[Healthcare professionals' perception of advanced nursing practice in Ehpad with regard to the risk of drug iatrogenicity in heart failure patients]. / Perception des professionnels de santé sur la pratique avancée infirmière en Ehpad au regard du risque d'iatrogénie médicamenteuse chez l'insuffisant cardiaque.

Medication iatrogenia is a real public health problem. Elderly people are particularly at risk, due to their multiple pathologies, including heart failure; residents of residential care facilities for the dependent elderly (Ehpad) are no exception. Studies show that this risk is avoidable in 60% of cases, and that advanced practice nurses (APNs) can play a pivotal role in preventive measures. How would the role of the APN be perceived by other healthcare professionals working with these heart failure patients institutionalized in Ehpad?

Polypathologies and Animal Models of Traumatic Brain Injury.

Traumatic brain injury (TBI) is an important health issue for the worldwide population, as it causes long-term pathological consequences for a diverse group of individuals. We are yet to fully elucidate the significance of TBI polypathologies, such as neuroinflammation and tau hyperphosphorylation, and their contribution to the development of chronic traumatic encephalopathy (CTE) and other neurological conditions. To advance our understanding of TBI, it is necessary to replicate TBI in preclinical models. Commonly used animal models include the weight drop model; these methods model human TBI in various ways and in different animal species. However, animal models have not demonstrated their clinical utility for identifying therapeutic interventions. Many interventions that were successful in improving outcomes for animal models did not translate into clinical benefit for patients. It is important to review current animal models and discuss their strengths and limitations within a TBI context. Modelling human TBI in animals encounters numerous challenges, yet despite these barriers, the TBI research community is working to overcome these difficulties. Developments include advances in biomarkers, standardising, and refining existing models. This progress will improve our ability to model TBI in animals and, therefore, enhance our understanding of TBI and, potentially, how to treat it.

Interprofessional collaboration in primary care: what effect on patient health? A systematic literature review.

BACKGROUND: In a period of change in the organization of primary care, Interprofessional Collaboration (IPC) is presented as one of the solutions to health issues. Although the number of inter-professional interventions grounded in primary care increases in all developed countries, evidence on the effects of these collaborations on patient-centred outcomes is patchy. The objective of our study was to assess the effects of IPC grounded in the primary care setting on patient-centred outcomes. METHODS: We conducted a systematic literature review using the PubMed, Embase, PsycINFO and CINAHL databases from 01/01/1995 to 01/03/2021, according to the PRISMA guidelines. Studies reporting the effects of IPC in primary care on patient health outcomes were included. The quality of the studies was assessed using the revised Downs and Black checklist. RESULTS: Sixty-five articles concerning 61 interventions were analysed. A total of 43 studies were prospective and randomized. Studies were classified into 3 main categories as follows: 1) studies with patients at cardiovascular risk (28 studies)-including diabetes (18 studies) and arterial hypertension (5 studies); 2) studies including elderly and/or polypathological patients (18 studies); and 3) patients with symptoms of mental or physical disorders (15 studies). The number of included patients varied greatly (from 50 to 312,377). The proportion of studies that reported a positive effect of IPC on patient-centred outcomes was as follows: 23 out of the 28 studies including patients at cardiovascular risk, 8 out of the 18 studies of elderly or polypathological patients, and 11 out of the 12 studies of patients with mental or physical disorders. CONCLUSIONS: Evidence suggests that IPC is effective in the management of patients at cardiovascular risk. In elderly or polypathological patients and in patients with mental or physical disorders, the number of studies remains very limited, and the results are heterogeneous. Researchers should be encouraged to perform studies based on comparative designs: it would increase evidence on the positive effect and benefits of IPC on patient variables.

Benefits and Risks in Polypathology and Polypharmacotherapy Challenges in the Era of the Transition of Thalassaemia from a Fatal to a Chronic or Curable Disease.

