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The objectives of this work were to assess the diagnostic sensitivity and specificity of nasopharyngeal (NP) swabs for viral community-acquired pneumonia (CAP) and the performance of pneumonia severity index (PSI) and CURB-65 severity scores in the viral CAP in adults. A prospective observational cohort study of consecutive 341 hospitalized adults with CAP was performed between January 2018 and March 2020. Demographics, comorbidities, symptoms/signs, analytical data, severity scores, antimicrobials, and outcomes were recorded. Blood, NP swabs, sputum, and urine samples were collected at admission and assayed by multiplex real time-PCR, bacterial cultures, and Streptococcus pneumoniae and Legionella pneumophila antigens detection, to determine the etiologies and quantify the viral load. The etiology was identified in 174 (51.0%) patients, and in 85 (24.9%) it was viral, the most frequent rhinovirus and influenza virus. The sensitivity of viral detection in sputum (50.7%) was higher than in NP swabs (20.9%). Compared with sputum, the positive predictive value and specificity of NP swabs for viral diagnosis were 95.8% and 96.9%, respectively. Performance of PSI and CURB-65 scores in all CAP with etiologic diagnosis were as expected, with mortality associated with higher values, but they were not associated with mortality in patients with viral pneumonia. NP swabs have lower sensitivity but high specificity for the diagnosis of viral CAP in adults compared with sputum, reinforcing the use NP swabs for the diagnostic etiology work-up. The PSI and CURB-65 scores did not predict mortality in the viral CAP, suggesting that they need to be updated scores based on the identification of the etiological agent.

Resumen: Objetivos: Conocer si existe variabilidad en los programas formativos de los residentes de Medicina Interna ofertados en la Comunidad Autónoma de Andalucía y, en su caso, generar un documento de consenso con propuestas para disminuir la misma. Material y métodos: Estudio transversal mediante encuestas de opinión a los tutores y residentes de último año de los hospitales andaluces. Resultados: Obtuvimos un porcentaje de participación del 70% de los residentes y del 53% de los tutores. Detectamos gran variabilidad en la duración en determinadas rotaciones consideradas relevantes y que la oferta de algunas era inexistente en unos centros. La proporción de guardias de urgencias frente a las de especialidad osciló del 15 al 72%. Conclusiones: Existe una importante variabilidad en numerosas áreas de formación del residente de Medicina Interna en Andalucía. Creemos que resulta fundamental establecer y desarrollar medidas que permitan mejorar esta situación. Abstract: Objectives: To know if there is variability in the training programs of residents of Internal Medicine offered in the Autonomous Community of Andalusia and, if appropriate, to generate a consensus document with proposals to reduce it. Material and methods: Cross-sectional study through opinion polls of tutors and senior residents of a Andalusian hospitals. Results: We obtained a participation percentage of 70% of the residents and 53% of the tutors. We detected great variability in duration in certain some rotations considered relevant and that the supply of some of them was non-existent in some centers. The proportion of emergency and specialty guards ranged from 15 to 72%. Conclusions: There is an important variability in many areas of training of residents of Internal Medicine in Andalusia. We believe that it is essential to establish and develop measures actions to improve this situation.

In 2017, a questionnaire was developed in Italian with the aim of determining clinicians' perceptions of deprescription in the elderly population. The objective was to translate and cross-culturally adapt this deprescription questionnaire to Spanish.Forward and blind-back translations, followed by a synthesis and adaptation by a third translator. Development of an expert panel to evaluate the adequacy of the translation, the understandability of the translated question and the usefulness of each question. A comprehensibility analysis was carried out on physicians familiar with deprescription.The Spanish version of the questionnaire was obtained, where the average degree of difficulty in the direct and the back-translation was low/moderate. In the first phase of the panel of experts, 4 questions had sections considered "indeterminate" and one question was "doubtful". After the second phase, all the questions were considered "adequate" except for one.This is the first cross-cultural adaptation to Spanish of this questionnaire, which will provide a tool to assess clinicians' perception of this practice and establish improvements to carry out this activity.

