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Patients with multimorbidity increasingly impact healthcare systems, both in primary care and in hospitals. This is particularly true in Internal Medicine. This population associates with higher mortality rates, polypharmacy, hospital readmissions, post-discharge syndrome, anxiety, depression, accelerated age-related functional decline, and development of geriatric syndromes, amongst others. Internists and Hospitalists, in one of their roles as Generalists, are increasingly asked to attend to these patients, both in their own Departments as well as in surgical areas. The management of polypathology and multimorbidity, however, is often complex, and requires specific clinical skills and corresponding experience. In addition, patients' needs, health-care environment, and routines have changed, so emerging and re-emerging specific competences and approaches are required to offer the best coordinated, continuous, and comprehensive integrated care to these populations, to achieve optimal health outcomes and satisfaction of patients, their relatives, and staff. This position paper proposes a set of emerging and re-emerging competences for internal medicine specialists, which are needed to optimally address multimorbidity now and in the future.

Background Digital transformation in healthcare and the growth of health data generation and collection include an important challenge for the secondary use of healthcare records in the health research field. Likewise, due to the ethical and legal constraints for using sensitive data, understanding how health data is managed by dedicated infrastructures called data hubs is essential to facilitate data sharing and reuse. Methods In order to capture the different data governance behind health data hubs across Europe, a survey focused on analysing the feasibility of linking individual-level data between data collections and the generation of health data governance patterns was carried out. The target audience of this study was National, European, and Worldwide data hubs. In total, the designed survey was sent to a representative list of 99 health data hubs in January 2022. Results In total, 41 survey responses received till June 2022 were analysed in-depth. Stratification methods were performed to cover the different levels of granularity identified in some data hubs’ characteristics. Firstly, a general pattern of data governance for data hubs was defined. Afterward, specific profiles were defined, generating specific patterns of data governance through the stratifications in terms of the kind of organisation (centralised vs. decentralised), and role (data controller or data processor) of the health data hubs interviewees. Conclusions The in-depth analysis of the responses from health data hubs interviewees across Europe provided a list of the most frequent aspects that concluded a set of specific recommendations on data management and governance, taking into account the constraints of sensitive data. In summary, a data hub should work in a centralised way providing a Data Processing Agreement and a formal procedure to identify data providers, as well as data quality control, data integrity and anonymisation methods.

Introduction: Heart failure is an extremely prevalent disease in the elderly population of the world. Most patients present signs and symptoms of decompensation of the disease due to worsening congestion. This congestion has been clinically assessed through clinical signs and symptoms and complementary imaging tests, such as chest radiography. Recently, pulmonary and inferior vena cava ultrasound has been shown to be useful in assessing congestion but its prognostic significance in elderly patients has been less well evaluated. Objectives: This study aims to compare the clinical and radiological characteristics and predictive values for mortality in patients admitted for heart failure through the determination of B lines by lung ultrasound and the degree of collapsibility of the inferior vena cava (IVC). Secondarily, the study aims to assess the prediction of 30-day mortality based on the diameter of the IVC by means of the ROC curve. Methods: This is an observational cohort study based on data collected in the PROFUND-IC study, a nationwide multicentric registry of patients admitted with decompensated heart failure. Data were collected from these patients between October 2020 and April 2022. Results: A total of 482 patients were entered into the PROFUND-IC registry between October 2020 and April 2022. Bedside clinical ultrasound was performed during admission in 301 patients (64.3%). The number of patients with more than 6 B-lines on lung ultrasound amounted to 194 (66%). Statistically significant differences in 30-day mortality (22.1% vs. 9.2%; p = 0.01) were found in these patients. The sum of patients with IVC collapsibility of less than 50% amounted to 195 (67%). Regarding prognostic value, collapsibility data were significant for the number of admissions in the last year (12.5% vs. 5.5%; p = 0.04), in-hospital mortality (10.1% vs. 3.3%, p = 0.04) and 30-day mortality (22.6% vs. 8.1%; p < 0.01), but not for readmissions. Regarding the prognostic value of IVC diameter for 30-day mortality, the area under the ROC curve (AUC) was 0.73, with a p < 0.01. The curve cut-off point with the highest sensitivity (70%) and specificity (70.3%) was for an IVC value of 22.5 mm. In the logistic regression analysis, we observed that the variable most associated with patient survival at 30 days was the presence of a collapsible inferior vena cava, with more than 50% OR 0.359 (CI 0.139–0.926; p = 0.034). Conclusions: The subgroups of patients analyzed with more than six B lines per field and IVC collapsibility less than or equal to 50%, as measured by clinical ultrasound, had higher 30-day mortality rates than patients who did not fall into these subgroups. IVC diameter may be a good independent predictor of 30-day mortality in patients with decompensated heart failure. Comparing both ultrasound variables, it seems that in our population, the assessment of the inferior vena cava may be more associated with short-term prognosis than the pulmonary congestion variables assessed by B lines.

