[Deprescription in old people: It's time to take action]. / Deprescripción en personas mayores: es el momento de pasar a la acción.

The use of drugs has undeniable benefits to the elderly, but it is not exempt from undesirable effects. Deprescription is the process of systematic medication review with the target of achieving the best risk-benefit ratio based on the best available evidence. This process is especially important for polymedicated elderly patients as well as those overtreated, frail, terminally ill and at the end of life. The deprescription must be done in stages, establishing a close follow-up in case problems appear after withdrawal. In the decision-making process, it is very important to consider the patient and caregivers opinion, assessing the objectives of the treatment according to the clinical, functional and social situation of the patient. There are multiple tools to make it easier for clinicians to select which drugs to deprescribe (Beers criteria, STOPP-START…). The most susceptible to intervention pharmacological groups are: antihypertensives, antidiabetics, statins, benzodiazepines, antidepressants, anticholinergics, anticholinesterase agents, and neuroleptics.

[Clinical and epidemiological characteristics of SARS-CoV-2 infections in family physicians: A case-control study]. / Características clínico-epidemiológicas de la infección por el virus SARS-CoV-2 en médicos de familia: un estudio de casos y controles.

OBJECTIVE: To identify the sociodemographic, clinical and epidemiological characteristics associated with the presence of infection by the SARS-CoV-2 virus in family physicians who carry out their work in Primary Care (PC) or in Hospital Emergencies. DESING: Observational analytical case-control study. SITE: Primary care. PARTICIPANTS: 969 Primare Care Physicians, Hospital Emergency physicians and other extrahospitalry centers that had PCR for the detection of the SARS-CoV-2. Of these, 133 participated as cases (PCR positive) and 836 as controls (PCR negative). INTERVENTIONS: No. MAIN MEASUREMENTS: Sociodemographic and work, contact with a COVID-19 patient, symptoms present during the process, first manifested symptom, previous chronic pathologies, and tobacco use. RESULTS: 13.7% (95% CI: 11.6-16.0) were cases infected with SARS-CoV-2. The most frequently declared symptoms by those infected were a feeling of fatigue/tiredness (69.2%; 95% CI: 60.9-77.4%), cough (56.4%; 95% CI: 47.6-65.2%) and headache (55.6%; 95% CI: 46.8-64.4%).Using logistic regression, the variables independently associated with SARS-CoV-2 virus infection in Family Physicians were: previous contact with a COVID-19 patient (OR: 2.3; 95% CI: 1.2-4.2), present fatigue / tiredness (OR: 2.2; 95% CI: 1.2-3.9), smell alteration (4.6; 95% CI: 1.7-12.5), taste alteration (OR: 32.0; 95% CI: 9.6-106.8), cough (OR: 3.0; 95% CI: 1.7-5.3) and fever (OR: 6.1; 95% CI: 3.2-11.4). CONCLUSIONS: Symptoms independently related to SARS-CoV-2 virus infection in Family Physicians were fatigue, fever, cough, and altered taste and smell. The presence of these symptoms could facilitate the diagnosis of suspected COVID-19 disease and the earlier selection of those that require confirmatory tests.

[Quality of life in people with depression and physical comorbidity from a gender perspective]. / Calidad de vida en personas con depresión y comorbilidad física desde una perspectiva de género.

OBJECTIVE: The aim of the study is to describe from a gender perspective how people with depression and physical comorbidity perceive their quality of life. The study included 380 people over 49 years of age with at least one of the following pathologies: diabetes, chronic obstructive pulmonary disease and ischemic heart disease. Participants were recruited from 31 teams the primary care of in Catalonia. Quality of life was measured using the EuroQol Scale. In addition, sociodemographic variables were collected, as well as the severity of depression, the index of economic deprivation and area of residence. The adjusted relationship between sex and dimensions of quality of life was assessed by means of multivariate logistic regression. RESULTS: 81.3% were women; the mean age was 68.4 years (SD: 8.8). The mean on the Visual Analogue Scale was 57.8 (SD: 17.4) in men and 55.8 (SD: 18.6) in women. The mean of the EQ-Health Index was 0.74 (SD: 0.17) in men and 0.65 (SD: 0.2) in women (p = 0.001). The probability of having problems of the EQ-5D showed sex as the most important factor (woman = 1/man = 0) in: self-care OR: 2.29 (95% CI 1.04-5.07) and daily activities OR: 3.09 (95% CI 1.67-5.71). Mobility was associated with age OR: 1.87 (95% CI 1.22-2.86), pain with area of residence OR: 2.51 (95% CI 1.18-5,34) and the BDI with anxiety/depression OR: 4,77 (95% CI 1.77-12,88). CONCLUSION: The perception quality of life of women with depression and physical comorbidity is lower than that of men and, in both cases, it is lower than that of the general population.

