The PREDG study: A randomised controlled trial testing whether an educational intervention can prevent gestational weight gain in women with obesity.

OBJECTIVE: The PREDG trial was designed to study the influence of an educative program on gestational weight gain in women with pregestational obesity. METHODS: Randomized controlled clinical trial (https://www.isrctn.com/ISRCTN61793947) in 169 women with pregestational obesity (BMI ≥30 kg/m2). Women were randomized to participate in a group education program in nutrition and physical activity or conventional follow-up in a specialized Unit of Obesity and Pregnancy. The nutritional intervention was adjusted to prepregnancy BMI and to the physical activity intensity. Quality was based on the Mediterranean diet. Macronutrients were distributed as follows: 50% carbohydrates, 20% protein and 30% fat. Adequate gestational weight gain was defined between 5 and 9 kg (IOM 2009). Mean gestational weight gain was compared between groups by using the T Student test and frequencies of adequate gestational weight gain were compared by using ꓫ2. RESULTS: Gestational weight gain was lower in the intervention group: 8 (4-11) vs 9.2 (6-13) kg, p 0.026. Gestational weight gain was below 9 kg in 24 of 39 (61.5%) women of the intervention vs 10 of 41 (24.4%) of the control group (p 0.001). Regarding obstetric complications, there were 15 (8.3%) cases of gestational diabetes with no differences between the groups. There were 14 of 85 (18.2%) cases of gestational hypertension or preeclampsia in the intervention group compared with 26 of 84 (32.5%) in the control group (p 0.040). With reference to neonatal weight, there were 7 of 82 (8.5%) large for gestational age neonates in the intervention group compared with 15 of 79 (19.2%) in the control group (p 0.050). CONCLUSIONS: A group-based educative and structured intervention results in an adequate weight gain and lower rates of gestational hypertension, preeclampsia and large for gestational age neonates in pregnant women with obesity.

Cooperative Effect of Chemical and Physical Processes for Flame Retardant Additives in Recycled ABS.

In the present work, the effectiveness of four non-halogenated flame retardants (FR) (aluminium trihydroxide (ATH), magnesium hydroxide (MDH), Sepiolite (SEP) and a mix of metallic oxides and hydroxides (PAVAL)) in blends with recycled acrylonitrile-butadiene-styrene (rABS) was studied in order to develop a more environmentally friendly flame-retardant composite alternative. The mechanical and thermo-mechanical properties of the obtained composites as well as their flame-retardant mechanism were evaluated by UL-94 and cone calorimetric tests. As expected, these particles modified the mechanical performance of the rABS, increasing its stiffness at the expense of reducing its toughness and impact behavior. Regarding the fire behavior, the experimentation showed that there is an important synergy between the chemical mechanism provided by MDH (decomposition into oxides and water) and the physical mechanism provided by SEP (oxygen barrier), which means that mixed composites (rABS/MDH/SEP) can be obtained with a flame behavior superior to that of the composites studied with only one type of FR. In order to find a balance between mechanical properties, composites with different amounts of SEP and MDH were evaluated. The results showed that composites with the composition rABS/MDH/SEP: 70/15/15 wt.% increase the time to ignition (TTI) by 75% and the resulting mass after ignition by more than 600%. Furthermore, they decrease the heat release rate (HRR) by 62.9%, the total smoke production (TSP) by 19.04% and the total heat release rate (THHR) by 13.77% compared to unadditivated rABS; without compromising the mechanical behavior of the original material. These results are promising and potentially represent a greener alternative for the manufacture of flame-retardant composites.

Role of Air Bubble Inclusion on Polyurethane Reaction Kinetics.