Deprescription is the revision of the therapeutic plan with the aim of simplifying it, taking into account patient preferences, prognosis and environment. This strategy is particularly relevant in older patients, mostly polymedicated individuals, since they are exposed to numerous adverse effects and interactions and tend to have less adherence to treatments.To identify the deprescribing tools for older patients available in the scientific literature, classify them according to their design and describe their main features and potential applicability in clinical practice.A search was conducted in PubMed and EMBASE for relevant literature published before July 2021. The PRISMA-ScR method was applied, extracting variables related to study and tool characteristics as well as potential clinical applicability. The main inclusion criteria were studies focused on designing or developing deprescribing tools for older patients and those that indicated the features of the deprescribing tool used in detail.Fourteen of 723 papers met the inclusion criteria, and 12 tools were identified: 6 "algorithm-based tools" and 6 "criterion-based tools". Though all tools are aimed at older patients, there are certain peculiarities regarding their design, population, application setting and variables included. Of the 6 criterion-based tools found, 4 used the Delphi method for their design and development. Furthermore, most of them agree on the pharmacological groups that are likely to be deprescribed.Taking into account the importance of the clinical situation and priorities in the care plan in the deprescribing process, the authors believe that tools which help to evaluate these aspects are the most suitable for application in clinical practice. However, it is necessary to continue studying applicability in real-life clinical scenarios and to obtain health results.

The value of serial lung ultrasound (LUS) in patients with COVID-19 is not well defined. In this multicenter prospective observational study, we aimed to assess the prognostic accuracy of serial LUS in patients admitted to hospital due to COVID-19. The serial LUS protocol included two examinations (0–48 h and 72–96 h after admission) using a 10-zones sequence, and a 0 to 5 severity score. Primary combined endpoint was death or the need for invasive mechanical ventilation. Calibration (Hosmer–Lemeshow test and calibration curves), and discrimination power (area under the ROC curve) of both ultrasound exams (SCORE1 and 2), and their difference (DIFFERENTIAL-SCORE) were performed. A total of 469 patients (54.2% women, median age 60 years) were included. The primary endpoint occurred in 51 patients (10.9%). Probability risk tertiles of SCORE1 and SCORE2 (0–11 points, 12–24 points, and ≥25 points) obtained a high calibration. SCORE-2 showed a higher discrimination power than SCORE-1 (AUC 0.72 (0.58–0.85) vs. 0.61 (0.52–0.7)). The DIFFERENTIAL-SCORE showed a higher discrimination power than SCORE-1 and SCORE-2 (AUC 0.78 (0.66–0.9)). An algorithm for clinical decision-making is proposed. Serial lung ultrasound performing two examinations during the first days of hospitalization is an accurate strategy for predicting clinical deterioration of patients with COVID-19.

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.

[EN] Background and objective: The objective of the study was to evaluate the effects of a multidisciplinary intervention on the outcomes of polypathological patients (PP). Methods: A multicenter quasi-experimental pre-post study with a 12-month follow up was performed. In-hospital, at discharge and outpatient clinics patients who met criteria of PP between March 2012 and October 2013 were included. The multidisciplinary approach was defined by 11 interventions performed by general practitioners, internal medicine physicians, team care nurses and hospital pharmacists. The primary outcome was reduction in the number of hospital admissions and days of hospitalization. Secondary outcomes included mortality and the effects of 11 interventions on mortality. Results: 420 patients were included. Mean patient age was 77.3 (SD: 8.90) and average number of PP defining categories was 2.99 (SD: 1.00). Number of hospital admissions and days of hospitalization decreased significantly after intervention: 1.52 (SD: 1.35) versus 0.82 (SD: 1.29), p < 0.001, and 13.77 (SD: 15.20) versus 7.21 (SD: 12.90), p < 0.001 respectively. 12-month mortality was 37.7%. PP who failed to receive a structured medical visit from the internal medicine physician and educational workshops from the team care nurses had a higher risk of exitus in the next 12 months, HR: 1.68; 95% CI: 1.15–2.46, p = 0.007 and HR: 2.86; 95% CI: 1.92–4.27, p < 0.001, respectively. Conclusions: This multidisciplinary intervention reduced the risk of PP hospital admission and days of hospitalization. Educational workshop programs for PP and their caregivers and structured IM medical visits were associated with improvements of survival., [ES] Introducción y objetivo: El objetivo del estudio fue evaluar los resultados en salud tras la implantación de una intervención multidisciplinar a pacientes pluripatológicos (PP). Metodología: Se realizó un estudio multicéntrico antes-después cuasi-experimental, con seguimiento a 12 meses. Se incluyeron pacientes que cumplían los criterios de PP entre marzo de 2012 y octubre de 2013, tanto en el ámbito hospitalario como en atención primaria. El enfoque multidisciplinar fue definido por 11 intervenciones realizadas por médicos de familia, médicos internistas, enfermeras y farmacéuticos hospitalarios. El resultado fundamental fue la reducción en el número de ingresos hospitalarios y días de hospitalización al año de seguimiento. Los resultados secundarios incluyeron la mortalidad y los efectos de las intervenciones sobre la misma. Resultados: Se incluyeron 420 pacientes. La edad media de los pacientes fue de 77,3 (DE: 8,90) y la media de categorías definitorias de PP fue de 2,99 (DE: 1,00). El número de ingresos hospitalarios y los días de hospitalización disminuyeron significativamente después de la intervención: 1,52 (DE: 1,35) versus 0,82 (DE: 1,29), p < 0,001 y 13,77 (DE: 15,20) versus 7,21 (DE: 12,90), p < 0,001, respectivamente. La mortalidad a los 12 meses fue del 37,7%. Los PP que no recibieron la visita médica estructurada del médico internista tras la inclusión y los talleres educativos de las enfermeras tuvieron un mayor riesgo de exitus en los 12 meses de seguimiento, HR: 1,68; IC del 95%: 1,15-2,46, p = 0,007 y HR: 2,86; IC del 95%: 1,92-4,27, p < 0,001, respectivamente. Conclusiones: Esta intervención multidisciplinaria reduce el riesgo de ingreso y los días de ingreso hospitalario en PP. Los programas de talleres educativos para PP y sus cuidadores, y las visitas médicas estructuradas por parte de medicina interna se asociaron con una mayor supervivencia.