Comorbidities associated with maternal mortality from COVID-19 in Mexico.

INTRODUCTION: In Mexico, there is a syndemic in pregnant women, where the epidemic of obesity and chronic diseases coexists with that of coronavirus disease 2019 (COVID-19), which has been associated with a higher risk of maternal mortality. OBJECTIVE: To evaluate the association of comorbidities during pregnancy with maternal mortality from COVID-19 in Mexico. MATERIAL AND METHODS: SISVER COVID-19 databases and epidemiological surveillance reports on maternal mortality were used. Multivariate logistic regression models were used to evaluate the association of comorbidities with maternal deaths from COVID-19. RESULTS: A total of 29,416 pregnant women were evaluated, out of which 39% were positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); the risk of maternal mortality was 3.24 times higher (p < 0.01) for positive in comparison with negative women. COVID-19 is the leading cause of maternal death since July 2020 and explains more than 50% of total deaths in 2021. Chronic kidney disease (odds ratio [OR]: 4.11; p < 0.01) and diabetes (OR: 2.53; p < 0.01) were the two main comorbidities that were positively associated with maternal death from COVID-19. CONCLUSION: Comorbidities during pregnancy that are possibly associated with an increase in the inflammatory response and an alteration of the immune response increase the risk of maternal death from COVID-19 in Mexican pregnant women.

INTRODUCCIÓN: En México existe una sindemia en las mujeres gestantes, donde coexiste la epidemia de obesidad y enfermedades crónicas con la de enfermedad por coronavirus 2019 (COVID-19), lo que se ha asociado con un mayor riesgo de mortalidad. OBJETIVO: Evaluar la asociación de las comorbilidades en la mortalidad materna por COVID-19 en México. MATERIAL Y MÉTODOS: Se utilizaron las bases de datos de COVID-19 del SISVER y los reportes de vigilancia epidemiológica de muertes maternas. Se utilizaron modelos de regresión logística multivariante para evaluar la asociación de las comorbilidades durante la gestación con mortalidad materna por COVID-19. RESULTADOS: Se evaluaron 29,416 mujeres embarazadas, el 39% fueron positivas para coronavirus 2 del síndrome respiratorio agudo grave, el riesgo de mortalidad materna fue 3.24 veces mayor (p < 0.01) para las mujeres positivas en comparación con las negativas. La COVID-19 es la primera causa de muerte materna desde julio del 2020 y explica más del 50% del total de muertes en el 2021. La enfermedad renal crónica (razón de momios [RM]: 4.11; p < 0.01) y la diabetes (RM: 2.53; p < 0.01) fueron las dos principales comorbilidades asociadas positivamente a la mortalidad materna por COVID-19. CONCLUSIÓN: Las comorbilidades durante el embarazo posiblemente asociadas con un incremento de la respuesta inflamatoria y alteración de la respuesta inmunitaria incrementan el riesgo de muerte materna por COVID-19 en mujeres gestantes mexicanas.

Prevalence of the potential drug-drug interactions between pangenotypic direct-acting antivirals and the concomitant medications associated with patients with chronic hepatitis C virus infection in Spain. / Prevalencia de las potenciales interacciones medicamentosas entre los antivirales de acción directa pangenotípicos y la medicación concomitante asociada a los pacientes con infección del virus de la hepatitis C crónica en España.

