[The Strategic Plan for the development of Internal Medicine in Andalusia]. / El Plan Estratégico para el desarrollo de la Medicina Interna en Andalucía.

The Strategic Plan for the Development of Internal Medicine in Andalusia arose from the need that the internal medicine doctors had to redefine the purpose and values of their specialty to cope with the numerous changes occurring in the health care area. The project was developed in three phases. First, the tendency of the health care system and current position of the specialty were analyzed. After, the internal and external opinions on the present-future of Internal Medicine were checked out. Finally, five strategic lines with their action plans were established. Specific objectives were defined within each line: results to be achieved, methodology according to action plan. After several years of collegial work in this initiative, very positive results have been achieved. We conclude that the Strategic Plan has been useful to better define the position of our specialty and to state which tools such as those mentioned are effective to cope with the new challenges that may occur in other groups.

El Plan Estratégico para el desarrollo de la Medicina Interna en Andalucía / The strategic plan for the development of internal medicine in Andalusia

El Plan Estratégico para el Desarrollo de la MedicinaInterna en Andalucía surgió de la necesidad sentidapor los internistas de redefinir la misión y valores denuestra especialidad, para afrontar los numerososcambios que estaban ocurriendo en la arenasanitaria. El proyecto se desarrolló en tres fases:primero se analizaron las tendencias del sistemasanitario y la situación actual de la especialidad;posteriormente se pulsó la opinión interna y externasobre el presente-futuro de la Medicina Interna; yfinalmente se establecieron 5 líneas estratégicas consus planes de acción. Dentro de cada línea sedelimitaron objetivos específicos, resultados alograr, y metodología acorde al plan de acción. Trasvarios años de trabajo colegiado en esta iniciativa sehan logrado resultados muy positivos. Concluimosque el Plan Estratégico ha resultado útil para situarmejor nuestra especialidad, y que herramientascomo la detallada son efectivas para afrontar nuevosretos que puedan acaecer a otros colectivos

The Strategic Plan for the Development of InternalMedicine in Andalusia arose from the need thatthe internal medicine doctors had to redefine thepurpose and values of their specialty to cope withthe numerous changes occurring in the health carearea. The project was developed in three phases.First, the tendency of the health care system andcurrent position of the specialty were analyzed.After, the internal and external opinions on thepresent-future of Internal Medicine were checkedout. Finally, five strategic lines with their actionplans were established. Specific objectives weredefined within each line: results to be achieved,methodology according to action plan. After severalyears of collegial work in this initiative, very positiveresults have been achieved. We conclude that theStrategic Plan has been useful to better definethe position of our specialty and to state which toolssuch as those mentioned are effective to cope withthe new challenges that may occur in other groups (AU)

[Risk factors associated to mortality and functional deterioration in pluripathologic patients with heart failure]. / Factores de riesgo asociados a la mortalidad y al deterioro funcional en la insuficiencia cardíaca del paciente pluripatológico.

