Asociación entre la necesidad de cuidados paliativos y enfermedades crónicas en pacientes atendidos en un hospital peruano / Association between the need for palliative care and chronic diseases in patients treated in a peruvian hospital

RESUMEN Objetivos. Evaluar la asociación entre las enfermedades crónicas (EC) y la necesidad de cuidados paliativos (NCP). Materiales y métodos. Se realizó un estudio transversal analítico en un hospital peruano durante el 2019. Se incluyó a pacientes hospitalizados con EC y se excluyó gestantes y a los hospitalizados en unidades críticas. En la evaluación de la NCP se aplicó el instrumento SPICT-ESTM, adicionalmente se evaluaron características sociodemográficas y clínicas. La fuerza de asociación se calculó con regresiones de Poisson con varianza robusta para estimar razones de prevalencia crudas (RP) y ajustadas (RPa) por confusores. Resultados. Se evaluó 172 pacientes, la media de edad fue 61 años, donde el 54,7% eran varones y 123 pacientes tenían NCP. En el modelo crudo se encontró asociación con tener enfermedad cerebrovascular (RP: 1,23; p=0,028), cualquier tipo de cáncer (RP: 1,38; p<0,001), cardiopatías (RP: 1,29; p=0,007), nefropatía (RP: 1,42, p<0,001) y enfermedad de Alzheimer (RP: 1,42; p<0,001). La asociación se mantuvo en la mayoría de EC evaluadas en el modelo ajustado, excepto para cardiopatía (RPa: 1,11; p=0,320). La fuerza de asociación fue menor en el caso de diabetes mellitus (RP: 0,78; p=0,044). Conclusión. La NCP en pacientes con enfermedades crónicas hospitalizados es alta y más frecuente en pacientes con cáncer, enfermedad cerebrovascular, problemas renales y enfermedad de Alzheimer. Los programas de cuidado de pacientes con diabetes mellitus pueden disminuir la NCP.

ABSTRACT Objectives. To assess the association between chronic disease (CD) and the need for palliative care (NPC). Materials and methods. An analytical cross-sectional study was carried out in a Peruvian hospital during 2019. Patients hospitalized with CD were included, and pregnant women and those hospitalized in critical units were excluded. The SPICT-ESTM instrument was used to assess the NPC; sociodemographic and clinical characteristics were also evaluated. The strength of association was calculated with Poisson regressions with robust variance to estimate crude prevalence ratios (PR) and adjusted prevalence ratios (aPR) by confounders. Results. A total of 172 patients were evaluated, the mean age was 61 years, where 54.7% were male and 123 patients had NPC. In the crude model, we found an association with having cerebrovascular disease (PR: 1.23; p=0.028), any type of cancer (PR: 1.38; p<0.001), heart disease (PR: 1.29; p=0.007), nephropathy (PR: 1.42, p<0.001) and Alzheimer's disease (PR: 1.42; p<0.001). The association was maintained for most of the evaluated CDs in the adjusted model, except for heart disease (aPR: 1.11; p=0.320). The association strength was lower for diabetes mellitus (PR: 0.78; p=0.044). Conclusion. NPC in hospitalized chronically ill patients is high and more frequent in patients with cancer, cerebrovascular disease, renal problems and Alzheimer's disease. Care programs for patients with diabetes mellitus may decrease NPC.

Association between the need for palliative care and chronic diseases in patients treated in a peruvian hospital. / Asociación entre la necesidad de cuidados paliativos y enfermedades crónicas en pacientes atendidos en un hospital peruano.

OBJECTIVES.: To assess the association between chronic disease (CD) and the need for palliative care (NPC). MATERIALS AND METHODS.: An analytical cross-sectional study was carried out in a Peruvian hospital during 2019. Patients hospitalized with CD were included, and pregnant women and those hospitalized in critical units were excluded. The SPICT-ESTM instrument was used to assess the NPC; sociodemographic and clinical characteristics were also evaluated. The strength of association was calculated with Poisson regressions with robust variance to estimate crude prevalence ratios (PR) and adjusted prevalence ratios (aPR) by confounders. RESULTS.: A total of 172 patients were evaluated, the mean age was 61 years, where 54.7% were male and 123 patients had NPC. In the crude model, we found an association with having cerebrovascular disease (PR: 1.23; p=0.028), any type of cancer (PR: 1.38; p<0.001), heart disease (PR: 1.29; p=0.007), nephropathy (PR: 1.42, p<0.001) and Alzheimer's disease (PR: 1.42; p<0.001). The association was maintained for most of the evaluated CDs in the adjusted model, except for heart disease (aPR: 1.11; p=0.320). The association strength was lower for diabetes mellitus (PR: 0.78; p=0.044). CONCLUSION.: NPC in hospitalized chronically ill patients is high and more frequent in patients with cancer, cerebrovascular disease, renal problems and Alzheimer's disease. Care programs for patients with diabetes mellitus may decrease NPC.