In this study, we investigated the influence of mixing conditions on the foaming process of water blown polyurethane (PU) foams obtained at different mixing speeds (50, 500, 1000 and 2000 rpm). In particular, the morphological evolution during the foaming process, in terms of the bubble size and bubble density, was studied via optical observations, while the effects on the reaction kinetics were monitored using in situ FTIR spectroscopy. At the slow mixing speed (50 rpm), no air bubbles were included and the early foaming process was characterized by the formation of new bubbles (CO2 nucleation), provided by the blowing reaction. Later on, it was observed that the coalescence affected the overall foaming process, caused by the gelling reaction, which was inhibited by the indigent mixing conditions and could not withstand the bubbles expansion. As a result, a PU foam with a coarse cellular structure and an average bubble size of 173 µm was obtained. In this case, the bubbles degeneration rate, dN/dt, was -3095 bubble·cm-3·s-1. On the contrary, at 500 rpm, air bubbles were included into the PU reaction system (aeration) and no formation of new bubbles was observed during the foaming process. After this, the air bubbles underwent growth caused by diffusion of the CO2 provided by the blowing reaction. As the gelling reaction was not strongly depleted as in the case at 50 rpm, the coalescence less affected the bubble growth (dN/dt = -2654 bubble·cm-3·s-1), leading to a PU foam with an average bubble size of 94 µm. For the foams obtained at 1000 and 2000 rpm, the bubble degeneration was first affected by coalescence and then by Ostwald ripening, and a finer cellular structure was observed (with average bubble sizes of 62 µm and 63 µm for 1000 rpm and 2000 rpm, respectively). During the first foaming stage, the coalescence was less predominant in the bubble growth (with dN/dt values of -1838 bubble·cm-3·s-1 and -1601 bubble·cm-3·s-1, respectively) compared to 50 rpm and 500 rpm. This occurrence was ascribed to the more balanced process between the bubble expansion and the PU polymerization caused by the more suitable mixing conditions. During the late foaming stage, the Ostwald ripening was only responsible for the further bubble degeneration (with dN/dt values of -89 bubble·cm-3·s-1 and -69 bubble·cm-3·s-1, respectively).

Characterization and Properties of Water-Blown Rigid Polyurethane Foams Reinforced with Silane-Modified Nanosepiolites Functionalized with Graphite.

In the present study, a promising flame retardant consisting of 80 wt% silane-modified nanosepiolites functionalized with 20 wt% graphite (SFG) is used to obtain a synergistic effect principally focussed on the thermal stability of water-blown rigid polyurethane (RPU) foams. Density, microcellular structure, thermal stability and thermal conductivity are examined for RPU foams reinforced with different contents of SFG (0, as reference material, 2, 4 and 6 wt%). The sample with 6 wt% SFG presents a slightly thermal stability improvement, although its cellular structure is deteriorated in comparison with the reference material. Furthermore, the influence of SFG particles on chemical reactions during the foaming process is studied by FTIR spectroscopy. The information obtained from the chemical reactions and from isocyanate consumption is used to optimize the formulation of the foam with 6 wt% SFG. Additionally, in order to determine the effects of functionalization on SFG, foams containing only silane-modified nanosepiolites, only graphite, or silane-modified nanosepiolites and graphite added separately are studied here as well. In conclusion, the inclusion of SFG in RPU foams allows the best performance to be achieved.

Effect of the Molecular Structure of TPU on the Cellular Structure of Nanocellular Polymers Based on PMMA/TPU Blends.

In this work, the effects of thermoplastic polyurethane (TPU) chemistry and concentration on the cellular structure of nanocellular polymers based on poly(methyl-methacrylate) (PMMA) are presented. Three grades of TPU with different fractions of hard segments (HS) (60%, 70%, and 80%) have been synthesized by the prepolymer method. Nanocellular polymers based on PMMA have been produced by gas dissolution foaming using TPU as a nucleating agent in different contents (0.5 wt%, 2 wt%, and 5 wt%). TPU characterization shows that as the content of HS increases, the density, hardness, and molecular weight of the TPU are higher. PMMA/TPU cellular materials show a gradient cell size distribution from the edge of the sample towards the nanocellular core. In the core region, the addition of TPU has a strong nucleating effect in PMMA. Core structure depends on the HS content and the TPU content. As the HS or TPU content increases, the cell nucleation density increases, and the cell size is reduced. Then, the use of TPUs with different characteristics allows controlling the cellular structure. Nanocellular polymers have been obtained with a core relative density between 0.15 and 0.20 and cell sizes between 220 and 640 nm.

Analysis of the Foaming Window for Thermoplastic Polyurethane with Different Hard Segment Contents.