Beta thalassaemia major (TM), a potentially fatal haemoglobinopathy, has transformed from a fatal to a chronic disease in the last 30 years following the introduction of effective, personalised iron chelation protocols, in particular the use of oral deferiprone, which is most effective in the removal of excess iron from the heart. This transition in TM has been achieved by the accessibility to combination therapy with the other chelating drugs deferoxamine and deferasirox but also therapeutic advances in the treatment of related co-morbidities. The transition and design of effective personalised chelation protocols was facilitated by the development of new non-invasive diagnostic techniques for monitoring iron removal such as MRI T2*. Despite this progress, the transition in TM is mainly observed in developed countries, but not globally. Similarly, potential cures of TM with haemopoietic stem cell transplantation and gene therapy are available to selected TM patients but potentially carry high risk of toxicity. A global strategy is required for the transition efforts to become available for all TM patients worldwide. The same strategy could also benefit many other categories of transfusional iron loaded patients including other thalassaemias, sickle cell anaemia, myelodysplasia and leukaemia patients.

A randomized clinical trial of home telemonitoring in patients with advanced heart and lung diseases.

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 < 0.05). This tendency was maintained in the subgroups of patients with multimorbidity (34.2% vs. 46.9%, p < 0.05), intermediate risk of mortality (36.5% vs. 51.1%, p < 0.05), and those included after hospital discharge (34.9% vs. 50.5%, p < 0.01). HRQoL significantly improved (TELECARE/UCARE EuroQol baseline of 56.2 ± 18.2/55.1 ± 19.7, p = 0.054, and 64 ± 19.9/56.3 ± 21.6; p < 0.01 at the end), and perceived satisfaction was also higher (6.77 ± 0.52 vs. 6.62 ± 0.81, p < 0.001; highest possible score = 7). A trend to mortality decrease was also observed (12.9% vs. 19.3%, p = 0.13). TELECARE was cost-efficacious (TELECARE/UCARE QALY 3.94 Euros/0.81Euros). 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.

[Experimentation of a night shift nursing position in EHPAD]. / Expérimentation d'un poste infirmier de nuit en Ehpad.

The Nouvelle-Aquitaine Regional Health Agency is experimenting with a night nurse position shared between several accommodation facilities for dependent elderly.

The effects of the glycaemic control on the severity of the delirium in the advanced phase of Alzheimer's disease.

BACKGROUND: Behavioral and psychological symptoms of dementia (BPSD) and delirium are common in advanced phases of Alzheimer's disease (AD). METHODS: Thirty-eight moderate-severe AD patients were enrolled (n=16 affected by type 2 diabetes). Each patient received a comprehensive geriatric assessment (CGA) (including evaluation of BPSD and frailty), and a complete metabolic evaluation (including the measurement of the glycated hemoglobin, HbA1c). RESULTS: Both the hyper- and hypo-glycemic extremes of the glycemic spectrum worsened BPSD, but delirium was more susceptible to hypoglycemic events. The severity of delirium was significantly related to cognitive function (r = -0.585, p<0.001) and frailty (r = +0.440, p<0.05). CONCLUSIONS: The measurement of HbA1c was useful for evaluating the risk of delirium in relationship to glycemic control and nutritional status.

Simplification of the Barthel scale for screening for frailty and severe dependency in polypathological patients. / Simplificación de la escala de Barthel para el cribado de fragilidad y dependencia severa en pacientes pluripatológicos.

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±9.8years; 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.

Analysis of patients shared in consultations of internal medicine and other medical specialties. / Análisis de pacientes compartidos en consultas de medicina interna y otras especialidades médicas.

BACKGROUND AND OBJECTIVE: The aging population is resulting in an increasing number of patients with multiple diseases that require treatment by various specialties. We examined the evolution of consultations and of the percentage of patients treated by several medical specialties. METHODS: We analysed internal medicine (IM) consultations and those of other medical specialties in a hospital during 1997, 2007 and 2017 for the general population and for those older than 65 years. RESULTS: Over the course of 20 years, the rate of first IM consultations per 1000 inhabitants increased 44%, and that of other medical specialties increased 137%. The percentage of patients seen by more than one specialty went from 13.8% in 1997 to 32.6% in 2017 and reached 45.5% for those older than 65 years. CONCLUSIONS: The care for populations with growing comorbidity has a major impact on health systems and requires organisational changes for their care.

