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PubMed2006

Molecular diagnosis of Theileria and Babesia species infecting cattle in Northern Spain using reverse line blot macroarrays.

BACKGROUND: Piroplasmosis in cattle is caused by tick-borne haemoprotozoan parasites of the genera Theileria and Babesia. Molecular detection techniques offer higher sensitivity and specificity than microscopy examination methods and serological tests. A reverse line blot (RLB) macroarray that included generic and species-specific probes for Theileria annulata, Theileria buffeli, Babesia bovis, Babesia bigemina, Babesia divergens and Babesia major was used to study the presence and identity of the piroplasm species infecting 263 bovine blood samples from 79 farms, most of them in Northern Spain. Microscopy examination of blood smears and haematology were also performed whenever possible to identify animals with parasitaemia. RESULTS: RLB hybridisation identified infection in 54.0% of the samples, whereas only 28.8% were positive by microscopy examination. The most frequently found species was T. buffeli, present in 42.6% of the samples. T. annulata was found in 22 samples (8.4%) from 12 farms, including 9 farms (14 samples) located in Northern Spain where presence of the vector is not very common. Babesia infections were less frequently detected: B. major was found in 3.0% of the samples, B. bigemina in 2.7%, B. bovis in 2.3% and B. divergens in 1.1%. Mixed infections were detected in 14 samples, accounting for six different combinations of species. CONCLUSION: This is the first report in which B. major and B. divergens have been detected in Spain using molecular identification techniques and the first time that B. bovis has been detected in Northern Spain. The detection of T. annulata in Northern Spain suggests that the distribution of Mediterranean theileriosis might be changing. Samples with positive RLB hybridisation but negative microscopy had haematology values within the normal ranges suggesting that they corresponded to chronic carriers that may serve as reservoirs of the infection. In this sense, sensitive and specific laboratorial tests like RLB that clearly identify the parasite and can detect subclinical infections are essential to establish good control measures.

Animals↗
PubMed1996

Analysis of compliance with oral contraception in Spain.

OBJECTIVE: The study was designed to analyze factors related to compliance in oral hormonal contraception in Spain. METHOD: A review study and a multicenter analysis of experience of compliance by 300 doctors, by means of a questionnaire and discussion about the determinants of contraceptive use. RESULTS: Compliance is a major problem in Spain, being influenced mainly by side-effects, the general perception of the method and personal factors. The different factors involved in non-compliance in Spain were analyzed, with regard to the perspective of the professionals. CONCLUSIONS: Strategies to improve compliance in Spain aim mainly at improving the general perception of the method and the accessibility of family planning centers. Factors associated with compliance are still not well known in our country. Better knowledge of the determinants of non-compliance in Spain is needed. For this purpose, another research group was formed to conduct a national study among women.

Contraception Behavior↗
PubMedDate not supplied

[State of cancer in Spain: incidence].

It is estimated that at present in Spain around 162,000 cases of cancer are diagnosed each year (without including non-melanoma skin cancer), of which 25,600 correspond to colorectal carcinomas, which is the most frequent of all tumours in absolute terms. The next tumour in terms of frequency is lung cancer with 18,800 new cases, followed by breast cancer in women with 15,979 cases. When the incidence of cancer is compared with that in neighbouring countries, Spain shows adjusted rates in men higher than those of the average for the EU, occupying the 5th place. However, in women, Spain shows the lowest rates together with Greece. Spain occupies the first place for cancer of the bladder in men, with rates that are considerably higher than those of the rest of the countries. It is important to verify the increase underway in the incidence of cancer in Spain and the contrast that this represents facing the evolution of mortality. For many important tumoral localisations (lung, stomach, bladder), the population registers do not cover the provinces where there is a greater mortality.

Europe↗
PubMedDate not supplied

[Epidemiology of multiple sclerosis in Spain. Prevalence and incidence data].

INTRODUCTION: Traditionally, Spain has been considered to be an area with a low prevalence of multiple sclerosis. However, the most recent studies show much higher figures than those previously described. OBJECTIVE: We aim to summarize the current data on prevalence and incidence of the disorder in Spain so as to determine the true situation regarding multiple sclerosis in this country. DEVELOPMENT: We have evaluated all the epidemiological data published on the descriptive epidemiology of multiple sclerosis in Spain, and analyzed the differences in method which might explain the disparity between the figures quoted. We also studied the data on incidence available, mainly in the Alcoi health district, where we carried out the most prolonged incidence study in Spain. CONCLUSIONS: The figures for prevalence given by the most recent studies include Spain in the area of moderate risk. The analysis of prevalence figures seem to indicate that these have varied with time and, at least in some zones, the incidence has increased in recent years.