ObjectivesDespite the demonstrated efficacy of physiotherapy in palliative care programmes, there are scarce data of its real-life impact on patients’ and caregivers’ wellness and stress. Our aim was to assess effectiveness of a 30-day physiotherapy programme in psychological wellness and health-related quality of life (HRQoL) of patients with advanced chronic diseases or cancer and in their caregivers’ stress.MethodsQuasiexperimental before–after study applying personalised kinesitherapy, exercise with curative effects, respiratory physiotherapy, therapeutic massages and ergotherapy. Psychological wellness, HRQoL and caregiver’s strain outcomes were measured.Results207 patients (60% men, with a mean age of 73.6±12 years) were included; 129 (62.3%) with advanced cancer, and the remaining 78 with advanced chronic diseases. Psychological wellness (Emotional Stress Detection Tool decreased from 12.4±3 to 11±3; pConclusionsA personalised physiotherapy programme incorporated to integral palliative care improved psychological wellness, HRQoL and caregivers’ strain of patients with advanced chronic diseases and cancer.

SEMI‐COVID‐19 Network.-- This article also appears in: COVID-19 and Long-term Care, COVID-19 Collection., This letter comments on the article by Joseph Ouslander.

Background Nursing homes are highly vulnerable to the occurrence of COVID-19 outbreaks, which result in high lethality rates. Most of them are not prepared to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Method A coordinated on-site medicalization program (MP) in response to a sizeable COVID-19 outbreak in 4 nursing homes was organized, with the objectives of improving survival, offering humanistic palliative care to residents in their natural environment, and reducing hospital referrals. Ten key processes and interventions were established (provision of informatics infrastructure, medical equipment, and human resources, universal testing, separation of “clean” and “contaminated” areas, epidemiological surveys, and unified protocols stratifying for active or palliative care approach, among others). Main outcomes were a composite endpoint of survival or optimal palliative care (SOPC), survival, and referral to hospital. Results Two hundred and seventy-two of 457 (59.5%) residents and 85 of 320 (26.5%) staff members were affected. The SOPC, survival, and referrals to hospital occurred in 77%, 72.5%, and 29% of patients diagnosed before the start of MP, with respect to 97%, 83.7%, and 17% of those diagnosed during the program, respectively. The SOPC was independently associated to MP (OR = 15 [3–81]); and survival in patients stratified to active approach, to the use of any antiviral treatment (OR = 28 [5–160]). All outbreaks were controlled in 39 [37–42] days. Conclusions A coordinated on-site MP of nursing homes with COVID-19 outbreaks achieved a higher SOPC rate, and a reduction in referrals to hospital, thus ensuring rigorous but also humanistic and gentle care to residents.

Background: The presence of oxidative stress, telomere shortening, and apoptosis in polypathological patients (PP) with sarcopenia and frailty remains unknown. Methods: Multicentric prospective observational study in order to assess oxidative stress markers (catalase, glutathione reductase (GR), total antioxidant capacity to reactive oxygen species (TAC-ROS), and superoxide dismutase (SOD)), absolute telomere length (aTL), and apoptosis (DNA fragmentation) in peripheral blood samples of a hospital-based population of PP. Associations of these biomarkers to sarcopenia, frailty, functional status, and 12-month mortality were analyzed. Results: Of the 444 recruited patients, 97 (21.8%), 278 (62.6%), and 80 (18%) were sarcopenic, frail, or both, respectively. Oxidative stress markers (lower TAC-ROS and higher SOD) were significantly enhanced and aTL significantly shortened in patients with sarcopenia, frailty or both syndromes. No evidence of apoptosis was detected in blood leukocytes of any of the patients. Both oxidative stress markers (GR, p = 0.04) and telomere shortening (p = 0.001) were associated to death risk and to less survival days. Conclusions: Oxidative stress markers and telomere length were enhanced and shortened, respectively, in blood samples of polypathological patients with sarcopenia and/or frailty. Both were associated to decreased survival. They could be useful in the clinical practice to assess vulnerable populations with multimorbidity and of potential interest as therapeutic targets.

© 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.

