

We studied 156 cases. The overall diagnostic yield was 73.7% for HFUS (sensitivity, 74.5%; specificity, 73%) and 79.9% for punch biopsy (sensitivity, 76%; specificity, 82%). In the subgroup analyses, HFUS had a PPV of 93.3% for superficial BCC (vs. 92% for punch biopsy). In the analysis by tumor size, HFUS achieved an overall diagnostic yield of 70.4% for tumors measuring 40mm² or less and 77.3% for larger tumors; the NPV was 82% in both size groups. Punch biopsy performed better in the diagnosis of small lesions (overall diagnostic yield of 86.4% for lesions ≤40mm² vs. 72.6% for lesions >40mm²).

CONCLUSIONS

HFUS imaging was particularly useful for ruling out infiltrating BCCs, diagnosing simple, superficial BCCs, and correctly classifying BCCs larger than 40mm².

A Spanish version of the Skin Cancer Index: a questionnaire for measuring quality of life in patients with cervicofacial nonmelanoma skin cancer

INTRODUCTION

The Skin Cancer Index (SCI) is the first specific patient-reported outcome measure for patients with cervicofacial nonmelanoma skin cancer. To date, only the original English version has been published.

OBJECTIVES

To develop a Spanish version of the SCI that is semantically and linguistically equivalent to the original, and to evaluate its measurement properties in this different cultural environment.

MATERIAL AND METHODS

A cross-sectional study was conducted of the cultural adaptation and empirical validation of the questionnaire, analysing the psychometric properties of the new index at different stages.

RESULTS

Of 440 patients recruited to the study, 431 (95%) completed the Spanish version of the SCI questionnaire, in a mean time of 6·3 min (SD 2·9). Factor analysis of the scale revealed commonality and loading values of < 0·5 for three of the 15 items. The remaining 12 items converged into two components: appearance/social aspects (seven items) and emotional aspects (five items). Both domains presented a high level of internal consistency, with Cronbach's alpha values above 0·8. The convergent-discriminant validity analysis produced correlations higher than 0·3 for the mental component of the Short Form Health Survey-12v2 Health Questionnaire (correlation coefficient 0·39) and the Dermatology Quality of Life Index (correlation coefficient -0·30). In the test-retest, nine of the 12 items produced a weighted kappa value exceeding 0·4, and for the remaining three items, the absolute agreement percentage exceeded 60%.

CONCLUSIONS

The Spanish version of the SCI quality of life scale has been satisfactorily adapted and validated for use in Spanish-speaking countries and populations.

Skin cancer prevention and detection campaign at golf courses on Spain's Costa del Sol

BACKGROUND AND OBJECTIVES

Skin cancer prevention and detection campaigns targeting specific groups are necessary and have proven to be more effective than those aimed at the general population. Interventions in outdoor tourist spots have proven successful, although none have specifically targeted golf courses. The aims of this study were to describe the risk profile of golfers and golf course workers and evaluate the impact of a skin cancer prevention and early detection intervention.

MATERIAL AND METHODS

This was a cross-sectional descriptive study conducted at 6 golf courses. The intervention included a skin examination and completion of a questionnaire about demographic details, risk factors, and sun exposure and sun protection habits. Participants were also given advice on sun protection measures, self-examination, and use of sunscreens, and were asked about their satisfaction with the intervention and their intention to change their current behaviors. The effect was measured in terms of the diagnoses made, satisfaction with the intervention, reported intention to change, and potential effect in terms of existing risk factors.

RESULTS

Of the 351 participants (57% golfers and 43% golf course workers), 70.4% had fair skin, 11.7% had a family history of skin cancer, and 8.5% had a personal history of skin cancer. Skin cancer and actinic keratoses were diagnosed in 10.7% and 40% of the golfers, respectively. The session was rated positively by 99.4% of the participants; 93.9% stated that they intended to improve their sun exposure habits and 93.4% said that they planned to examine their skin more frequently.

CONCLUSIONS

Our findings confirm that golf course workers and, in particular, golfers are an important target for skin cancer prevention campaigns. This is the first intervention to specifically target golf courses, and it proved to be both feasible and useful. Its success appears to be attributable to numerous factors: it was conducted at golf courses, had multiple components, and was preceded by a motivational campaign.

Analysis of patients with Chlamydia trachomatis genital infection in an STD clinic

INTRODUCTION AND OBJECTIVES

Chlamydia trachomatis genital infection is common in our setting and early treatment can prevent complications. The aim of this study was to report on patients diagnosed with C trachomatis genital infection in a sexually transmitted disease (STD) clinic.

