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La ciudad de los Dioses/ The City of the Gods (Leer en Espanol: Level 2) (Spanish Edition)

HRQL levels varied significantly between the different dimensions making up the CD-QOL scale, with dysphoria being the dimension that obtained the highest mean score of This was followed by limitations caused by the illness, which had an average rating of The distribution of each dimension is represented in figure 1. With regard to individual items, numbers 6, 8, and 9 the latter two relating to the perception of having received inadequate treatment obtained the lowest mean scores, as shown in table III.

Patient age and sex, along with time to diagnosis and the length of time following a gluten-free diet, were found to be the independent factors that determined the HRQL of adult patients with CD, as assessed with both univariate and multivariate analyses. Women rated the dimension health problems lower than men For the remaining dimensions, no gender differences were observed.

Age was associated with a lower score in the health problems dimension, which was rated significantly lower by patients between 31 and 40 years of age, as determined through univariate analysis Table II. The multivariate analysis revealed an association between an advanced patient age and a lower rating for this dimension Table IV. The amount of time it took until an accurate diagnosis of CD was made significantly affected the ratings of all dimensions of the CD-QOL index Table II ; however, the multivariate analysis only showed a significant association for the inadequate treatment dimension, in the sense that the greater the amount of time to diagnosis, the worse the subjects rated this dimension Table IV.

This significant association was maintained after the multivariate analysis, both for the overall index as well as in three of the four dimensions Table IV. A longer period on a gluten-free diet was associated with a higher overall rating on the CD-QOL scale and in the dysphoria and limitations dimensions. The inadequate treatment dimension showed a significant inverse relation. This study evaluates the HRQL of a representative sample of Spanish adults with CD, both globally and among its various dimensions, in order to determine the factors that are determinant or associated with it.


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What differentiates this study from previous research is that it is the first study conducted using a CD-QOL questionnaire 14 that had been linguistically and culturally adapted and validated for use in a Spanish context, specifically for adults with CD. The main result of this study is that our series of adult Spanish celiac subjects, representative of the general celiac population, expressed a mean HRQL of Thus, the quality of life levels reported by patients recruited in Spanish hospitals ranged from 80 points for patients who strictly followed a gluten-free diet to 70 points for patients who did not follow a gluten-free diet either unknowingly or intentionally 22 , while newly diagnosed cases and patients who had followed a gluten-free diet for longer than a year showed overall mean HRQL ratings of points Studies based on the same instrument but used in other sociocultural contexts are rare, mostly because the original CD-QOL questionnaire was only validated in One study conducted on celiac patients in an area of New York USA which used the CD-QOL questionnaire found quality of life levels higher than those documented in our study 27 , but other studies based on more generic instruments e.

Our results suggest that the HRQL found in the general population of adult celiac subjects may be lower than that observed in patients recruited in a hospital setting, giving rise to the hypothesis that periodic medical check-ups improve the quality in life for these patients by encouraging a stricter compliance with a gluten-free diet.


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In fact, the correct maintenance of a gluten-free diet has repeatedly been shown to be an independent factor associated with a better quality of life among celiac patients, both in children 31 and adults 19,20,22,32, Our study did not examine the adherence to medical follow-up among the study subjects; therefore, further studies must be made to provide solid data to support this hypothesis.

In our study, patient gender was shown to be an independent factor associated with the perception of HRQL in CD, one that has a significant effect on both the health problems and inadequate treatment dimensions of the CD-QOL questionnaire, with women giving an average rating 6. One speculative explanation for this may be the greater difficulty perceived by the Spanish men in our series in finding substitutions or alternatives for foods when following a gluten-free diet in comparison to women, or the greater value placed on the act of eating on the part of men.

In the Spanish context, women generally bear greater responsibility for buying and preparing food, perhaps conditioning a greater dependence on the part of men in this respect. We feel that the ratio of men to women in our series does not affect this result, as it was controlled for by univariate and multivariate analyses. At any rate, it should be noted that the disproportionate numbers of men and women in our sample do not in any way reflect the distribution of men and women in the adult celiac population in Spain, but rather a different rate of response to a voluntary questionnaire among the sexes.

In fact, all the epidemiological studies carried out to date have repeatedly documented the overall predominance of CD among women, with a female:male ratio varying from 2. In cases of adult onset CD, the frequency among women may be even greater; prior studies of CD in Spain with somewhat different data have estimated the proportional frequency to be between and 35,36 and up to among adult patients newly diagnosed with CD The lowest scores on the CD-QOL questionnaire were for items directly related to diet, namely items 6, 8, and 9.