OBJECTIVE: To determine the comorbidity and potential for drug-drug interactions (DDIs) among pangenotypic direct-acting-antivirals (pDAAs) and the concomitant medications associated with chronic hepatitis C (CHC) patients in routine clinical practice in Spain. METHODS: Retrospective observational study. Included patients were ≥18 years, diagnosed with CHC, on antiviral treatment and required medical attention during 2017. Two groups were differentiated according to age ranges (<50 and ≥50 years). The variables collected were: age, gender, general/specific comorbidity, concomitant medication and potential DDIs (www.hep-druginteractions.org). The pDAAs analysed were: a) Sofosbuvir/Velpatasvir (SOF/VEL), b) Glecaprevir/Pibrentasvir (GLE/PIB) and c) Sofosbuvir/Velpatasvir/Voxilaprevir (SOF/VEL/VOX). Bivariate statistical analysis, P<.05. RESULTS: 3,430 patients with a mean age of 56.9 years and 60.3% males were enrolled. The average Charlson index was 0.8. Age range distribution: 18-49 years (28.9%) and ≥50 years (71.1%). The average number of medications per patient/year was 3.1 (SD 2.6). The total percentage of potential DDIs was: 8.6% minor DDIs, 40.5% clinically significant DDIs and 10.0% contraindicated medication. These DDIs were greater in patients ≥50 years (8.6%, 43.8% and 12.4%, respectively, P<.001). For all ages, SOF/VEL showed a lower percentage of: minor interactions (1.3% vs. 6.6% and 5.9%, P<.001); clinically significant interactions (53.4%, vs. 77.4% and 66.3%, P<.001) and contraindicated medication (1.7% vs. 8.3% and 10.7%, P<.001) compared to GLE/PIB and SOF/VEL/VOX, respectively. CONCLUSIONS: Patients with CHC present high comorbidity and concomitant medication use, particularly elderly patients, thus implying a greater exposure to potential DDIs. Although the DDI rate was considerable with the three combinations analysed, SOF/VEL showed a lower number of clinically significant interactions.

Ethnic variance between Asian and European American women in a six month prospective model of eating disorder and social anxiety symptom comorbidity.

Eating disorders and social anxiety are highly comorbid. Understanding this comorbidity may improve treatment outcomes, as social anxiety can impair the ability to benefit from eating disorder treatment. The primary model of social anxiety and eating disorder comorbidity includes social appearance anxiety, high standards, and maladaptive perfectionism. In the current study, we tested for ethnic invariance between Asians (n = 82) and European Americans (n = 182) in a cross-sectional and prospective comorbidity model of social anxiety and eating disorder symptoms. Differences were found across ethnicity in eating disorder and social anxiety symptom comorbidity. Maladaptive perfectionism predicted social anxiety and eating disorder symptoms in European Americans, whereas social appearance anxiety predicted social anxiety and eating disorder symptoms in Asians. Our findings suggest that interventions for social anxiety and eating disorders in Asian populations may be improved by assessing and targeting social appearance anxiety, while maladaptive perfectionism should be targeted among European Americans.

Comorbidity, concomitant medication, use of resources and healthcare costs associated with chronic hepatitis C virus carriers in Spain. / Comorbilidad, medicación concomitante, uso de recursos y costes sanitarios asociados a los pacientes portadores del virus de la hepatitis C crónica en España.

