Prepandemic viral community-acquired pneumonia: Diagnostic sensitivity and specificity of nasopharyngeal swabs and performance of clinical severity scores.

The objectives of this work were to assess the diagnostic sensitivity and specificity of nasopharyngeal (NP) swabs for viral community-acquired pneumonia (CAP) and the performance of pneumonia severity index (PSI) and CURB-65 severity scores in the viral CAP in adults. A prospective observational cohort study of consecutive 341 hospitalized adults with CAP was performed between January 2018 and March 2020. Demographics, comorbidities, symptoms/signs, analytical data, severity scores, antimicrobials, and outcomes were recorded. Blood, NP swabs, sputum, and urine samples were collected at admission and assayed by multiplex real time-PCR, bacterial cultures, and Streptococcus pneumoniae and Legionella pneumophila antigens detection, to determine the etiologies and quantify the viral load. The etiology was identified in 174 (51.0%) patients, and in 85 (24.9%) it was viral, the most frequent rhinovirus and influenza virus. The sensitivity of viral detection in sputum (50.7%) was higher than in NP swabs (20.9%). Compared with sputum, the positive predictive value and specificity of NP swabs for viral diagnosis were 95.8% and 96.9%, respectively. Performance of PSI and CURB-65 scores in all CAP with etiologic diagnosis were as expected, with mortality associated with higher values, but they were not associated with mortality in patients with viral pneumonia. NP swabs have lower sensitivity but high specificity for the diagnosis of viral CAP in adults compared with sputum, reinforcing the use NP swabs for the diagnostic etiology work-up. The PSI and CURB-65 scores did not predict mortality in the viral CAP, suggesting that they need to be updated scores based on the identification of the etiological agent.

Adaptación transcultural a la versión española del cuestionario “Structured History of Medication Use” para la conciliación de la medicación al ingreso / Cross-cultural adaptation to the Spanish version of the “Structured HIstory of Medication Use” questionnaire for medication reconciliation at admission

Antecedentes y objetivoEl cuestionario “Structured HIstory of Medication use” (SHIM) es una herramienta diseñada para obtener una visión completa de la medicación del paciente antes del ingreso mediante una entrevista estructurada, y ha demostrado su potencial para prevenir errores de conciliación. El objetivo de este estudio fue adaptar transculturalmente el cuestionario SHIM al español.Pacientes y métodosTraducción directa e inversa seguidas de una síntesis y adaptación, que contó con la participación de un panel de expertos, para garantizar la equivalencia entre el cuestionario original y su versión española. Posteriormente se realizó un análisis de la comprensibilidad de la versión española del cuestionario mediante entrevistas cognitivas en una muestra de pacientes polimedicados en seguimiento por el Servicio de Medicina Interna.ResultadosSe obtuvo la versión española del cuestionario SHIM (SHIM-e). El grado de dificultad asignado por los traductores a la traducción directa e inversa fue bajo. Durante la fase de síntesis y adaptación se resolvieron tres discrepancias y se decidió emplear, en la versión del cuestionario adaptada al español, algunos términos de uso común en la entrevista clínica. El análisis de la comprensibilidad, realizado en una muestra de 10 pacientes polimedicados e ingresados en la Unidad de Cirugía General y de Aparato Digestivo, mostró una comprensibilidad del 100% para todos los ítems, excepto para el número 13 que fue del 90%.ConclusionesEste trabajo presenta la primera adaptación transcultural al español del cuestionario SHIM. Los procesos de traducción directa e inversa han presentado una dificultad baja y los resultados de las entrevistas cognitivas muestran un nivel alto de comprensibilidad para la versión española de esta herramienta.

Cross-cultural adaptation to the Spanish version of the "Structured HIstory of Medication Use" questionnaire for medication reconciliation at admission. / Adaptación transcultural a la versión española del cuestionario "Structured HIstory of Medication Use" para la conciliación de la medicación al ingreso.