Proyecto PROFUND., [ES] Objetivos: Analizar la sensibilidad (S), la especificidad (E) y los valores predictivos positivo (VPP) y negativo (VPN) de cada dimensión del índice de Barthel (IB) con respecto al cuestionario completo en pacientes pluripatológicos (PPP). Métodos: Estudio transversal multicéntrico. Se consideraron dos puntos de corte del IB (≥ 90 puntos para el cribado de fragilidad y < 60 puntos para el diagnóstico de dependencia severa). Para cada dimensión y combinaciones de dos dimensiones se calcularon la S, la E, el VPP y el VPN con respecto al IB completo. Resultados: El IB medio de los 1.632 PPP incluidos (edad media de 77,9 ± 9,8 años, 53% varones) fue 69 ± 31 (< 90 en el 58,7% y < 60 en el 31,4% de pacientes). La dimensión «alimentación» obtuvo los mayores VPN para tener un IB ≥ 60 y ≥ 90 puntos (87% y 99,6%, respectivamente). Las dimensiones «deambular» y «subir y bajar escaleras» obtuvieron el mayor VPP para tener un IB ≥ 60 y ≥ 90 (99,2/99,5% y 81/92%, respectivamente; la combinación de ambas preguntas aumentó el VPP al 95 y al 99,6%, respectivamente. Conclusiones: Los PPP de ámbito hospitalario presentan con elevada frecuencia deterioro funcional. La dimensión referente a alimentarse obtuvo el mayor VPN, por lo que se puede utilizar para el diagnóstico de dependencia severa, mientras que la combinación de deambular y subir y bajar escaleras obtuvo el mayor VPP, pudiendo utilizarse para plantear el cribado de fragilidad de los PPP., [EN] Objectives: To analyse the sensitivity, specificity and positive predictive (PPV) and negative predictive (NPV) values of each measure of the Barthel index (BI) compared with the full questionnaire for polypathological patients (PPPs). Methods: Multicentre cross-sectional study. We considered 2 cut-off points for the BI (≥ 90 points for screening frailty and < 60 points for diagnosing severe dependence). For each measure and combination of 2 measures, we calculated the sensitivity, specificity, PPV and NPV with respect to the full BI. Results: The mean BI of the 1,632 included PPPs (mean age, 77.9 ± 9.8 years; 53% men) was 69 ± 31 (< 90 for 58.7% and < 60 for 31.4% of the patients). The “feeding” measure achieved the highest NPV, for a BI ≥ 60 and ≥ 90 points (87% and 99.6%, respectively). The “walking” and “going up and down stairs” measures achieved the highest PPV, for a BI ≥ 60 and ≥ 90 (99.2%/99.5% and 81%/92%, respectively. The combination of the 2 measures increased the PPV to 95% and 99.6%, respectively. Conclusions: PPPs in hospital settings have a high rate of functional impairment. The measure for feeding achieved the highest NPV and can therefore be employed for diagnosing severe dependence. The combination of the measures for walking and going up and down stairs achieved the highest PPV and can therefore be employed to propose frailty screening for PPPs.

BACKGROUND Due to an increase in life expectancy, the prevalence of chronic diseases is on the rise too. Clinical Practice Guidelines (CPGs) provide recommendations for suitable interventions regarding different chronic diseases. But a deficit in the implementation of these CPGs could be identified. The PITeS-TIiSS tool, a personalized ontology-based Clinical Decision Support System (CDSS), aims to reduce the variability, prevent errors and consider interactions between different CPGs recommendations, among other benefits. OBJECTIVE To design, develop and validate an ontology-based CDSS which provides personalized recommendations related to drug prescription. The target population is elderly patients with chronic diseases and polypharmacy aiming to reduce complications related to these types of conditions and, also, offering integrated care. METHODS A study scenario about atrial fibrillation and treatment with anticoagulants was selected to validate the tool. After this, a series of knowledge sources were identified, such as CPGs, PROFUND index, LESS/CHRON criteria, and STOPP/START criteria, to extract the information. Modeling was carried out using an ontology, and mapping was done with HL7 FHIR and SNOMED CT. Once the CDSS was developed, validation was carried out by using a retrospective case study. RESULTS This project was funded in January 2015 and approved by the Ethics Committee on 24 November 2015. Two different tasks have been carried out to test the functioning of the tool. On the one hand, retrospective data from a real patient who met the inclusion criteria were used. In addition, the analysis of an adoption model has been performed through the study of the requirements and characteristics that a CDSS must meet in order to be well accepted and used by health professionals. The results have been favourable and allow the proposed research to continue to the next phase. CONCLUSIONS An ontology-based CDSS has been successfully designed, developed, and validated. However, as future work, the validation in a real environment should be performed to ensure the tool is usable and reliable. CLINICALTRIAL

