Primary Care Research Unit

Salamanca, Spain

Primary Care Research Unit

Salamanca, Spain
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Emilsson L.,Primary Care Research Unit | Emilsson L.,University of Oslo | Magnus M.C.,Norwegian Institute of Public Health | Stordal K.,Norwegian Institute of Public Health | Stordal K.,Ostfold Hospital Trust
Clinical Gastroenterology and Hepatology | Year: 2015

Background & Aims: There have been inconsistent reports of prenatal and perinatal factors that affect risk for development of celiac disease. We assessed the association of fetal growth, birth weight, and mode of delivery with development of celiac disease within the Norwegian Mother and Child (MoBa) Cohort Study. Methods: The MoBa cohort contains pregnancy information on 95,200 women and data on their 114,500 children, which were collected in Norway from 1999 through 2008; it is linked to the Medical Birth Registry. Women and children with celiac disease were identified from the National Patient Registry and from women's responses to MoBa questionnaires. We calculated odds ratios (ORs) for celiac disease by using a multivariable logistic regression model, adjusting for maternal celiac disease, sex of children, and children's age (model 1); in a second model, we adjusted for age of gluten introduction and duration of breastfeeding (model 2). Results: We identified 650 children with celiac disease and 107,828 controls in the MoBa database. We found no association between birth weight or height with celiac disease (born small for gestational age was not associated). Celiac disease was not associated with mode of delivery (cesarean section, model 1: OR, 0.84; 95% confidence interval [CI], 0.65-1.09, and model 2: OR, 0.83; 95% CI, 0.63-1.09). Maternal celiac disease, adjusted for age and sex of the children (OR, 12.45; 95% CI, 8.29-18.71) and type 1 diabetes (model 1: OR, 2.58; 95% CI, 1.19-5.53, and model 2: OR, 2.61; 95% CI, 1.14-5.98) were associated with development of celiac disease in children, whereas maternal type 2 diabetes and gestational diabetes were not. Conclusions: On the basis of analysis of the Norwegian MoBa cohort, development of celiac disease in children is significantly associated with sex of the child, maternal celiac disease, and type 1 diabetes but not with intrauterine growth. © 2015 AGA Institute.


Emilsson L.,Primary Care Research Unit | Emilsson L.,University of Oslo | Wijmenga C.,University of Groningen | Murray J.A.,Mayo Medical School | And 2 more authors.
Clinical Gastroenterology and Hepatology | Year: 2015

Background & Aims: First-degree relatives of individuals with celiac disease are at increased risk for this disorder, but little is known about their risk for other autoimmune diseases. We assessed the risk of nonceliac autoimmune disease in first-degree relatives and spouses of people with celiac disease. Methods: We identified individuals with celiac disease by searching computerized duodenal and jejunal biopsies, collected from 1969 through 2008, at 28 pathology departments in Sweden. Celiac disease was identified based on biopsy reports of villous atrophy (equal to Marsh grade 3; n=29,096). Individuals with celiac disease were matched with up to 5 controls (people without celiac disease) for sex, age, county, and calendar year (total, 144,522 controls). Through Swedish health care registries, we identified all first-degree relatives (fathers, mothers, siblings, and offspring) and spouses of individuals with celiac disease (n= 84,648) and controls (n= 430,942). We used Cox regression analysis to calculate hazard ratios (HRs) for nonceliac autoimmune disease (Crohn's disease, type 1 diabetes mellitus, hypothyroidism, hyperthyroidism, psoriasis, rheumatoid arthritis, sarcoidosis, systemic lupus erythematosus, or ulcerative colitis) in these groups. Results: During the follow-up period (median, 10.8 y), 3333 of the first-degree relatives of patients with celiac disease (3.9%) and 12,860 relatives of controls (3.0%) had an autoimmune disease other than celiac disease. First-degree relatives of people with celiac disease were at increased risk of nonceliac autoimmune disease, compared with controls (HR, 1.28; 95% confidence interval, 1.23-1.33), as were spouses (HR, 1.20; 95% confidence interval, 1.06-1.35). Risk estimates for nonceliac autoimmune disease did not differ between first-degree relatives and spouses of individuals with celiac disease (interaction test: P= .11). HRs for nonceliac autoimmune disease were highest in the first 2 years of follow-up evaluation. Conclusions: First-degree relatives and spouses of individuals with celiac disease are at increased risk of nonceliac autoimmune disease. In addition to genetic factors, environmental factors and ascertainment bias might contribute to the increased risk of autoimmunity in first-degree relatives of individuals with celiac disease. © 2015 AGA Institute.