BACKGROUND AND OBJECTIVE: The "Structured HIstory of Medication use" (SHIM) questionnaire is a tool developed to obtain an accurate pre-admission overview of medications, involving a structured interview with patients, and has demonstrated its potential to prevent reconciliation errors. The objective of this study was to cross-culturally adapt the SHIM questionnaire to Spanish. PATIENTS AND METHODS: Forward and blind-back translations followed by a synthesis and adaptation, with the participation of an expert panel, to guarantee the equivalence between the original questionnaire and the Spanish version. Subsequently, pilot testing of the Spanish version was carried out through cognitive interviews in a sample of polymedicated patients under follow-up by the Department of Internal Medicine. RESULTS: The Spanish version of the SHIM questionnaire (SHIM-e) was obtained. Scores for difficulty assigned by translators involved in forward and back translations were low. During the synthesis and adaptation phase, three discrepancies were resolved, and the expert panel decided to include some terms commonly used for clinical interviews in the Spanish version of the questionnaire. The pilot testing, which was performed in a sample of 10 polymedicated patients admitted to the Department of General and Digestive Surgery, showed 100% comprehensibility for all items, except for number 13, which was 90%. CONCLUSIONS: This work presents the first cross-cultural adaptation to Spanish of the SHIM questionnaire. The forward and blind-back translations presented low difficulty and the results of the pilot testing showed a high level of comprehensibility for the Spanish version of this tool.

Dorsalgia tras colangiopancreatografía retrógrada endoscópica / Back pain after endoscopic retrograde cholangiopancreatography

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Ketoacidosis Due to Empagliflozin, a Paradigm Shift: Case Report and Review of Literature.

INTRODUCTION: Sodium-glucose cotransporter 2(SGLT2)-inhibitors are new antihyperglycemic agents that have shown a reduction in cardiovascular events in type 2 diabetes mellitus. Recent warnings have been developed about an increased risk of euglycemic and moderate hyperglycemic diabetic ketoacidosis with the use of SGLT2 inhibitors, but its real incidence is not available yet. CASE REPORT: We present a case of DKA with moderate hyperglycemia in a patient treated with metformin and empagliflozin. CONCLUSION: DKA in patients treated with SGLT2 inhibitors can be presented as euglycemic and moderated hyperglycemia. This special presentation poses a physician's challenge.

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

Objetivo: Analizar el uso inadecuado de medicamentos en pacientes pluripatológicos de edad avanzada. Método: Estudio multicéntrico, observacional y prospectivo. Se reclutaron 672 pacientes mayores de 75 años hospitalizados en Medicina Interna entre abril de 2011 y marzo de 2012. Se utilizaron los criterios Beers, STOPP-START y ACOVE para detectar el uso inadecuado de medicamentos, y los resultados se compararon entre pacientes pluripatológicos y no pluripatológicos. Resultados: De 672 pacientes incluidos, 419 (62%) eran pluripatológicos y el 89,3% de ellos presentaban un uso inadecuado de medicamentos, frente al 79,4% de los no pluripatológicos (p <0,01). El 40,3% de los pacientes pluripatológicos cumplía criterios de Beers, el 62,8% criterios STOPP, el 62,3% criterios START y el 65,6% criterios ACOVE. El uso inadecuado de medicamentos fue mayor en los pacientes pluripatológicos con independencia de la herramienta utilizada. Conclusiones: La alta prevalencia de uso inadecuado de medicamentos en pacientes pluripatológicos hace necesario desarrollar estrategias para mejorar la adecuación farmacológica (AU)

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 (AU)

Potentially Inappropriate Antihypertensive Prescriptions to Elderly Patients: Results of a Prospective, Observational Study.