A series of thermoplastic polyurethanes (TPUs) with different amounts of hard segments (HS) (40, 50 and 60 wt.%) are synthesized by a pre-polymer method. These synthesized TPUs are characterized by Shore hardness, gel permeation chromatography (GPC), differential scanning calorimetry (DSC), wide angle X-ray diffraction (WAXD), dynamic mechanical thermal analysis (DMTA), and rheology. Then, these materials are foamed by a one-step gas dissolution foaming process and the processing window that allows producing homogeneous foams is analyzed. The effect of foaming temperature from 140 to 180 °C on the cellular structure and on density is evaluated, fixing a saturation pressure of 20 MPa and a saturation time of 1 h. Among the TPUs studied, only that with 50 wt.% HS allows obtaining a stable foam, whose better features are reached after foaming at 170 °C. Finally, the foaming of TPU with 50 wt.% HS is optimized by varying the saturation pressure from 10 to 25 MPa at 170 °C. The optimum saturation and foaming conditions are 25 MPa and 170 °C for 1 h, which gives foams with the lowest relative density of 0.74, the smallest average cell size of 4 µm, and the higher cell nucleation density of 8.0 × 109 nuclei/cm3. As a final conclusion of this investigation, the TPU with 50 wt.% HS is the only one that can be foamed under the saturation and foaming conditions used in this study. TPU foams containing 50 wt.% HS with a cell size below 15 microns and porosity of 1.4-18.6% can be obtained using foaming temperatures from 140 to 180 °C, saturation pressure of 20 MPa, and saturation time of 1 h. Varying the saturation pressure from 10 to 25 MPa and fixing the foaming temperature of 170 °C and saturation pressure of 1 h results in TPU foams with a cell size of below 37 microns and porosity of 1.7-21.2%.

Effectiveness of a home-based nursing support and cognitive restructuring intervention on the quality of life of family caregivers in primary care: A pragmatic cluster-randomized controlled trial.

BACKGROUND: Caregivers of patients with chronic conditions or disability experience fatigue, burden and poor health-related quality of life. There is evidence of the effectiveness of support interventions for decreasing this impact. However, little is known about the benefits of home-based nursing intervention in primary health care. OBJECTIVES: To evaluate the effectiveness of a home-based, nurse-led-intervention (CuidaCare) on the quality of life of caregivers of individuals with disabilities or chronic conditions living in the community, measured at 12-month follow-up. METHODS: A pragmatic, two-arm, cluster-randomized controlled trial with a 1-year follow-up period was performed between June 2013 and December 2015. Consecutive caregivers aged 65 years or older, all of whom assumed the primary responsibility of caring for people with disabling conditions for at least 6 months a year, were recruited from 22 primary health care centers. Subsequently, 11 centers were randomly assigned to usual care group, and 11 were assigned to the intervention group. The caregivers in the intervention group received the usual care and additional support (cognitive restructuring, health education and emotional support). The primary outcome was quality of life, assessed with the EQ-5D instrument (visual analog scale and utility index score); the secondary outcome variables were perception of burden, anxiety, and depression. Data were collected at baseline, at the end of the intervention, and at the 6- and 12-month follow-up visits. We analyzed the primary outcome as intention-to-treat, and missing data were added using the conditional mean single imputation method. RESULTS: A total of 224 caregivers were included in the study (102 in the intervention group and 122 in the usual care group). Generalized Estimating Equation models showed that the CuidaCare intervention was associated with a 5.46 point (95% CI: 2.57; 8.35) change in the quality of life, as measured with the visual analog scale adjusted for the rest of the variables at 12 months. It also produced an increase of 0.04 point (95% CI: 0.01; 0.07) in the utilities. No statistically significant differences were found between the two groups at 12 months with respect to the secondary outcomes. CONCLUSIONS: The findings suggest that incorporating a home-based, nurse-led-intervention for caregivers into primary care can improve the health-related quality of life of caregivers of patients with chronic or disabling conditions.

[Characteristics and one-year outcomes in elderly patients hospitalised with heart failure and preserved, mid-range and reduced ejection fraction]. / Características y resultados tras un año en pacientes ancianos ingresados con insuficiencia cardiaca y fracción de eyección reducida, intermedia o conservada.