OBJECTIVES: To assess the comorbidity, concomitant medications, healthcare resource use and healthcare costs of chronic hepatitis C virus patients in the Spanish population. PATIENTS AND METHODS: Retrospective, observational, non-interventional study. Patients included were≥18 years of age who accessed medical care between 2010-2013. Patients were divided into 2 groups based on the presence or absence of liver cirrhosis. The follow-up period was 12 months. Main assessment criteria included general comorbidity level (determined by the resource utilisation band score) and prevalence of specific comorbidities, concomitant medications, healthcare resource use and healthcare costs. Statistical analysis was performed using regression models and ANCOVA, P<.05. RESULTS: One thousand fifty-five patients were enrolled, the mean age was 57.9 years and 55.5% were male. A percentage of 43.5 of patients had a moderate level of comorbidity according to the resource utilisation band score. The mean time from diagnosis was 18.1 years and 7.5% of the patients died during the follow-up period. The most common comorbidities were dyslipidaemia (40.3%), hypertension (40.1%) and generalised pain (38.1%). Cirrhosis was associated with cardiovascular events (OR 3.8), organ failures (OR 2.2), alcoholism (OR 2.1), diabetes (OR 1.2) and age (OR 1.2); P<.05. The most commonly used medications were anti-infectives (67.8%) and nervous system medications (66.8%). The mean total cost per patient was 3,198€ (71.5% healthcare costs, 28.5% indirect/non-healthcare costs). In the corrected model, the total costs per patient-year were 2,211€ for those without cirrhosis and 7,641€ for patients with cirrhosis; P<.001. CONCLUSIONS: Chronic hepatitis C virus patients are associated with a high level of comorbidity and the use of concomitant medications, especially in patients with liver cirrhosis. Chronic hepatitis C virus infection represents a substantial economic burden on the Spanish National Health System.

[Efectos sobre el perfil metabólico, el índice de masa corporal, la composición corporal y la comorbilidad en adolescentes con obesidad mórbida, que han fallado al manejo conservador para bajar de peso, operados de manga gástrica laparoscópica. Reporte del primer grupo de cirugía bariátrica pediátrica en México].

INTRODUCTION: Obesity is a world pandemic; in Mexico 3 out of 10 adolescents suffer from it. Conservative management of morbid obesity is not effective and bariatric surgery is the only useful therapy. International pediatric bariatric surgery series are scarce and in Mexico there is limited experience. METHOD: We analyze the metabolic repercussions, comorbidities and complications in our series of Mexican adolescents with morbid obesity who underwent a gastric sleeve between 2011 and 2015. RESULTS: 54 morbid obese adolescents were included, 10 fulfilled criteria for surgery. 5 were male, mean age 14.3 ± 1.4 years, weight 117.3 ± 15.2 kg, initial body mass index 43.71 ± 4.1, waist 130.3 ± 6.8 cm, 8 dyslipidemia, 6 metabolic syndrome, 5 liver steatosis, 4 hypertension, 3 type-2 diabetes. Complications: 2 atelectasis, 1 fistula, 1 pneumonia, 1 cholelithiasis; no patient developed nutritional deficits. Weight loss of 33% one-year after surgery and 23% at 2 years. Body fat decreased 22.4% and water content increased 36.1%. Excess weight loss was significant p = 0.001. Two-years after surgery severe steatosis and diabetes had subsided, lipid profile improved and only one patient remained hypertensive. DISCUSSION: Our results demonstrate that all serious comorbidities associated to morbid obesity were improved (diabetes, dyslipidemia and hypertension) and will confer a better prognosis for these children. CONCLUSIONS: Gastric sleeve is useful in morbid obese adolescents. Longer follow-up is needed.

INTRODUCCIÓN: La obesidad es una pandemia mundial; 3 de cada 10 adolescentes en México la padecen. En la obesidad mórbida, el manejo conservador es un fracaso y la cirugía bariátrica es el único tratamiento útil. No hay experiencia en México y los reportes internacionales son aislados. MÉTODO: Análisis de las repercusiones metabólicas, efecto sobre la comorbilidad y complicaciones, en adolescentes con obesidad mórbida operados con manga gástrica de 2011 a 2015. RESULTADOS: De 54 pacientes con obesidad mórbida, 10 cumplieron criterios; 5 varones; edad de 14.3 ± 1.4 años; peso de 117.3 ± 15.2 kg; índice de masa corporal basal de 43.71 ± 4.1; cintura de 130.3 ± 6.8 cm; 8 con dislipidemia; 6 con síndrome metabólico; 5 con esteatosis hepática; 4 con hipertensión; 3 con diabetes tipo 2. Complicaciones: 2 atelectasias, 1 fístula, 1 neumonía, 1 colelitiasis; ninguno con carencia nutricional. Disminución del peso al año del 33% y a los 2 años del 23%. Disminución de la grasa del 22.4%. Aumento de agua corporal del 36.1%. Pérdida del exceso de peso significativa p = 0.001. A los 2 años, remisión de esteatosis grave y de diabetes, el perfil lipídico mejoró, la hipertensión arterial persistió solo en uno. DISCUSIÓN: Lo más destacado es la mejoría o curación de la comorbilidad, con curación de la diabetes, la hipertensión y la dislipidemia, que dará mejor pronóstico a estos niños. CONCLUSIONES: La manga gástrica es útil en adolescentes con obesidad mórbida, con mejoría de la comorbilidad grave. Se requiere un mayor seguimiento.