The impact of anaemia, transfusion dependency, comorbidities and polypharmacy in elderly patients with low-risk myelodysplastic syndromes.

Myelodysplastic syndromes (MDS) are heterogeneous clonal disorders ranging from indolent conditions with a near-normal life expectancy to forms approaching acute myeloid leukaemia. Comorbid conditions have rarely been systematically studied among patients with MDS. Older age per se has a negative impact on survival of MDS patients, in particular of those with lower risk. However, age indirectly affects also the survival of higher-risk patients by limiting their eligibility to intensive treatments. In addition, ageing is associated with an increasingly high risk of developing comorbidity, and a high prevalence of comorbid diseases has indeed been reported in MDS patients. The impact of multi-morbidities/comorbidities and polypharmacy in patients with low-risk MDS patients is a poorly explored topic. We focused on medications, multi-morbidities and comorbidities of 155 low-risk MDS patients followed in the haematological outpatients clinics or in medical/oncology wards of our University Hospital. One or more comorbidities were present at diagnosis in 24 younger patients with MDS syndromes (31%), whereas 56 older patients with MDS (75%) presented 1 or more comorbidities (P < 0.001).The most frequent comorbidity was cardiac comorbidity 18% in younger patients and 25% in older patients. With no statistical significance between older and younger patients, congestive heart failure was the most frequent observed disease. Our study has shown a statistical correlation between transfusion dependency and polypathology (P = 0.0014). These data were also confirmed in a subanalysis of the younger group of patients. Our study has shown that comorbidity is very common among patients with MDS, potentially affecting the clinical course and outcome of MDS patients.

Diagnostic value of a simplified Pfeiffer questionnaire for polypathological patients. / Valor diagnóstico de un cuestionario de Pfeiffer simplificado en pacientes pluripatológicos.

OBJECTIVES: To analyse the correlation, sensitivity, specificity and positive predictive (PPV) and negative predictive (NPV) values of each question on the Pfeiffer questionnaire (SPMSQ) compared with the full questionnaire for polypathological patients (PPPs). METHODS: Multicentre cross-sectional study. An SPMSQ score is considered pathological if 3 or more errors are recorded. For each question and combination of 2 questions, we calculated the correlation (kappa index), sensitivity, specificity and predictive values compared with the full SPMSQ. RESULTS: Of the 1632 PPPs included (mean age, 77.9±9.8 years, 53% men), 1434 performed the SPMSQ (the remaining presented delirium); 39% of the PPPs were pathological. The question "What day is it today?" and the command "Count backwards by 3s from 20" obtained good correlation and NPV (85 and 89%, respectively); the combination of both increased the NPV to 97%. The question "When were you born?' achieved good correlation and greater PPV (93%). CONCLUSIONS: The combination of the question "What day is it today?" and the command "Count backwards by 3s from 20" achieved a high NPV. The question related to the date of birth achieved the highest PPV.

Care models for polypathological patients. / Modelos de atención al paciente pluripatológico.

Polypathological patients have specific clinical, functional, psychoaffective, social, family and spiritual characteristics. These patients are generally elderly and frail and have frequent decompensations. They frequently use healthcare resources, have significant functional impairment and have a high index of dependence. This results in a significant social impact, high mortality and a high consumption of resources. The current healthcare models have not answered these needs, which causes problems with accessibility to healthcare services, a lack of coordination among these services, a higher probability of adverse events related to polypharmacy and a high consumption of resources. In the past decade, the healthcare models have changed and are characterized by work in multidisciplinary and interlevel teams, patient self-care, the availability of tools for decision making, information and communication systems and prevention. The goal is to have prepared and proactive health teams and an informed and active patient population. The assessment of health results, processes and the costs for these programs is still based on moderate to low evidence. It is therefore not an easy task to determine the type and intensity of interventions or to determine the patient groups that could gain more benefits.

Aging with HIV in the ART era.

In the current era of therapy for human immunodeficiency virus (HIV), life expectancy for persons living with HIV (PLWH) approaches that of the general population. This newly prolonged survival among PLWH is associated with an increased prevalence of comorbidities due to the inflammation, immune activation and immune senescence associated with HIV infection. Higher prevalence of tobacco and alcohol use, co-infection with viral hepatitis and traditional cardiovascular risk factors such as hypertension and hyperlipidemia contribute as well. In this review, we hope to describe the current comorbidities occurring among PLWH and bring increased awareness for conditions that may otherwise not be considered given the younger age at time of presentation.

