Eficiencia de las unidades geriátricas de agudos: metaanálisis de estudios controlados / Efficiency of acute geriatric units: a meta-analysis of controlled studies

Objetivo. Tras objetivar la eficacia en la reducción de la incidencia de deterioro funcional y mayor probabilidad de volver al domicilio previo entre los pacientes ancianos hospitalizados por patología médica aguda atendidos en unidades geriátricas de agudos (UGA) frente a las unidades de cuidados convencionales nos proponemos evaluar la eficiencia de dicha atención. Material y métodos. Revisión sistemática y metaanálisis de estudios controlados (aleatorizados, no aleatorizados y casos-control) que compararon la atención en UGA con la atención en unidades convencionales de hospitalización en pacientes de 65 y más años con patología médica aguda. Se excluyeron estudios sobre bases de datos administrativas, los que evaluaban la atención sobre una sola patología y los que valoraban unidades con cuidados en fase aguda y subaguda. Se realizó una revisión bibliográfica de artículos publicados hasta el 31 de agosto de 2008 en Medline, Embase, Biblioteca Cochrane y listado de referencias de revisiones sistemáticas y artículos revisados. La selección de los estudios y extracción de datos sobre estancia y costes de atención hospitalaria se realizó por dos investigadores de forma independiente. Resultados. Se incluyeron 11 estudios, de los que 5 fueron aleatorizados, 4 no aleatorizados y 2 estudios caso-control disponiendo de datos de estancia para todos ellos y de costes hospitalarios en 7 (4 ensayos clínicos, 2 estudios no aleatorizados y 1 caso-control). El análisis global de todos los estudios mostró que, en comparación con los ancianos hospitalizados en unidades convencionales, los que lo hicieron en las UGA tuvieron una reducción estadísticamente significativa de la estancia hospitalaria (diferencia de medias de – 1,01 días; IC del 95%, –1,66 a –0,36) y de los costes hospitalarios de atención (diferencia de medias de –330 dólares; IC del 95%, –540 a –120). Conclusiones. La atención en UGA es más eficiente que la proporcionada en unidades convencionales ya que, además de conseguir una reducción de la incidencia de deterioro funcional al alta y aumentar la probabilidad de volver al domicilio previo, lo hacen con una reducción de la estancia media hospitalaria y los costes hospitalarios de la atención(AU)

Objective. After analysing the effectiveness in the reduction in the incidence of functional impairment and a higher probability of returning home between elderly patients hospitalised due to an acute medical illness cared for in acute geriatric units (AGU) compared to conventional care units, we propose to assess the efficiency of this care. Material and methods. A systematic review and meta-analysis was made of controlled studies (randomised, no randomised and case-control) that compared care in UGA with care in conventional hospital units of patients of 65years and over with an acute medical illness. Studies on administrative data bases, those that evaluated care of a single disease, and those that assessed units with care in the acute and sub-acute phase were excluded. A literature review was performed on articles published up to 31st of August 2008 in Medline, Embase, Cochrane Library, and references of systematic reviews and reviewed articles. The selection of the studies and the extraction of data on the hospital stay and care costs was made independently by two different researchers. Results. A total of 11 studies were included, of which 5 were randomised, 4 were non-randomised, and 2 case control, all of them providing data on hospital stay, with 7 of them providing data on hospital costs (4 clinical trials, 2 non-randomised and 1 case-control). The overall analysis of all the studies showed that those admitted to UGA had a statistically significant reduction in hospital length of stay compared to the elderly hospitalised in conventional units (mean difference –1.01days; 95% CI, –1.66 to –0.36) and hospital care costs (mean difference of –330 US dollars; 95% CI, –540 to –120). Conclusions. Care in AGU is more efficient than that provided in conventional units, since, as well as achieving a reduction in the incidence of functional impairment at discharge and increasing the probability of returning home, they reduce mean hospital stay and the hospital care costs(AU)

[Efficiency of acute geriatric units: a meta-analysis of controlled studies]. / Eficiencia de las unidades geriátricas de agudos: metaanálisis de estudios controlados.