Addressing tuberculosis patients' medical and socio-economic needs: a comprehensive programmatic approach.

OBJECTIVE: For a cohort of patients with tuberculosis in Carabayllo, Peru, we describe the prevalence of medical comorbidities and socio-economic needs, the efforts required by a comprehensive support programme ('TB Cero') to address them and the success of this programme in linking patients to care. METHODS: Patients diagnosed with tuberculosis in Carabayllo underwent evaluations for HIV, diabetes, mental health and unmet basic needs. For patients initiating treatment during 14 September, 2015-15 May, 2016, we abstracted data from evaluation forms and a support request system. We calculated the prevalence of medical comorbidities and the need for socio-economic support at the time of tuberculosis diagnosis, as well as the proportion of patients successfully linked to care or support. RESULTS: Of 192 patients, 83 (43%) had at least one medical comorbidity other than tuberculosis. These included eight (4%) patients with HIV, 12 (6%) with diabetes and 62 (32%) deemed at risk for a mental health condition. Of patients who required follow-up for a comorbidity, 100% initiated antiretroviral therapy, 71% attended endocrinology consultations and 66% attended psychology consultations. Of 126 (65%) patients who completed the socio-economic evaluation, 58 (46%) reported already receiving food baskets from the municipality, and 79 (63%) were given additional support, most commonly food vouchers and assistance in accessing health care. CONCLUSION: Carabayllo tuberculosis patients face many challenges in addition to tuberculosis. A collaborative, comprehensive treatment support programme can achieve high rates of linkage to care for these needs.

Reliability of the MDi Psoriasis® Application to Aid Therapeutic Decision-Making in Psoriasis. / Fiabilidad de una aplicación de ayuda a la toma de decisiones terapéuticas en el paciente con psoriasis (MDi Psoriasis®).

BACKGROUND: Therapeutic decisions in psoriasis are influenced by disease factors (e.g., severity or location), comorbidity, and demographic and clinical features. OBJECTIVE: We aimed to assess the reliability of a mobile telephone application (MDi-Psoriasis) designed to help the dermatologist make decisions on how to treat patients with moderate to severe psoriasis. METHOD: We analyzed interobserver agreement between the advice given by an expert panel and the recommendations of the MDi-Psoriasis application in 10 complex cases of moderate to severe psoriasis. The experts were asked their opinion on which treatments were most appropriate, possible, or inappropriate. Data from the same 10 cases were entered into the MDi-Psoriasis application. Agreement was analyzed in 3 ways: paired interobserver concordance (Cohen's κ), multiple interobserver concordance (Fleiss's κ), and percent agreement between recommendations. RESULTS: The mean percent agreement between the total of 1210 observations was 51.3% (95% CI, 48.5-54.1%). Cohen's κ statistic was 0.29 and Fleiss's κ was 0.28. Mean agreement between pairs of human observers only, excluding the MDi-Psoriasis recommendations, was 50.5% (95% CI, 47.6-53.5%). Paired agreement between the recommendations of the MDi-Psoriasis tool and the majority opinion of the expert panel (Cohen's κ) was 0.44 (68.2% agreement). CONCLUSIONS: The MDi-Psoriasis tool can generate recommendations that are comparable to those of experts in psoriasis.

Clinical, Diagnostic, and Therapeutic Implications in Psoriasis Associated With Cardiovascular Disease. / Implicaciones clínicas, diagnósticas y terapéuticas de la psoriasis y enfermedad cardiovascular.

