A trial-based cost-effectiveness analysis of antibiotic prescription strategies for non-complicated respiratory tract infections in children.

BACKGROUND: Antibiotic prescription for respiratory tract infections (RTIs) in children attending primary care centres is almost double that predicted according to bacterial prevalence. Delayed antibiotic prescription (DAP) is designed to deploy a more rational use of antibiotics. While studies have evaluated DAP efficacy and safety for children with RTIs, little research has been conducted on the economic implications. METHODS: Our trial compared cost-effectiveness for DAP, immediate antibiotic prescription (IAP), and no antibiotic prescription (NAP) for children aged 2-14 years with acute uncomplicated RTIs attended to in 39 primary care centres in Spain. The main outcome was the incremental cost-effectiveness ratio (ICER), measured in euros per gained quality-adjusted life days (QALDs). Net monetary benefit (NMB) was also calculated as a tool for decision making. The analysis was performed from a societal perspective for a time horizon of 30 days, and included healthcare direct costs, non-healthcare direct and indirect costs, and the antimicrobial resistance (AMR) cost. RESULTS: DAP was the most cost-effective strategy, even when the cost of AMR was included. QALD values for the three strategies were very similar. IAP compared to DAP was more costly (109.68 vs 100.90 euros) and similarly effective (27.88 vs 27.94 QALDs). DAP compared to NAP was more costly (100.90 vs 97.48 euros) and more effective (27.94 vs. 27.82 QALDs). The ICER for DAP compared to NAP was 28.84 euros per QALD. The deterministic sensitivity analysis indicated that non-healthcare indirect costs had the greatest impact on the ICER. The cost-effectiveness acceptability curve showed that DAP was the preferred option in approximately 81.75% of Monte Carlo iterations, assuming a willingness-to-pay value of 82.2 euros per gained QALD. CONCLUSIONS: When clinicians are in doubt about whether an antibiotic is needed for children with RTIs attending PC centres, those treated with the DAP strategy will have slightly better efficiency outcomes than those treated with IAP because its costs are lower than those of IAP. DAP is also the most cost-effective strategy over a time horizon of 30 days if AMR is considered, despite higher short-term costs than NAP. However, if in the long term the costs of AMR are larger than estimated, NAP could also be an alternative strategy. TRIAL REGISTRATION: This trial has been registered at www. CLINICALTRIALS: gov (identifier NCT01800747; Date: 28/02/2013 (retrospectively registered).

Controlled trial of balance training using a video game console in community-dwelling older adults.

BACKGROUND: gamification is a potentially attractive option for improving balance and reducing falls. OBJECTIVES: to assess the effect of balance training using the NintendoTM Wii game console on balance (primary outcome), falls and fear of falling. DESIGN: quasi-randomised, open-label, controlled clinical trial in parallel groups, carried out on community-dwelling patients over 70 years, able to walk independently. Participants were assigned 1:1 to the intervention or control group. Balance training was conducted using the Nintendo WiiFitTM twice a week for 3 months. Balance was assessed using the Tinetti balance test (primary outcome), the unipedal stance and the Wii balance tests at baseline, 3 months and 1 year. Falls were recorded and Fear of falling was assessed by the Falls Efficacy Scale (Short-FES-I). RESULTS: 1,016 subjects were recruited (508 in both the intervention and the control group; of whom 274 and 356 respectively completed the 3-month assessment). There was no between-group difference in the Tinetti balance test score, with a baseline mean of 14.7 (SD 1.8) in both groups, and 15.2 (1.3) at 3 months in the intervention group compared to 15.3 (1.7) in controls; the between-group difference was 0.06 (95% CI 0.30-0.41). No differences were seen in any of the other balance tests, or in incident falls. There was a reduction in the fear of falling at 3 months, but no effect at 1 year. CONCLUSIONS: the study found no effect of balance training using the NintendoTM Wii on balance or falls in older community-dwelling patients.The study protocol is available at clinicaltrials.gov under the code NCT02570178.

[Adequacy of treatment for osteoporosis in primary prevention. Quantitative and qualitative study]. / Adecuación del tratamiento de la osteoporosis en prevención primaria. Estudio cuantitativo y cualitativo.