© 2020 The Authors., [Background]: Using technologies of information and communication (TICs) is emerging in medical assistance. TICs application for medical assistance is promising. Its applicability in advanced heart and/or respiratory failure is still controversial because studies have shown methodological weakness which could put in danger their conclusions. Our objective is to evaluate efficacy of the application of home monitoring biological parameters in a multi-level model of coordinated clinical care for patients with chronic diseases with advanced heart (HF) and/or respiratory failure (RF) in comparison with conventional clinical care., [Method/Design]: Multicentric, phase III, randomized, parallel groups, controlled clinical trial. Patients with advanced HF and/or RF were eligible to participate. Patients received medical assistance by a multi-level model of coordinated clinical care with or without home monitoring. Follow up was performed until 180 days after inclusion. Primary efficacy outcome was defined as the percentage of patients with hospitalization/emergency room visits. Secondary efficacy outcomes were hospital admissions, admissions to hospital emergencies and Primary Care Emergencies, number of days of hospital stay, total cost per patient in euros, mortality, change in functional status, quality of life, assistance and technology devices. Intention to treat, as well as per protocol, and incremental cost-effectiveness analysis will be performed. The number of recruits patients per arm is set at 255, a total of 510 patients., [Discussion]: This trial could provide some knowledge about the real impact of home monitoring for patients with advanced HF and/or RF within a multi-level model of integrated care., This study was conducted with support of the Health Ministry of the Andalusian Regional Government.

Brief Summary The addition of home monitoring to an integrated care model in patients with advanced chronic heart/lung diseases decreases mortality, hospital and emergency admissions, improves functional status, HRQoL, and is cost-effective. Background Telemonitoring is a promising implement for medicine, but its efficacy is unknown in patients with advanced heart and lung failure (AHLF). Objective To determine the efficacy of a telemonitoring system added to coordinated clinical care in patients with AHLF. Design Randomized phase 3 multicenter clinical trial with parallel groups in adult patients. Participants Five spanish centers including patients with AHLF at discharge or in out-patient clinics. Intervention Patients were randomly assigned to receive a remote bio-parameters telemonitoring system (TELECARE) or best usual care (UCARE). TELECARE patients were provided with devices that collected symptoms and bio-parameters, and transferred them synchronously to a call-center, with a real-time health-care response. Main Measures Primary end point was the need of admissions/emergency room visits at 45, 90, 180 days. Secondary end points included health care requirements, mortality, functional assessment, health related quality of life (HRQoL), perceived satisfaction, and cost-efficacy. Results 510 patients were included (54.5% women, median age 76.5 years; 63.1% suffered heart failure, 13.9% lung failure, and 22.9% both conditions). Clinical and functional features were comparable in both arms. TELECARE globally needed less admissions with respect UCARE after 45 days of inclusion (35.4% vs. 46.9%, p Conclusions The addition of a telemonitoring system to an integrated care model in patients with AHLF decreases hospital and emergency admissions, improves functional status as well as HRQoL, and is cost-efficacious.

Polypathological patients constitute a prevalent, fairly homogeneous population, which is characterised by high clinical complexity, substantial vulnerability and significant resource consumption, in addition to high mortality and the need for comprehensive, coordinated care. It is particularly important to establish a reliable prognosis in these patients. It is also extremely useful for professionals involved in the decision-making process for patients and their families in vital planning and their preferences, for strategic health planning in management fields, and for clinical research, by facilitating their incorporation into clinical trials and other intervention studies. Two prognostic instruments stand out in terms of suitability for polypathological patients: PROFUND and PROFUNCTION. The former faithfully stratifies the risk of dying at 12 months and four years and the latter, the risk of suffering a significant functional deterioration at 12 months. In terms of the healthcare approach in patients with multiple pathologies, creating and executing a consensual, personalised action plan that is adapted to the patient's reality is encouraged. The plan will consider the prognosis, and the evidence and viability of interventions; its ultimate aim will be to ensure the synergy and alignment of the health team's goals and strategies with peoples' values and preferences, in order to achieve a more proactive health model focused on supporting patients in their ability to manage their illnesses. In the personalised action plan, the main areas of intervention are: health promotion and prevention; patient and caregiver activation and self-management; activation of a social support network and social support; optimisation of pharmacotherapy; rehabilitation, functional and cognitive preservation measures; and anticipated decision planning.