Background Drug interactions (DIs) are a significant cause of medication-related problems. The aging population, high chronic diseases prevalence and polypharmacy are closely associated factors. Aim of the review To study the prevalence, types and associated factors of DIs in multimorbidity patients of over 65 years of age in primary care. Methods Relevant studies on DI prevalence in this population were reviewed in PubMed, Cochrane Library and EMBASE (January 2000-December 2015). Independent variables (duration, target population, age, sex, mean of drugs and diseases, geographical localization, DI databases used and study designs) and dependent variables (prevalence, number of DIs per 100 patients and per patient, number of clinically-relevant DIs per 100 patients, most common DI and associated factors) were classified for each article. Results The search generated 749 articles and 46 duplicates were discarded. After reviewing, 10 articles were included. Seven studies were observational and 3 were quasi-experimental. Seven out of 10 used interaction databases. Only 2 studies described both actual and potential DIs. The prevalence of multimorbidity patients with DI ranged from 25.1 to 100% and the number of DIs per 100 patients was from 30 to 388.3. All the lower values correspond to the study conducted at the nursing home. This could be due to special care offered in these centres, where the medication is more controlled. The most frequent DIs were reported in five articles. However, these results could not be correlated since they were ranked using different methodologies. ACEIs, diuretics and NSAID were the most common therapeutic groups. Finally, 5 studies identified factors associated with the presence of potential DIs. The number of drugs and age were the most significant factors. Conclusions There is little evidence of prevalence of actual and potential DIs in elderly patients with multimorbidity in outpatient settings, showing widely heterogeneous results.

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.

It is unknown whether the digital application of automated ICD-9-CM codes recorded in the medical history are useful for a first screening in the detection of polypathological patients. In this study, the objective was to identify the degree of intra- and inter-observer concordance in the identification of in-patient polypathological patients between the standard clinical identification method and a new automatic method, using the basic minimum data set of ICD-9-CM codes in the digital medical history. For this, a cross-sectional multicenter study with 1518 administratively discharged patients from Andalusian hospitals during the period of 2013&ndash, 2014 has been carried out. For the concordance between the clinical definition of a polypathological patient and the polypathological patient classification according to ICD-9-CM coding, a 0.661 kappa was obtained (95% confidence interval (CI), 0.622&ndash, 0.701) with p &lt, 0.0001. The intraclass correlation coefficient between both methods for the number of polypathological patient categories was 0.745 (95% CI, 0.721&ndash, 0.768, p &lt, 0.0001). The values of sensitivity, specificity, positive-, and negative predictive values of the automated detection using ICD-9-CM coding were 78%, 88%, 78%, and 88%, respectively. As conclusion, the automatic identification of polypathological patients by detecting ICD-9-CM codes is useful as a screening method for in-hospital patients.

The prevalence, relationships and outcomes of sarcopenia and frailty in polypathological patients remain unknown. We performed a multicenter prospective observational study in six hospitals in order to assess prevalence, clinical features, outcome and associated risk factors of sarcopenia and frailty in a hospital-based population of polypathological patients. The cohort was recruited by performing prevalence surveys every 14 days during the inclusion period (March 2012&ndash, June 2016). Sarcopenia was assessed by means of EWGSOP criteria and frailty by means of Fried&rsquo, s criteria. Skeletal muscle mass was measured by tetrapolar bioimpedanciometry. All patients were followed for 12 months. Factors associated with sarcopenia, frailty and mortality were analyzed by multivariate logistic regression, and Kaplan&ndash, Meier curves. A total of 444 patients (77.3 &plusmn, 8.4 years, 55% males) were included. Sarcopenia was present in 97 patients (21.8%), this being moderate in 54 (12.2%), and severe in 43 (9.6%), frailty was present in 278 patients (62.6%), and 140 (31.6%) were pre-frail, combined sarcopenia and frailty were present in the same patient in 80 (18%) patients. Factors independently associated to the presence of both, sarcopenia and frailty were female gender, older age, different chronic conditions, poor functional status, low body mass index, asthenia and depressive disorders, and low leucocytes and lymphocytes count. Mortality in the 12-months follow-up period was 40%. Patients with sarcopenia, frailty or both survived significantly less than those without these conditions. Sarcopenia and frailty are frequent and interrelated conditions in polypathological patients, shadowing their survival. Their early recognition and management could improve health-related outcomes in this population.

BACKGROUND The increasing incidence of osteoporotic hip fracture (HF) has raised the requirements of red blood cell (RBC) transfusions, whereas this scarce resource may cause morbidity and mortality. STUDY DESIGN AND METHODS This study was a multicenter, randomized, double-blind, clinical trial that aimed to assess efficacy of ferric carboxymaltose (FCM) with or without erythropoietin (EPO) in reducing RBC transfusion in the perioperative period of HF. Participants (patients > 65 years admitted with HF and hemoglobin [Hb] levels of 90-120 g/L) were randomly assigned to receive a preoperative single dose of 1 g of FCM (short intravenous [IV] infusion over 15 min), plus 40,000 IU of subcutaneous EPO (EPOFE arm); versus 1 g of IV FCM plus subcutaneous placebo (FE arm); and versus IV and subcutaneous placebo (placebo arm). Primary endpoint was the percentage of patients who received RBC transfusion, and secondary endpoints were the number of RBC transfusions per patient, survival, hemoglobinemia, and health-related quality of life (HRQoL; by means of Short Form 36 Version 2 questionnaire). RESULTS A total of 306 patients (85% women, mean age 83 ± 6.5 years) were included. A total of 52, 51.5, and 54% of patients required RBC transfusion in the EPOFE, FE, and placebo arms, respectively, with no significant differences in the number of RBC transfusions per patient, survival, HRQoL, and adverse events among treatment groups. A significant increase in Hb levels was achieved at discharge (102 g/L vs. 97 g/L) and 60 days after discharge (125 g/L vs. 119 g/L) in the EPOFE arm with respect to placebo arm; in addition, a higher rate of patients recovered from anemia in the EPOFE arm with respect to the placebo arm (52% vs. 39%), 60 days after discharge. CONCLUSION Preoperative treatment with FCM alone or in combination with EPO improved recovery from postoperative anemia, but did not reduce the needs of RBC transfusion in patients with HF.