Schmitt J.,TU Dresden | Von Kobyletzki L.,Lund University | Von Kobyletzki L.,Primary Care Research Unit | Svensson A.,Skåne University Hospital | Apfelbacher C.,University of Heidelberg
British Journal of Dermatology | Year: 2011

Summary Background: Long-term low-level topical anti-inflammatory therapy has been suggested as a new paradigm in the treatment of atopic eczema (AE). Objectives To determine the efficacy and tolerability of topical corticosteroids and calcineurin inhibitors for flare prevention in AE. Methods Systematic review of randomized controlled trials reporting efficacy of topical corticosteroids and/or topical calcineurin inhibitors for flare prevention in AE. Identification of relevant articles by systematic electronic searches (Cochrane Library, Medline) supplemented by hand search. Primary efficacy endpoint: proportion of participants experiencing at least one flare during proactive anti-inflammatory treatment. Relative risks (RRs) and corresponding 95% confidence intervals (CIs) were calculated and pooled by pharmaceutical agent using random-effects meta-analysis. Sensitivity analysis included meta-regression to explore the influence of study-specific covariates. Results Nine articles reporting on eight vehicle-controlled trials were included. Three, four and one trial(s) evaluated proactive therapy with topical tacrolimus, fluticasone propionate and methylprednisolone aceponate, respectively. Each agent under study was more efficacious to prevent flares than vehicle. Meta-analysis suggested that topical fluticasone propionate (RR 0·46, 95% CI 0·38-0·55) may be more efficacious to prevent disease flares than topical tacrolimus (RR 0·78, 95% CI 0·60-1·00). Meta-regression indicated robustness of these findings. Proactive anti-inflammatory therapy was generally well tolerated. The trials identified, however, do not allow firm conclusions about long-term safety. Conclusions Vehicle-controlled trials indicate efficacy of proactive treatment with tacrolimus, fluticasone propionate and methylprednisolone aceponate to prevent AE flares. Indirect evidence from vehicle-controlled trials suggests that twice weekly application of the potent topical corticosteroid fluticasone propionate may be more efficacious to prevent AE flares than tacrolimus ointment. Head to head trials should be conducted to confirm these results. Future studies are also needed to evaluate the long-term safety of proactive treatment of AE. © 2010 British Association of Dermatologists.


Choi H.,Harvard University | Schmidbauer N.,Norwegian Institute For Air Research | Sundell J.,Tsinghua University | Hasselgren M.,Primary Care Research Unit | And 3 more authors.
PLoS ONE | Year: 2010

Background: The risk of indoor exposure to volatile organic compounds (VOCs) on allergic airway diseases in children remains unknown. Objective: We examined the residential concentrations of VOCs, emitted from building materials, paints, furniture, and other lifestyle practices and the risks of multiple allergic diseases as well as the IgE-sensitization in pre-school age children in Sweden. Methods: In a case-control investigation (198 case children with asthma and allergy and 202 healthy controls), air samples were collected in the room where the child slept. The air samples were analyzed for the levels of eight classes of VOCs. Results: A natural-log unit of summed propylene glycol and glycol ethers (PGEs) in bedroom air (equal to interquartile range, or 3.43 - 15.65 μg/m3) was associated with 1.5-fold greater likelihood of being a case (95% CI, 1.1 - 2.1), 1.5-fold greater likelihood of asthma (95% CI, 1.0 - 2.3), 2.8-fold greater likelihood of rhinitis (95% CI, 1.6 - 4.7), and 1.6-fold greater likelihood of eczema (95% CI, 1.1 - 2.3), accounting for gender, secondhand smoke, allergies in both parents, wet cleaning with chemical agents, construction period of the building, limonene, cat and dog allergens, butyl benzyl phthalate (BBzP), and di(2-ethylhexyl)phthalate (DEHP). When the analysis was restricted to the cases, the same unit concentration was associated with 1.8-fold greater likelihood of IgE-sensitization (95% CI, 1.1 - 2.8) compared to the non-IgE sensitized cases. No similar associations were found for the other classes of VOCs. Conclusion: We propose a novel hypothesis that PGEs in indoor air exacerbate and/or induce the multiple allergic symptoms, asthma, rhinitis and eczema, as well as IgE sensitization respectively. © 2010 Choi et al.