[ES] Los pacientes pluripatológicos constituyen una población prevalente y homogénea, caracterizada por su complejidad clínica, vulnerabilidad, consumo de recursos y mortalidad que requiere una asistencia integral y coordinada. Establecer un pronóstico certero en esta población resulta de utilidad para la toma de decisiones clínicas por parte de los profesionales, la planificación de las preferencias de pacientes y familiares, y el diseño de estrategias en el ámbito de la gestión sanitaria. También es importante para la investigación clínica, al facilitar la posible incorporación de estos pacientes a ensayos clínicos y otros estudios de intervención. Los índices PROFUND y PROFUNCTION son 2 instrumentos pronósticos que predicen de manera fidedigna el riesgo de fallecer o de sufrir un deterioro funcional, respectivamente. Para el abordaje asistencial de los pacientes pluripatológicos se propugna la construcción y ejecución de un plan de acción personalizado, consensuado y adaptado a la realidad del paciente. Este tendrá en cuenta el pronóstico, la evidencia y viabilidad de las intervenciones, así como la sinergia de las metas y estrategias del equipo sanitario con los valores y las preferencias de las personas para conseguir un modelo de salud centrado en apoyar la capacidad de las mismas para gestionar sus enfermedades. En este plan los principales ámbitos de intervención son: la promoción y prevención de la salud, la activación y autogestión del paciente y el cuidador, la red de apoyo social, la optimización farmacoterapéutica, la rehabilitación y medidas de preservación funcional y cognitiva, y la planificación anticipada de decisiones., [EN] Polypathological patients constitute a prevalent, fairly homogeneous population, which is characterised by high clinical complexity, substantial vulnerability and significant resource consumption, in addition to high mortality and the need for comprehensive, coordinated care. It is particularly important to establish a reliable prognosis in these patients. It is also extremely useful for professionals involved in the decision-making process for patients and their families in vital planning and their preferences, for strategic health planning in management fields, and for clinical research, by facilitating their incorporation into clinical trials and other intervention studies. Two prognostic instruments stand out in terms of suitability for polypathological patients: PROFUND and PROFUNCTION. The former faithfully stratifies the risk of dying at 12 months and four years and the latter, the risk of suffering a significant functional deterioration at 12 months. In terms of the healthcare approach in patients with multiple pathologies, creating and executing a consensual, personalised action plan that is adapted to the patient's reality is encouraged. The plan will consider the prognosis, and the evidence and viability of interventions; its ultimate aim will be to ensure the synergy and alignment of the health team's goals and strategies with peoples’ values and preferences, in order to achieve a more proactive health model focused on supporting patients in their ability to manage their illnesses. In the personalised action plan, the main areas of intervention are: health promotion and prevention; patient and caregiver activation and self-management; activation of a social support network and social support; optimisation of pharmacotherapy; rehabilitation, functional and cognitive preservation measures; and anticipated decision planning.

Background/objectives The PROFUND index stratifies accurately the 12-month mortality risk of polypathological patients (PPs), but its fitness over a longer follow-up period remains unknown. We aimed to explore the calibration and discrimination power of PROFUND index over 4-years, in order to assess its follow-up interval generalizability. Design Multicenter prospective cohort-study. Setting 33 Spanish hospitals. Participants PPs included after hospital discharge, outpatient clinics, or home hospitalization. Measurements Mortality over a 4-year follow-up period. Methods PROFUND index calibration was assessed by risk-quartiles predicted/observed mortality (Hosmer–Lemeshow goodness-of-fit test), and its discrimination power by ROC curves. Results A total of 768 patients were included (630 [82%] of them completed the 4-year follow-up). Global mortality rate was 63.5%. When assessing individual patient scores, mortality was 52% in the lowest risk group (0–2 points in PROFUND score); 73.5% in the low-intermediate risk group (3–6 points), 85% in the intermediate-high group (7–10 points); and 92% in the highest risk group (≥11 points). Accuracy testing of the PROFUND index showed good calibration ( P =.8 in the Hosmer–Lemeshow goodness-of-fit test), and also a good discrimination power (AUC=0.71 [0.67–0.77] in ROC curve). Conclusions The PROFUND index maintained its accuracy in predicting mortality of polypathological patients over a 4-year follow-up period. This index may be of potential usefulness in deciding the most appropriate health-care interventions in populations with multimorbidity.