INTRODUCTION: Previous studies of antihypertensive treatment of older patients have focused on blood pressure control, cardiovascular risk or adherence, whereas data on inappropriate antihypertensive prescriptions to older patients are scarce. OBJECTIVES: The aim of the study was to assess inappropriate antihypertensive prescriptions to older patients. METHODS: An observational, prospective multicentric study was conducted to assess potentially inappropriate prescription of antihypertensive drugs, in patients aged 75 years and older with arterial hypertension (HTN), in the month prior to hospital admission, using four instruments: Beers, Screening Tool of Older Person's Prescriptions (STOPP), Screening Tool to Alert Doctors to the Right Treatment (START) and Assessing Care of Vulnerable Elders 3 (ACOVE-3). Primary care and hospital electronic records were reviewed for HTN diagnoses, antihypertensive treatment and blood pressure readings. RESULTS: Of 672 patients, 532 (median age 85 years, 56% female) had HTN. 21.6% received antihypertensive monotherapy, 4.7% received no hypertensive treatment, and the remainder received a combination of antihypertensive therapies. The most frequently prescribed antihypertensive drugs were diuretics (53.5%), angiotensin-converting enzyme inhibitors (ACEIs) (41%), calcium antagonists (32.2%), angiotensin receptor blockers (29.7%) and beta-blockers (29.7%). Potentially inappropriate prescription was observed in 51.3% of patients (27.8% overprescription and 35% underprescription). The most frequent inappropriately prescribed drugs were calcium antagonists (overprescribed), ACEIs and beta-blockers (underprescribed). ACEI and beta-blocker underprescriptions were independently associated with heart failure admissions [beta-blockers odds ratio (OR) 0.53, 95% confidence interval (CI) 0.39-0.71, p < 0.001; ACEIs OR 0.50, 95% CI 0.36-0.70, p < 0.001]. CONCLUSION: Potentially inappropriate prescription was detected in more than half of patients receiving antihypertensive treatment. Underprescription was more frequent than overprescription. ACEIs and beta-blockers were frequently underprescribed and were associated with heart failure admissions.

[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.

Elderly patients treated with psychotropic medicines admitted to hospital: associated characteristics and inappropriate use.

PURPOSE: The purpose of this study is to describe the characteristics of older patients treated with psychotropic medicines and the associated factors and to assess their inappropriate use. METHODS: An observational, prospective study was carried out in 672 elderly patients admitted to seven hospitals for a year. A comparison of sociodemographic characteristics, geriatric variables, multimorbidity and the number of prescribed medicines taken in the preceding month before hospitalization between patients treated with psychotropics and those not treated was performed. To assess factors associated with psychotropics, multivariate logistic regression analyses were performed. Inappropriate use was assessed using the Beers and the STOPP criteria. RESULTS: A total of 57.5 % patients (median [Q1-Q3] age 81.7 [78.2-86.1], 65.7 % female) were treated with psychotropics (44.2 % anxiolytics, 22.6 % antidepressants and 10.8 % antipsychotics). Independent factors associated with the use of psychotropics were female gender (OR = 2.3; CI 95 %,1.6-3.5), some degree of disability on admission (slight [OR = 2.2; 1.2-4.2], moderate [OR = 3.2, 1.6-6.6], severe [OR = 3.4; 1.4-8] and very severe [OR = 5.1; 2.0-12.8]) and polypharmacy (5-9 medicines [OR = 3.0; 1.3-6.9] and ≥10 medicines [OR = 6.0; 2.7-13.6]). The associated factors varied depending on the different types of psychotropics. In patients treated with psychotropics, the percentage of those with at least one Beers (61.6 %) or at least one STOPP (71.4 %) criteria was significantly higher in comparison with those not treated with psychotropics (30.7 and 47.7 %, respectively, p < 0.001). CONCLUSIONS: Psychotropics are widely used in the elderly population and often their use is inappropriate. Female gender, a poor functional status and polypharmacy, are the characteristics linked to their use. Interventional strategies should be focused on patients with these characteristics.

Inappropriate prescribing to the oldest old patients admitted to hospital: prevalence, most frequently used medicines, and associated factors.

BACKGROUND: Scientific evidence on treatments of chronic diseases in patients 85 years old or older is very limited, as is available information on inappropriate prescription (IP) and its associated factors. The study aimed to describe medicine prescription, potentially inappropriate medicines (PIM) and potentially prescribing omissions (PPO) and their associated factors on this population. METHODS: In the context of an observational, prospective and multicentric study carried out in elderly patients admitted to seven Spanish hospitals for a year, a sub-analysis of those aged 85 years and over was performed. To assess PIMs, the Beers and STOPP criteria were used, and to assess PPOs, the START and the ACOVE-3 criteria were used. To assess factors associated with IP, a multivariate logistic regression analysis was performed. Patients were selected randomly every week on consecutive days from the hospitalization lists. RESULTS: A total of 336 patients were included in the sub-analysis with a median (Q1-Q3) age of 88 (86-90) years. The median medicines taken during the month prior to admission was 10 (7-13). Forty-seven point two per cent of patients had at least one Beers-listed PIM, 63.3% at least one STOPP-listed PIM, 53.6% at least one START-listed PPO, and 59.4% at least one ACOVE-3-listed PPO. Use of benzodiazepines in patients who are prone to falls (18.3%) and omission of calcium and vitamin D supplements in patients with osteoporosis (13.3%) were the most common PIM and PPO, respectively. The main factor associated with the Beers-listed and the STOPP-listed PIM was consumption of 10 or more medicines (OR = 5.7, 95% CI 1.8-17.9 and OR = 13.4, 95% CI 4.0-44.0, respectively). The main factors associated with the START-listed PPO was a non-community dwelling origin (OR 2.3, 95% CI 1.0-5.0), and multimorbidity (OR1.8, 95% CI 1.0-3.1). CONCLUSIONS: Prescribed medicines and PIM and PPO prevalence were high among patients 85 years and over. Benzodiazepine use in those who are prone to falls and omission of calcium and vitamin D in those with osteoporosis were the most frequent PIM and PPO, respectively. Factors associated with PIM and PPO differed with polypharmacy being the most important factor associated with PIM.

