Identifying patients with advanced chronic conditions for a progressive palliative care approach: a cross-sectional study of prognostic indicators related to end-of-life trajectories.

OBJECTIVES: 2 innovative concepts have lately been developed to radically improve the care of patients with advanced chronic conditions (PACC): early identification of palliative care (PC) needs and the 3 end-of-life trajectories in chronic illnesses (acute, intermittent and gradual dwindling). It is not clear (1) what indicators work best for this early identification and (2) if specific clinical indicators exist for each of these trajectories. The objectives of this study are to explore these 2 issues. SETTING: 3 primary care services, an acute care hospital, an intermediate care centre and 4 nursing homes in a mixed urban-rural district in Barcelona, Spain. PARTICIPANTS: 782 patients (61.5% women) with a positive NECPAL CCOMS-ICO test, indicating they might benefit from a PC approach. OUTCOME MEASURES: The characteristics and distribution of the indicators of the NECPAL CCOMS-ICO tool are analysed with respect to the 3 trajectories and have been arranged by domain (functional, nutritional and cognitive status, emotional problems, geriatric syndromes, social vulnerability and others) and according to their static (severity) and dynamic (progression) properties. RESULTS: The common indicators associated with early end-of-life identification are functional (44.3%) and nutritional (30.7%) progression, emotional distress (21.9%) and geriatric syndromes (15.7% delirium, 11.2% falls). The rest of the indicators showed differences in the associations per illness trajectories (p<0.05). 48.2% of the total cohort was identified as advanced frailty patients with no advanced disease criteria. CONCLUSIONS: Dynamic indicators are present in the 3 trajectories and are especially useful to identify PACC for a progressive PC approach purpose. Most of the other indicators are typically associated with a specific trajectory. These findings can help clinicians improve the identification of patients for a palliative approach.

Pulmonary endometriosis: conservative treatment with GnRH agonists.

The lung is an infrequent location of extragenital endometriosis, an exceptional cause of hemoptysis or pneumothorax. Adequate management has not yet been well established. We present two cases of pulmonary endometriosis, parenchymal and pleural. The presenting symptoms were catamenial hemoptysis and pneumothorax, respectively, which were treated with GnRH analogues. The first patient received Buserelin (900 micrograms/day intranasally) for 6 months. After 15 months of normal menstrual activity, the symptoms reappeared. The patient was then treated with Triptorelin (3.75 mg/month intramuscularly) for 6 months and remains asymptomatic and menstruating 14 months after discontinuing treatment. The patient presenting with pneumothorax was treated with leuprolide (1 mg/day subcutaneously) for 6 months and is asymptomatic 1 year after stopping treatment. These results suggest that GnRH analogues may be an acceptable alternative to danazol in the medical management of pulmonary endometriosis.

[Booster effect in elderly patients living in geriatric institutions]. / Efecto empuje en pacientes de la tercera edad residentes en instituciones geriátricas.

BACKGROUND: Tuberculinic response is weaker in elderly patients. To know the real tuberculinic reactivity in elderly patients living in geriatric institutions in Catalonia, Spain, and to reduce the probability of false negatives this study was carried out to detect the booster effect. METHODS: Three hundred forty-three individuals with a mean age of 81 +/- 6.5 years, residing in four geriatric centers within the Central Health Care Region of Catalonia, were studied. After performing the first Mantoux intradermoreaction this was repeated at one week in case of negativity. A third test was carried out after one more week on persistence of negativity. Qualitative study was carried out on cell immunity in those patients whose first Mantoux test was negative. RESULTS: The first Mantoux test was positive in 163 patients (47.5%) and the performance of the second and third test in cases of negativity of the previous test increased the number of positivities by 12.5% and 4.1%, respectively, up to a total of 220 patients (64%). In the patients who did not react to the first intradermoreaction and who preserved cell immunity a booster effect was obtained in 57 (52.8%). The prevalence of tuberculous infection in this group of elderly patients calculated in the group with preserved cell immunity was 81.2% while the morbidity of tuberculous disease in the positive cases in the Mantoux test was 1.8%. CONCLUSIONS: Given the high frequency of the booster effect in elderly people, systematic testing is recommended to investigate tuberculinic reactivity in patients who are initially negative on Mantoux intradermoreaction.