INTRODUCTION: The latest European Society of Cardiology Heart Failure (HF) guidelines define three types of HF according to the ejection fraction (EF): HF with reduced EF (HFrEF) when EF<40%, HF with mid-range EF (HFmrEF), when EF 40-49%, and HF with preserved EF (HFpEF) when EF≥50%. The objective of this study was to analyse the characteristics and results of elderly patients hospitalised with HF according to the new classification using EF. METHODS: A prospective study was carried out with 531 HF patients aged ≥75 years classified according to EF, and admitted in the geriatric wards of 6 hospitals in Spain. An analysis was performed on the demographic and clinical characteristics, as well as well as the morbidity and mortality at one year of follow-up. RESULTS: As regards EF, 17.1% had HFrEF, 10% had HFmrEF, and 72.9% had HFpEF. Patients with HFmrEF were more similar to those with HFrEF in terms of a younger age, predominance of men, and previous admission due to HF. This was also the case with the use of drugs for neurohormonal blockade. Patients with HFrEF (compared to those with HFmrEF and HFpEF), had higher mortality (35.2%, 24.5%, and 25.6%, respectively), more readmissions for HF (17.6%, 15.1%, and 14.5%, respectively), and more events (61.5%, 45.3%, and 52.5%, respectively), although there were no significant differences. There were also no differences observed in the survival analysis between the EF groups and the time-dependent outcome variables. CONCLUSIONS: In elderly patients hospitalised with HF, those classified as HFmrEF did not show any clear differences with respect to those with HFrEF or HFpEF. There were no differences in terms of morbidity and mortality.

Identification and Quantification of Cell Gas Evolution in Rigid Polyurethane Foams by Novel GCMS Methodology.

This paper presents a new methodology based on gas chromatography-mass spectrometry (GCMS) in order to separate and quantify the gases presented inside the cells of rigid polyurethane (RPU) foams. To demonstrate this novel methodology, the gas composition along more than three years of aging is herein determined for two samples: a reference foam and foam with 1.5 wt% of talc. The GCMS method was applied, on one hand, for the accurate determination of C5H10 and CO2 cell gases used as blowing agents and, on the other hand, for N2 and O2 air gases that diffuse rapidly from the surrounding environment into foam cells. GCMS results showed that CO2 leaves foam after 2.5 month (from 21% to 0.03% for reference foam and from 17% to 0.03% for foam with 1.5% talc). C5H10 deviates during 3.5 months (from 28% up to 39% for reference foam and from 29% up to 36% for foam with talc), then it starts to leave the foam and after 3.5 year its content is 13% for reference and 10% for foam with talc. Air diffuses inside the cells faster for one year (from 51% up to 79% for reference and from 54% up to 81% for foam with talc) and then more slowly for 3.5 years (reaching 86% for reference and 90% for foam with talc). Thus, the fast and simple presented methodology provides valuable information to understand the long-term thermal conductivity of the RPU foams.

Results of an anaemia treatment protocol complementary to blood transfusion in elderly patients with hip fracture.

BACKGROUND: Anaemia is a very common condition in elderly patients with hip fracture. The side effects of blood transfusions are well known, and further research on potential alternative therapies is needed. OBJECTIVES AND DESIGN: A non-controlled descriptive study, conducted on 138 patients admitted for hip fracture, aimed at analysing the effects of an anaemia treatment protocol adjunctive to transfusion, based on the use of supra-physiological doses of intravenous iron and erythropoietin (IS/EPOS). The variables collected were, medical history, physical and cognitive status prior to fracture, as well as the need of blood products, medical complications during admission and their functional outcome at three and six months after the fracture were evaluated. Transfusion rates were compared with a historical control group when the only treatment for acute anaemia was transfusion (2011). RESULTS: Almost half (63, 48%) of the patients received blood transfusion, with (91,70%) IS/EPOD. Intravenous iron did not reduce the percentage of transfused patients (56% vs. 44%), but it did reduce the number of blood units required (0.7 units less in IS/EPO group). Patients who required transfusion had a longer hospital stay, (1.7 days; 13.2 vs. 11.5; p<0.005). Patients who received IS had better functional recovery assessed with Barthel index and the Functional Ambulation Categories (FAC scale) at 3 and 6 months after the fracture. Patients with malnutrition or subtrochanteric fracture needed more tabletransfusions (p<0.005). Functional recovery at 3 and 6 months after fracture was better in patients who received intravenous iron. Neither blood transfusions nor intravenous iron were associated with infectious complications or increased mortality. The patient series of this study was compared with a group of patients with hip fracture and similar characteristics seen in 2011, before intravenous iron was available, revealing a 17% reduction in blood transfusion needs (p<0.005). CONCLUSION: The use of intravenous iron in elderly patients with hip fracture may help to reduce the number of blood units needed for the treatment of anaemia, although a causal relationship cannot be established due to not having a control group. Transfusions were associated with longer hospital stay in elderly patients with hip fracture.