OBJECTIVE: Quantitative study: To assess the prevalence of inadequacy of treatment for osteoporosis in primary prevention (OPP) in women aged 60-74years. Qualitative study: To evaluate the diagnostic and treatment criteria of the OPP and it's variability in primary care physicians (PC) and specialists. MATERIAL AND METHODS: Quantitative study: observational, cross-sectional and retrospective study. POPULATION: women aged 60-74years with active treatment for OPP (n=424) in May 2012. Inadequacy if they had ≤2 risk factors with a DXA or DXA T-score ≥-2.4. Qualitative study: Delphi technique (15items) and two rounds of consultation. PERIOD: March-April 2014. POPULATION: PC physicians, rheumatologists and orthopaedic surgeons (n=251). Random sampling. RESULTS: Quantitative study: degree of inadequacy is 63.4%. In 43.2% isn't mention a diagnosis of osteoporosis. In 82.3% there isn't mention of risk factors. TREATMENT: bisphosphonate 40.3% and calcium +vitaminD 47.9%. Qualitative study: 23% respond to the first round, and of these 67% the second round. Items with higher agreement were the important of the evaluation of risk factors for diagnosis and bisphosphonates for treatment. Items with fewer consensuses were using the FRAX and densitometry and treatment with only calcium +vitaminD. CONCLUSIONS: The percentage of inadequacy is high. The degree of registration in medical history is low. The Delphi method is useful for detecting discrepancies between recommendations of clinical practice guidelines and results.

Impact of a workplace 'sit less, move more' program on efficiency-related outcomes of office employees.

BACKGROUND: Few studies have examined the impact of 'sit less, move more' interventions on workplace performance. This study assessed the short and mid-term impacts of and patterns of change within, a 19-week workplace web-based intervention (Walk@WorkSpain; W@WS; 2010-11) on employees´ presenteeism, mental well-being and lost work performance. METHODS: A site randomised control trial recruited employees at six Spanish university campuses (n = 264; 42 ± 10 years; 171 female), assigned by worksite and campus to an Intervention (IG; used W@WS; n = 129; 87 female) or an active Comparison group (A-CG; pedometer, paper diary and self-reported sitting time; n = 135; 84 female). A linear mixed model assessed changes between the baseline, ramping (8 weeks), maintenance (11 weeks) and follow-up (two months) phases for the IG versus A-CG on (i) % of lost work productivity (Work Limitations Questionnaire; WLQ); (ii) three scales for presenteeism (WLQ) assessing difficulty meeting scheduling demands (Time), performing cognitive and inter-personal tasks (Mental-Interpersonal) and decrements in meeting the quantity, quality and timeliness of completed work (Output); and (iii) mental well-being (Warwick-Edinburgh Mental Well-being Scale). T-tests assessed differences between groups for changes on the main outcomes. In the IG, a multivariate logistic regression model identified patterns of response according to baseline socio-demographic variables, physical activity and sitting time. RESULTS: There was a significant 2 (group) × 2 (program time points) interaction for the Time (F [3]=8.69, p = 0.005), Mental-Interpersonal (F [3]=10.01, p = 0.0185), Output scales for presenteeism (F [3]=8.56, p = 0.0357), and for % of lost work performance (F [3]=10.31, p = 0.0161). Presenteeism and lost performance rose significantly in both groups across all study time points; after baseline performance was consistently better in the IG than in the A-CG. Better performance was linked to employees being more active (Time, p = 0.041) and younger (Mental-interpersonal, p = 0.057; Output, p = 0.017). Higher total sitting time during nonworking days (Mental-interpersonal, p = 0.019) and lower sitting time during workdays (WLQ Index, p = 0.013) also improved performance. CONCLUSION: Versus an active comparison condition, a 'sit less, move more` workplace intervention effectively reduced an array of markers of lost workday productivity. TRIAL REGISTRATION: NCT02960750 ; Date of registration: 07/11/2016.

Can a workplace 'sit less, move more' programme help Spanish office employees achieve physical activity targets?

We evaluated the impact of a workplace 'sit less, move more' programme (Walk@WorkSpain, W@WS, 19-week) on self-reported activity-related energy expenditure (AREE) in Spanish office employees (n = 264; 42 ± 10 years; 171 female) randomly assigned to Intervention (IG; used W@WS; n = 129) or comparison groups (CGs; n = 135). A linear mixed model assessed changes in METs-min/wk of total, vigorous, moderate and light physical activity (IPAQ short form) between baseline and 2 months follow-up. Over the CG, IG significantly increased light intensity AREE (P = 0.027). W@WS secured sustained increases on AREE-but not on achieving PA recommendations-providing translational evidence that active living in office employees can be increased.

Study protocol of a randomized clinical trial evaluating the effectiveness of a primary care intervention using the Nintendo™ Wii console to improve balance and decrease falls in the elderly.

