Cross-cultural adaptation of the FRAIL scale for critically ill patients in Spain.

AIM: To translate and culturally adapt the FRAIL scale into Spanish and perform a preliminary test of diagnostic accuracy in patients admitted to intensive care units. DESIGN: Cross-sectional diagnostic study. METHODS: Five intensive care units (ICU) in Spain were participated. Stage 1: Three native Spanish-speaking bilingual translators familiar with the field of critical care translated the scale from English into Spanish. Stage 2: Three native English-speaking bilingual translators familiar with critical care medicine. Stage 3: Authors of the original scale compared the English original and back-translated versions of the scale. Stage 4: Five nurses with more than 5 years of ICU experience and five critical care physicians assessed the comprehension and relevance of each of the items of the Spanish version in 30 patients of 3 different age ranges (<50, 50-65 and >65 years). RESULTS: The FRAIL scale was translated and adapted cross-culturally for patients admitted to intensive care units in Spain. The process consisted of four stages: translation, back translation, comparison and pilot test. There was good correspondence between the original scale and the Spanish version in 100% of the items. The participating patients assessed the relevance (content validity) and comprehensibility (face validity) of each of the items of the first Spanish version. The relevance of some of the items scored low when the scale was used in patients younger than 65 years. CONCLUSIONS: We have cross-culturally adapted the FRAIL scale, originally in English, to Spanish for its use in the critical care medical setting in Spanish-speaking countries. IMPLICATIONS FOR PROFESSIONALS: Physicians and nurses can apply the new scale to all patients admitted to the intensive care units. Nursing care can be adapted according to frailty, trying to reduce the side effects of admission to these units for the most fragile patients. REPORTING METHOD: The manuscript's authors have adhered to the EQUATOR guidelines, using the COSMIN reporting guideline for studies on the measurement properties of patient-reported outcome measures. PATIENT OR PUBLIC CONTRIBUTION: In a pilot clinical study, we applied the first version of the FRAIL-Spain scale to intensive care unit (ICU) patients. Five nurses with more than 5 years of ICU experience and five critical care physicians assessed the relevance (content validity) and comprehensibility (face validity) of the five items of the first Spanish version. Relevance was assessed using a 4-point Likert scale ranging from 1 (no relevance) to 4 (high relevance), and comprehensibility was assessed as poor, acceptable or good. Each health professional applied the scale to three patients (total number of patients = 30) of three different age ranges (<50, 50-65 and >65 years) and recorded the time of application of the scale to each patient. Although the frailty scales were initially created by geriatricians to be applied to the elders, there is little experience with their application in critically ill patients of any age. Therefore, more information is needed to determine the relevance of using this scale in critical care patients. In this pilot study, we considered that nurses and critical care physicians should evaluate frailty using this adapted scale in adult patients admitted to the Intensive Care Units.

Liver dysfunction associated with artificial nutrition in critically ill patients.

INTRODUCTION: Liver dysfunction associated with artificial nutrition in critically ill patients is a complication that seems to be frequent, but it has not been assessed previously in a large cohort of critically ill patients. METHODS: We conducted a prospective cohort study of incidence in 40 intensive care units. Different liver dysfunction patterns were defined: (a) cholestasis: alkaline phosphatase of more than 280 IU/l, gamma-glutamyl-transferase of more than 50 IU/l, or bilirubin of more than 1.2 mg/dl; (b) liver necrosis: aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l, plus bilirubin of more than 1.2 mg/dl or international normalized ratio of more than 1.4; and (c) mixed pattern: alkaline phosphatase of more than 280 IU/l or gamma-glutamyl-transferase of more than 50 IU/l, plus aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l. RESULTS: Seven hundred and twenty-five of 3,409 patients received artificial nutrition: 303 received total parenteral nutrition (TPN) and 422 received enteral nutrition (EN). Twenty-three percent of patients developed liver dysfunction: 30% in the TPN group and 18% in the EN group. The univariate analysis showed an association between liver dysfunction and TPN (p < 0.001), Multiple Organ Dysfunction Score on admission (p < 0.001), sepsis (p < 0.001), early use of artificial nutrition (p < 0.03), and malnutrition (p < 0.01). In the multivariate analysis, liver dysfunction was associated with TPN (p < 0.001), sepsis (p < 0.02), early use of artificial nutrition (p < 0.03), and calculated energy requirements of more than 25 kcal/kg per day (p < 0.05). CONCLUSION: TPN, sepsis, and excessive calculated energy requirements appear as risk factors for developing liver dysfunction. Septic critically ill patients should not be fed with excessive caloric amounts, particularly when TPN is employed. Administering artificial nutrition in the first 24 hours after admission seems to have a protective effect.

Usos y abusos en el diagnóstico de los trastornos psicogénicos del movimiento / Use and abuse in the diagnosis of psychogenic movement disorders

En los últimos años pareciera haber sido redescubierta la posibilidad de que los movimientos involuntarios anormales constituyan un síntoma de la histeria de conversión. Se constata un movimiento pendular nuevamente; los trastornos psicogénicos del movimiento parecen estar siendo sobrediagnosticados, a pesar de su relativa rareza. Esta tendencia puede ser explicada de diversas maneras. En primer lugar, por la misma naturaleza de los trastornos del movimiento en general, los cuales a menudo presentan apariencias extrañas o patrones poco habituales que pueden sorprender incluso al especialista experimentado. En segundo término, debido a que el diagnóstico de los trastornos del movimiento es principalmente fenomenológico, se tiende a considerar los casos raros o bizarros como psicogénicos, reviviendo ciertamente antiguas tendencias de la neurología clínica. Más aún, actualmente los neurólogos jóvenes están mal entrenados para reconocer la histeria, pudiendo fácilmente aplicar este diagnóstico a síntomas esotéricos o entendidos pobremente, especialmente si coexisten con perturbaciones psiquiátricas. Los criterios diagnósticos actuales que incluyen conceptos tales como trastornos del movimiento establecidos clínicamente, documentados, probables y posibles, reflejan bien estas dificultades diagnósticas pero son difíciles de recordar, poco prácticas e incluso engañosas. Claves que permiten sospechar un trastorno psicogénico subyacente son el comienzo abrupto, los eventos vitales concomitantes, la litigación, la inconsistencia de síntomas y la asociación con incapacidades pseudoneurológicas, tales como la debilidad y pérdida sensorial. Sin embargo, sólo se puede efectuar un diagnóstico definitivo cuando: 1) El movimiento anormal en cuestión aparece fenomenológicamente incompatible con el trastorno del movimiento que puede simular. El examen electrofisiológico puede ayudar en el temblor, en los síndromes de sobresalto y en la mioclonía pero no sirve en la distonía y el parkinsonismo. 2) Es posible revertir consistentemente el movimiento a través de la administración de placebo bien planeada. Se debe admitir que persistirá un cierto grado de incertidumbre en algunos casos (probables o posibles), en los cuales estos prerrequisitos puaden no ser factibles. Sin embargo, la sospecha -aunque imposible de probar- de una causa o refuerzo psicogénico de síntomas, aún en cuadros orgánicos, no es patrimonio exclusivo de los trastornos del movimiento