Graphical abstract, Highlights • Elderly people living in nursing-homes are at high-risk of suffering COVID-19. • Scarce information about their death-risk scoring is available to guide clinicians' decisions. • Accuracy of COVID-19 prognostic scores, CURB-65, Charlson and PROFUND were assessed. • CURB-65 and PROFUND showed the highest accuracy. • Charlson and COVID-19 specific tools lacked enough accuracy for this population., Elderly people are more severely affected by COVID-19. Nevertheless scarce information about specific prognostic scores for this population is available. The main objective was to compare the accuracy of recently developed COVID-19 prognostic scores to that of CURB-65, Charlson and PROFUND indices in a cohort of 272 elderly patients from four nursing homes, affected by COVID-19. Accuracy was measured by calibration (calibration curves and Hosmer-Lemeshov (H-L) test), and discriminative power (area under the receiver operation curve (AUC-ROC). Negative and positive predictive values (NPV and PPV) were also obtained. Overall mortality rate was 22.4 %. Only ACP and Shi et al. out of 10 specific COVID-19 indices could be assessed. All indices but CURB-65 showed a good calibration by H-L test, whilst PROFUND, ACP and CURB-65 showed best results in calibration curves. Only CURB-65 (AUC-ROC = 0.81 [0.75–0.87])) and PROFUND (AUC-ROC = 0.67 [0.6–0.75])) showed good discrimination power. The highest NPV was obtained by CURB-65 (95 % [90–98%]), PROFUND (93 % [77–98%]), and their combination (100 % [82–100%]); whereas CURB-65 (74 % [51–88%]), and its combination with PROFUND (80 % [50–94%]) showed highest PPV. PROFUND and CURB-65 indices showed the highest accuracy in predicting death-risk of elderly patients affected by COVID-19, whereas Charlson and recent developed COVID-19 specific tools lacked it, or were not available to assess. A comprehensive clinical stratification on two-level basis (basal death risk due to chronic conditions by PROFUND index, plus current death risk due to COVID-19 by CURB-65), could be an appropriate approach.

Resumen Objetivos Analizar el perfil de prescripcion farmacologica y los factores asociados a polifarmacia en pacientes con enfermedades cronicas no neoplasicas en fase avanzada. Material y metodos Estudio observacional transversal, multicentrico, realizado en 41 hospitales espanoles (proyecto PALIAR). Se definio polifarmacia como el consumo habitual de 5 o mas farmacos en los ultimos 3 meses y polifarmacia excesiva cuando dicho numero era de 10 o mas. El grado de adherencia fue evaluado mediante una encuesta rellenada por el paciente o su cuidador. Se analizaron los factores relacionados con la polifarmacia y la no adherencia al tratamiento. Resultados De 1.847 pacientes, completaron la encuesta 1.778 (96,2%). La edad media fue 78,74 ± 10 anos. Los farmacos mas prescritos fueron: antihipertensivos (82,6%), gastroprotectores (73,8%), antiagregantes/anticoagulantes (70,3%) y psicotropicos (51,8%). La prevalencia de polifarmacia/polifarmacia-severa fue de 86,2-31,3% (consumo medio: 8 ± 3,5 farmacos). El 48,2% reconocia cometer errores en la toma: el 38,5% ocasionalmente y el 9,6% casi diariamente o siempre. La no-adherencia se relaciono con: cumplir criterios de paciente pluripatologico, > 3 ingresos en los ultimos 3 meses, deterioro cognitivo y la toma de > 5 farmacos. La polifarmacia se asocio con cumplir criterios de paciente pluripatologico, puntuacion ECOG 3 ingresos en los ultimos 3 meses. La polifarmacia severa se relaciono con cumplir criterios de paciente pluripatologico y > 3 ingresos en los ultimos 3 meses. Conclusiones La prevalencia de polifarmacia y errores en administracion de farmacos en pacientes con enfermedades medicas avanzadas es elevada, por lo que es necesario desarrollar estrategias para mejorar la adherencia en esta poblacion.

The management of patients with comorbidity and polypathology represents a challenge for all healthcare systems. Clinical practice guidelines (CPGs) have limitations when applied to this population. The aim of this study is to propose the terminology and methodology for optimally approach comorbidity and polypathology in the CPGs. Based on a literature review, we suggest a number of proposals for the approach in different phases of CPG preparation, with special attention to the inclusion of clusters of comorbidity in the initial questions the implementation of indirect evidence, the burden of disease management for patients and their environment, when establishing recommendations, as well as the strategies of dissemination and implementation. These proposals should be developed in greater depth with the implication of more agents in order to have valid and useful tools for this population.