BACKGROUND: Balance alteration is a risk factor for falls in elderly individuals that has physical, psychological and economic consequences. The objectives of this study are to evaluate the usefulness of an intervention utilizing the Nintendo™ Wii console in order to improve balance, thereby decreasing both the fear of falling as well as the number of falls, and to evaluate the correlation between balance as determined by the console and the value obtained in the Tinetti tests and the one foot stationary test. METHODS/DESIGN: This is a controlled, randomized clinical trial of individual assignment, carried out on patients over 70 years in age, from five primary care centers in the city of Mataró (Barcelona). 380 patients were necessary for the intervention group that carried out the balance board exercises in 2 sessions per week for a 3 month period, and 380 patients in the control group who carried out their usual habits. Balance was evaluated using the Tinetti test, the one foot stationary test and with the console, at the start of the study, at the end of the intervention (3 months) and one year later. Quarterly telephone follow-up was also conducted to keep track of falls and their consequences. DISCUSSION: The study aimed to connect the community with a technology that may be an easy and fun way to assist the elderly in improving their balance without the need to leave home or join rehabilitation groups, offering greater comfort for this population and decreasing healthcare costs since there is no need for specialized personnel. TRIAL REGISTRATION: Current Control Trial NCT02570178.

Self-reported sitting time and physical activity: interactive associations with mental well-being and productivity in office employees.

BACKGROUND: Little is known about how sitting time, alone or in combination with markers of physical activity (PA), influences mental well-being and work productivity. Given the need to develop workplace PA interventions that target employees' health related efficiency outcomes; this study examined the associations between self-reported sitting time, PA, mental well-being and work productivity in office employees. METHODS: Descriptive cross-sectional study. Spanish university office employees (n = 557) completed a survey measuring socio-demographics, total and domain specific (work and travel) self-reported sitting time, PA (International Physical Activity Questionnaire short version), mental well-being (Warwick-Edinburg Mental Well-Being Scale) and work productivity (Work Limitations Questionnaire). Multivariate linear regression analyses determined associations between the main variables adjusted for gender, age, body mass index and occupation. PA levels (low, moderate and high) were introduced into the model to examine interactive associations. RESULTS: Higher volumes of PA were related to higher mental well-being, work productivity and spending less time sitting at work, throughout the working day and travelling during the week, including the weekends (p < 0.05). Greater levels of sitting during weekends was associated with lower mental well-being (p < 0.05). Similarly, more sitting while travelling at weekends was linked to lower work productivity (p < 0.05). In highly active employees, higher sitting times on work days and occupational sitting were associated with decreased mental well-being (p < 0.05). Higher sitting times while travelling on weekend days was also linked to lower work productivity in the highly active (p < 0.05). No significant associations were observed in low active employees. CONCLUSIONS: Employees' PA levels exerts different influences on the associations between sitting time, mental well-being and work productivity. The specific associations and the broad sweep of evidence in the current study suggest that workplace PA strategies to improve the mental well-being and productivity of all employees should focus on reducing sitting time alongside efforts to increase PA.

Can an alert in primary care electronic medical records increase participation in a population-based screening programme for colorectal cancer? COLO-ALERT, a randomised clinical trial.

BACKGROUND: Colorectal cancer is an important public health problem in Spain. Over the last decade, several regions have carried out screening programmes, but population participation rates remain below recommended European goals. Reminders on electronic medical records have been identified as a low-cost and high-reach strategy to increase participation. Further knowledge is needed about their effect in a population-based screening programme. The main aim of this study is to evaluate the effectiveness of an electronic reminder to promote the participation in a population-based colorectal cancer screening programme. Secondary aims are to learn population's reasons for refusing to take part in the screening programme and to find out the health professionals' opinion about the official programme implementation and on the new computerised tool. METHODS/DESIGN: This is a parallel randomised trial with a cross-sectional second stage. PARTICIPANTS: all the invited subjects to participate in the public colorectal cancer screening programme that includes men and women aged between 50-69, allocated to the eleven primary care centres of the study and all their health professionals. The randomisation unit will be the primary care physician. The intervention will consist of activating an electronic reminder, in the patient's electronic medical record, in order to promote colorectal cancer screening, during a synchronous medical appointment, throughout the year that the intervention takes place. A comparison of the screening rates will then take place, using the faecal occult blood test of the patients from the control and the intervention groups. We will also take a questionnaire to know the opinions of the health professionals. The main outcome is the screening status at the end of the study. Data will be analysed with an intention-to-treat approach. DISCUSSION: We expect that the introduction of specific reminders in electronic medical records, as a tool to facilitate and encourage direct referral by physicians and nurse practitioners to perform colorectal cancer screening will mean an increase in participation of the target population. The introduction of this new software tool will have good acceptance and increase compliance with recommendations from health professionals. TRIAL REGISTRATION: Clinical Trials.gov identifier NCT01877018.