In recent years the concept of psoriasis as a systemic disease has gained acceptance due to its association with numerous comorbid conditions, particularly atherosclerosis and cardiovascular disease. Several studies have shown that patients with psoriasis, especially younger patients and those with more severe forms of psoriasis or with psoriatic arthritis, have a higher prevalence of risk factors and metabolic syndrome, as well as an increased risk of major cardiovascular events such as myocardial infarction, cerebrovascular disease, and peripheral arterial disease. Furthermore, it remains unclear which of the current treatments might be more effective in reducing cardiovascular risk in these patients. It is therefore important for dermatologists to be aware of this increased risk, to be able to detect modifiable risk factors early and, when appropriate, refer patients to other specialists for the prevention of major cardiovascular events.

[Counseling and preventive action in elderly population in hospitals and residences in Spain]. / Consejo y prevención a pacientes mayores en hospitales y residencias geriátricas en España.

OBJECTIVE: To establish the profile of elderly patients, and to assess current preventive actions in hospitals, geriatric residences, and different health-care centres in Spain. DESIGN: Cross-sectional descriptive study, based on a questionnaire to be answered by doctors who treat the elderly population in Spain (2013). SETTING: Health-care centres from different regions of Spain. PARTICIPANTS: A total of 420 practitioners from hospitals, residences and other community centres, with data from 840 geriatric clinics. MAIN MEASUREMENTS: Main outcome variables are: dependence, reason for assistance, comorbidity, professional consultation, and life style recommendations. Association factor, type of institution where patients have been attended. Analysis of prevalence and association using Chi-squared test. OUTCOMES: Two-thirds (66.7%) of the study population were shown to be dependent, with a higher percentage among women than men: 68.9% vs. 62.4% (P=.055). It was also found that among the population aged 85 or more, 88.6% of the women and 85.2% of the men suffered comorbidity. In spite of these results, only 6.6% of the patients suffering comorbidity received additional advice concerning healthy-lifestyle. A large majority (79.6%) of the patients treated in hospitals received advice concerning healthy lifestyle, while 59.62% of those treated in nursing homes received it (P<.001). CONCLUSIONS: It was observed that there is a lack of preventive action related to health promotion among the elderly, with differences between hospitals and geriatric residences. This suggests that it is time to put forward new specialised programs addressed to health professionals, in order to reinforce health promotion attitudes and preventive interventions in gerontology clinical practice.

Response to treatment and interval to surgery after preoperative short-course radiotherapy in rectal cancer. / Respuesta al tratamiento e intervalo de tiempo hasta la cirugía con radioterapia preoperatoria de curso corto en el cáncer de recto.

INTRODUCTION: Preoperative short-course radiotherapy with immediate surgery improves local control in patients with rectal cancer. Tumor responses are smaller than those described with radiochemotherapy. Preliminary data associate this lower response to the short period until surgery. The aim of this study is to analyze the response to preoperative short-course radiotherapy and its correlation with the interval to surgery especially analyzing patients with mesorectal fascia involvement. METHODS: A total of 155 patients with locally advanced rectal cancer treated with preoperative radiotherapy (5×5Gy) were retrospectively analyzed. Tumor response in terms of rates of complete pathological response, downstaging, tumor regression grading and status of the circumferential resection margin were quantified. RESULTS: The mean interval from radiotherapy to surgery was 23 days. The rate of complete pathological response was 2.2% and 28% experienced downstaging (stage decreased). No differences between these rates and interval to surgery were detected. Eighty-eight patients had magnetic resonance imaging for staging (in 31 patients the mesorectal fascia was involved).The mean time to surgery in patients with involvement of the fascia and R0 surgery was 27 days and 16 days if R1 (P=.016). The cutoff of 20 days reached the highest probability of achieving a free circumferential resection margin between patients with mesorectal fascia involvement, with no statistically significant differences: RR 3.036 95% CI=(0.691-13.328), P=.06. CONCLUSIONS: After preoperative short-course radiotherapy, an interval>20 days enhances the likelihood of achieving a free circumferential resection margin in patients with mesorectal fascia involvement.

Kidney Disease and Psoriasis. A New Comorbidity? / Enfermedad renal y psoriasis. ¿Una nueva comorbilidad?