AIM Changes in N-terminal pro B-type natriuretic peptide (NT-proBNP) levels and cystatin C (CysC) are predictors of adverse outcomes in acute heart failure. This study assess whether NT-proBNP variations might provide independent information in addition to that obtained from CysC levels. METHODS NT-proBNP levels were assessed in patients admitted due to acute heart failure using an observational study. Patients were classified as follows: group 1, those with a decrease in NT-proBNP levels of at least 30% from admission to 4 weeks after discharge; group 2, those with no significant changes in levels; and group 3, those who showed an increase in NT-proBNP of 30%. A multivariable Cox regression model and c-statistics were used. The primary end-point was all-cause mortality at 1-year follow-up. RESULTS A total of 195 patients completed the follow-up. The mortality rate reached 20.5% (40 patients); 14 out of the 32 in group 3. The cumulative incidence of death, according to the change in NT-proBNP and Kaplan-Meier analysis, showed a significant increase in group 3 (log-rank P = 0.004). In the multivariable analysis, NT-proBNP variation for group 3 (hazard ratio 4.27; P

Resumen Fundamento y objetivo Determinar el uso de anticoagulantes orales en pacientes pluripatologicos con fibrilacion auricular y su impacto sobre la mortalidad y el deterioro funcional. Pacientes y metodo Estudio observacional, prospectivo y multicentrico en pacientes pluripatologicos con fibrilacion auricular. Se recogieron datos demograficos, clinicos, funcionales, sociofamiliares, la escala CHADS2, los valores de hemoglobina, albumina y creatinina, y el uso de anticoagulantes orales. Tras un ano de seguimiento se valoro la supervivencia y el estado funcional. Resultados De 1.632 pacientes pluripatologicos, 532 (32,6%) tenian fibrilacion auricular. El riesgo embolico fue alto en 505 (94,9%), moderado en 24 (4,5%) y bajo en 3 (0,6%) pacientes. Se utilizaron anticoagulantes en el 61% de los pacientes con puntuacion ≥ 2 y en el 37,5% con puntuacion 1 en la escala CHADS2. Se hizo menor uso de anticoagulantes en los pacientes de mayor edad y con mas deterioro funcional y cognitivo. La insuficiencia cardiaca era mas frecuente en los pacientes que usaron anticoagulantes. No hubo diferencias segun la presencia de hipertension arterial, diabetes, anemia, insuficiencia renal o ictus. En el analisis multivariante, el uso de anticoagulantes se asocio de forma independiente con menor edad, menor deterioro cognitivo, ausencia de enfermedad hepatica y mayor riesgo embolico. La prescripcion de anticoagulantes se asocio de forma independiente con mayor supervivencia al ano, sin repercutir en el estado funcional de los pacientes pluripatologicos. Conclusiones Los anticoagulantes son infrautilizados en los pacientes pluripatologicos con fibrilacion auricular a pesar de asociarse a mayor supervivencia.

Background: Little is known about the fitness of the available tools in predicting functional decline of polypathological patients (PPs). Our objective was to assess accuracy of the Triage Risk Screening Tool (TRST), the Variable Indicative of Placement risk (VIP) and to develop a specific functional prognostic index adjusted to this population in a multicenter cohort of hospital-based PP. Methods: Prospective 12-month follow-up study of PPs from 36 hospitals. Functional decline was defined as loss of ≥20 points on Barthel’s index (BI). Accuracy of TRST/VIP was assessed by calibration/discrimination tests. Development of the new score was performed by dividing into a derivation cohort (constructing the index by logistic regression), and a validation cohort (in which calibration/discrimination of the index were tested). Results: Nine hundred and fifty-eight patients from the 1632 included survived during follow-up. Basal/12-month BI was 85/70, respectively. Mean fall in BI score was 11.7±24 points [353 (36.8%) fell by ≥20 points]. The activities for daily living that declined most frequently were toilet use, grooming, dressing and bathing. TRST/VIP fitted well but their discrimination power was poor (area under the curve=0.49 and 0.46, respectively). A simplified PROFUNCTION index was derived containing seven items (≥85 years, neurological condition, osteoarticular disease, III–IV functional class of dyspnea, ≥4 polypathology categories, basal BI