Efforts in developing useful tools to properly identify the end-of-life trajectory of patients with advanced medical diseases have been made, but the calibration and/or discriminative power of these tools has not been optimal.Our objective was to develop a new, reliable prognostic tool to identify the probability of death within six months in patients with chronic medical diseases.This was a multicenter, prospective, observational study in 41 Spanish hospitals, which included 1778 patients with one or more of the following: advanced conditions such as heart failure, respiratory failure, chronic renal failure, chronic liver disease, and/or chronic neurological disease. All patients were followed over six months. Each factor independently associated with death in the derivation cohort (884 patients from eastern areas of Spain) was assigned a prognostic weight, and the score was calculated by summing up the factors. The score's accuracy in the validation cohort (894 patients from western areas of Spain) was assessed by analyzing its calibration and discriminative power; we also calculated sensitivity, specificity, and positive and negative predictive values.Mortality in the derivation/validation cohorts was 37.6%/37.7%, respectively. We identified six independent predictors of mortality (≥85 years, three points; New York Heart Association Class IV/Stage 4 dyspnea on the modified Medical Research Council, 3.5 points; anorexia, 3.5 points; presence of pressure ulcer(s), three points; Eastern Cooperative Oncology Group Performance Status of three or more, four points; and albuminemia ≤2.5g/dL, four points). Mortality in the derivation/validation cohorts according to risk group was 20%/21.5% for patients with zero points; 33%/30.5% for those with 3-3.5 points; 46.3%/43% for those with four to seven points; and 67%/61% for those who reached 7.5 or more points, respectively. The calibration was good (Hosmer-Lemeshow test, P=0.39), as was the discriminative power (area under the receiver operating characteristic curve of 0.69 [0.66-0.72]). The sensitivity (85%), specificity (86%), positive and negative predictive values (64% and 80%, respectively) at 180 days were high.The PALIAR score is a precise and reliable tool for identifying the end-of-life trajectory in patients with advanced medical diseases.

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.

Many patients with non-neoplastic disease develop atrial fibrillation in advanced stages of their disease. The aim of this study is to determine the factors associated with the use of oral anticoagulants in patients with atrial fibrillation and non-neoplastic medical disease in a terminal stage, and whether their use is associated with a longer survival. Design is prospective, observational, multicentre study. Patients with atrial fibrillation and non-neoplastic disease (severe not reversible organ insufficiency) in a terminal stage were included between February 2009 and September 2010. A 6-month follow-up was carried out. We included 314 patients with a mean (SD) age of 82.6 (7.0) years. Their mean (SD) scores in CHADS2 and ATRIA scales were 3.4 (1.2) and 4.7 (2.0), respectively. Anticoagulants were prescribed to 112 (37.5 %) patients. The use of anticoagulants was associated with age (OR 0.96 95 % CI 0.93-0.99, p = 0.046) and to the Barthel index (OR 1.01 95 % CI 1.00-1.02; p = 0.034). After performing a propensity score matching analysis, 262 patients were included in the survival analysis. After 6 months, 133 (50.8 %) patients were dead. The mortality is higher among patients who are not treated with oral anticoagulants (57.1 vs. 39.4 %; p = 0.006), but it is independently associated only with the Barthel index score (HR 0.99 95 % CI 0.98-1.00; p = 0.039), delirium (HR 1.60, 95 % CI 1.08-2.36; p = 0.018), anorexia (HR 1.58 95 % CI 1.05-2.38; p = 0.027), and with the use of calcium channel blockers (HR 0.50 95 % CI 0.30-0.84; p = 0.009). In patients with atrial fibrillation and non-neoplastic disease in a terminal stage, the use of oral anticoagulants is not independently associated with a higher probability of survival.

PurposeMany countries around the world have been undertaking initiatives to promote the improvement of care for people with chronic diseases. The purpose of this article is to showcase some of the innovations developed in Spain, with emphasis on the societal burden of chronicity and the emergent challenge of polypathology.MethodsThe database of the Observatory of Innovative Practices on Complex Chronic Disease Management (known in Spanish as OPIMEC and available at www.opimec.org) was used to identify innovations in Spain. Those that met five requirements were selected for this article. The person in charge of each innovation selected was contacted and asked to provide further information. All data gathered were organized in a similar way to facilitate a better understanding.FindingsSix out of 45 potentially eligible innovations were selected. The innovations are related to strategies, predictive tools, case management, home care and patient education.ConclusionThe innovations showed in this artic...

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: Little is known about the prevalence and impact of cognitive impairment in polypathological patients (PPs). Objectives: To assess the prevalence of cognitive impairment (CI) and delirium, their associated risk factors, and their impact on survival of a multicenter population of PPs. Methods: Prospective cohort study. Descriptive analysis of the prevalence, main clinical features of PPs with basal CI (by means of Short Portable Mental Status Questionnaire), and delirium (Confusion Assessment Method); and bivariate as well as multivariate assessment of the factors associated with both conditions. Survival analysis after 12 months follow-up by means of Kaplan–Meier curves, and multivariate analysis of mortality risk factors in PPs with CI, and those with delirium. Results: CI was present in 39% [28% mild to moderate (3–7 errors), and 11% severe (≥ 8 errors)] of the 1434 PPs assessed [in the remaining 11% (n=198) delirium was detected]; only 26% of them had been previously diagnosed with dementia. One-year mortality was 46%/31.4% in those with/without CI [p 2 mg/dL [p=0.003; RR=7.8 (2–26)], and polypharmacy [p=0.0019; RR=3.1 (1.2–8.1)]. Conclusion: CI, as well as delirium, is common in PPs. Both play a deleterious role in 12-month survival. A systematic cognitive assessment as well as prevention and early detection of delirium should be included in the clinical care of all PPs.