Humans↗
PubMed2003

[Current status of the diagnosis and treatment of urinary incontinence in Spain].

OBJECTIVES: To perform a review of the available literature about urinary incontinence (UI) epidemiology, diagnosis, treatment and results, mainly focusing on the stress UI, to expose the features about which may there be a consensus, and those that will need future research work. METHODS: Systematic review of the available spanish bibliography about the proposed topic. RESULTS: They prevalence of female UI in Spain varies between 20 and 50%, depending on age. There are no available data about incidence. The onset age of this disease has not been directly studied in any of the works reviewed, although from them it can be deduced that it is around 55 years. The patient with UI tends to hide the problem, and generally, doctors tend to not recognize it as a treatable pathology, so that supposedly there is a high prevalence off occult UI. UI is frequently related to many other pathologies. The diagnosis of UI in Spain is generally made following the international criteria collected in the available clinical practice guidelines, which describe the diagnostic process to be followed in detail. Diagnostic tests generally used in the diagnosis of UI have a sensitivity higher than 70% and a specificity around 65%. First choice treatment is conservative, including the use of physiotherapy by means of pelvic muscle exercises. It is considered that pharmacological treatment has not much effect, although it doesn't seem to have been investigated in depth in Spain. Surgery, in any of its various techniques, is the second choice treatment. Although studies on health results for UI are scarce, it is known that about one-quarter of all patients declare that their quality of life is affected. Economic studies about UI are very rare also and only offer results about some treatment items. CONCLUSIONS: To better precise the incidence and prevalence of UI in Spain, the performance of population epidemiological studies seems necessary. The weakness of the diagnostic process of UI in Spain appears to be detection in the initial stages. It is also necessary to have studies evaluating conservative and pharmacological therapies currently performed; these studies would allow to establish comparisons with the surgical treatments usually performed. It is also necessary to have studies that include cost calculation for integrated costs for UI.

Humans↗
PubMed2004

[Neurological investigation in Spain. Present and future].

OBJECTIVES: To analyze the situation of neurological research in relationship to the biomedical and neuroscience research in Spain. To discuss alternatives of neurology research for the future. METHODS: Author review. Review of neurology research bibliography by means of three quantitative bibliometric indexes of neurological publications in Medline (research in neurology, neurology evidence-based medicine publications, and clinical trials); and review of the database of grants funded by the FIS (Health Research Fund) in 1989 and in the 1994-2000 period. RESULTS: Spain is in a middle position in country biomedical publication ranking in Europe, although the Spanish expenditure from GNP granted to research is lower than the mean situation among EU countries. Investigation in neurosciences stands out in biomedical research in Spain, however the bibliometric indexes analyzed and the study performed of the database of the FIS are not favorable for Spanish Neurology. This study shows that, for the 1994-2000 period, the neurologists only performed 32.1% of the projects funded in clinical research, 6% in neurosciences; 66.7% in epidemiology; and 4.3% in management-public health. DISCUSSION AND CONCLUSIONS: The expenditure for biomedical research should be increased in Spain. Furthermore, clinical research and neurological clinical management research should be intensified. One of the better strategies to achieve this objective is to obtain medical part-time schedules for patient oriented research in hospitals. To solve this situation and to set up communication networks among basic neuro-scientific, clinicians and epidemiologists is one of the major challenges of the current neurological research in Spain.

Forecasting↗
PubMedDate not supplied

Risk factors for cervical intraepithelial neoplasia grade III/carcinoma in situ in Spain and Colombia.

