Clinical outcomes and safety of passive leg raising in out-of-hospital cardiac arrest: a randomized controlled trial.

BACKGROUND: There are data suggesting that passive leg raising (PLR) improves hemodynamics during cardiopulmonary resuscitation (CPR). This trial aimed to determine the effectiveness and safety of PLR during CPR in out-of-hospital cardiac arrest (OHCA). METHODS: We conducted a randomized controlled trial with blinded assessment of the outcomes that assigned adults OHCA to be treated with PLR or in the flat position. The trial was conducted in the Camp de Tarragona region. The main end point was survival to hospital discharge with good neurological outcome defined as cerebral performance category (CPC 1-2). To study possible adverse effects, we assessed the presence of pulmonary complications on the first chest X-rays, brain edema on the computerized tomography (CT) in survivors and brain and lungs weights from autopsies in non-survivors. RESULTS: In total, 588 randomized cases were included, 301 were treated with PLR and 287 were controls. Overall, 67.8% were men and the median age was 72 (IQR 60-82) years. At hospital discharge, 3.3% in the PLR group and 3.5% in the control group were alive with CPC 1-2 (OR 0.9; 95% CI 0.4-2.3, p = 0.91). No significant differences in survival at hospital admission were found in all patients (OR 1.0; 95% CI 0.7-1.6, p = 0.95) and among patients with an initial shockable rhythm (OR 1.7; 95% CI 0.8-3.4, p = 0.15). There were no differences in pulmonary complication rates in chest X-rays [7 (25.9%) vs 5 (17.9%), p = 0.47] and brain edema on CT [5 (29.4%) vs 10 (32.6%), p = 0.84]. There were no differences in lung weight [1223 mg (IQR 909-1500) vs 1239 mg (IQR 900-1507), p = 0.82] or brain weight [1352 mg (IQR 1227-1457) vs 1380 mg (IQR 1255-1470), p = 0.43] among the 106 autopsies performed. CONCLUSION: In this trial, PLR during CPR did not improve survival to hospital discharge with CPC 1-2. No evidence of adverse effects has been found. Clinical trial registration ClinicalTrials.gov: NCT01952197, registration date: September 27, 2013, https://clinicaltrials.gov/ct2/show/NCT01952197 .

Ten-Year Follow-Up of Clinical Governance Implementation in Primary Care: Improving Screening, Diagnosis and Control of Cardiovascular Risk Factors.

Current improvement strategies for the control of cardiovascular risk factors (CRFs) in Europe are based on quality management policies. With the aim of understanding the effect of interventions delivered by primary healthcare systems, we evaluated the impact of clinical governance on cardiovascular health after ten years of implementation in Catalonia. A cohort study that included 1878 patients was conducted in 19 primary care centres (PCCs). Audits that comprised 13 cardiovascular health indicators were performed and general practitioners received periodic (annual, biannual or monthly) feedback about their clinical practice. We evaluated improvement in screening, diagnosis and control of the main CRFs and the effects of the feedback on cardiovascular risk (CR), incidence of cardiovascular disease (CVD) and mortality, comparing baseline data with data at the end of the study (after a 10-year follow-up). The impact of the intervention was assessed globally and with respect to feedback frequency. General improvement was observed in screening, percentage of diagnoses and control of CRFs. At the end of the study, few clinically significant differences in CRFs were observed between groups. However, the reduction in CR was greater in the group receiving high frequency feedback, specifically in relation to smoking and control of diabetes and cholesterol (Low Density Lipoprotein (LDL) and High Density Lipoprotein (HDL)). A protective effect of having a cardiovascular event (hazard ratio (HR) = 0.64, 95% confidence interval (CI) = 0.44-0.94) or death (HR = 0.55, 95% CI = 0.35-0.88) was observed in patients from centres where general practitioners received high frequency feedback. Additionally, these PCCs presented improved cardiovascular health indicators and lower incidence and mortality by CVD, illustrating the impact of this intervention.

The ReCaPTa study - a prospective out of hospital cardiac arrest registry including multiple sources of surveillance for the study of sudden cardiac death in the Mediterranean area.