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 Objetivo Estudiar la asociacion entre diferentes comorbilidades y condiciones clinicas con la mortalidad en pacientes pluripatologicos (PPP) con enfermedad pulmonar obstructiva cronica (EPOC). Pacientes y metodos Estudio observacional, prospectivo y multicentrico. Se han incluido pacientes consecutivos con EPOC y criterios de PPP. Se han recogido las variables: edad, sexo, indice de Charlson, comorbilidades, indice de Barthel, indice de Lawton-Brody, test de Pfeiffer, escala de Gijon, nivel de educacion, hospitalizaciones en los ultimos 3 y 12 meses y supervivencia al cabo de un ano. Mediante un analisis univariante y una regresion logistica se ha establecido la relacion de las variables con la mortalidad. Resultados Se han incluido 688 PPP con EPOC con edad media 77,9 anos. La puntuacion media (DE) en el indice de Charlson fue 3,99 (2,07). Las comorbilidades mas frecuentes son insuficiencia cardiaca (59%), diabetes (48%), infarto de miocardio (29,4%), insuficiencia renal moderada (22%), enfermedad cerebrovascular (19%), hipertension arterial (71%), anemia (62%), fibrilacion auricular (34%), dislipemia (28%) y obesidad (21%). El 26% tenia dependencia para las actividades basicas de la vida diaria, el 47% precisaba de un cuidador y el 54% tenia riesgo de problema social. Al cabo de un ano fallecieron 258 pacientes (37%). El indice de Charlson, la dependencia para las actividades de la vida diaria y la anemia se asocian con una mayor mortalidad y la hipertension arterial y saber leer y escribir con menor mortalidad. Conclusiones La comorbilidad y la discapacidad son dos factores pronosticos en los pacientes con EPOC.

The objective was to determine perceived quality of care (PQC) in patients with multiple chronic conditions, whose care is structured in Andalusia (Spain) under polypathological patients (PP) care process, and identifying aspects for its improvement. The study was a community-based cross-sectional survey carried out in 4 primary care centers (which attended a total of 62,702 adults, of them, 662 were actively identified as PP). Finally, 461 PP and their caregivers were interviewed (69% of eligible population) including assessment of PQC following SERVQUAL model, clinical and demographical data. On a five-point Likert scale (from 1, 'much worse than expected'; to 5, 'much better'), PQC rated 3.68±0.59 (±S.D.). Independent PQC predictors were: empathy for family physician, identifying nurses, presence of peripheral artery disease or diabetes mellitus with vascular complications, and not having functional limitations. In this population-based survey, PP attended at primary care have an acceptable PQC. Measures aimed to lessening functional deterioration, supporting dependent patients, and improving relationship between PP and their healthcare professionals could increase PQC.

Resumen Objetivos Conocer la prevalencia de los factores de riesgo vascular (FRCV) y de enfermedad cardiovascular, y evaluar el tratamiento de los mismos en una poblacion multicentrica de pacientes pluripatologicos (PPP). Pacientes y metodo Estudio longitudinal en 36 hospitales (febrero de 2007 – junio de 2008). Analisis descriptivo de los FRCV y enfermedades cardiovasculares, y de la prescripcion de farmacos, asi como de los factores asociados a la polifarmacia. Resultados Se incluyeron 1.632 PPP, con una edad media de 77,9 ± 9,8 anos. La prevalencia de FRV fue: hipertension arterial 71,8%; obesidad 70,5%; diabetes mellitus 45,6% (36,4% con repercusion visceral); dislipemia 28,9% y tabaquismo 6,1%. La prevalencia de e nfermedad cardiovascular fue: insuficiencia cardiaca 37%; cardiopatia isquemica 20,7% y ambas el 20,9%; enfermedad cerebrovascular 25,8%; y arteriopatia periferica sintomatica 13,1%. La prevalencia de polifarmacia fue del 85,6% con un 63% de pacientes que recibian tratamiento hipolipemiante, 84% hipoglucemiante y 93% antihipertensivos, aunque solo el 28% de los pacientes con insuficiencia cardiaca tenian prescritos IECA/ARAII + betabloqueantes + diureticos. Los factores asociados a la polifarmacia fueron la existencia de cardiopatia o insuficiencia renal cronica, el indice de Charlson, el menor deterioro en la valoracion de las actividades instrumentales y el numero de ingresos en los 12 meses previos. Conclusiones Los FRV y las enfermedades cardiovasculares presentaron un notable protagonismo en los PPP. A pesar de la alta prevalencia de polifarmacia se ha detectado tratamiento suboptimo en alguna de las condiciones analizadas. El impacto positivo de la intensificacion de medidas de control de riesgo vascular en esta poblacion debe ser evaluado.