OBJECTIVE: After analysing the effectiveness in the reduction in the incidence of functional impairment and a higher probability of returning home between elderly patients hospitalised due to an acute medical illness cared for in acute geriatric units (AGU) compared to conventional care units, we propose to assess the efficiency of this care. MATERIAL AND METHODS: A systematic review and meta-analysis was made of controlled studies (randomised, no randomised and case-control) that compared care in UGA with care in conventional hospital units of patients of 65 years and over with an acute medical illness. Studies on administrative data bases, those that evaluated care of a single disease, and those that assessed units with care in the acute and sub-acute phase were excluded. A literature review was performed on articles published up to 31st of August 2008 in Medline, Embase, Cochrane Library, and references of systematic reviews and reviewed articles. The selection of the studies and the extraction of data on the hospital stay and care costs was made independently by two different researchers. RESULTS: A total of 11 studies were included, of which 5 were randomised, 4 were non-randomised, and 2 case control, all of them providing data on hospital stay, with 7 of them providing data on hospital costs (4 clinical trials, 2 non-randomised and 1 case-control). The overall analysis of all the studies showed that those admitted to UGA had a statistically significant reduction in hospital length of stay compared to the elderly hospitalised in conventional units (mean difference -1.01 days; 95% CI, -1.66 to -0.36) and hospital care costs (mean difference of -330 US dollars; 95% CI, -540 to -120). CONCLUSIONS: Care in AGU is more efficient than that provided in conventional units, since, as well as achieving a reduction in the incidence of functional impairment at discharge and increasing the probability of returning home, they reduce mean hospital stay and the hospital care costs.

IL-15 preferentially enhances functional properties and antigen-specific responses of CD4+CD28(null) compared to CD4+CD28+ T cells.

One of the most prominent changes during T-cell aging in humans is the accumulation of CD28(null) T cells, mainly CD8+ and also CD4+ T cells. Enhancing the functional properties of these cells may be important as they provide an antigen-specific defense against chronic infections. Recent studies have shown that IL-15 does in fact play an appreciable role in CD4 memory T cells under physiological conditions. We found that treatment with IL-15 increased the frequency of elderly CD4+CD28(null) T cells by the preferential proliferation of these cells compared to CD4+CD28+ T cells. IL-15 induced an activated phenotype in CD4+CD28(null) T cells. Although the surface expression of IL-15R α-chain was not increased, the transcription factor STAT-5 was preferentially activated. IL-15 augmented the cytotoxic properties of CD4+CD28(null) T cells by increasing both the mRNA transcription and storage of granzyme B and perforin for the cytolytic effector functions. Moreover, pretreatment of CD4+CD28(null) T cells with IL-15 displayed a synergistic effect on the IFN-γ production in CMV-specific responses, which was not observed in CD4+CD28+ T cells. IL-15 could play a role enhancing the effector response of CD4+CD28(null) T cells against their specific chronic antigens.

Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis.

OBJECTIVE: To assess the effectiveness of acute geriatric units compared with conventional care units in adults aged 65 or more admitted to hospital for acute medical disorders. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Medline, Embase, and the Cochrane Library up to 31 August 2008, and references from published literature. Review methods Randomised trials, non-randomised trials, and case-control studies were included. Exclusions were studies based on administrative databases, those that assessed care for a single disorder, those that evaluated acute and subacute care units, and those in which patients were admitted to the acute geriatric unit after three or more days of being admitted to hospital. Two investigators independently selected the studies and extracted the data. RESULTS: 11 studies were included of which five were randomised trials, four non-randomised trials, and two case-control studies. The randomised trials showed that compared with older people admitted to conventional care units those admitted to acute geriatric units had a lower risk of functional decline at discharge (combined odds ratio 0.82, 95% confidence interval 0.68 to 0.99) and were more likely to live at home after discharge (1.30, 1.11 to 1.52), with no differences in case fatality (0.83, 0.60 to 1.14). The global analysis of all studies, including non-randomised trials, showed similar results. CONCLUSIONS: Care of people aged 65 or more with acute medical disorders in acute geriatric units produces a functional benefit compared with conventional hospital care, and increases the likelihood of living at home after discharge.