BACKGROUND: Cardiovascular diseases are one of the leading causes of death in the industrialized world. Sudden cardiac death is very often the first manifestation of the disease and it occurs in the prehospital setting. The determination of the sudden cardiac death phenotype is challenging. It requires prospective studies in the community including multiple sources of case ascertainment that help to identify the cause and circumstances of death. The aim of the Clinical and Pathological Registry of Tarragona (ReCaPTa) is to study incidence and etiology of Sudden Cardiac Death in the Tarragona region (Catalonia, Spain). METHODS: ReCaPTa is a population-based registry of OHCA using multiple sources of surveillance. The population base is 511,662. This registry is compiled chronologically in a relational database and it prospectively contains data on all the OHCA attended by the EMS from April 2014 to April 2017. ReCaPTa collects data after each emergency medical assistance using an online application including variables of the onset of symptoms. A quality control is performed and it permits monitoring the percentage of cases included by the emergency crew. Simultaneously, data from the medico-legal autopsies is taken from the Pathology Center of the area. All the examination findings following a specific protocol for the sudden death study are entered into the ReCaPTa database by one trained person. Survivors admitted to hospital are followed up and their clinical variables are collected in each hospital. The primary care researchers analyze the digital clinical records in order to obtain medical background. All the available data will be reviewed after an adjudication process with the aim of identifying all cases of sudden cardiac death. DISCUSSION: There is a lack of population-based registries including multiple source of surveillance in the Mediterranean area. The ReCaPTa study could provide valuable information to prevent sudden cardiac death and develop new strategies to improve its survival.

Multicentric randomized clinical trial to evaluate the long-term effectiveness of a motivational intervention against smoking, based on the information obtained from spirometry in primary care: the RESET study protocol.

BACKGROUND: Spirometry is the recommended method of evaluating pulmonary function when respiratory disease is suspected in smokers. Nonetheless, no evidence exists of the usefulness of information obtained from this test as a motivational strategy for smoking cessation. The primary objective of this study is to evaluate the effectiveness of a motivational intervention based on spirometry results in achieving long-term smoking cessation. METHODS/DESIGN: We propose a multicenter randomized clinical trial in the primary care setting. STUDY SUBJECTS: We will recruit active smokers of both sexes, aged 35-70 years, with a cumulated smoking habit exceeding 10 packs/year and who consult for any reason with their primary care physician in the 20 health centers in the province of Tarragona (Spain). Patients with a history of lung disease or who have undergone exploratory measures of pulmonary function in the preceding 12 months will be excluded. All patients who agree to participate will provide signed informed consent prior to their inclusion. A total of 1000 smokers will be consecutively randomized to a control or intervention group (1:1). INTERVENTION: Participants in both groups will receive brief (5-minute) health counseling, in accordance with usual clinical practice. In a consultation lasting about 15 minutes, participants in the intervention group will also receive detailed, personalized information about the results of a spirometry test and about their lung age compared with their chronological age. Both groups will be followed up for 12 months. Main variables and analysis: The main variable will be sustained smoking abstinence at 12 months after the intervention, as confirmed by CO breath testing and urine cotinine test. Results will be analyzed based on intention to treat, using the chi-square test and logistical regression if necessary to adjust for confounding variables. DISCUSSION: We expect the rate of prolonged smoking abstinence in the intervention group will be at least 5% higher than in the control group. If this strategy proves effective, it could easily be included in the health promotion activities offered in primary care settings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02153047 . Registered on 28/05/2014.

Cobertura y asociación con variables clínicas de la vacunación antineumocócica en la población mayor de 65 años de Tarragona-Valls / Coverage and association with clinical variables of antipneumococcal vaccination of the population over 65 years-old in Tarragona-Valls