Aiarzaguena J.M.,Primary Care Research Unit | Gaminde I.,Innovation and Continuous Education Unit | Clemente I.,City College of New York | Garrido E.,Onati Health Care Center
Patient Education and Counseling | Year: 2013

Objective: To examine (1) how physicians present an explanation of symptoms in terms of a hormonal imbalance as a means to initiate a psychosocial discussion with somatizing patients; and (2) how they respond to this explanation of symptoms. Methods: Qualitative study of 11 sequences in which physicians explain patients' symptoms in terms of a hormonal imbalance are micro-analyzed using Conversation Analysis. Results: Symptom explanations (SEs) were vague, tentative, and uncertain. Two patterns of SEs (general vs. specific) and five different patterns of patient response were found. Patient responses are classified according to whether they occur during or after the SE, and according to the degree of work patients carry out to verbalize a response. Conclusion: Symptom explanations elicited varying degrees of patient agreement, and allowed physicians to obtain patients' permission to conduct a psychosocial exploration. Practice implications: Physicians may start SEs by associating symptoms to a hormonal imbalance, and by relating them to universally recognizable emotions and familiar situations. Excessive emphasis on long and complex SEs and on seeking extended verbalizations of patient agreement may be counterproductive and antagonize the patient. © 2013 Elsevier Ireland Ltd.


Mutasingwa D.R.,University of Toronto | Ge H.,University of Toronto | Upshur R.E.G.,Primary Care Research Unit | Upshur R.E.G.,University of Toronto
Canadian Family Physician | Year: 2011

Objective: To examine the applicability of 10 common clinical practice guidelines (CPGs) to elderly patients with multiple comorbidities. Design: Content analysis of published Canadian CPGs for the following chronic diseases: diabetes, dyslipidemia, dementia, congestive heart failure, depression, osteoporosis, hypertension, gastroesophageal reflux disease, chronic obstructive pulmonary disease, and osteoarthritis. Main outcome measures: Presence or absence of 4 key indicators of applicability of CPGs to elderly patients with multiple comorbidities. These indicators include any mention of older adults or people with comorbidities, time needed to treat to benefit in the context of life expectancy, and barriers to implementation of the CPG. Results: Out of the 10 CPGs reviewed, 7 mentioned treatment of the elderly, 8 mentioned people with comorbidities, 4 indicated the time needed to treat to benefit in the context of life expectancy, 5 discussed barriers to implementation, and 7 discussed the quality of evidence. Conclusion: This study shows that although most CPGs discuss the elderly population, only a handful of them adequately address issues related to elderly patients with comorbidities. In order to make CPGs more patient centred rather than disease driven, guideline developers should include information on elderly patients with comorbidities.


Starfield B.,Johns Hopkins University | Mangin D.,Primary Care Research Unit
Quality in Primary Care | Year: 2010

This discussion paper reflects on the pay-for-performance system in UK general practice - the Quality and Outcomes Framework (QOF) - from an international viewpoint. The QOF intends to bring the best scientific evidence to bear on primary care practice. However, the QOF and patientcentred medicine are often at odds. Inadequacies and commercial bias in the creation of evidence make the scientific basis of the QOF questionable. The framework for the QOF does not align well with the scope of primary care, making its basis as a tool for quality measurement questionable. The extent of impact of the QOF on health outcomes and on equity of health outcomes needs examination. Attention to resolution of patients' problems is an important aim of quality improvement activities. Alternative modes of improving patient care maybe better than the QOF. © 2010 Radcliffe Publishing.