Spanish list of potentially inappropriate drugs in the elderly (ES-PIA project).

PURPOSE: In the last decades, different criteria have been developed for detecting inappropriate prescription in older patients. In Spain, translations and adaptations of international lists are available but it would be necessary a national list which could cope with the peculiarities of our health system, existing pharmaceutical market, and prescription habits. We propose in this project the creation of a Spanish potentially inappropriate drugs list which could be applicable in our clinical scenario. METHODS: We use a Delphi method involving 25 experts from different backgrounds (Clinical Pharmacology, Geriatrics, Rational Use of Drugs and Pharmacy, Primary Care and Pharmacoepidemiology, and Pharmacovigilance) that were asked to participate in two-round questionnaires. For analysis, current recommendations of Worth and Pigni were applied, and every statement was classified into one of three groups: strong, moderate, or low agreement. Statements with strong agreement were accepted to be part of the inadequate prescription list. Moderate agreement statements were selected to enter the second questionnaire, and statements with low agreement were further analyzed to determine if it was due to heterogeneity or due to dispersion in the answers. RESULTS: The first questionnaire consisted of 160 proposed sentences, of which 106 reached a high agreement, 32 a moderate agreement, and 22 a low agreement. All sentences proposed in the second questionnaire reached a strong agreement. The total accepted sentences were 138. CONCLUSIONS: We offer a list of inadequate prescription in older patients adapted to the Spanish pharmacopeia and according to the prescription habits in our environment.

Influence of the Characteristics of Expandable Graphite on the Morphology, Thermal Properties, Fire Behaviour and Compression Performance of a Rigid Polyurethane Foam.

Three types of expandable graphite (EG) differing in particle size and expansion volume, are compared as flame retardant additives to rigid polyurethane foams (RPUFs). In this paper we discuss microstructure, thermal stability, fire behavior, and compression performance. We find that ell size distributions were less homogeneous and cell size was reduced. Furthermore, thermal conductivity increased along with EG loading. Thermogravimetric analysis (TGA) showed that EG only increased residue yield differently. The results indicate that a higher expansion of EG increased the limiting oxygen index (LOI) value, whereas a bigger particle size EG improved the rating of the vertical burning test (UL94). Results from the cone calorimeter test showed that a bigger particle size EG effectively reduced peak of heat release rate (pHRR). Furthermore, a higher expansion, led to a decrease in smoke production (TSP). The combination of both characteristics gives extraordinary results. The physical⁻mechanical characterization of the EG/RPUF foams revealed that their compression performance decreased slightly, mostly due to the effect of a bigger size EG.

Health Literacy and Health Outcomes in Very Old Patients With Heart Failure.