Measurement of the ankle brachial index with a non-mercury sphygmomanometer in diabetic patients: a concordance study.

BACKGROUND: The removal of mercury sphygmomanometers from health centers requires the validation of other instruments to measure blood pressure in the limbs to calculate the ankle-brachial index (ABI). METHODS: Descriptive cross-sectional study of agreement between two measurement methods in type 2 diabetes patients from three urban primary healthcare centres in the Barcelonès Nord i Maresme area (Catalonia, Spain). RESULTS: 211 patients were included, from these, 421 limbs were available for study. The mean age of the participants was 67 years (SD = 10), 51.7% were women. CONCLUSION: The combination of a Doppler device with the hybrid sphygmomanometer is a simple and reliable method to measure ABI showing that hybrid sphygmomanometer is a good alternative to the use of mercury sphygmomanometers.

Level of distress, somatisation and beliefs on health-disease in newly arrived immigrant patients attended in primary care centres in Catalonia and definition of professional competences for their most effective management: PROMISE Project.

BACKGROUND: Newly arrived immigrant patients who frequently use primary health care resources have difficulties in verbal communication. Also, they have a system of beliefs related to health and disease that makes difficult for health care professionals to comprehend their reasons for consultation, especially when consulting for somatic manifestations. Consequently, this is an important barrier to achieve optimum care to these groups. The current project has two main objectives: 1. To define the different stressors, the level of distress perceived, and its impact in terms of discomfort and somatisation affecting the main communities of immigrants in our area, and 2. To identify the characteristics of cross-cultural competence of primary health care professionals to best approach these reasons for consultation. METHODS/DESIGN: It will be a transversal, observational, multicentre, qualitative-quantitative study in a sample of 980 people from the five main non-European Union immigrant communities residing in Catalonia: Maghrebis, Sub-Saharans, Andean South Americans, Hindustanis, and Chinese. Sociodemographic data, level of distress, information on the different stressors and their somatic manifestations will be collected in specific questionnaires. Through a semi-structured interview and qualitative methodology, it will be studied the relation between somatic manifestations and particular beliefs of each group and how these are associated with the processes of disease and seeking for care. A qualitative methodology based on individual interviews centred on critical incidents, focal groups and in situ questionnaires will be used to study the cross-cultural competences of the professionals. DISCUSSION: It is expected a high level of chronic stress associated with the level of somatisations in the different non-European Union immigrant communities. The results will provide better knowledge of these populations and will improve the comprehension and the efficacy of the health care providers in prevention, communication, care management and management of resources.

Effectiveness of regular reporting of spirometric results combined with a smoking cessation advice by a primary care physician on smoking quit rate in adult smokers: a randomized controlled trial. ESPIROTAB study.

BACKGROUND: Undiagnosed airflow limitation is common in the general population and is associated with impaired health and functional status. Smoking is the most important risk factor for this condition. Although primary care practitioners see most adult smokers, few currently have spirometers or regularly order spirometry tests in these patients. Brief medical advice has shown to be effective in modifying smoking habits in a large number of smokers but only a small proportion remain abstinent after one year. The aim of this study is to evaluate the effectiveness of regular reporting of spirometric results combined with a smoking cessation advice by a primary care physician on smoking quit rate in adult smokers. METHODS/DESIGN: Intervention study with a randomized two arms in 5 primary care centres. A total of 485 smokers over the age of 18 years consulting their primary care physician will be recruited.On the selection visit all participants will undergo a spirometry, peak expiratory flow rate, test of smoking dependence, test of motivation for giving up smoking and a questionnaire on socio-demographic data. Thereafter an appointment will be made to give the participants brief structured advice to give up smoking combined with a detailed discussion on the results of the spirometry. After this, the patients will be randomised and given appointment for follow up visits at 3, 6, 12 and 24 months. Both arms will receive brief structured advice and a detailed discussion of the spirometry results at visit 0. The control group will only be given brief structured advice about giving up smoking on the follow up. Cessation of smoking will be tested with the carbon monoxide test. DISCUSSION: Early identification of functional pulmonary abnormalities in asymptomatic patients or in those with little respiratory symptomatology may provide "ideal educational opportunities". These opportunities may increase the success of efforts to give up smoking and may improve the opportunities of other preventive actions to minimise patient risk. Comparing adult smokers in the intervention group with those in the control group, a minimum improvement expected with respect to the rates of smoking cessation would represent a large number of avoided morbimortality. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01296295.

Delayed Antibiotic Prescription for Children With Respiratory Infections: A Randomized Trial.