Fundamento: En Cataluña, el programa de vacunación antineumocócica(VAN), que incluye a todas las personas mayores de 65años se inició en 1999. Tres años después, analizamos las coberturasvacunales según presencia de factores de riesgo para padecer neumonía.Métodos: Estudio observacional transversal, emplazado en 8Áreas Básicas de Salud (ABS) de Tarragona. Se incluyeron todas laspersonas mayores de 64 años asignados a las 8 ABS participantes(n=11241). Mediante revisión de historias clínicas informatizadas ydel Registro informático de vacunaciones, valoramos en cadapaciente si había recibido la VAN antes de enero de 2002, así comola presencia de enfermedades o factores de riesgo para sufrir neumonía.Resultados: La cobertura vacunal global fue 44,4% (37,1% en65-74 años, 53,9% en 75-84 y 51,5% en 85-99 años). Las mayorescoberturas se dieron entre aquellos con neoplasia activa (56,7%),nefropatía crónica (55,3%), enfermedad pulmonar crónica (54,2%) ycardiopatía crónica (53,5%). Las menores coberturas se observaronen fumadores (38,9%), pacientes enólicos (43,6%) y hepatopatíacrónica (46,5%). La cobertura VAN fue 38,9% (IC 95%: 37,6-40,2)entre las personas sin ningún factor de riesgo, del 47,7% (IC 95%:46,1-49,4) entre aquellos con un factor, y del 52,7% (IC 95%:52,6-54,8) entre aquellos con dos o más factores.Conclusiones: A pesar de una cobertura global aceptable, existenamplios subgrupos de pacientes con alto riesgo que no han recibidola VAN. Los resultados sugieren que, tratando de alcanzar altascoberturas globales, la presencia de factores de riesgo es poco tenidaen cuenta para prescribir o no la VAN

Background: In Catalonia, a polyanccharide pneumococcalvaccine (PPV) programme which includes subjects over 65 yearsold, was started in 1999. Three years later, we study the vaccinecover in relation to the presence of risk factors for pneumonia.Methods: Cross-sectional observational study conducted in 8Basic Health Areas (BHA) of Tarragona. All the subjects over 65years old and assigned to one of the 8 basic health areas participatingin the study were included (n= 11241). Using computerized clinicalrecords and vaccination records we evaluated whether each patienthad received PPV before January 2002, and the presence of diseaseor risk factors for pneumonia.Results: Global vaccination coverage was 44.4% (37.1% in 65-74 years, 53.9% in 75-84 and 51.5% in 85-99 years). The greatestcoverage was recorded in subjects with active neoplasm (56.7%),chronic necropathy (55.3%), chronic lung disease (54.2%) and chroniccardiopathy (53.5%). The least coverage was recorded in smokers(38.9%), alcoholic patients (43.6%) and chronic liver disease(46.5%). AVP coverage was 38.9% (CI 95%: 37.6-40.2) in subjectswithout any risk factors, 47.7% (CI 95%: 46.1-49.4) in those withone factor, and 52.7% (CI 95%:52.6-54.8) in those with two or morefactors.Conclusions: In spite of an acceptable global coverage, there arelarge subgroups of high risk patients who have not received PPV. Theresults suggest that, in an attempt to achieve extended global coverage,the presence of risk factors is largely ignored when deciding whetherto prescribe PPV or not

[Coverage and association with clinical variables of antipneumococcal vaccination of the population over 65 years old in Tarragona-Valls]. / Cobertura y asociación con variables clínicas de la vacunación antineumocócica en la población mayor de 65 anos de Tarragona-Valls.

BACKGROUND: In Catalonia, a polyanccharide pneumococcal vaccine (PPV) programme which includes subjects over 65 years old, was started in 1999. Three years later, we study the vaccine cover in relation to the presence of risk factors for pneumonia. METHODS: Cross-sectional observational study conducted in 8 Basic Health Areas (BHA) of Tarragona. All the subjects over 65 years old and assigned to one of the 8 basic health areas participating in the study were included (n=11241). Using computerized clinical records and vaccination records we evaluated whether each patient had received PPV before January 2002, and the presence of disease or risk factors for pneumonia. RESULTS: Global vaccination coverage was 44.4% (37.1% in 65-74 years, 53.9% in 75-84 and 51.5% in 85-99 years). The greatest coverage was recorded in subjects with active neoplasm (56.7%), chronic necropathy (55.3%). chronic lung disease (54.2%) and chronic cardiopathy (53.5%). The least coverage was recorded in smokers (38.9%), alcoholic patients (43.6%) and chronic liver disease (46.5%). AVP coverage was 38.9% (CI 95%: 37.6-40.2) in subjects without any risk factors, 47.7% (CI 95%: 46.1-49.4) in those with one factor, and 52.7% (CI 95%: 52.6-54.8) in those with two or more factors. CONCLUSIONS: In spite of an acceptable global coverage, there are large subgroups of high risk patients who have not received PPV. The results suggest that, in an attempt to achieve extended global coverage, the presence of risk factors is largely ignored when deciding whether to prescribe PPV or not.