INTRODUCTION AND OBJECTIVES: Health literacy (HL) has been associated with lower mortality in heart failure (HF). However, the results of previous studies may not be generalizable because the research was conducted in relatively young and highly-educated patients in United States settings. This study assessed the association of HL with disease knowledge, self-care, and all-cause mortality among very old patients, with a very low educational level. METHODS: This prospective study was performed in 556 patients (mean age, 85 years), with high comorbidity, admitted for HF to the geriatric acute-care unit of 6 hospitals in Spain. About 74% of patients had less than primary education and 71% had preserved systolic function. Health literacy was assessed with the Short Assessment of Health Literacy for Spanish-speaking Adults questionnaire, knowledge of HF with the DeWalt questionnaire, and HF self-care with the European Heart Failure Self-Care Behaviour Scale. RESULTS: Disease knowledge progressively increased with HL; compared with being in the lowest (worse) tertile of HL, the multivariable beta coefficient (95%CI) of the HF knowledge score was 0.60 (0.01-1.19) in the second tertile and 0.87 (0.24-1.50) in the highest tertile, P-trend = .008. However, no association was found between HL and HF self-care. During the 12 months of follow-up, there were 189 deaths. Compared with being in the lowest tertile of HL, the multivariable HR (95%CI) of mortality was 0.84 (0.56-1.27) in the second tertile and 0.99 (0.65-1.51) in the highest tertile, P-trend = .969. CONCLUSIONS: No association was found between HL and 12-month mortality. This could be partly due to the lack of a link between HL and self-care.

Use of bone scintigraphy in the early diagnosis of bisphosphonate related osteonecrosis of the jaw. Case report and review of the literature.

The main aim of the present report is to show the potential utility of bone scintigraphy for the diagnosis of jaw osteonecrosis. We report the history of a 62-year-old woman underwent breast cancer surgery in 2010. Moreover, patient received postoperative radiotherapy and chemotherapy. Intravenous bisphosphonates were also added to the treatment strategy to reduce the risk of bone metastasis. However, a hypermetabolic focus on left hemimandible was evidenced with a bone scintigraphy during follow up. After a careful study, the diagnosis of Bisphosphonate Related Ostneonecrosis of the Jaw (BRONJ) was carried out. This case highlights that bone scintigraphy may be extremely helpful for the early detection of BRONJ in high risk patient. Key words:Bone scintigraphy, mandibular osteonecrosis, bisphosphonates.

The frailty syndrome is associated with adverse health outcomes in very old patients with stable heart failure: A prospective study in six Spanish hospitals.

BACKGROUND: Most studies on the association between the frailty syndrome and adverse health outcomes in patients with heart failure (HF) have used non-standard definitions of frailty. This study examined the association of frailty, diagnosed by well-accepted criteria, with mortality, readmission and functional decline in very old ambulatory patients with HF. METHODS: Prospective study with 497 patients in six Spanish hospitals and followed up during one year. Mean (SD) age was 85.2 (7.3) years, and 79.3% had LVEF >45%. Frailty was diagnosed as having ≥3 of the 5 Fried criteria. Readmission was defined as a new episode of hospitalisation lasting >24h, and functional decline as an incident limitation in any activity of daily living at the 1-year visit. Statistical analyses were performed with Cox and logistic regression, as appropriate, and adjusted for the main prognostic factors at baseline. RESULTS: At baseline, 57.5% of patients were frail. The adjusted hazard ratio (95% confidence interval) for mortality among frail versus non-frail patients was 1.93 (1.20-3.27). Mortality was higher among patients with low physical activity [1.64 (1.10-2.45)] or exhaustion [1.83 (1.21-2.77)]. Frailty was linked to increased risk of readmission [1.66 (1.17-2.36)] and functional decline [odds ratio 1.67 (1.01-2.79)]. Slow gait speed was related to functional decline [odds ratio 3.59 (1.75-7.34)]. A higher number of frailty criteria was associated with a higher risk of the three study outcomes (P trend<0.01 in each outcome). CONCLUSIONS: Frailty was associated with increased risk of 1-year mortality, hospital readmission and functional decline among older ambulatory patients with HF.

Acute paraparesis as presentation of an occult follicular thyroid carcinoma: A case report.

INTRODUCTION: Follicular thyroid carcinoma is the second most frequent type of well differentiated thyroid tumours. It is usually confined to the thyroid gland, however it can metastasize in a later stage of the disease. Signs and symptoms associated with bone metastasis are rare as first clinical manifestations. CASE REPORT: An 84-year-old female complained with acute paraparesis. Magnetic resonance imaging revealed an extensive intraosseous infiltrating lesion compatible with a bone metastasis from an occult tumour. Biopsy samples were compatible with bone metastasis from a follicular thyroid carcinoma. The patient was submitted to total thyroidectomy followed by iodine ablative therapy. DISCUSSION: Follicular thyroid carcinoma presentation with symptoms related to bone metastasis is rare. Patients with bone lesions, such as pathological fractures or compressive symptoms should be studied since they may have clinically unapparent lesions from an unknown tumour. Patients with FTC should be submitted to total thyroidectomy. Bone lesions may be addressed to improve quality of life however this decision depends on disease extent. CONCLUSION: Acute paraparesis is a rare form of presentation of thyroid carcinoma. These neoplasms must be taken into account when investigating metastasis to the bone from unknown neoplasms.