A case-control study of 525 histologically confirmed cases of cervical intraepithelial neoplasia grade III and 512 controls was done in Spain and Colombia to assess the role of various risk factors taking into account the effect of human papillomavirus (HPV). The presence of HPV DNA, assessed by a polymerase chain reaction-based method, was the strongest risk factor identified. In Spain the adjusted odds ratio (OR) and 95% confidence interval (CI) (numbers in parentheses) were 56.9 (24.8-130.6) and, in Colombia, were 15.5 (8.2-29.4). In addition to HPV, the multivariate analysis revealed independent effects of early age at first intercourse (in Spain ORa, 4.3; 95% CI, 2.0-9.3 for ages < 17 versus 20+ years and in Colombia ORa, 9.0; 95% CI, 2.6-30.9 for ages < 14 versus 20+ years), and antibodies to Chlamydia trachomatis (in Spain ORa, 2.3; 95% CI, 1.1-4.5; and in Colombia ORa, 1.7; 95% CI, 1.1-2.7). High parity showed a significant effect only in Colombia (ORa, 2.0; 95% CI, 1.0-5.0 for > or = 6 versus 1) while number of partners of the woman and specially of her husband showed a strong effect in Spain only (ORa, 6.9; 95% CI, 3.1-15.3 for partners of the husband > or = 21 versus 1-5). Smoking and use of oral contraceptives did not show significant or consistent associations. Among HPV-DNA positive women early age at first intercourse and high parity increased the risk of cervical intraepithelial neoplasia III but the effect was statistically significant only for the former.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

[Drug consumption in diabetes mellitus (III). Trends of hypoglycemic agents use and consumption in Tarragona, Catalonia, and Spain (1988- 1991). Group for the Study of Diabetes in Tarragona].

BACKGROUND: To analyze the evolution of the use of drugs in diabetes, the consumption of hypoglycemic medication in the province of Tarragona, the autonomic community of Catalonia and Spain as a whole, was studied. A qualitative evaluation of the tendencies of prescription, as an indirect index of quality in the health care to diabetics was performed. METHODS: The sales of oral hypoglycemic medication (OH) and insulin (INS) were accounted for in the study environment between 1988-1991. To make consumption uniform a standardized unit of measure was used with defined daily doses (DDD)/1,000 inhabitants/day (Drug Utilization Research Group) of the different groups of drugs. Total consumption was obtained by a primary data source (Intercontinental Medical Statistics), and periodically compared with a secondary source (registry of public prescriptions within Tarragona). RESULTS: A progressive increase in the consumption of hypoglycemic drugs was observed: 16.1 to 21.2 DDD/1,000 inhabitants/day (31%) in Spain; 17.7 to 19.8 (12%) in Catalonia and 19 to 23 (21%) in Tarragona. The increase in consumption of INS in Tarragona (43%) was greater than that of OH (12%). In Catalonia, it was much greater (INS: 23%, OH: 7%) and was parallel in Spain (36% and 30%, respectively). The OH/INS index decreased in Catalonia and Tarragona (1.3 and 1.9 in 1991) and remained practically constant (2.3-2.4) in Spain. A global decrease was produced in the consumption of slow insulins with a significant increase in intermediate, premixed and fast insulins. A growing increase in glibenclamide much greater than the remaining sulphonylureas was seen, in addition there was a persistent and low use (less than 1 DDD/100 inhabitants/day) of biguanides. Significative variations of medication consumption were registered according to the territory analyzed. CONCLUSIONS: From 1988 to 1991 there has been an increase in the use of hypoglycemic drugs. The use of oral hypoglycemics has remained constant in relation to insulins in Spain and in Catalonia and, more so in Tarragona, there is a progressive inclination to the use of insulin. The evolution of consumption suggests important asymmetry in the quality of health care and denotes progression in the global educative offer to diabetics.

Diabetes Mellitus↗
PubMed1996

Lung cancer mortality among males of Catalonia and Spain compared with other European countries between 1975-1977 and 1987-1989.

This study compares the lung cancer mortality rates among males in the years 1975-1977 and 1987-1989 in Catalonia and Spain with other European countries selected for their geographical proximity. Adjusted calculations using the direct method have been made for male lung cancer mortality. Adjusted truncated rates for the age groups 0-44, 45-64 and more than 65 years were also calculated, as well as percent differences between the mortality rates of each period studied. Lung cancer mortality rates for males in Catalonia and Spain show relative increments of 46.58% and 52.41%, respectively. In contrast, lung cancer mortality in countries such as England-Wales and Switzerland have decreased. Moreover, the 0-44 year age group in Catalonia and Spain shows the absolute highest rates in the 1987-1989 period among all the countries analyzed. The marked contrast of the lung cancer mortality rate evolution in Catalonia and Spain compared with some other European countries and the considerable increase of the mortality in younger age groups indicate the need to intensify lung cancer control measures.