OBJECTIVES: To assess the effectiveness and safety of delayed antibiotic prescription (DAP) compared to immediate antibiotic prescription (IAP) and no antibiotic prescription (NAP) in children with uncomplicated respiratory infections. METHODS: Randomized clinical trial comparing 3 antibiotic prescription strategies. The participants were children with acute uncomplicated respiratory infections attended to in 39 primary care centers. Children were randomly assigned into prescription arms as follows: (1) DAP, (2) IAP, or (3) NAP. Primary outcomes were symptom duration and severity. Secondary outcomes were antibiotic use, parental satisfaction, parental beliefs, additional primary care visits, and complications at 30 days. RESULTS: In total, 436 children were included in the analysis. The mean (SD) duration of severe symptoms was 10.1 (6.3) for IAP, 10.9 (8.5) for NAP, and 12.4 (8.4) for DAP (P = .539), although the differences were not statistically significant. The median (interquartile range) of the greatest severity for any symptom was similar for the 3 arms (median [interquartile range] score of 3 [2-4]; P = .619). Antibiotic use was significantly higher for IAP (n = 142 [96%]) compared to DAP (n = 37 [25.3%]) and NAP (n = 17 [12.0%]) (P < .001). Complications, additional visits to primary care, and satisfaction were similar for all strategies. Gastrointestinal adverse effects were higher for IAP. CONCLUSIONS: There was no statistically significant difference in symptom duration or severity in children with uncomplicated respiratory infections who received DAP compared to NAP or IAP strategies; however, DAP reduced antibiotic use and gastrointestinal adverse effects.

Female genital mutilation: perceptions of healthcare professionals and the perspective of the migrant families.

BACKGROUND: Female Genital Mutilation (FGM) is a traditional practice which is harmful to health and is profoundly rooted in many Sub-Saharan African countries. It is estimated that between 100 and 140 million women around the world have been victims of some form of FGM and that each year 3 million girls are at risk of being submitted to these practices. As a consequence of the migratory phenomena, the problems associated with FGM have extended to the Western countries receiving the immigrants. The practice of FGM has repercussions on the physical, psychic, sexual and reproductive health of women, severely deteriorating their current and future quality of life. Primary healthcare professionals are in a privileged position to detect and prevent these situations of risk which will be increasingly more present in Spain. METHODS/DESIGN: The objective of the study is to describe the knowledge, attitudes and practices of the primary healthcare professionals, working in 25 health care centres in Barcelona and Girona regions, regarding FGM, as well as to investigate the perception of this subject among the migrant communities from countries with strong roots in these practices. A transversal descriptive study will be performed with a questionnaire to primary healthcare professionals and migrant healthcare users.Using a questionnaire specifically designed for this study, we will evaluate the knowledge, attitudes and skills of the healthcare professionals to approach this problem. In a sub-study, performed with a similar methodology but with the participation of cultural mediators, the perceptions of the migrant families in relation to their position and expectancies in view of the result of preventive interventions will be determined.Variables related to the socio-demographic aspects, knowledge of FGM (types, cultural origin, geographic distribution and ethnicity), evaluation of attitudes and beliefs towards FGM and previous contact or experience with cases or risk situations will be obtained. DISCUSSION: Knowledge of these harmful practices and a preventive approach from a transcultural perspective may represent a positive intervention model for integrative care of immigrants, respecting their values and culture while also being effective in eliminating the physical and psychic consequences of FGM.

Perception of primary health professionals about female genital mutilation: from healthcare to intercultural competence.

BACKGROUND: The practice of Female Genital Mutilation (FGM), a deeply-rooted tradition in 28 countries in Sub-Saharan Africa, carries important negative consequences for the health and quality of life of women and children. Migratory movements have brought this harmful traditional practice to our medical offices, with the subsequent conflicts related to how to approach this healthcare problem, involving not only a purely healthcare-related event but also questions of an ethical, cultural identity and human rights nature. METHODS: The aim of this study was to analyse the perceptions, degree of knowledge, attitudes and practices of the primary healthcare professionals in relation to FGM. A transversal, descriptive study was performed with a self-administered questionnaire to family physicians, paediatricians, nurses, midwives and gynaecologists. Trends towards changes in the two periods studied (2001 and 2004) were analysed. RESULTS: A total of 225 (80%) professionals answered the questionnaire in 2001 and 184 (62%) in 2004. Sixteen percent declared detection of some case in 2004, rising three-fold from the number reported in 2001. Eighteen percent stated that they had no interest in FGM. Less than 40% correctly identified the typology, while less than 30% knew the countries in which the practice is carried out and 82% normally attended patients from these countries. CONCLUSION: Female genital mutilations are present in primary healthcare medical offices with paediatricians and gynaecologists having the closest contact with the problem. Preventive measures should be designed as should sensitization to promote stands against these practices.