Polypathology, an emerging phenomenon and a challenge for healthcare systems. / La pluripatología, un fenómeno emergente y un reto para los sistemas sanitarios.

Improvements in living conditions and scientific advances have led to an unprecedented demographic change. The curing of numerous acute diseases and the growing adoption of unhealthy lifestyles have caused a pandemic of cumulative chronic diseases that constitute the leading cause of death worldwide. Currently, the most common situation is the coexistence of multiple chronic diseases (or polypathology). This situation undermines socio-economic development and increases inequality. This results in an overriding need to change the way in which health and disease are addressed. Healthcare systems are not prepared to meet the needs of complex polypathological patients. In this article, we summarise the challenges facing healthcare systems and states, as well as the main recommendations from the organisations responsible for healthcare.

Amyloid and tau PET demonstrate region-specific associations in normal older people.

ß-amyloid (Aß) and tau pathology become increasingly prevalent with age, however, the spatial relationship between the two pathologies remains unknown. We examined local (same region) and non-local (different region) associations between these 2 aggregated proteins in 46 normal older adults using [18F]AV-1451 (for tau) and [11C]PiB (for Aß) positron emission tomography (PET) and 1.5T magnetic resonance imaging (MRI) images. While local voxelwise analyses showed associations between PiB and AV-1451 tracer largely in the temporal lobes, k-means clustering revealed that some of these associations were driven by regions with low tracer retention. We followed this up with a whole-brain region-by-region (local and non-local) partial correlational analysis. We calculated each participant's mean AV-1451 and PiB uptake values within 87 regions of interest (ROI). Pairwise ROI analysis demonstrated many positive PiB-AV-1451 associations. Importantly, strong positive partial correlations (controlling for age, sex, and global gray matter fraction, p<.01) were identified between PiB in multiple regions of association cortex and AV-1451 in temporal cortical ROIs. There were also less frequent and weaker positive associations of regional PiB with frontoparietal AV-1451 uptake. Particularly in temporal lobe ROIs, AV-1451 uptake was strongly predicted by PiB across multiple ROI locations. These data indicate that Aß and tau pathology show significant local and non-local regional associations among cognitively normal elderly, with increased PiB uptake throughout the cortex correlating with increased temporal lobe AV-1451 uptake. The spatial relationship between Aß and tau accumulation does not appear to be specific to Aß location, suggesting a regional vulnerability of temporal brain regions to tau accumulation regardless of where Aß accumulates.

Polypathology, polypharmacy, medication regimen complexity and drug therapy appropriateness. / Pluripatología, polifarmacia, complejidad terapéutica y uso adecuado de la medicación.

Polypathological patients are usually elderly and take numerous drugs. Polypharmacy affects 85% of these individuals and is not associated with greater survival. On the contrary, polypharmacy exposes these individuals to more adverse effects, such as weight loss, falls, functional and cognitive impairment and hospitalisations. The complexity of a drug regimen covers more aspects than the simple number of drugs consumed. The galenic form, the dosage and the method for preparing the drug can impede the understanding of and compliance with prescriptions. Both polypharmacy and therapeutic complexity are associated with poorer adherence by patients. To prevent polypharmacy, reduce complexity and improve adherence, the appropriate use of drugs is needed. Proper prescribing consists of selecting drugs that have clear evidence for their use in the indication, which are appropriate for the patient's circumstances, are well tolerated and cost-effective and whose benefits outweigh the risks. To improve the drug prescription, periodic reviews of the drugs need to be conducted, especially when the patient changes doctor and during healthcare transitions. The Beers and STOPP/START (Screening Tool of Older Person's potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment) criteria are effective tools for this improvement. Deprescription for polymedicated polypathological patients that considers their clinical circumstances, prognosis and preferences can contribute to a more appropriate use of drugs.