OBJECTIVES: Incidence, clinical features, and outcome of heart failure in patients with other chronic pathologies have been scarcely evaluated. The aim of the present study was to prospectively assess these issues, and the prognostic and factors associated to functional deterioration in a cohort of pluripathologic patients (PP) with heart failure (HF), attended in areas of Internal Medicine of a tertiary teaching hospital in the south of Spain. METHODS: Prospective observational study of all patients, attended in Internal Medicine areas of a tertiary teaching hospital, during June 2003. Patients were stratified in two cohorts: PP with HF as main category (PP-HF), and PP with no HF. Patients with two or more chronic diseases, distributed into seven categories (defined by a panel of experts) were considered PP. Incidence of PP-HF, functional evaluation (at baseline, at admission, and at discharge), and burden of hospital care (by means of urgent and programmed assistances, as well as episodes of hospitalization) in the last 12 months were analyzed. Chi-square, Fisher, "t" Student or U-Mann-Whitney and Rho de Spearman test were used for group comparisons. A multivariate analysis of predictors of survival and functional deterioration (fall in Barthel's scale > or = 10 points between baseline-discharge values) was performed in the PP-HF cohort. A p < 0.05 was considered significant. RESULTS: 132 pluripathologic patients (55 in PP-HF, and 77 in PP cohort) were included, from a global cohort of 339. Global incidence of PP-HF was 38,9/100 admissions. Mean age of PP-HF patients was 78, 50.9% were females; mortality rate and mean hospital stay were 23.6% and 12.2 days, respectively. Patients of PP-HF cohort compared to those of PP, were older (78 +/- 9.5 vs 73 +/- 10.8; p < 0.005), and suffered more chronic diseases (p = 0.0001). Functional abilities (at baseline, at admission, and at discharge), mean hospital stay, mortality, and burden of care in the previous 12 months were similar. Better functional abilities (OR: 1.136 [0.94-1.842]; p = 0.055), and less associated chronic diseases (OR: 0.072 [0.006-0.943], p = 0.045) were independently associated to survival; while older age (OR: 1,217 [1.016-1.457]; p = 0.03), and a poorer functional status at baseline (OR:1.80 [1.019-1.144]; p = 0.01) were associated to functional deterioration. CONCLUSIONS: Heart failure prevalent disease in pluripathologic patients. Specific factors associated to survival were gender and less chronic conditions; while those associated to functional deterioration during hospital stay were age and a poor functional status at baseline.

Factores de riesgo asociados a la mortalidad y al deterioro funcional en la insuficiencia cardíaca del paciente pluripatológico / Risk factors associated to mortality and functional deterioration in pluripathologic patients with heart failure

Introducción y objetivos. La incidencia, las características clínicas y evolutivas de los pacientes con insuficiencia cardíaca (IC) y otras patologías crónicas han sido escasamente evaluadas. El propósito de este estudio fue evaluar los factores pronósticos asociados al deterioro funcional de una cohorte de pacientes pluripatológicos (PP) con IC atendidos en diferentes áreas de Medicina Interna. Métodos. Estudio prospectivo de todos los PP atendidos en áreas de Medicina Interna de un hospital de tercer nivel durante el mes de junio de 2003. Los pacientes se estratificaron en dos cohortes: aquellos PP con IC como categoría principal (PP-IC) y PP sin IC (PP-noIC). Se consideraron PP aquellos que presentaban más de 2 enfermedades crónicas distribuidas dentro de siete posibles categorías (definidas por un panel de expertos). Se analizó la incidencia de PP-IC, la evolución funcional (basalmente, al ingreso y al alta) y la utilización de recursos hospitalarios (medidos por asistencias de urgencias o programadas y los reingresos en el último año). Los test de ji cuadrado, Fisher, «t» de Student o U-Mann-Whitney y Rho de Spearman fueron utilizados para la comparación de los grupos. Se realizó un análisis multivariante en la cohorte de PP-IC para determinar los predictores de supervivencia y deterioro funcional. Se consideró una p significativa si era inferior a 0,05. Resultados. Se incluyó un total de 132 PP (55 PP con IC y 77 PP sin IC) de un total de 339 pacientes hospitalizados. La incidencia global de PP-IC fue de 38,9/100 ingresos/mes. La edad media de los PP-IC fue de 78 años, el 50,9% eran mujeres, la estancia media fue de 12,2 días y la tasa de mortalidad del 23,6%. Los pacientes PP-IC eran mayores comparados con el subgrupo PP-noIC (78 ± 9,5 frente a 73 ± 10,8; p < 0,005) y padecían de más enfermedades crónicas (p = 0,0001). No hubo diferencias en el estado funcional (basal, al ingreso y al alta), en la estancia media, en la tasa de mortalidad y la utilización de recursos hospitalarios en el último año. Una mejor situación funcional (odds ratio [OR]: 1.136 [0,94-1,842]; p = 0,055) y un menor número de comorbilidades no definitorias de pluripatología (OR: 0,072 [0,006-0,943]; p = 0,045) se asociaron de forma independiente a la supervivencia, mientras que la mayor edad (OR: 1,217 [1,016-1,457]; p = 0,03) y un peor estado funcional basal (OR: 1,80 [1,019-1,144]; p = 0,01) se asociaron a un mayor deterioro funcional. Conclusiones. La IC fue altamente prevalente en la cohorte analizada de PP. Los factores pronósticos específicos asociados a una mayor supervivencia fueron el sexo masculino y la menor presencia de comorbilidad no definitoria de categoría, mientras que el deterioro funcional durante el ingreso se relacionó con la edad y con un peor estado funcional basal