Safety and Effectiveness of Shoulder Arthroplasties in Spain: A Systematic Review.

The effectiveness and safety of shoulder arthroplasties in the general context of a Spanish patient population remains unclear. The aim of this study was to ascertain both the effectiveness and safety of primary shoulder arthroplasties and the prosthesis types used in Spain. A systematic review of all the available literature evaluating the effectiveness and safety of primary shoulder arthroplasties in Spain was performed. A narrative synthesis was performed, and evidence tables were created in four dimensions: study design, arthroplasty characteristics, safety, and effectiveness. Orthopaedic Data Evaluation Panel (ODEP) scores were used to evaluate prosthesis types. Twenty-one studies were selected that included a total of 1293 arthroplasties. The most common indication was fractures, while the prosthesis most frequently used was the Delta Xtend (ODEP 10A). The most common complication was scapular notching. Prosthesis revision rate was approximately 6% for follow-ups between 12 and 79 months. In addition, significant improvements were observed in the Constant-Murley test score after the intervention. Currently in Spain, shoulder arthroplasty can be considered a safe and effective procedure with functional recovery and pain reduction for eligible patients with humeral fracture, rotator cuff arthropathy, fracture sequelae and malunion of the proximal humerus, and degenerative disease. Future longitudinal research and population-based studies could serve to confirm these results and identify points of improvement.

The Barcelona-Asymptomatic Intracranial Atherosclerosis study: Subclinical intracranial atherosclerosis as predictor of long-term vascular events.

BACKGROUND AND AIMS: Symptomatic intracranial atherosclerosis (ICAS) is associated with a high risk of stroke recurrence and occurrence of other vascular events. However, ICAS has been poorly studied from its asymptomatic stage. The objective of our study was to determine if subclinical intracranial atherosclerosis is associated with long-term incident vascular events in Caucasians. METHODS: The Barcelona-Asymptomatic Intracranial Atherosclerosis (AsIA) Study is a population-based study that enrolled 933 subjects with a moderate-high vascular risk and without history of stroke or coronary disease, and determined the prevalence of asymptomatic ICAS and associated risk factors. At baseline visit, carotid atherosclerosis and ICAS were screened by color-coded duplex ultrasound, and moderate-severe stenosis was confirmed by magnetic resonance angiography. At baseline, 8.9% of subjects had asymptomatic ICAS, of whom 3.3% were moderate-severe. In the longitudinal phase, subjects were prospectively followed-up to assess the incidence of a combined primary endpoint of vascular events (stroke, acute coronary syndrome and/or vascular death). RESULTS: After 7.17 years of follow-up, there were 51 incident cerebrovascular events (16 transient ischemic attacks, 27 ischemic, 8 hemorrhagic strokes), 63 incident coronary events and 23 vascular deaths. After multivariate Cox regression analyses adjusted by age, sex, vascular risk and presence of carotid plaques, ICAS was an independent predictor for overall vascular events (HR 1.83 [1.10-3.03], p = 0.020), and moderate-severe intracranial stenosis was also an independent predictor for cerebrovascular events (HR 2.66 [1.02-6.94], p = 0.046). CONCLUSIONS: Asymptomatic ICAS is independently associated with the incidence of future vascular events in our population. These findings might have implications for the development of primary prevention strategies.

[Process indicators: tools for monitoring the management of severe trauma cases in Catalonia]. / Indicadores de proceso como herramienta para monitorizar la asistencia al paciente con traumatismo grave en Cataluña.

OBJECTIVES: Process indicators have been widely used to monitor the way trauma care is provided. We aimed to analyze whether data from a hospital's severe trauma register could facilitate the evaluation of aspects of the initial management of severe injuries. MATERIAL AND METHODS: Observational, retrospective population-based study. A working group of experts selected a set of trauma care process indicators relevant to some aspects of initial care, diagnosis, and treatment of severely injured patients. Four of the indicators referred to prehospital care and 5 to hospital care. We calculated the observed and expected compliance rates for all the indicators. RESULTS: A total of 1526 cases (44.4%) were analyzed for 2013; 1908 (55.6%) were analyzed for 2014. We were able to evaluate 3 of the 4 prehospital process indicators: endotracheal intubation in patients with a score of 􀀀 8 on the Glasgow coma scale (GCS) (84% compliance), venous access established before hospital arrival (83.4%), and placement of a neck collar to immobilize the cervical spine (72.7%). Compliance for the hospital-phase indicators were as follows: performance of a computed tomography scan of the head within 60 minutes in cases with a GCS of 􀀀 13 (5.3% compliance, craniotomy in candidate patients within 2 hours of diagnosis (65%), diagnostic examination for abdominal injuries within 60 minutes in patients with systolic blood pressure 􀀀 90 mm Hg (89.3%), and therapeutic laparotomy or angiography within 4 hours of abdominal injury in candidate patients with systolic blood pressure 􀀀 90 mm Hg (51.7%). Compliance was 69.9% for the last process indicator: surgical treatment of open fractures within 8 hours of an accident. CONCLUSION: Our findings show that a hospital trauma register provides data about care process indicators that can allow us to monitor the quality of care of severely injured patients.