Background Frail and polypathological patients (PP) are often undertreated with evidence-based cardiovascular drugs, as their benefits are uncertain in this population. Objectives To determine the effects of treatment with renin–angiotensin system blockers/inhibitors (ACEI/ARB), statins and/or beta-blockers on survival rates and functional decline in PP with evidence-based clinical indications for treatment with any of these drug families. Method Prospective observational multicentre cohort study with a 12-month follow-up period. We selected PP with any condition of the following: chronic heart failure, coronary heart disease, chronic renal disease, cerebrovascular disease, peripheral artery disease, diabetes mellitus with any visceral involvement, hypertension, and dyslipidaemia. Clinical, functional (Barthel index), socio-familial risk data and drug prescriptions were measured at baseline. Multivariate Cox proportional hazards and logistic regression models were used to identify variables independently associated with survival and functional decline. Results The analysis included 1260 PP. The mean age was 79 ± 9.5 years. The mortality rate was 34.5%. Statin (aHR 0.671; P = 0.001), beta-blocker plus statin (aHR 0.645; P = 0.007), ACEI/ARB plus statin (aHR 0.680; P = 0.002), or combined ACEI/ARB plus statin plus beta-blocker (aHR 0.541; P = 0.000) prescriptions were associated with longer survival times. Additionally, PP whose Barthel index was ≥ 60 showed a lower risk of disability progression if treated with statins (aOR = 0.476; P = 0.000), or their combinations, mainly with ACEI/ARB plus beta-blockers (aOR 0.563; P = 0.031). Conclusions The prescription of statins, alone or in combination with other drugs, may impact the survival and functional decline in polypathological patients. Further prospective blinded randomised assays are needed to confirm these observations.

Resumen Introduccion Existe incertidumbre para identificar adecuadamente la trayectoria del final de la vida en pacientes con enfermedades medicas cronicas en fases avanzadas, hecho que dificulta en muchos casos la planificacion de servicios y el proceso de transicion, de unos objetivos de supervivencia a unos terapeuticos de calidad de vida. Objetivos Evaluar la sensibilidad, especificidad, valores predictivos positivo y negativo, e indice de validez de los criterios de enfermedad medica terminal del National Hospice Organization estadounidense, la Palliative Prognostic Index y la Eastern Cooperative Oncology Group (ECOG) en pacientes con enfermedades cardiacas, neumologicas, hepaticas, renales y/o neurologicas en estadio avanzado; y construir-validar un indice especifico para determinar con mayor certidumbre esta frontera. Metodos Estudio de cohortes prospectivas multicentrico con inclusion de pacientes con criterios predefinidos de enfermedad avanzada en organos comentados. Recogida de datos demograficos, clinico-asistenciales, de estratificacion y estadiaje de enfermedad(es), funcionales, analiticos, criterios de la National Hospice Organization, ECOG, valores predictivos positivos y Palliative Prognostic Index; y de la variable final (fallecimiento) a los 180 dias de la inclusion. Analisis de sensibilidad, especifidad, valores predictivos positivos, negativos e indice de validez de los criterios de la National Hospice Organization, escala ECOG y Palliative Prognostic Index a los 30, 60, 90, 120, 150 y 180 dias. Derivacion, si procede, del indice PALIAR, tras analisis multivariante y ponderacion de los factores de riesgo (beta del f. riesgo/beta menor del modelo) y posterior validacion en cohorte de validacion y cohorte historica PROFUND. Resultados Actualmente estan incuyendo pacientes 50 investigadores de 33 hospitales de toda Espana, y se han incluido 1.138 pacientes (el 92,5% durante un ingreso hospitalario, siendo el 51,4% varones con edad media de 78,5 anos). La media de enfermedades cronicas criterio de inclusion ha sido 1,4/paciente (el 44,5% de los pacientes con enfermedad neurologica, el 38,6% con insuficiencia cardiaca, el 34,2% con insuficiencia respiratoria, el 12% con hepatopatia y el 6,5% con insuficiencia renal cronica). El 69% de los pacientes cumplio criterios de pluripatologia, (media del indice de Charlson 3,4), recibiendo una media de 8 farmacos de prescripcion cronica. La media del indice de Barthel se situo en 40 puntos presentando dependencia de un cuidador el 77% de los pacientes. Un 46% estaban en situacion III o IV de la ECOG-PS y la media de la PPS se ha situado en 45 puntos. Conclusion El poder contar con una herramienta precisa que nos permita identificar con cierta certidumbre y precocidad el inicio de la trayectoria del final de la vida en estos pacientes nos permitira articular estrategias especificas de intervencion para este colectivo. Por ello pensamos que el proyecto PALIAR podra contestar con rigor a la pregunta y objetivos propuestos.