Concordance of Barthel Index, ECOG-PS, and Palliative Performance Scale in the assessment of functional status in patients with advanced medical diseases.

OBJECTIVE: Analysing most relevant clinical features and concordance between different functional scales in patients with advanced medical diseases (PAMD). METHODS: Cross-sectional multicentre study that included PAMD (heart, lung, kidney, liver, and neurological diseases) in hospital settings from February 2009 to October 2010. We analysed clinical, biological and functional features in performing activities of daily living (ADL) by medians of Barthel Index (BI); additionally we assessed their performance status by medians of Eastern Cooperative Oncology Group-Performance Status (ECOG-PS) and Palliative Performance Scale (PPS) scores. We evaluated the concordance of these instruments in assessing functional impairment by κ and intraclass correlation coefficient tests. RESULTS: 1847 patients were included (average age 79 years, 50.1% men). Most common symptoms were dyspnoea (62.31%), asthenia (23%) and delirium (20.14%). Functional assessment showed a high prevalence of severe or total impairment in performing basic ADL by medians of used instruments (BI median=35 (IQR=70), and 52.1% of patients with severe-total impairment; ECOG-PS median=2 (IQR 30), and 44% of patients with severe-total impairment; and PPS median=50 (IQR 30), and 32% of patients with severe-total impairment). Concordance among these instruments was acceptably good (κ indexes ranging from 0.653 to 0.745 (p<0.0001)). CONCLUSIONS: PAMD represent a population with severe functional impairment, which requires a multidisciplinary approach for proper management. Assessment of functional ability in this population by BI, ECOG-PS, and PPS showed good concordance.

[Characteristics of potentially inappropriate prescribing of drugs in elderly polypathological patients]. / Características del uso inadecuado de medicamentos en pacientes pluripatológicos de edad avanzada.

OBJECTIVE: To analyse potentially inappropriate prescribing (PIP) in elderly polypathological patients (PP). METHOD: Multicentre observational, prospective study of 672 patients aged 75 years and older hospitalised in Internal Medicine between April 2011 and March 2012. The Beers, STOPP-START and ACOVE criteria were used to detect potentially inappropriate prescribing and the results of PP and non-PP patients were compared. RESULTS: Of the 672 patients included, 419 (62%) were polypathological, of which 89.3% met PIP criteria versus 79.4% of non-polypathological patients (p <0.01). 40.3% of polypathological patients met at least one Beers criteria, 62.8% at least one STOPP criteria, 62.3% at least one START criteria and 65.6% at least one ACOVE criteria. The rate of potentially inappropriate prescribing was higher in polypathological patients regardless of the tool used. CONCLUSIONS: Given the high rate of potentially inappropriate prescribing in polypathological patients, strategies to improve prescribing adequacy must be developed.

Validation of PROFUND prognostic index over a four-year follow-up period.

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.

Obesity, knee osteoarthritis, and polypathology: factors favoring weight loss in older people.

AIM: We aimed to explore the meaning of obesity in elderly persons with knee osteoarthritis (KO) and to determine the factors that encourage or discourage weight loss. BACKGROUND: Various studies have demonstrated that body mass index is related to KO and that weight loss improves symptoms and functional capacity. However, dietary habits are difficult to modify and most education programs are ineffective. DESIGN: A phenomenological qualitative study was conducted. Intentional sampling was performed in ten older persons with KO who had lost weight and improved their health-related quality of life after participating in a health education program. A thematic content analysis was conducted following the stages proposed by Miles and Huberman. FINDINGS: Participants understood obesity as a risk factor for health problems and stigma. They believed that the cause of obesity was multifactorial and criticized health professionals for labeling them as "obese" and for assigning a moral value to slimness and diet. The factors identified as contributing to the effectiveness of the program were a tolerant attitude among health professionals, group education that encouraged motivation, quantitative dietary recommendations, and a meaningful learning model based on social learning theories. CONCLUSION: Dietary self-management without prohibitions helped participants to make changes in the quantity and timing of some food intake and to lose weight without sacrificing some foods that were deeply rooted in their culture and preferences. Dietary education programs should focus on health-related quality of life and include scientific knowledge but should also consider affective factors and the problems perceived as priorities by patients.