Carlstedt F.,Primary Care Research Unit | Jonsson B.A.G.,Lund University | Bornehag C.-G.,Karlstad University
Indoor Air | Year: 2013

Polyvinyl chloride (PVC) flooring material contains phthalates, and it has been shown that such materials are important sources for phthalates in indoor dust. Phthalates are suspected endocrine-disrupting chemicals (EDCs). Consecutive infants between 2 and 6months old and their mothers were invited. A questionnaire about indoor environmental factors and family lifestyle was used. Urinary metabolites of the phthalates diethyl phthalate (DEP), dibutyl phthalate (DBP), butylbenzyl phthalate (BBzP), and dietylhexyl phthalate (DEHP) were measured in the urine of the children. Of 209 invited children, 110 (52%) participated. Urine samples were obtained from 83 of these. Urine levels of the BBzP metabolite monobenzyl phthalate (MBzP) was significantly higher in infants with PVC flooring in their bedrooms (P<0.007) and related to the body area of the infant. Levels of the DEHP metabolites MEHHP (P<0.01) and MEOHP (P<0.04) were higher in the 2-month-old infants who were not exclusively breast-fed when compared with breast-fed children. The findings indicate that the use of soft PVC as flooring material may increase the human uptake of phthalates in infants. Urinary levels of phthalate metabolites during early life are associated with the use of PVC flooring in the bedroom, body area, and the use of infant formula. Practical Implications: This study shows that the uptake of phthalates is not only related to oral uptake from, for example, food but also to environmental factors such as building materials. This new information should be considered when designing indoor environment, especially for children. © 2012 John Wiley & Sons A/S.


Recio-Rodriguez J.I.,Primary Care Research Unit | Gomez-Marcos M.A.,Primary Care Research Unit | Patino-Alonso M.C.,University of Salamanca | Agudo-Conde C.,Primary Care Research Unit | And 2 more authors.
BMC Cardiovascular Disorders | Year: 2012

Background: Our aim was to analyze the relationship between abdominal obesity and general obesity, with subclinical atherosclerosis, arterial stiffness and wave reflection in healthy, diabetics and hypertensive subjects.Methods: A cross-sectional descriptive study was made of 305 individuals (diabetics 32.8%, hypertensive subjects 37.0% and healthy individuals 30.2%). Measurements: Body mass index (BMI), waist circumference (WC), body fat percentage (BFP) and waist/height ratio (WHtR). Arterial stiffness was assessed according to pulse wave velocity (PWV), intima-media thickness of the common carotid artery (C-IMT), augmentation index (central and peripheral), ankle-brachial index (ABI), and central and peripheral pulse pressure.Results: WC and WHtR showed a positive correlation to PWV and C-IMT in the studied groups. After adjusting for age, gender, high sensitivity c-reactive protein, serum glucose and the presence of diabetes, hypertension, smoking, dyslipidemia, antidiabetic drugs, lipid-lowering drugs, and atherosclerotic plaques, it was seen that for every 0.1 point increase in WHtR, and for every cm increase in WC, the PWV increased 0.041 and 0.029 m/sec, and C-IMT increased 0.001 mm and 0.001 mm, respectively.Conclusions: The measures of abdominal obesity (WHtR and WC) correlates better than BMI and BFP with arterial stiffness evaluated by PWV, and with subclinical atherosclerosis evaluated by C-IMT, independently of the presence of diabetes or hypertension.Trial Registration: Clinical Trials.gov Identifier: NCT01325064. © 2012 Recio-Rodriguez et al; licensee BioMed Central Ltd.


Wang L.,Primary Care Research Unit
Primary health care research & development | Year: 2013

Osteoporosis is a highly prevalent and costly disease associated with aging. Previous studies have indicated low intervention rates in primary care; however, there is little research investigating the prescribing patterns of osteoporosis medications by primary-care physicians. We conducted a population-based retrospective cohort study to examine trends in osteoporosis medication utilization in primary care between 1 January 2000 and 31 December 2009 in Ontario, Canada. All Ontario residents aged 65 years or older and eligible for public health coverage were included in the analysis (∼1.46 million residents in 2000, ∼1.75 million residents in 2009). Analysis of 10-year data indicates a trend toward higher utilization of osteoporosis medications among elderly primary-care patients. In 2000, 100 038 unique patients were prescribed an osteoporosis medication by a family physician; by 2009, this number increased to 301 679. Age-group analyses suggest an inverted U-shaped pattern, whereby utilization rates increase with advancing age and then decline for the oldest age groups. Utilization rates were the lowest for the 100+ age group. This study indicates increased utilization of osteoporosis-related medications among elderly primary-care patients over a recent 10-year time period. It is unclear whether the observed increase in utilization is due to higher rates of osteoporosis. Further research is needed to determine the appropriateness of this higher utilization.

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