The first of these, item 6 "It affects me that I'm limited as to what I can eat with my friends" , refers directly to the negative social repercussions arising from a gluten-free diet whereas the other two items with low scores denote concepts which appear to contradict each other, namely item 8 "I feel that dietary treatment is sufficient for my illness" and item 9 "I feel like there are not enough treatment options available". While dietary treatment is considered to be a sufficient therapeutic intervention for curing CD, patients simultaneously recognize that it is difficult to comply with a strict, gluten-free diet and they would like to have more treatment options, perhaps including a broader variety of dietetic options directed at greater standardization towards a non-restricted diet.

The celiac patients in our series also expressed anxiety about the possibility of developing cancer item 4: "I am worried about having a higher risk of cancer due to my illness" , with an average score of 3 out of 5 points, in direct contrast with the fact that CD is not specifically associated with a higher risk of cancer Indeed, the type of tumor for which CD patients present an increased risk, intestinal lymphoma 39 , is not only quite rare, but also becomes less likely in patients following a gluten-free diet to the point that they present no higher risk for this type of cancer than the general population.

In contrast, CD actually represents a protective factor against several other types of neoplasms, such as breast and endometrial tumors The perceived risk of certain comorbidities commonly associated with CD, such as osteoporosis and its clinical manifestation as bone fractures 40,41 , was not observed in our sample.

Of the four dimensions that make up the CD-QOL, dysphoria received the highest scores in our series of CD patients, followed by health problems. Inadequate treatment was the dimension which received the lowest mean score. This is in agreement with previous studies conducted with Spanish celiac subjects 14, One new finding from our study is that HRQL expressed as the overall CD-QOL index as well as in two of its dimensions, dysphoria and limitations increased in accordance with the length of time that patients followed a gluten-free diet. Only the dimension inadequate treatment showed an inverse relationship between duration of treatment and HRQL.

This result is in agreement with that found in a previous Spanish study conducted by Casellas, et al. The strength of our study comes from its ample sample size 1, subjects , the representative nature of the sample with regard to celiac population in Spain as a whole, and the controlling for possible confounders by means of multivariate analysis. Together, these aspects make our study an accurate assessment of HRQL of adult celiac patients in Spain. However, our study has several limitations due to the absence of a non-randomized sampling protocol.

The way in which we collected the data, due to the study design and the process of working through celiac patient associations, hindered us from knowing the exact response rates and profiles of the patients, who may have received the questionnaire and chosen not to respond. The high proportion of females who responded to the survey also may affect the representativeness of our research. The attitudes of patients who responded voluntarily to treatment may be more favorable than those of patients who did not respond; thus, participation in this study could reflect either a greater involvement on the part of the patient in controlling his or her illness most likely with a stricter compliance with a gluten-free diet , or, in contrast, the involvement of the most affected patients.

In conclusion, our study explores for the first time the levels of HRQL in a broad sample of Spanish adults with celiac disease, recruited from the general population throughout Spain and thus potentially representative of the general celiac population on a national level. Overall, the perceived HRQL levels were within an average range, influenced by patient sex and age along with the time to diagnosis and the duration of treatment with a gluten-free diet.

It is important to note that HRQL increased significantly as the longer the patients followed a gluten-free diet.

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Future research should focus on additional determinant factors for the lower overall HRQL of celiac patients recruited from the general population with regard to their counterparts recruited in a hospital setting. This study would not have been possible without the collaboration of the associations and groups of celiac patients throughout Spain, through which we were able to reach the greatest number of CD patients.

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Dig Dis Sci ; Black JL, Orfila C.

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Impact of coeliac disease on dietary habits and quality of life. J Hum Nutr Diet ; Santolaria S, Montoro M.

Enfermedad celiaca, dieta sin gluten y calidad de vida relacionada con la salud. Rev Esp Enferm Dig ; Fatigue as a determinant of health in patients with celiac disease. J Clin Gastroenterol ; Quality of life in screen-detected and typical coeliac disease and the effect of excluding dietary gluten. Eur J Gastroenterol Hepatol ; Benefit on health-related quality of life of adherence to gluten-free diet in adult patients with celiac disease. Health-related quality of life and other patient-reported outcomes in the European centralized drug regulatory process: A review of guidance documents and performed authorizations of medicinal products to Patient-reported outcomes as primary end points in clinical trials of inflammatory bowel disease.

Clin Gastroenterol Hepatol ; Silvester JA, Rashid M. Long-term follow-up of individuals with celiac disease: an evaluation of current practice guidelines. Can J Gastroenterol ; Available from: www. Coeliac disease: the association between quality of life and social support network participation. J Hum Nutr Diet The Spanish version of EuroQol: a description and its applications.

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European Quality of Life scale. Med Clin Barc ; Supl It has been restored several times, the most recent one giving it its current appearance. The southern doorway and the main altarpiece are in Renaissance style.

ISBN 13: 9788497130608

Notable items in the sacristy include several paintings, a paxboard by Becerril and an excellent Baroque chest of drawers. The new tower, completed in the 19th century, comprises four sections crafted in stone. X Switch to mobile version.