Objectives. Incidence, clinical features, and outcome of heart failure in patients with other chronic pathologies have been scarcely evaluated. The aim of the present study was to prospectively assess these issues, and the prognostic and factors associated to functional deterioration in a cohort of pluripathologic patients (PP) with heart failure (HF), attended in areas of Internal Medicine of a tertiary teaching hospital in the south of Spain. Methods. Prospective observational study of all patients, attended in Internal Medicine areas of a tertiary teaching hospital, during Juny 2003. Patients were stratified in two cohorts: PP with HF as main category (PP-HF), and PP with no HF. Patients with two or more chronic diseases, distributed into seven categories (defined by a panel of experts) were considered PP. Incidence of PP-HF, functional evaluation (at baseline, at admission, and at discharge), and burden of hospital care (by means of urgent and programmed assistances, as well as episodes of hospitalization) in the last 12 months were analyzed. Chi-square, Fisher, «t» Student or U-Mann-Whitney and Rho de Spearman test were used for group comparisons. A multivariate analysis of predictors of survival and functional deterioration (fall in Barthel´s scale ≥ 10 points between baseline-discharge values) was performed in the PP-HF cohort. A p < 0.05 was considered significant. Results. 132 pluripathologic patients (55 in PP-HF, and 77 in PP cohort) were included, from a global cohort of 339. Global incidence of PP-HF was 38,9/100 admissions. Mean age of PP-HF patients was 78, 50.9% were females; mortality rate and mean hospital stay were 23.6% and 12.2 days, respectively. Patients of PP-HF cohort compared to those of PP, were older (78 ± 9.5 vs 73 ± 10.8; p < 0.005), and suffered more chronic diseases (p = 0.0001). Functional abilities (at baseline, at admission, and at discharge), mean hospital stay, mortality, and burden of care in the previous 12 months were similar. Better functional abilities (OR: 1.136 [0.94-1.842]; p = 0.055), and less associated chronic diseases (OR: 0.072 [0.006-0.943], p = 0.045) were independently associated to survival; while older age (OR: 1,217 [1.016-1.457]; p = 0.03), and a poorer functional status at baseline (OR:1.80 [1.019-1.144]; p = 0.01) were associated to functional deterioration. Conclusions. Heart failure prevalent disease in pluripathologic patients. Specific factors associated to survival were gender and less chronic conditions; while those associated to functional deterioration during hospital stay were age and a poor functional status at baseline

Perspectivas y evolución de la SEMI / Perspectives and evolution of SEMI

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Epidemiology of Pneumocystis carinii pneumonia in southern Spain.

In order to investigate the impact of Pneumocystis carinii infection in southern Spain following the introduction of highly active anti-retroviral therapy (HAART), all cases of pneumocystosis between 1998 and 1999 were identified from data compiled by the national surveillance system. In total, 498 cases of pneumocystosis were recorded, of which 87% involved HIV-positive patients. The mean age, length of hospital stay and mortality were higher for HIV-negative patients. There was a higher number of cases in winter. Despite HAART implementation, pneumocystosis remains a significant health problem for both HIV-positive and HIV-negative patients.