Background A comprehensive evaluation of polypathological patients (PP) should always include a functional evaluation. For this purpose, a modified version of the Barthel Index (BI) is the most applied questionnaire, and it consists of a 10-variable scale. The aim of this study was to develop a screening and confirmation tool to diagnose high disability with the fewest number of dimensions of the BI as possible. Method This present cross-sectional observational multicentre study included PP attended in 36 Spanish hospitals that were divided into two geographical areas (Western and Eastern). The Western area was considered to be the derivation subgroup of PP, and the Eastern area was the validation subgroup. Complete disability for each item (value of 0) was assessed for the diagnosis of severe disability. Diagnostic validity indices (sensitivity, specificity, negative and positive predictive values [NPV and PPV, respectively], and negative and positive likelihood ratios [NLR and PLR, respectively]) were determined for the derivation subgroup. The dimensions with the best diagnostic validity indices were then used to evaluate the validation subgroup. Results The analysis included 1521 PP, 753 PP from the Western area and 768 PP from the Eastern area. Needing complete help for bathing showed the highest NPV and lowest NLR in the derivation/validation subgroups (NPV 96.87/95.54, NLR 0.07/0.13). Being disabled for feeding alone showed high PPV and PLR values (PPV 97.97/95.65, PLR 109.25/49.62), as did disability for transfers (PPV 98.48/97.96, PLR 143.36/107.68). In addition, complete disability for feeding and transfers had the best PPV and PLR in both subgroups (PPV 100/100, PLR X/0). Conclusions A two-dimension mini-Barthel Index may represent a reliable diagnostic test for severe disability in PP.

To determine the use of oral anticoagulants in polypathological patients with atrial fibrillation and its influence on mortality and loss of functionality.Patients with polypathological patient criteria and atrial fibrillation were included in an observational, prospective and multicenter study. Data on demographic, clinical, functional and sociofamilial characteristics, CHADS2 score, levels of hemoglobin, albumin and creatinine, use of oral anticoagulants and survival and functional status at one year were collected.Five hundred and thirty-two (32.6%) of 1,632 polypathological patients had atrial fibrillation. The stroke risk was high in 505 (94.9%), moderate in 24 (4.5%) and low in 3 (0.6%) patients. Oral anticoagulants were used in 61% of patients with CHADS2 score≥2 and in 37.5% with CHADS2 score=1. Oral anticoagulants were less used in older patients, with more functional and cognitive impairment. Heart failure was associated with more use of oral anticoagulants. There was no difference by the presence of hypertension, diabetes, anemia, renal insufficiency or stroke. In multivariate analysis the use of oral anticoagulants was independently associated with lower age, lower cognitive impairment, absence of hepatic disease and with higher stroke risk. The prescription of oral anticoagulants was independently associated with more survival at one year with no influence on functional status.Oral anticoagulants are underused in polypathological patients with atrial fibrillation despite being associated with more survival.

There is a concern about the accuracy of the available prognostic indexes when applying them to the emergent population of polypathological patients (PP).To develop a 1-year mortality predictive index on PP, we developed a multicenter prospective cohort-study recruiting 1.632 PP after hospital discharge, outpatient clinics, or home hospitalization, from 33 hospitals. Potential risk factors were obtained in the 1.525 PP who completed follow-up. Each factor independently associated with mortality in the derivation cohort (757 PP from western hospitals) was assigned a weight, and risk scores were calculated by adding the points of each factor. Accuracy was assessed in the validation cohort (768 PP from eastern hospitals) by risk quartiles calibration, and discrimination power, by ROC curves. Finally, accuracy of the index was compared with that of the Charlson index.Mortality in the derivation/validation cohorts was 35%/39.5%, respectively. Nine independent mortality predictors were identified to create the index (age ≥85 years, 3 points; No caregiver or caregiver other than spouse, 2 points; active neoplasia, 6 points; dementia, 3 points; III-IV functional class on NYHA and/or MRC, 3 points; delirium during last hospital admission, 3 points; hemoglobinemia10 g/dl, 3 points; Barthel index60 points, 4 points; ≥4 hospital admissions in last 12 months, 3 points). Mortality in the derivation/validation cohorts was 12.1%/14.6% for patients with 0-2 points; 21.5%/31.5% for those with 3-6 points; 45%/50% for those with 7-10 points; and 68%/61.3% for those with ≥11 points, respectively. Calibration was good in derivation/validation cohorts, and discrimination power by area under the curve was 0.77/0.7. Calibration of the Charlson index was good, but discrimination power was suboptimal (area under the curve, 0.59).This prognostic index provides an accurate and transportable method of stratifying 1-year death risk in PP.