Perfil de prescripción farmacológica en pacientes con enfermedades crónicas no neoplásicas en fase avanzada / Drug prescription profile in patients with advanced chronic diseases

Objetivos. Analizar el perfil de prescripción farmacológica y los factores asociados a polifarmacia en pacientes con enfermedades crónicas no neoplásicas en fase avanzada. Material y métodos. Estudio observacional transversal, multicéntrico, realizado en 41 hospitales españoles (proyecto PALIAR). Se definió polifarmacia como el consumo habitual de 5 o más fármacos en los últimos 3 meses y polifarmacia excesiva cuando dicho número era de 10 o más. El grado de adherencia fue evaluado mediante una encuesta rellenada por el paciente o su cuidador. Se analizaron los factores relacionados con la polifarmacia y la no adherencia al tratamiento. Resultados. De 1.847 pacientes, completaron la encuesta 1.778 (96,2%). La edad media fue 78,74 ± 10 años. Los fármacos más prescritos fueron: antihipertensivos (82,6%), gastroprotectores (73,8%), antiagregantes/anticoagulantes (70,3%) y psicotrópicos (51,8%). La prevalencia de polifarmacia/polifarmacia-severa fue de 86,2-31,3% (consumo medio: 8 ± 3,5 fármacos). El 48,2% reconocía cometer errores en la toma: el 38,5% ocasionalmente y el 9,6% casi diariamente o siempre. La no-adherencia se relacionó con: cumplir criterios de paciente pluripatológico, > 3 ingresos en los últimos 3 meses, deterioro cognitivo y la toma de > 5 fármacos. La polifarmacia se asoció con cumplir criterios de paciente pluripatológico, puntuación ECOG < 3, edad < 85 años y > 3 ingresos en los últimos 3 meses. La polifarmacia severa se relacionó con cumplir criterios de paciente pluripatológico y > 3 ingresos en los últimos 3 meses. Conclusiones. La prevalencia de polifarmacia y errores en administración de fármacos en pacientes con enfermedades médicas avanzadas es elevada, por lo que es necesario desarrollar estrategias para mejorar la adherencia en esta población (AU)

Objectives. To analyze the prescription profile and the factors associated with multiple medications (polypharmacy) and non-adherence in patients with advanced chronic diseases. Material and methods. Longitudinal cross-sectional study including 41 Spanish hospitals (PALIAR project). Polypharmacy was defined as a prescribed treatment with five or more drugs, and excessive polypharmacy when the number was ten or more. The adherence was evaluated using a questionnaire completed by the patients or their caregivers. Description of drug prescription profile and analysis was performed on the risk factors associated with multiple medications and non-adherence. Results. The study included 1847 patients, and 1778 (96.2%) completed the questionnaire. Mean age was 78.74±10 years. Antihypertensives (82.6%), gastroprotectives (73.8%), anti-platelets/anticoagulants (70.3%), and psychotropic drugs (51.8%) were the most frequently prescribed drugs. Prevalence of polypharmacy/excessive polypharmacy was 86.2%/31.3%, with a mean of 8±3.5 drugs per patient. Errors in treatment compliance were detected in 48.2% of patients, but 38.5% and 9.6% referred to an occasional or almost daily failure, respectively. Factors associated with non-adherence were: to be a patient with multiple diseases, cognitive impairment, three or more 3 hospital admissions in the last three months, and having polypharmacy. Factors associated with polypharmacy were: to be a patient with multiple diseases, an ECOG score <3, age <85 years, and 3 or more hospital admissions. Factors associated with excessive polypharmacy were: to be a patient with multiple diseases and previous frequent hospital admissions. Conclusions. The prevalence of polypharmacy in patients with advanced chronic diseases is high, and mistakes in treatment compliance are frequent. Further studies with better defined objectives and more specific therapeutic limits are needed (AU)