MATERIAL AND METHODS

This was a descriptive, cross-sectional, observational study of patients diagnosed with C. trachomatis infection between 2010 and 2011. We recorded demographic data and information on sexual habits, concomitant sexually transmitted infections (STIs), and various aspects of treatment.

RESULTS

In total, 12.3% of the samples analyzed were positive for C trachomatis genital infection. Sixty-two patients (43 men) with a mean age of 31 years were studied; 75% were heterosexual and 87% had had a sexual partner in the previous 2 months. Condom use was inconsistent in 81%, 79%, and 65% of patients who practiced vaginal, oral, and anal sex, respectively. Thirteen percent of the patients had symptoms and anogenital warts were the most common associated STI. The most widely used treatment was doxycycline.

CONCLUSIONS

A high prevalence of genital C. trachomatis infection was detected in our STD clinic, and the majority of cases were found in young men. We observed a high rate of asymptomatic infection in patients who do not engage in high-risk sexual behavior and who had come to the clinic for another reason. Systematic screening of C. trachomatis infection should be implemented in STD units to enable the early treatment of patients and their recent sexual partners.

Predictors of hospital admission in exacerbations of chronic obstructive pulmonary disease

OBJECTIVE

To identify factors predictive of hospital admission among patients attending an emergency department (ED) with exacerbation of chronic obstructive pulmonary disease (COPD) and to determine if these were consistent with Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations.

DESIGN

In a prospective cohort of 2487 COPD patients with exacerbations conducted in 16 EDs, clinical data were obtained and physical examination and blood gas analyses were performed on arrival at the ED and at decision time about hospitalisation. Multivariate analyses were performed using hospital admission as the dependent measure.

RESULTS

In multivariate analysis, factors predictive of hospital admission on ED arrival were previous hospitalisation for COPD exacerbation (OR 2.03, 95%CI 1.32-3.11), resting dyspnoea (OR 3.05, 95%CI 2.39-3.88) and altered blood gas (PaO2 = 45-60 mmHg, OR 2.7, 95%CI 2.12-3.44; PaO2 < 45 mmHg, OR 3.24, 95%CI 2.14-4.92; PaCO2 = 56-65 mmHg, OR 2.35, 95%CI 1.58-3.51; and PaCO2 > 65 mmHg, OR 6.98, 95%CI 4.03-12.09). The predictive capacity of the model using variables available at decision time was better than for those at ED arrival (area under the receiver operating characteristic curve 0.89 and 0.83). These factors are included in the GOLD recommendations.

CONCLUSION

Among COPD patients presenting to the ED with exacerbation, factors immediately associated with episode severity were independent predictors of hospitalisation. Our criteria for hospitalisation are in line with GOLD recommendations.

[Long-term survival of ischemic stroke]

OBJECTIVE

Ischemic stroke is a serious vascular disease whose long term prognosis in all of its dimensions is not known. We have studied the long-term survival and its predictors after a first episode of acute ischemic stroke (atherothrombotic and cardioembolic).

PATIENTS AND METHODS

A retrospective cohort study was made of patients with a first episode of ischemic stroke. The ictus was classified into atherothrombotic, cardioembolic, lacunar and undetermined. Patients were followed up for 10 years.

RESULTS

A total of 415 cases (60% men) with mean age of 68.4 years, were included. Mean follow-up was 66 months (95% CI: 24-108 months). Overall survival at 10 years was 55.4% (54.9-55.9) (atherothrombotic, 57.7% vs cardioembolic, 43.7%, P=.002). In the multivariate analysis, variables related to mortality in acute ischemic stroke were age, chronic renal failure, dyslipidemia, history of heart failure, atrial fibrillation (AF), presenting as hemiplegia, signs of acute ischemia and perilesional edema in the brain scan on hospital admission. Involvement of the territory of right middle cerebral artery and treatment with statins were associated to a better prognosis.

CONCLUSIONS

Survival of patients after ischemic stroke at ten year is over 40%, and atherothrombotic stroke as a better prognosis than cardioembolic one.

[Condom use and number of sexual partners among male syphilis patients who report having sex with men]

BACKGROUND AND OBJECTIVES

Recent years have seen a resurgence of syphilis in Spain due to changes in sexual behavior. Here we describe the incidence of the disease in our clinic and investigate its relationship with the sexual habits of men who have sex with men (MSM).

PATIENTS AND METHODS

A cross-sectional descriptive study of incident cases of syphilis in 2007 and 2008 was performed, followed by a case-control study of sexual behavior in the previous year to compare MSM with and without syphilis.