[Geriatric intervention in elderly hip fracture patients admitted to University Hospital of Guadalajara: Clincal, healthcare and economical repercussions]. / Intervención geriátrica en el anciano ingresado por fractura de cadera en el Hospital Universitario de Guadalajara: repercusión clínica, asistencial y económica.

OBJECTIVE: To evaluate the healthcare outcomes and economic impact of geriatric intervention in patients over 75 years old with hip fracture in acute phase. MATERIAL AND METHODS: Retrospective study of patients admitted to the University Hospital of Guadalajara (HUGU) due to hip fracture. An analysis was made of the number of cases per year, preoperative period, hospital stay, and mortality of all the patients over 75 years admitted to the HUGU due to hip fracture between 2002 and 2013. RESULTS: A total of 2942 patients were included. Comparing the activity of 2013 to that of 2006, the mean hospital stay fell from 18.5 to 11.2 days (-39.2%), and mortality from 8.9% to 6.8% (-23%). In contrast, the mean preoperative stay remained at a mean of 2.7 days versus 2.4 in previous years in the early post-intervention period. Hospital stay decreased, despite a progressive annual increase in the daily cost of hospitalisation due to hip fracture surgery, the reduced stay led to a reduction of the total cost by more than 900,000 euros each year. Geriatric intervention has gradually reduced mean hospital stay and mortality, although with a tendency to increase mean preoperative stay. CONCLUSIONS: Geriatric intervention in patients with hip fracture reduces mortality and length of hospital stay, and decreasing costs.

Rationale and methods of the multicenter randomised trial of a heart failure management programme among geriatric patients (HF-Geriatrics).

BACKGROUND: Disease management programmes (DMPs) have been shown to reduce hospital readmissions and mortality in adults with heart failure (HF), but their effectiveness in elderly patients or in those with major comorbidity is unknown. The Multicenter Randomised Trial of a Heart Failure Management Programme among Geriatric Patients (HF-Geriatrics) assesses the effectiveness of a DMP in elderly patients with HF and major comorbidity. METHODS/DESIGN: Clinical trial in 700 patients aged ≥ 75 years admitted with a primary diagnosis of HF in the acute care unit of eight geriatric services in Spain. Each patient should meet at least one of the following comorbidty criteria: Charlson index ≥ 3, dependence in ≥ 2 activities of daily living, treatment with ≥ 5 drugs, active treatment for ≥ 3 diseases, recent emergency hospitalization, severe visual or hearing loss, cognitive impairment, Parkinson's disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), anaemia, or constitutional syndrome. Half of the patients will be randomly assigned to a 1-year DMP led by a case manager and the other half to usual care. The DMP consists of an educational programme for patients and caregivers on the management of HF, COPD (knowledge of the disease, smoking cessation, immunizations, use of inhaled medication, recognition of exacerbations), diabetes (knowledge of the disease, symptoms of hyperglycaemia and hypoglycaemia, self-adjustment of insulin, foot care) and depression (knowledge of the disease, diagnosis and treatment). It also includes close monitoring of the symptoms of decompensation and optimisation of treatment compliance. The main outcome variables are quality of life, hospital readmissions, and overall mortality during a 12-month follow-up. DISCUSSION: The physiological changes, lower life expectancy, comorbidity and low health literacy associated with aging may influence the effectiveness of DMPs in HF. The HF-Geriatrics study will provide direct evidence on the effect of a DMP in elderly patients with HF and high comorbidty, and will reduce the need to extrapolate the results of clinical trials in adults to elderly patients. TRIAL REGISTRATION: (ClinicalTrials.gov number, NCT01076465).