OBJETIVOS.: Evaluar la asociación entre las enfermedades crónicas (EC) y la necesidad de cuidados paliativos (NCP). MATERIALES Y MÉTODOS.: Se realizó un estudio transversal analítico en un hospital peruano durante el 2019. Se incluyó a pacientes hospitalizados con EC y se excluyó gestantes y a los hospitalizados en unidades críticas. En la evaluación de la NCP se aplicó el instrumento SPICT-ESTM, adicionalmente se evaluaron características sociodemográficas y clínicas. La fuerza de asociación se calculó con regresiones de Poisson con varianza robusta para estimar razones de prevalencia crudas (RP) y ajustadas (RPa) por confusores. RESULTADOS.: Se evaluó 172 pacientes, la media de edad fue 61 años, donde el 54,7% eran varones y 123 pacientes tenían NCP. En el modelo crudo se encontró asociación con tener enfermedad cerebrovascular (RP: 1,23; p=0,028), cualquier tipo de cáncer (RP: 1,38; p<0,001), cardiopatías (RP: 1,29; p=0,007), nefropatía (RP: 1,42, p<0,001) y enfermedad de Alzheimer (RP: 1,42; p<0,001). La asociación se mantuvo en la mayoría de EC evaluadas en el modelo ajustado, excepto para cardiopatía (RPa: 1,11; p=0,320). La fuerza de asociación fue menor en el caso de diabetes mellitus (RP: 0,78; p=0,044). CONCLUSIÓN.: La NCP en pacientes con enfermedades crónicas hospitalizados es alta y más frecuente en pacientes con cáncer, enfermedad cerebrovascular, problemas renales y enfermedad de Alzheimer. Los programas de cuidado de pacientes con diabetes mellitus pueden disminuir la NCP.

PANLAR Consensus Recommendations for the Management in Osteoarthritis of Hand, Hip, and Knee.

OBJECTIVE: The objective of this consensus is to update the recommendations for the treatment of hand, hip, and knee osteoarthritis (OA) by agreeing on key propositions relating to the management of hand, hip, and knee OA, by identifying and critically appraising research evidence for the effectiveness of the treatments and by generating recommendations based on a combination of the available evidence and expert opinion of 18 countries of America. METHODS: Recommendations were developed by a group of 48 specialists of rheumatologists, members of other medical disciplines (orthopedics and physiatrists), and three patients, one for each location of OA. A systematic review of existing articles, meta-analyses, and guidelines for the management of hand, hip, and knee OA published between 2008 and January 2014 was undertaken. The scores for Level of Evidence and Grade of Recommendation were proposed and fully consented within the committee based on The American Heart Association Evidence-Based Scoring System. The level of agreement was established through a variation of Delphi technique. RESULTS: Both "strong" and "conditional" recommendations are given for management of hand, hip, and knee OA and nonpharmacological, pharmacological, and surgical modalities of treatment are presented according to the different levels of agreement. CONCLUSIONS: These recommendations are based on the consensus of clinical experts from a wide range of disciplines taking available evidence into account while balancing the benefits and risks of nonpharmacological, pharmacological, and surgical treatment modalities, and incorporating their preferences and values. Different backgrounds in terms of patient education or drug availability in different countries were not evaluated but will be important.

Osteoarthritis in Latin America: Study of Demographic and Clinical Characteristics in 3040 Patients.