OBJETIVO: Los indicadores de proceso (IP) se han utilizado ampliamente para monitorizar los procesos asistenciales al paciente traumático. Nuestro objetivo es analizar la capacidad de un registro hospitalario de traumatismo grave para evaluar algunos aspectos de la atención inicial al traumatismo grave. METODO: Observacional, retrospectivo de datos incluidos en un registro poblacional. A partir de un consenso de expertos se seleccionaron una serie de IP que se aplicaron a una población de accidentados. Los IP seleccionados analizan algunos aspectos de la atención inicial, diagnósticos y terapéuticos. Cuatro de ellos se refieren a la fase prehospitalaria y 5 a la fase hospitalaria. Para todos ellos se calculó la tasa de cumplimiento (observados vs esperados). RESULTADOS: Fueron analizados 1.526 casos (44,4%) correspondientes al año 2013 y 1.908 (55,6%) del 2014. Tres de los cuatro IP relacionados con la atención prehospitalaria pudieron ser analizados: intubación orotraqueal en paciente con puntuación de la Escala del Coma de Glasgow (GCS) 8 (84% de cumplimiento); acceso vascular canalizado antes de la llegada al hospital (83,4% de cumplimiento); y contención cervical aplicada in situ (72,7% de cumplimiento). En la fase hospitalaria: realización de tomografía computarizada (TC) craneal en los primeros 60 min en GCS ô€€€ 13 (5,3% de cumplimiento); craneotomía en paciente candidato en las primeras 2 horas después del diagnóstico (65% de cumplimiento); exploración diagnóstica en traumatismo abdominal en los primeros 60 minutos en pacientes con presión arterial sistólica (PAS) 90 mmHg (89,3% de cumplimiento); y laparotomía o angiografía terapéutica en paciente candidato en las 4 primeras horas tras el trauma abdominal y PAS 90 (51,7% de cumplimiento). El último indicador, cirugía de fractura abierta en las primeras 8 horas tras el accidente, presentó un 69,9% de cumplimiento. CONCLUSIONES: Nuestro estudio muestra las posibilidades y dificultades que un registro de traumatismo en base hospitalaria ofrece para evaluar la asistencia al paciente traumático a través de indicadores de proceso establecidos.

Alerts in electronic medical records to promote a colorectal cancer screening programme: a cluster randomised controlled trial in primary care.

BACKGROUND: Participation rates in colorectal cancer screening are below recommended European targets. AIM: To evaluate the effectiveness of an alert in primary care electronic medical records (EMRs) to increase individuals' participation in an organised, population-based colorectal cancer screening programme when compared with usual care. DESIGN AND SETTING: Cluster randomised controlled trial in primary care centres of Barcelona, Spain. METHOD: Participants were males and females aged 50-69 years, who were invited to the first round of a screening programme based on the faecal immunochemical test (FIT) (n = 41 042), and their primary care professional. The randomisation unit was the physician cluster (n = 130) and patients were blinded to the study group. The control group followed usual care as per the colorectal cancer screening programme. In the intervention group, as well as usual care, an alert to health professionals (cluster level) to promote screening was introduced in the individual's primary care EMR for 1 year. The main outcome was colorectal cancer screening participation at individual participant level. RESULTS: In total, 67 physicians and 21 619 patients (intervention group) and 63 physicians and 19 423 patients (control group) were randomised. In the intention-to-treat analysis screening participation was 44.1% and 42.2% respectively (odds ratio 1.08, 95% confidence interval [CI] = 0.97 to 1.20, P = 0.146). However, in the per-protocol analysis screening uptake in the intervention group showed a statistically significant increase, after adjusting for potential confounders (OR, 1.11; 95% CI = 1.02 to 1.22; P = 0.018). CONCLUSION: The use of an alert in an individual's primary care EMR is associated with a statistically significant increased uptake of an organised, FIT-based colorectal cancer screening programme in patients attending primary care centres.