Inappropriate prescribing to older patients admitted to hospital: a comparison of different tools of misprescribing and underprescribing.

PURPOSE: This study aims to assess inappropriate prescribing (IP) to elderly patients during the month prior to hospitalization and to compare different IP criteria. METHODS: An observational, prospective and multicentric study was carried out in the internal medicine services of seven Spanish hospitals. Patients aged 75years and older were randomly selected after hospital admission for a year. To assess potentially inappropriate medicines (PIMs), the Beers and STOPP criteria were used and to assess potentially prescribing omissions (PPOs), the START criteria and ACOVE-3 medicine quality indicators were used. An analysis to assess factors associated with IP was performed. RESULTS: 672 patients [median age (Q1-Q3) 82 (79-86) years, 55.9% female] were included. Median prescribed medicines in the month prior to hospitalization were 10(Q1-Q3 7-13). The prevalence of IP was 87.6%, and 54.3% of patients had PIMs and PPOs concurrently. A higher prevalence rate of PIMs was predicted using the STOPP criteria than with the Beers criteria (p<0.001) and a higher prevalence of PPOs using the ACOVE-3 criteria than using the START criteria (p<0.001) was observed. Polypharmacy (≥ 10 medicines) was the strongest predictor of IP [OR=11.34 95% confidence interval (CI) 4.96-25.94], PIMs [OR=14.16, 95% CI 6.44-31.12], Beers-listed PIMs [OR=8.19, 95% CI 3.01-22.28] and STOPP-listed PIMs [OR=8.21, 95% CI 3.47-19.44]. PIMs was the strongest predictor of PPOs [OR=2.79, 95% CI 1.81-4.28]. CONCLUSIONS: A high prevalence of polypharmacy and PIMs and PPOs were reported. More than half the patients had simultaneous PIMs and PPOs. The related factors to PIMs and PPOs were different.

[Drug prescription profile in patients with advanced chronic diseases]. / Perfil de prescripción farmacológica en pacientes con enfermedades crónicas no neoplásicas en fase avanzada.

OBJECTIVES: To analyze the prescription profile and the factors associated with multiple medications (polypharmacy) and non-adherence in patients with advanced chronic diseases. MATERIAL AND METHODS: Longitudinal cross-sectional study including 41 Spanish hospitals (PALIAR project). Polypharmacy was defined as a prescribed treatment with five or more drugs, and excessive polypharmacy when the number was ten or more. The adherence was evaluated using a questionnaire completed by the patients or their caregivers. Description of drug prescription profile and analysis was performed on the risk factors associated with multiple medications and non-adherence. RESULTS: The study included 1847 patients, and 1778 (96.2%) completed the questionnaire. Mean age was 78.74±10 years. Antihypertensives (82.6%), gastroprotectives (73.8%), anti-platelets/anticoagulants (70.3%), and psychotropic drugs (51.8%) were the most frequently prescribed drugs. Prevalence of polypharmacy/excessive polypharmacy was 86.2%/31.3%, with a mean of 8±3.5 drugs per patient. Errors in treatment compliance were detected in 48.2% of patients, but 38.5% and 9.6% referred to an occasional or almost daily failure, respectively. Factors associated with non-adherence were: to be a patient with multiple diseases, cognitive impairment, three or more 3 hospital admissions in the last three months, and having polypharmacy. Factors associated with polypharmacy were: to be a patient with multiple diseases, an ECOG score <3, age <85 years, and 3 or more hospital admissions. Factors associated with excessive polypharmacy were: to be a patient with multiple diseases and previous frequent hospital admissions. CONCLUSIONS: The prevalence of polypharmacy in patients with advanced chronic diseases is high, and mistakes in treatment compliance are frequent. Further studies with better defined objectives and more specific therapeutic limits are needed.