Adolescent↗
PubMed2005

Molecular epidemiology of hepatitis B virus in Spain: identification of viral genotypes and prediction of antigenic subtypes by limited sequencing.

The hepatitis B virus (HBV) genotypes were studied by a line probe assay (LiPA) and by direct sequencing of a 339 nucleotide fragment from the S region of the viral genome in samples from 269 carriers living in Spain, either native to Spain (231) or immigrants from Africa, Asia, and Eastern Europe (38). The sequences were also used to predict the HBV surface antigen (HBsAg) subtype on the basis of the amino acids specified at selected positions of the HBsAg molecule. Agreement between the two genotyping methods was found in most cases (98.1%) and a HBV genotype could be assigned to all samples. The viral groups D/ayw2 (30.1%), D/ayw3 (28.6%), and A/adw2 (21.2%) were prevalent, with an additional participation of the groups D/ayw4 (4.8%), F/adw4q- (1.9%), A/ayw1 (1.9%), and D/adw3 (0.7%), all of them present among the autochthonous carriers. Strains from genotypes B and C were found exclusively among Chinese immigrants. Genotype E strains were found in immigrants from Central Africa and in one patient native of Spain. Point mutations leading to amino acid changes of residues involved in the expression of the HBsAg subtype determinants were found in 12 samples (4.5%). Some mutations would predict the putative novel genotype-subtype associations A/adw4q+, A/ayr, D/ayr, and E/ayw1, while others would suggest the loss of subtype-specific determinants. The finding of HBV strains characteristic for Africa among the autochthonous carriers confirms the emergence of African HBV strains in Spain.

Adolescent↗
PubMed1989

Paediatric drug prescribing. A comparison of Tenerife (Canary Islands, Spain) and Sweden.

The prescribing of medicines for ambulant children below 14 years of age has been compared between Tenerife (Spain) and Sweden. Data obtained from a random sample of 1327 children in a prospective study in Tenerife were compared with data from 3901 children in a Swedish survey linking diagnosis and therapy. Upper respiratory tract infection was the main diagnosis in both countries and antibiotics was the most frequently prescribed drug group (28.2% in Tenerife and 28.8% in Sweden). Half of the children in Sweden did not receive any medication, but only 10% of those in Tenerife did not receive a prescription. Children who received a prescription on average got 1.4 drugs in Sweden and 2.3 in Spain. Amongst the ten most commonly prescribed products in Sweden there were 11 active pharmacological principles as compared to 25 in Spain. These most frequently used preparations accounted for two thirds of all the prescriptions for children in Sweden and one third in Tenerife. In conclusion, drugs were significantly more often used to treat paediatric outpatients in Tenerife than in Sweden. The prescribing physician in Spain also chose a wider variety of drugs and more commonly used fixed combination products.

Atlantic Islands↗
PubMed1989

Epidemiological appraisal of the active role of women in the decline of infant mortality in Spain during the twentieth century.

This paper is concerned with the question of the role which the psycho-cultural development experienced by women in developed countries throughout this century may have played in the decline of infant mortality, taking in Spain between 1900 and 1979 as a basis for observation. We think that, by studying the psycho-cultural development of women, included under the general concept of standard of living, we can take a step forward in explaining such a frequently investigated but nonetheless incompletely understood subject as is that of the marked decline of infant mortality which has taken place in this century in developed countries in general, and in Spain in particular. To this effect, we have attempted to demonstrate the need to consider socio-cultural factors, in addition to the already repeatedly studied economic and biomedical ones; the more so when we take into account the marked decline in infant mortality which occurred in Spain in the 1940s, in which period there was a pronounced stagnation in the economy. To this purpose, we have studied fertility, not only as a gauge of the biological risks which generate a certain reproductive pattern for infant mortality, but also as an indicator of the socio-cultural development of women. Similarly, and through a review of historical documents, we have analysed the role of women in birth control, their incorporation into more qualified jobs, their level of education, their growing awareness of their own situation in society, as well as pertinent legislative changes. All these processes affect the health of children through factors which, although they are very difficult to evaluate and quantify, have previously been described and examined in other studies. Our study has shown the probable relationship between the decline of fertility and the decrease of infant mortality, in view of the fact that there has been a pronounced decrease of parity and fertility in women belonging to the oldest fertile age groups. Similarly, the indications pointed out with respect to the processes mentioned above lead us to infer that in Spain the woman has played a significant role in the decline of infant mortality produced in this century, and especially in the first half of the century. We have embarked on a scantily developed line of investigation, and suggest the need for new studies on the subject.