BACKGROUND: Latin America is a heterogeneous region made up of different populations, cultures, latitudes, altitudes, and immigrants from different areas and ethnic groups. OBJECTIVE: The purpose of this study is to describe the clinical and demographic profile of patients with osteoarthritis (OA) evaluated by a selected group of rheumatologists in 13 Latin American countries. METHODS: A descriptive, observational, cross-sectional study was conducted in 13 Latin American countries of patients with symptomatic OA. Data were collected over a 3-month period using an ad hoc questionnaire to evaluate the clinical and demographic features of OA seen by rheumatologists. RESULTS: Among the 3040 patients, their average age was 62.5 years, and female-to-male ratio was 4.8:1. Patients with body mass index of greater than 30 kg/m or obesity was found in 38.2%. Approximately 88% had primary OA. Joints with OA were as follows: knee 31.2%, hand 9.5%, hand and knee 22.9%, proximal and distal interphalangeal joints (erosive OA) 6.5%, axial 6.6%, and hip 1.3%. Approximately 88.5% had radiographic severity of grade 2 or 3 on Kellgren-Lawrence scale (0-4). Nonsteroidal anti-inflammatory drugs were the predominant OA treatment included in combinations with glucosamine sulfate/chondroitin and viscosupplementation. Associated comorbidities included hypertension (39%), obesity (36.3%), diabetes mellitus (12%), and without comorbidity (12.7%). CONCLUSIONS: This is 1 of the largest population studies that evaluated the characteristics of OA in 3040 patients evaluated by rheumatologists in 13 Latin American countries. This study provides important data for each Latin American country to develop new health care planning in management of OA.

Effects of topical human amniotic fluid and human serum in a mouse model of keratoconjunctivitis sicca.

PURPOSE: To compare the effects of topical human amniotic fluid (HAF), topical human serum (HS), and topical artificial tears in a mouse model of dry eye. METHODS: Thirty C57BL/6 mice were divided into 3 treatment groups: HAF, HS, and preservative-free artificial tears. Dry eye was induced by an injection of botulinum toxin B (BTX-B) into the lacrimal gland. Tear production and ocular surface fluorescein staining were evaluated in each mouse at 6 time points during a 4-week period. Goblet cell density was assessed in stained histological sections. Apoptotic keratocytes were evaluated by terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling test assay. RESULTS: A significant decrease in tear production was observed 3 days after BTX-B injection in all groups. At week 1, the HAF and HS groups had improved tear production compared with the control group (P < 0.001 and P = 0.003, respectively). HAF had a significantly improved fluorescein staining score compared with the HS (P = 0.043) and control (P = 0.007) groups at week 2. Goblet cell density was significantly decreased in the control group compared with the HAF and HS groups (P < 0.001). No difference in the amount of terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling-positive keratocytes was observed among the groups. CONCLUSION: HAF was superior to HS and artificial tears for improving corneal staining within 2 weeks of therapy in this induced mouse model of keratoconjunctivitis sicca. Clinical studies are needed to ascertain the benefits of these therapies in patients with ocular surface disorders associated with dry eye.

Sealing and healing of clear corneal incisions with an improved dextran aldehyde-PEG amine tissue adhesive.

PURPOSE: To create a non-cytotoxic, spontaneously curing tissue adhesive that is strongly bonding and persistent enough that 1-2 µL is capable of sealing a clear corneal incision throughout the first five days of healing. METHODS: A novel prototype delivery device capable of delivering 1-2 µL of a two-component adhesive delivered aqueous solutions of dextran aldehyde and star PEG amine, which mixed by diffusion and crosslinked to form an adhesive hydrogel. Adhesive hydrogels were tested for rates of degradation in phosphate-buffered saline, leak pressures when used to seal clear corneal incisions in enucleated rabbit eyes, and in vitro cytotoxicity when placed in contact with NIH3T3 fibroblast cells. Two formulations were used in vivo to seal clear corneal incisions in New Zealand White rabbits. Wound integrity after 1, 3, 5 and 7 days of healing was assessed by measuring the leak pressures of enucleated eyes. RESULTS: Tissue adhesives formed by combining aqueous solutions of dextran aldehyde (MW 10,000, 50% oxidized) and an 8-arm star poly(ethylene glycol) (MW 10,000) having two primary amine groups at the end of each arm gave mean leak pressures as high as 141 ± 35 mm Hg and exhibited no in vitro cytotoxicity. When 1-2 µL was used in vivo to seal clear corneal incisions in New Zealand White rabbits, the adhesive maintained an eye leak pressure of at least 120 mm Hg and remained visibly present at the wound site for 5 days. CONCLUSIONS: The combination of an 8-arm star poly(ethylene glycol), MW 10,000, having two primary amine groups at the end of each arm and dextran aldehyde (MW 10,000, 50% oxidized) forms a tissue adhesive that cures spontaneously, is non-cytotoxic, and is strongly bonding and persistent enough that 1-2 µL is capable of sealing a clear corneal incision through the first 5 days of healing.

Postrefractive surgery dry eye.