An inter-rater reliability study of the prescribing indicated medications quality indicators of the Assessing Care Of Vulnerable Elders (ACOVE) 3 criteria as a potentially inappropriate prescribing tool.

PURPOSE: There are limited tools to assess potential prescribing omissions (PPOs) or underprescribing in the elderly. The ACOVE project defines comprehensive quality care indicators for older people and some of these indicators focused on appropriate use of medicines. The aim of the present study was to assess the inter-rater reliability between observers using the ACOVE 3 prescribing indicated medications indicators and compare it with the inter-rater reliability obtained for the Screening Tool of Older Person's Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria. METHODS: In the context of an observational and multicentric study of a cohort of 672 patients 75 years and older who were hospitalized in Internal Medicine services of seven Spanish hospitals, an inter-rater reliability study using the ACOVE selected indicators and the STOPP/START criteria was carried out between April 2011 and March 2012. Three patients were randomly selected in each participating hospital, one for each four months of study. RESULTS: A total of 21 patients (mean (SD) age of 84.3 (5.6) years, 57.1% female) were included in the inter-rater reliability study. For the STOPP, START and ACOVE criteria, the median kappa coefficient for the seven hospital analyses was 0.97, 0.92 and 0.95, respectively. Out of 123 total indicators in only 7 (5.7%) was the kappa coefficient value below 0.75. Only for 2 (5.6%) of the 37 studies selected ACOVE quality indicators was the kappa coefficient value less than 0.75. CONCLUSIONS: A high inter-rater reliability was obtained for the selected underprescribing quality indicators of ACOVE 3. These quality indicators may be considered a useful tool in detecting underprescribing to the elderly patients.

Efectos adversos neuropsiquiátricos asociados con efavirenz / Neuro-psychiatric adverse effects associated with Efavirenz

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[Incidence and clinical features of patients with comorbidity attended in internal medicine areas]. / Incidencia y características clínicas de los pacientes con pluripatología ingresados en una unidad de medicina interna.

BACKGROUND AND OBJECTIVE: Our objective was to assess the incidence and clinical features of patients with numerous disorders--comorbidity patients (CP)--and to clinically validate the CP criteria defined by a panel of experts (patients with 2 or more chronic diseases, distributed into seven categories). PATIENTS AND METHOD: Prospective observational study of all patients, attended in internal medicine areas of a tertiary teaching hospital, during June 2003. Patients were stratified in 3 cohorts: CP, palliative, and general (GE). Incidence of CP, functional evaluation (at baseline, at admission, and at discharge), and burden of hospital care (by means of urgent and programmed visits, as well as episodes of hospitalization) in the last 12 months were analyzed. 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 CP cohort. RESULTS: 339 patients (CP cohort: 132; palliative: 52; GE: 155) were included. The overall incidence was 38.9/100 admissions/month. CP were older (75 [11] vs 67 [16]); had higher mortality (19.3% vs 6.1%; relative risk [RR]: 3.66 [95% confidence interval [CI], 1.65-8.13]; lower functional ability at baseline (45 vs 95), at admission (20 vs 75), and at discharge (20 vs 95); higher rates of significant functional deterioration (16% vs 7%; RR = 2.47 [95% CI, 1.15-5.35]); and required more burden of hospital care by means of urgent care (3.6 [3.4] episodes vs 2.4 [1.9]), and hospitalizations (1.9 [1.3] vs 1.5 [1]) than GE patients. Chronic digestive/hepatic diseases (odds ratio [OR] = 48.3 [2.4-980.9], peripheric vascular disease/diabetes with visceral involvement (OR = 5.6 [CI 95%, 1.1-28.6]), and better functional ability at admission were associated with survival. Female gender (OR ) 46.6 [CI 95%, 4.5-486.9]), chronic lung disease (OR = 8.9 [CI 95%, 1.2-64]), and neurologic disease with disability (OR = 8 [CI 95%, 1.1-58.9]), were associated with significant functional deterioration during hospital stay. CONCLUSIONS: The defined CP criteria were highly accurate in detecting a population of patients with high attention in Internal Medicine areas, high mortality rates, clinical frailty (more need of hospital care), and significant functional deterioration. Barthel's scale identified correctly this group of patients, and was independently associated with survival.