Value of bacterial antigen detection in the diagnostic yield of transthoracic needle aspiration in severe community acquired pneumonia.

BACKGROUND: Transthoracic needle aspiration (TNA) with an ultrathin needle is a safe and highly specific procedure for obtaining a diagnosis in bacterial pneumonias, but its sensitivity is at best 70%. A study was performed to assess whether Streptococcus pneumoniae and Haemophilus influenzae type b antigen detection by latex agglutination from the TNA sample enhanced the diagnostic yield. METHODS: Blood cultures, TNA with an ultrathin needle (culture, Gram stain, and latex agglutination), serological tests, and pneumococcal antigen detection in the urine by counterimmunoelectrophoresis were performed in samples from 18 of 23 consecutive patients with severe community acquired pneumonia. RESULTS: The causative organism was identified in 16 cases (88%): S pneumoniae (10 cases), S pneumoniae plus H influenzae (two cases), Legionella pneumophila (three cases), and Mycoplasma pneumoniae (one case). The investigation of antigens by latex agglutination in the pulmonary aspirate increased the diagnostic yield of TNA from 50% to 78% and provided a rapid diagnosis (in less than two hours) with therapeutic implications in seven cases. Its effectiveness was not modified by prior antibiotic therapy. CONCLUSIONS: A latex agglutination test on the pulmonary aspirate enhances the diagnostic yield of TNA in severe community acquired pneumonia.

Five-day treatment of non-severe, community-acquired pneumonia with josamycin.

This study assessed the efficacy of oral josamycin 1 g bd for five days as treatment for non-severe, community-acquired pneumonia in patients less than 60 years of age who were not at obvious risk of developing respiratory tract infection caused by aerobic Gram-negative bacilli. Of the 84 patients (43 male, 41 female) with a mean age of 33 years who were enrolled during a 14-month period, the clinical outcome was invariably favourable. All patients became afebrile within three days of starting therapy; the mean duration of fever after initiating treatment was 1.7 days. Therefore, according to the study protocol, josamycin therapy was discontinued on day five. A chest X-ray performed four to six weeks after completing treatment was normal in every case and no relapses were observed during a six-week follow-up period. We conclude that a five-day course of josamycin is effective monotherapy for community-acquired pneumonia in patients without the clinical features of severe infection.

Nutritional supplementation of elderly hip fracture patients. A randomized, double-blind, placebo-controlled trial.

BACKGROUND: undernourishment is common in elderly hip fracture patients and has been linked to poorer recovery and increased post-operative complications. OBJECTIVE: to determine whether a nutritional supplement may (i) help elderly patients return to pre-fracture functional levels 6 months post-fracture and (ii) decrease fracture-related complications and mortality. DESIGN: a double-blind, randomized, placebo-controlled clinical trial. SETTING: a county hospital near Barcelona. SUBJECTS: 171 patients, aged 70 and older, hospitalized for hip fracture between July 1994 and July 1996. METHODS: we randomized patients to intervention (n = 85) or control (n = 86) group. Patients received a nutritional supplement containing 20 g of protein and 800 mg of calcium or placebo for 60 days. We determined functional levels by the Barthel index, the mobility index and by the use of walking aids. We performed assessments during hospitalization and at 2 and 6 months post-fracture. FINDINGS: the two groups were comparable at study entry. We observed no differences in return to functional status 6 months post-fracture (61% intervention group vs 55% in control group) nor in fracture-related mortality (13% in intervention group vs 10% in control group). The intervention group suffered fewer in-hospital [odds ratio 1.88 (95% CI 1.01 - 3.53), P = 0.05] and total complications [odds ratio 1.94 (95% CI 1.02-3.7), P = 0.04] than the control group. CONCLUSION: based on our results, we cannot recommend routine nutritional supplementation of all elderly hip fracture patients. While nutritional supplementation may be useful in decreasing complications, this reduction does not result in improvement in functional recovery and nor does it decrease fracture-related mortality. Selected patients may, however, benefit from nutritional supplementation.