Adult↗
PubMed2006

Was there an urban height penalty in Spain, 1840-1913?

We explore whether there was an urban height penalty in Spain during the period of early industrialization from 1840 to 1913, using data from Spain's Southeastern coast and from Castile-Leon. Our results indicate that in the Mediterranean Coast of Southeastern Spain urban heights were well above rural ones for most of the period considered. In Castile-Leon, however, urban and rural heights were about the same until 1870 but urban heights were intermittently above rural ones thereafter. Hence, in Spain urban heights were not always below rural ones in stark contrast to the pattern obtained in other parts of Europe and North America.

Agriculture↗
PubMed2006

Geographic differences in the incidence of cytogenetic abnormalities of acute myelogenous leukemia (AML) in Spain.

The incidence of chromosomal abnormalities in acute myeloid leukemia (AML) differs according to geographical regions in Spain. We analyse 1,271 consecutive patients diagnosed of AML between 1995 and 2002 in three different regions of Spain: northern, central and southern. There were 624 males (55%) and 505 females (45%). Age ranged between 1 month and 94 years with a median of 61 years. Abnormal karyotypes were observed in 64% of cases. Numerical abnormalities as sole cytogenetic changes were detected in 15% of patients, while structural aberrations were present in 28% of cases, and both abnormalities were found in 22% of patients. A significantly higher proportion of t(15;17) was observed in the south of Spain (21.6%) than in the central (17%) or northern regions (12.6%) (p=0.03). By contrast, patients from the south of Spain showed lower incidence of t(8;21) (0%, compared to 1.6% and 3.6% in central and northern areas, respectively, p=0.04). These differences were maintained in the age-adjusted analysis. Trisomy 8 showed similar incidence in southern and central areas, while the incidence in the northern area was lower (14% and 10%, respectively, p=0.04). Other chromosomal abnormalities, such as inv(16) or 11q23 rearrangements, were found at similar frequencies in the three regions.

Adolescent↗
PubMed2004

Consistently high plasma high-density lipoprotein-cholesterol levels in children in Spain, a country with low cardiovascular mortality.

Coronary heart disease (CHD) mortality is relatively low in Spain compared with other developed countries and has remained low despite an apparent increase in mean plasma cholesterol concentration in adults over the last several years. It is accepted that pathologic processes related to arteriosclerosis development begin in childhood and seem to be related to the presence of cardiovascular risk factors at this age. High-density lipoprotein-cholesterol (HDL-C) levels in children have been inversely correlated with the incidence of coronary heart disease in the different countries studied. Childhood plasma lipoprotein profile might contribute to the low coronary heart disease mortality in Spain. Thus, we analyzed data on lipid levels over time in schoolchildren in Spain in the last decade. Plasma lipid levels were analyzed in prepuberal children (6 to 8 years) in 3 school-based surveys performed by our group in Madrid in 1987, 1993, and 1999. A significant increase in plasma total cholesterol (P < .05) and low-density lipoprotein-cholesterol (LDL-C) (P < .01) levels in prepuberal children was observed over the last decade. However, the mean concentration of plasma HDL-C remained stable and very high. These high levels of plasma HDL-C in Spanish school children may help to explain why the coronary heart disease mortality rate in Spain is low compared with that in other developed countries.

Apolipoproteins↗
PubMed2006

Human herpesvirus-8 infection and Kaposi's sarcoma after liver and kidney transplantation in different geographical areas of Spain.