RESULTS

We recorded 26 new cases of syphilis, 19 of which were diagnosed at early stages. Eight patients were infected with human immunodeficiency virus and 15 were classed as MSM. Sixty-five MSM without syphilis were selected as a control group. MSM with syphilis had a larger number of sexual partners: odds ratio (OR), 3.98 (95% confidence interval [CI], 0.90-17.46) for the category "2 to 5 sexual partners"; OR, 3.22 (95% CI, 0.84-12.43) for the category "more than 5 sexual partners". The inconsistent use of condoms was significantly more common among MSM with syphilis than among those without syphilis (OR, 3.96; 95% CI, 1.15-13.61; p=0.02).

CONCLUSIONS

Syphilis continues to be a public health problem in our setting, particularly among homosexual and bisexual men. In this study, inconsistent use of condoms and a greater number of sexual partners were risk factors for syphilis in MSM. The development of prevention programs targeting this at-risk population should be considered a priority.

[Cost analysis of Mohs micrographic surgery in high-risk facial basal cell carcinoma]

INTRODUCTION

Mohs micrographic surgery (MMS) is the treatment of choice for high-risk facial basal cell carcinoma (BCC) as it offers the greatest chance of cure with maximum preservation of healthy tissue. Its use in Spanish public health care hospitals is still limited, however, due to the controversy surrounding its cost.

OBJECTIVES

To determine the cost of MMS with fresh tissue to treat high-risk facial BCC and compare this to the estimated cost of conventional surgery in a Spanish public hospital. A secondary objective was to identify cost-optimization strategies for MMS.

MATERIAL AND METHODS

Cross-sectional study of a consecutive series of patients with high-risk facial BCC who underwent MMS at the Department of Dermatology at Hospital Costa del Sol in Malaga, Spain between July 2006 and December 2007. We performed a descriptive analysis of the clinical characteristics of the patients and surgical factors. We calculated the total and mean cost of MMS and compared the results to the estimated costs of conventional surgery using patients as their own controls. Differences were analyzed according to tumor site and size, histologic subtype, and recurrence.

RESULTS

Seventy-nine patients (mean age, 62 years) with 81 high-risk facial BCCs, 97.5% of which were primary tumors, underwent MMS. The most common tumor site was the nose (57%) followed by the orbital region (25%). Histology showed that 64% of the tumors were infiltrative or micronodular carcinomas. Tumor-free margins were achieved in all patients, with no more than 2 stages required in 88% of the cases. The most common surgical reconstruction techniques were direct closure (21%) and closure with a local skin flap or graft (71%); the corresponding estimates for conventional surgery were 2% and 89%, respectively. The total and mean cost of MMS was e106,129.07 and e1325.80, respectively (compared to e97 700 and e1208.70 for conventional surgery). The difference in mean costs between MMS and conventional surgery was not significant (P=0.534).

CONCLUSIONS

MMS is a viable, effective technique that does not generate significantly higher costs than conventional surgery in selected patients with high-risk facial BCC. Certain technical and organizational strategies could contribute to optimizing the cost of MMS.

Statistical inference: hypothesis testing

The aim of statistical inference is to predict the parameters of a population, based on a sample of data. Inferential statistics encompasses the estimation of parameters and model predictions. The present article describes the hypothesis tests or statistical significance tests most commonly used in healthcare research.

Cost Analysis of Mohs Micrographic Surgery in High-Risk Facial Basal Cell Carcinoma

INTRODUCTION

Mohs micrographic surgery (MMS) is the treatment of choice for high-risk facial basal cell carcinoma (BCC) as it offers the greatest chance of cure with maximum preservation of healthy tissue. Its use in Spanish public health care hospitals is still limited, however, due to the controversy surrounding its cost.

OBJECTIVES

To determine the cost of MMS with fresh tissue to treat high-risk facial BCC and compare this to the estimated cost of conventional surgery in a Spanish public hospital. A secondary objective was to identify cost-optimization strategies for MMS.

MATERIAL AND METHODS

Cross-sectional study of a consecutive series of patients with high-risk facial BCC who underwent MMS at the Department of Dermatology at Hospital Costa del Sol in Malaga, Spain between July 2006 and December 2007. We performed a descriptive analysis of the clinical characteristics of the patients and surgical factors. We calculated the total and mean cost of MMS and compared the results to the estimated costs of conventional surgery using patients as their own controls. Differences were analyzed according to tumor site and size, histologic subtype, and recurrence.