Little is known about the prevalence of the recently defined polypathology notion in hospital populations. Patients admitted to medical wards were assessed using established criteria of polypathology. Prevalence of polypathology, interobserver reliability, clinical features, nutritional status, and HRQoL were assessed using clinical data and interview, mini-nutritional assessment (MNA), and the 12-item short-form health survey (SF-12) scales. Of a total of 812 patients studied, 196 (24%) met polypathology criteria (65% men, of mean age 71.3 ± 11.6 years, mean defining chronic diseases 2.4 ± 0.046, and other comorbidities 2.6 ± 0.094). Interobserver reliability for the detection of cases was good (κ = 0.628). Their mean Charlson index/prescribed drugs were 3.3/6, respectively. Severe dyspnea, delirium, or active neoplasia were present in 44, 15, and 11%. A bad nutritional status/risk of malnutrition was evident in 10.3/52.6%, and correlated with the number of previous hospitalizations (p = 0.041), and the presence of active neoplasia (p = 0.037). Mean physical/mental summaries of HRQoL were 33.9 ± 10, and 42 ± 13, and correlated with a better nutritional status (p = 0.011, and p = 0.001, respectively). Polypathology affects one quarter of inpatients in a hospital setting, and can be easily and reliably identified. The diversity and complexity of patient needs underscore the need for continuity of care between community and hospital, crossing sub-speciality lines and institutional boundaries.

Introduccion La fiebre de duracion intermedia (FDI) es una causa importante de fiebre. Las etiologias mas importantes no estan bien definidas en la actualidad. Metodos Estudio prospectivo de los casos de FDI atendidos entre 1983�1989 y 2004�2005. Se realizaron cultivos y estudios serologicos para la deteccion de Brucella melitensis, Coxiella burnetii, Rickettsia typhi, Rickettsia conorii, citomegalovirus y virus de Epstein-Barr en todos los pacientes. Se llevaron a cabo otros estudios microbiologicos, serologicos, radiologicos y pruebas invasivas adicionales segun el criterio del clinico responsable. Resultados En el periodo de 1983 a 1989 se incluyeron 505 pacientes y 179 desde 2004 a 2005. Se alcanzo un diagnostico etiologico en 410 (81,1%) y 109 (60,9%), respectivamente. La causa de FDI fue infecciosa en 389 pacientes del primer periodo (94,8% del total de pacientes con diagnostico etiologico) y 92 del segundo (84,4%). La mayoria fueron infecciones sistemicas, 328 (80%) en 1983�1989 y 74 (67,8%) en 2004�2005, seguidas de infecciones focales, 9,5% y 16,5%, respectivamente. La fiebre Q fue la etiologia mas frecuente en ambos periodos. En 2004�2005, la brucelosis disminuyo mientras que la infeccion por el VIH se mostro como una causa emergente de FDI. El origen de la FDI fue no infeccioso en el 5,1% y el 15,5% de los casos, respectivamente. Conclusiones La fiebre Q es la causa mas frecuente de FDI en el sur de Espana. Son necesarios estudios prospectivos mas amplios para identificar los cambios en el espectro etiologico de esta entidad. Infecciones virales, como la infeccion por el VIH, deben ser contempladas como causa de FDI.

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.

Resumen Objetivos Determinar la prevalencia de interacciones medicamentosas en pacientes pluripatologicos polimedicados y los factores asociados. Como objetivo secundario determinamos la aceptacion de un programa de notificacion de interacciones medicamentosas con recomendaciones dirigido a los facultativos prescriptores. Sujetos y metodos Estudio transversal en 3 centros de salud del area sanitaria de un hospital universitario. Se incluyeron todos los pacientes pluripatologicos a quienes se les habia recomendado 5 o mas farmacos diferentes de forma simultanea. Las interacciones medicamentosas se detectaron mediante el programa Drug-Reax System® (Micromedex), Bot del Consejo General de Colegios Oficiales de Farmaceuticos de Espana, o mediante busqueda bibliografica. Fueron seleccionadas como relevantes aquellas interacciones medicamentosas consideradas por los investigadores farmaceuticos como susceptibles de intervencion. La aceptacion del programa de notificacion de interacciones medicamentosas se evaluo mediante una encuesta dirigida a los facultativos de atencion primaria («aceptable», recomendacion oportuna que potencialmente puede modificar el tratamiento). Resultados Fueron incluidos 283 pacientes pluripatologicos polimedicados, con una edad media de 74,5 anos (rango 43–100 anos). La media de condiciones patologicas por paciente fue de 2,5 y de prescripciones de 9,7. De un total de 2.748 prescripciones medicamentosas se identificaron 1.053 interacciones medicamentosas que afectaron a 250 enfermos (96,5%). Se consideraron interacciones relevantes el 45%. La presencia de cardiopatia isquemica, haber estado ingresado en 2 o mas ocasiones y recibir 7 o mas prescripciones se asocio con la presencia de interacciones medicamentosas. Desde el servicio de farmacia se emitieron 177 notificaciones para otros tantos facultativos responsables de cada paciente que contenian 473 recomendaciones sobre las interacciones detectadas. Un 72% de las recomendaciones ofrecidas desde Farmacia fueron respondidas y se consideraron «aceptables» el 84% de estas. Conclusiones Casi la totalidad de los pacientes pluripatologicos polimedicados estan expuestos a interacciones medicamentosas y de ellas, aproximadamente un 60% requiere alguna intervencion. La notificacion personalizada de interacciones a los medicos de atencion primaria es aceptada y puede ser una accion estrategica que mejore el cociente beneficio riesgo de la prescripcion farmacologica.