PURPOSE OF REVIEW: To report the recently published literature on ocular surface changes after refractive surgery, as well as the outcomes of treatment modalities on postrefractive surgery dry eye. RECENT FINDINGS: Cyclosporine, the first US Food and Drug Administration approved agent to treat the underlying pathological mechanism of chronic dry eye, has demonstrated promising results in dry eye patients. Further, there may be an additive effect of topical cyclosporine and punctal occlusion. Femtosecond lasers for corneal flaps in laser in-situ keratomileusis seem to induce fewer signs and symptoms of dry eye and may be attributed to the creation of thinner flaps. SUMMARY: Dry eye is one of the most common complications after photorefractive keratectomy and laser in-situ keratomileusis. Keratorefractive surgery is known to cause damage to the corneal sensory nerves. Several studies have demonstrated a decrease in corneal sensation, tear secretion, and tear film stability several months after keratorefractive surgery. For patients with preoperative dry eye, the ocular surface must be treated accordingly prior to surgery.

Analysis of clear corneal incision integrity in an ex vivo model.

PURPOSE: To determine the most favorable sutureless incision configuration to minimize extraocular fluid inflow after cataract surgery. SETTING: The Wilmer Eye Institute, Baltimore, Maryland, USA. METHODS: Five fresh human eyes were used in the study. Two 27-gauge needles connected to a saline solution bag and a digital manometer were inserted through the limbus 180 degrees from each other. Intraocular pressure (IOP) was maintained at 15 to 20 mm Hg. Three incisions were performed in different quadrants of each cornea: uniplanar 1.0 mm and 3.0 mm tunnel lengths and 2-step 3.0 mm tunnel length. India ink was applied to the incision site, and IOP fluctuation was induced by applying pressure to the limbal area of the opposite quadrant using an ophthalmodynamometer. Imaging was performed before and after pressure application. RESULTS: The linear distance of India ink inflow after pressure application was higher than the prepressure measurements in the 1.0 mm and 3.0 mm incision groups (P = .039 and P = .023, respectively). The maximum mean of inflow after pressure application was not higher than the prepressure measurement in the 2-step incision group (P = .105). The total ink area measured before and after pressure applications in the incisions of the 3 groups was not significantly different (P = .285). CONCLUSIONS: Intraocular pressure fluctuations may promote entry of bacteria-size particles into the eye when 1.0 mm and 3.0 mm single-plane incisions are performed. Stepped incisions seem to be more resistant to inflow in the presence of IOP fluctuation.

Antimicrobial efficacy of riboflavin/UVA combination (365 nm) in vitro for bacterial and fungal isolates: a potential new treatment for infectious keratitis.

PURPOSE: To demonstrate the antimicrobial properties of riboflavin/UVA (365 nm) against common pathogens. METHODS: One group of bacteria (Pseudomonas aeruginosa [PA], Staphylococcus aureus [SA], and Staphylococcus epidermidis [SE]) was tested by using Kirby-Bauer discs with (1) empty disc (Control - C); (2) riboflavin 0.1% (B2); (3) riboflavin 0.1% previously activated by UVA (B2'); (4) UVA alone (UVA); (5) group 2+additional UVA exposure (UVA+B2); and (6) group 3+additional UVA exposure (UVA+B2'). In addition, another group of microbes was tested with the same approach: methicillin-resistant S. aureus (MRSA), multidrug-resistant P. aeruginosa (MDRPA), drug-resistant Streptococcus pneumoniae (DRSP), and Candida albicans (CA). The mean growth inhibition zone (GIZ) in square millimeters was measured around the discs. The mean standard deviation (MSD) was calculated to be 3.65 when alpha = 0.01. A mean deviation (MD) > MSD indicates a significant difference. RESULTS: In the first group, the GIZ was significantly greater after UVA (MD = 14.30), UVA+B2 (MD = 39.61), and UVA+B2' (MD = 40.45) when compared with C, B2, and B2'. UVA alone was less effective than UVA+B2 (MD = 25.31) and UVA+B2' (MD = 26.15). The second group demonstrated increased GIZ in UVA (MD = 6.98), UVA+B2 (MD = 17.80), and UVA+B2' (MD = 21.15) when compared with C, B2, and B2'. UVA alone was less effective against the second group of bacteria than was UVA+B2 (MD = 10.82) and UVA+B2' (MD = 14.17). CA did not show any GIZ after treatment. CONCLUSIONS: Riboflavin/UVA was effective against SA, SE, PA, MRSA, MDRPA, and DRSP, but was ineffective on CA and has the potential for use in treatment of microbial keratitis in the future.