Psoriasis is a chronic inflammatory disease that has been associated with cardiovascular and metabolic comorbidities, particularly in young patients and patients with more severe forms of the disease. Recent studies have also linked psoriasis to kidney disease, and this would seem only logical, as the kidney is both a target of classic cardiovascular risk factors and susceptible to the toxic effects of some of the traditional drugs used to control psoriasis. In this article, we would like to draw readers' attention to this recently described comorbidity and stress the importance of early detection, as once chronic kidney disease develops, it cannot be reversed. When evaluating patients with psoriasis, particularly when they are candidates for systemic therapy, we believe it is important to order laboratory tests including glomerular filtration rate and a simple urine test to screen for albuminuria (albumin/creatinine ratio).

The Spanish Society of Neurology's official clinical practice guidelines for epilepsy. Special considerations in epilepsy: comorbidities, women of childbearing age, and elderly patients.

INTRODUCTION: The characteristics of some population groups (patients with comorbidities, women of childbearing age, the elderly) may limit epilepsy management. Antiepileptic treatment in these patients may require adjustments. DEVELOPMENT: We searched articles in Pubmed, clinical practice guidelines for epilepsy, and recommendations by the most relevant medical societies regarding epilepsy in special situations (patients with comorbidities, women of childbearing age, the elderly). Evidence and recommendations are classified according to the prognostic criteria of Oxford Centre of Evidence-Based Medicine (2001) and the European Federation of Neurological Societies (2004) for therapeutic interventions. CONCLUSIONS: Epilepsy treatment in special cases of comorbidities must be selected properly to improve efficacy with the fewest side effects. Adjusting antiepileptic medication and/or hormone therapy is necessary for proper seizure management in catamenial epilepsy. Exposure to antiepileptic drugs (AED) during pregnancy increases the risk of birth defects and may affect fetal growth and/or cognitive development. Postpartum breastfeeding is recommended, with monitoring for adverse effects if sedative AEDs are used. Finally, the elderly are prone to epilepsy, and diagnostic and treatment characteristics in this group differ from those of other age groups. Although therapeutic limitations may be more frequent in older patients due to comorbidities, they usually respond better to lower doses of AEDs than do other age groups.

[Challenges of lopinavir/ritonavir in the chronicity of human immunodeficiency virus infection]. / Desafíos de lopinavir/ritonavir en la cronicidad de la infección por virus de la inmunodeficiencia humana.

Combination antiretroviral therapy (ART) has increased patient survival, which is currently similar to that of the general population in western countries. However, ART is unable to completely restore normal health, given the persistence of chronic immune activation. Human immunodeficiency virus (HIV) infection has become a chronic disease and 50% of patients will soon be older than 50 years. Currently, there is a debate on the possibility of accelerated aging in the HIV-infected population. An overlap has been observed between chronic inflammation, age-related comorbidities, lifestyle, and the long-term toxicity of ART. ART-related toxicity can encourage the development of comorbidities, especially cardiovascular and renal complications, while toxicity-especially that of thymidine analogs-can also contribute to inflammation and aging. Evidence is available on simplification strategies with boosted protease inhibitor monotherapy aiming to avoid or reduce potential or demonstrated toxicity. Currently, studies are underway of dual therapy strategies with lopinavir/ritonavir (LPV/r) with distinct antiretroviral agents. The studies with the largest samples are those with raltegravir and lamivudine. The GARDEL trial has demonstrated that dual therapy with LPV/r plus a generic drug such as lamivudine is non-inferior to triple therapy in treatment- naïve patients. All of the above indicates the response to the challenge posed to LPV/r by the chronic phase of the disease and by the need to reduce costs.

[Successful aging and indicators of frailty in the elderly. Octabaix Study]. / Envejecimiento satisfactorio e indicadores de fragilidad en los mayores de la comunidad. Estudio Octabaix.