Prescription Strategies in Acute Uncomplicated Respiratory Infections: A Randomized Clinical Trial.

IMPORTANCE: Delayed antibiotic prescription helps to reduce antibiotic use with reasonable symptom control. There are different strategies of delayed prescription, but it is not yet clear which one is the most effective. OBJECTIVE: To determine the efficacy and safety of 2 delayed strategies in acute, uncomplicated respiratory infections. DESIGN, SETTING, AND PARTICIPANTS: We recruited 405 adults with acute, uncomplicated respiratory infections from 23 primary care centers in Spain to participate in a pragmatic, open-label, randomized clinical trial. INTERVENTIONS: Patients were randomized to 1 of 4 potential prescription strategies: (1) a delayed patient-led prescription strategy; (2) a delayed prescription collection strategy requiring patients to collect their prescription from the primary care center; (3) an immediate prescription strategy; or (4) a no antibiotic strategy. Delayed prescription strategies consist of prescribing an antibiotic to take only if the symptoms worsen or if there is no improvement several days after the medical visit. MAIN OUTCOMES AND MEASURES: The primary outcomes were the duration of symptoms and severity of symptoms. Each symptom was scored using a 6-point Likert scale (scores of 3 or 4 were considered moderate; 5 or 6, severe). Secondary outcomes included antibiotic use, patient satisfaction, and patients' beliefs in the effectiveness of antibiotics. RESULTS: A total of 405 patients were recruited, 398 of whom were included in the analysis; 136 patients (34.2%) were men; mean (SD) age, 45 (17) years. The mean severity of symptoms ranged from 1.8 to 3.5 points on the Likert scale, and mean (SD) duration of symptoms described on first visit was 6 (6) days. The mean (SD) general health status on first visit was 54 (20) based on a scale with 0 indicating worst health status; 100, best status. Overall, 314 patients (80.1%) were nonsmokers, and 372 patients (93.5%) did not have a respiratory comorbidity. The presence of symptoms on first visit was similar among the 4 groups. The mean (SD) duration of severe symptoms was 3.6 (3.3) days for the immediate prescription group and 4.7 (3.6) days for the no prescription group. The median (interquartile range [IQR]) of severe symptoms was 3 (1-4) days for the prescription collection group and 3 (2-6) days for the patient-led prescription group. The median (IQR) of the maximum severity for any symptom was 5 (3-5) for the immediate prescription group and the prescription collection group; 5 (4-5) for the patient-led prescription group; and 5 (4-6) for the no prescription group. Patients randomized to the no prescription strategy or to either of the delayed strategies used fewer antibiotics and less frequently believed in antibiotic effectiveness. Satisfaction was similar across groups. CONCLUSIONS AND RELEVANCE: Delayed strategies were associated with slightly greater but clinically similar symptom burden and duration and also with substantially reduced antibiotic use when compared with an immediate strategy. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01363531.

Prenatal dichlorodiphenyldichloroethylene (DDE) and asthma in children.

Prevalence of asthma increases with increasing dichlorodiphenyldichloroethylene (DDE) levels. However, the effect of early-life exposure, the fundamental window of exposure, is unknown. We assessed the association between prenatal DDE and other organochlorine compounds, and atopy and asthma during infancy. All women presenting for antenatal care in Menorca (Spain) over 12 months starting in mid-1997 were invited to take part in a longitudinal study; 482 children were subsequently enrolled, and 468 (97.1%) provided complete outcome data up to the fourth year of study. Prenatal exposure of organochlorine compounds was measured in cord serum in 405 (83%) children. Asthma was defined on the basis of wheezing at 4 years of age, persistent wheezing, or doctor-diagnosed asthma. We measured specific immunoglobulin-E (IgE) against house dust mite, cat, and grass in sera extracted at 4 years of age. DDE (median = 1.03 ng/mL) was detected in all children, as well as hexachlorobenzene (0.68 ng/mL) and polychlorobiphenyls (0.69 ng/mL). Wheezing at 4 years of age increased with DDE concentration, particularly at the highest quartile [9% in the lowest quartile (< 0.57 ng/mL) vs. 19% in the highest quartile (1.90 ng/mL); relative risk = 2.63 (95% confidence interval 1.19-4.69), adjusting for maternal asthma, breast-feeding, education, social class, or other organochlorines]. The association was not modified by IgE sensitization and occurred with the same strength among nonatopic subjects and among those with persistent wheezing or diagnosed asthma. DDE was not associated with atopy alone. Prenatal exposure to DDE residues may contribute to development of asthma.