Little is known about the main features of the emergent population of PP. Our objective was to determine the clinical, care and social characteristics of a multi-institutional population of PP, by means of a crosssectional study including a reference population of hospital-based PP from 36 hospitals. The main clinical, functional, mental and social features and their associated factors were assessed: 1632 PP (53% males, mean age 77.9 9.8 years) were included. An informal caregiver was required by 52% (78% of caregivers were close female relatives). The mean inclusion criteria (Cat): were 2.7 0.8 (49.5% presented 3 Cat). The most frequent inclusion Cat were heart (77.5%), lung (45.6%), neurological (38.2%), and kidney diseases (32.2%), whereas the mean of other comorbidities was 4.5 2.7 per PP. The mean Charlson comorbidity index (CCI) was 4; 47.6%, and 52.4% presented dyspnea 3 on the NYHA, and on the MRC, respectively; nearly 19% required home oxygen therapy, 19% had suffered >1 fall in previous year, and 11% suffered an active neoplasia. The mean hospital admissions in last 12/3 months, and chronically prescribed drugs were 2/1, and 8 3, respectively. More than 70% presented obesity, while 60% had hypoalbuminemia. The basal/inclusion Barthel index (BI) score was 69 31/58 34 (BI score < 60 was present in 31.5%/44%, respectively); and the mean Pfeiffer score was 2.94 3.2 (43% answered with 3 errors). More than half of the subjects were at risk or already had established social problems. This emergent population is considerably homogeneous, highly complex, clinically vulnerable, functionally impaired, dependent on caregivers and socially fragile. They need to receive more attention in clinical research and more support in health interventions based on comprehensive attention and continuity of care.

It is a challenge to reliably identify the end-of-life trajectory in patients with advanced-stage chronic medical conditions. This makes advanced supportive care planning and transition from survival to comfort objectives more difficult in these emergent patient populations.To evaluate the sensitivity (Se), specificity (Sp), positive predictive values (PPV) and negative (NPV), and validity index (IV) of NHO criteria for terminal medical conditions, PPI and ECOG in patients with advanced heart, lung, liver, kidney and/or neurological diseases, and to build and validate an accurate index to determine this border-line.A multicentre prospective cohort study, with inclusion of patients with the predefined advanced medical diseases. Demographic, clinical, care, stratification and staging of disease(s), functional, analytical, NHO criteria, ECOG, PPS and PPI data collection; The end-point (death) will be assessed 180 days after inclusion. Analysis of Se, Sp, PPV, NPV, and IV of the NHO criteria, ECOG scale and PPI at 30, 60, 90, 120, 150 and 180 days. Derivation of PALIAR Index, after multivariate analysis and appropriate weighting of risk factors (beta of risk factor/lowest beta of the model), and validation in the validation cohort, and in the historical PROFUND cohort.The project is still ongoing, with 50 investigators from 33 hospitals throughout Spain, who have already included 1138 patients (92.5% during hospital admissions, 51.4% of them are male, with a mean age of 78.5 years). Mean inclusion chronic diseases were 1.4 per patient (44.5% of patients suffered chronic neurological diseases, 38.6% with heart failure, 34.2% with lung diseases, 12% with liver diseases, and 6.5% with renal diseases). Around 69% fulfilled the criteria of polypathological patients (mean Charlson index 3.4), and were prescribed around 8 drugs chronically. Mean Barthel index was 40 points, and 77% of them were dependent on a caregiver. Around 46% were ECOG-PS stage III or IV, and mean PPS score was 45 points.The availability of an accurate and powerful tool that could enable us to identify the end-of-life trajectory of these patients could allow us to establish specific intervention strategies for these populations. Therefore, and with these preliminary data, we believe that the PALIAR PROJECT will answer with rigour the questions and objectives of the study.