RESULTS

Seventy-nine patients (mean age, 62 years) with 81 high-risk facial BCCs, 97.5% of which were primary tumors, underwent MMS. The most common tumor site was the nose (57%) followed by the orbital region (25%). Histology showed that 64% of the tumors were infiltrative or micronodular carcinomas. Tumor-free margins were achieved in all patients, with no more than 2 stages required in 88% of the cases. The most common surgical reconstruction techniques were direct closure (21%) and closure with a local skin flap or graft (71%); the corresponding estimates for conventional surgery were 2% and 89%, respectively. The total and mean cost of MMS was e106,129.07 and e1325.80, respectively (compared to e97 700 and e1208.70 for conventional surgery). The difference in mean costs between MMS and conventional surgery was not significant (P=0.534).

CONCLUSIONS

MMS is a viable, effective technique that does not generate significantly higher costs than conventional surgery in selected patients with high-risk facial BCC. Certain technical and organizational strategies could contribute to optimizing the cost of MMS.

Measures of frequency, magnitude of association and impact in epidemiology

Epidemiology is concerned with groups of subjects belonging to populations, not with each individual subject, and takes into account both the subjects who contract a disease and those who do not. Comparison, thus, is a basic element of this discipline. Measures of frequency, association and impact are the main statistical resources employed in epidemiology to describe the distribution of healthcare problems, establishing a causal relationship between exposure and disease, enabling users to evaluate the impact of preventive measures in the field of public health.

[Validation of a Spanish questionnaire to evaluate habits, attitudes, and understanding of exposure to sunlight: "the beach questionnaire"]

BACKGROUND

Questionnaires are the usual method for investigating sun-related behavior. However,such tools must be validated through evaluation of their measurement properties.The aim of the present study was to assess the validity and reliability of a Spanish questionnaire evaluating habits, attitudes, and understanding of exposure to sunlight.

PATIENTS AND METHODS

In a cross-sectional study, the questionnaire was administered to a sample of 422 participants found on beaches. For the test-retest analysis, 70 hospital-based health professionals were interviewed on 2 separate occasions.The construct validity, internal consistency, and reproducibility were analyzed.

RESULTS

Factorial analysis of the principal components confirmed the construct validity with commonalities and factor saturations > 0.50, and revealed multiple dimensions with Cronbach a values > 0.70.The items on habits and understanding showed intraclass correlation and d coefficient values > 0.70, but those on attitude had lower stability values (0.50-0.80).

CONCLUSIONS

This is the first Spanish questionnaire with demonstrated validity and reliability for evaluating habits, attitudes, and understanding of exposure to sunlight. It will be a useful instrument for future epidemiologic studies and research into the prevention of skin cancer in Spain.

[Analysis of the epidemiological characteristics and prognostic factors in probable or confirmed invasive meningococcal disease in a cohort of adolescents and adults during an epidemic outbreak]

OBJECTIVE

To describe the profile of people suffering Invasive Meningococcal Disease in Andalusia and the Canary Islands, and identify the risk factors for death.

MATERIAL AND METHODS

A retrospective study was designed, recruiting cases from week 41 of 1995 to week 40 2000. Cases were probable or definite, and were extracted from the databases of the hospital by examining diagnosis at discharge or death.

RESULTS

167 cases were identified, with a mortality rate of 7.2%. Mean age was 28.88 years, this being greater in those who died (p = 0.041). There was no previous contact with the Health System before the diagnosis in 56.3% of the cases, this being associated with death (p = 0.017). The more frequent reason for contact was a low level of consciousness, and it was the only one associated to death (p = 0.036). Pharyngotonsilitis was associated with a lower incidence of death. About 24% of patients received antibiotics as out-patients and their use was associated to a lower incidence of death (p = 0.07). Temperature over 40 degrees C (p = 0.003) and heart rate lower than 60 beats per minute (p < 0.0005) were associated with death. Leucocytes in peripheral blood less than 4.500 cells/ microliter, or platelets less than 100.000 cells/microliter were associated with a greater proportion of deaths. In Cerebrospinal fluid, less than 5 leucocytes per microliter, or proteins less than 50 mg/dl were associated with more deaths. Neisseria meningitidis B was isolated in 47 patients (28.1%), and C in 77 cases (46.1%). Sepsis was significantly associated with death (p < 0.0005).

CONCLUSIONS

The absence of previous contacts with the Health System reveals an abrupt onset of Meningococcal disease, with less inflammatory response and very severe. Out of hospital antibiotic treatment and pharyngoamygdalitis are associated with a better prognosis.