UNLABELLED: Successful aging as a process of adaptation to the optimal state is little known in older people. OBJECTIVE: To describe successful aging and to analyze the factors associated with frailty in people aged 86 years. DESIGN: A cross-sectional study of a clinical trial at the second year of follow-up (Octabaix Study). SETTING: Seven Primary Care Centers. PARTICIPANTS: Non-institutionalized subjects born in 1924. MAIN MEASUREMENTS: Data on sociodemographic, comorbidity and geriatric assessment scales were collected. Frailty was defined by the presence of 3 or more of the following criteria: muscle weakness, slow walking, weight loss, exhaustion, low physical activity. Successful aging was defined as: Barthel index >90/100 and Lobo test ≥ 24/35. Multiple regression analysis was performed. RESULTS: A total of 273 patients were evaluated, 39.2% men. The prevalence of successful aging was 47.2% (129). In the unsuccessful aging, the frailty prevalence was 34.7% (50). The frailty factors associated with unsuccessful aging were low activity (OR: 7.56; 95%CI: 3.8 -14.9), weakness (OR: 6.08; 95%CI: 2.5-14.7), slowness (OR: 5.1; 95%CI: 2.8-9.5), and exhaustion (OR: 3.6; 95%CI: 1.6-8.3). The prevalence of successful aging is high in 86-year-old community-dwelling subjects. The low physical activity multiplied by seven, and muscle weakness by 6, were the factors most associated with unsuccessful aging. Therefore, incorporating screening designed to detect these two factors could improve future interventions towards more optimal aging in the community, if these results are confirmed in future studies.

[Development of clinical practice guidelines for patients with comorbidity and multiple diseases]. / Desarrollo de guías de práctica clínica en pacientes con comorbilidad y pluripatología.

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.

Cumulative life course impairment: the imprint of psoriasis on the patient's life.

We now realize that moderate to severe psoriasis takes a toll on the patient's overall health beyond the effects on the skin itself, and so we use quality of life (QOL) measures to assess how the individual perceives both the impact of disease and the response to treatment. However, available instruments give us a cross-sectional assessment of QOL at a specific moment, and we lack longitudinal studies of how a disease affects each and every aspect of a patient's life over time-including physical and psychological wellbeing, social and emotional relationships, vocational and employment decisions, and how they change the individual's outlook. A new concept, cumulative life course impairment (CLCI), captures the notion of the ongoing effect of a disease, providing us with a new paradigm for assessing the impact of psoriasis on QOL. Unlike conventional measurement tools and scales, which focus on a specific moment in the patient's life, a CLCI tool investigates the repercussions of disease that accumulate over a lifetime, interfering with the individual's full potential development and altering perspectives that might have been different had psoriasis not been present. The accumulated impact will vary from patient to patient depending on circumstances that interact differently over time as the burden of stigmatization, concomitant physical and psychological conditions associated with psoriasis, coping mechanisms, and external factors come into play and are modulated by the individual's personality.

[Predictive model and discriminant analysis of the development of dementia in patients with delirium in the emergency department]. / Modelo predictivo y análisis discriminante del desarrollo de demencia en pacientes con delirium en urgencias.

OBJECTIVE: The main aim of our study is to know the sociodemographic, clinical, analytical, and functional variables that predict the probability of developing dementia in patients with delirium who attend the emergency room. METHOD: All patients with delirium (n=45) from the emergency room who were admitted to the Geriatrics service of the General University Hospital of Ciudad Real (HGUCR) in 2016-2018 and met the inclusion and exclusion criteria were included. Subsequently, we ran a bivariate and multivariate analysis of the variables that predicted a diagnosis of dementia at six months and a discriminant analysis. RESULTS: 15.6% of patients presented dementia at six months of follow-up, 22.2% had developed cognitive impairment. We conducted a multivariate model (R2 Nagelkerke 0.459) for the probability of developing dementia, with elevated heart rate being the most crucial variable (OR=11.5). The model could excluded dementia with 100% accuracy. Finally, we achieved a discriminant function capable of correctly classifying 95.6% of the cases. It included the following variables of influence: pH, Lawton Brody index, calcium, urea, and heart rate. CONCLUSIONS: A few clinical and analytical variables that are easily detectable in the emergency room, especially tachycardia, could help us better identify those patients with delirium at higher risk of developing dementia, as well as formulate hypotheses about the variables involved in the development of dementia in patients with delirium.