Since data on human herpesvirus 8 (HHV-8) infection in Spain is not available, our purpose was to determine the prevalence of HHV-8 infection and the risk of developing Kaposi's sarcoma (KS) among organ transplant recipients in different geographical areas of Spain. The study population consisted of 1019 liver and kidney transplant recipients recruited in four transplant units in Spain. Only post-transplant serum samples were available for all participants. IgG anti-HHV-8 latent and lytic antigens were detected by using an indirect immunofluorescence assay as well as enzyme-linked immunosorbant assays. In available samples, HHV-8 DNA genome was detected by using a nested polymerase chain reaction in sera, blood mononuclear cells and KS tissues. The prevalence of HHV-8 infection after transplantation was calculated. To determine risk factors for infection, odds ratios (OR) and 95% confidence intervals (CI) were also calculated. Of the 788 kidney transplants, 5 (0.6%) were HHV-8-positive shortly after transplantation. Of the 231 liver transplant individuals, 8 (3.4%) developed IgG anti-HHV-8 antibodies after transplantation. Thus, incidence of HHV-8 infection is significantly higher among liver transplant recipients in comparison with that in the control population (OR=6, 95% CI=1.2-28.5, p<0.05). In this series, HHV-8 prevalence in liver transplant recipients was higher in the northern (6.6-6.9%) than in the central (2.9%) or the southeastern (1.4%) areas of Spain. Four renal transplant recipients (0.5%) and five of the liver transplant recipients (2.16%) developed KS after transplantation. Time of KS diagnosis after transplant is significantly higher in kidney transplant patients (33.7 months) than in liver transplant recipients (10.4 months), indicating that the latter have a higher risk of developing KS.

Adolescent↗
PubMed2006

New advances in molecular epizootiology of canine hematic protozoa from Venezuela, Thailand and Spain.

The prevalence of hematozoan infections (Hepatozoon canis and Babesia sp., particularly Babesia canis vogeli) in canids from Venezuela, Thailand and Spain was studied by amplification and sequencing of the 18S rRNA gene. H. canis infections caused simultaneously by two different isolates were confirmed by RFLP analysis in samples from all the geographic regions studied. In Venezuela, blood samples from 134 dogs were surveyed. Babesia infections were found in 2.24% of the dogs. Comparison of sequences of the 18S rRNA gene indicated that protozoan isolates were genetically identical to B. canis vogeli from Japan and Brazil. H. canis infected 44.77 per cent of the dogs. A representative sample of Venezuelan H. canis isolates (21.6% of PCR-positives) was sequenced. Many of them showed 18S rRNA gene sequences identical to H. canis Spain 2, albeit two less frequent genotypes were found in the sample studied. In Thailand, 20 dogs were analyzed. No infections caused by Babesia were diagnosed, whereas 30 per cent of the dogs were positive to hematozoan infection. Two protozoa isolates showing 99.7-100% identity to H. canis Spain 2 were found. In Spain, 250 dogs were studied. B. canis vogeli infected 0.01% of the animals. The sequence of the 18S rRNA gene in Spanish isolates of this protozoa was closely related to those previously deposited in GenBank (> 99% identity). Finally, 20 red foxes were screened for hematozoans employing semi-nested PCR and primers designed to detect Babesia/Theileria. Fifty percent of the foxes were positive to Theileria annae. In addition, it was found that the PCR assay was able as well to detect Hepatozoon infections. Thirty five percent of the foxes were infected with two different H. canis isolates showing 99.8-100% identity to Curupira 1 from Brazil.

Animals↗
PubMed2003

[Evaluation of scientific productivity at otorhinolaryngologic services in Spain in 1998-2002].

OBJECTIVES: To count the scientific contributions that were carried out at the Otorhinolarngology Departments in Spain from 1998 to 2002 years and to measure their scientific relevance using different bibliometrics tools. METHOD: Abstracts of articles located on MedLine (http://www.ncbi.nih.gov/PubMed) that have been published by Otorhinolaryngology departments in Spain, by a specific designed search strategy. Papers were classified by journal type (national/international) and study design (original or clinical case). A rank of productivity per hospital was design according to the following variables: total number of articles, total number of originals and cummulative impact factor (according to the category assigned by the Journal of Citation Reports, 2000 from the Institute for Scientific Information). RESULTS: A total of 18,472 papers were located, being 703 papers from 116 Otorhinolaryngology departments in Spain. This represents a 4% of the world's scientific production. There were 196 international and 498 papers in Spanish journals; in addition, 439 were original articles and 265 clinical cases. The centers in Spain with the most relevant scientific productivity are: Hospital Central de Asturias, Hospital Virgen del Rocío de Sevilla, Hospital La Paz de Madrid, Hospital Santa Creu i San Pau de Barcelona, Clínica Universitaria de Navarra and Clínica Puerta de Hierro de Madrid (all of them with a cummulated impact factor in 5 years > 10).

Bibliometrics↗