Limitación del esfuerzo terapéutico en pacientes con bacteriemia / Limitation of therapeutic effort in patients with bacteremia

Introducción: La limitación del esfuerzo terapéutico (LET) depende de factores médicos, éticos e individuales. Describimos las características de los pacientes con bacteriemia en los que se decidió limitar el esfuerzo terapéutico. Métodos: Estudio prospectivo de las bacteriemias en un hospital comunitario durante el año 2011. Se recogieron variables de los pacientes (edad, sexo, índice de Barthel, comorbilidades, índice de Charlson y factores exógenos) y del episodio infeccioso (etiología, foco, lugar de adquisición, expresividad clínica, LET y mortalidad hospitalaria). Se comparó el grupo en el que se realizó LET con el que no. Resultados: Se recogieron 233 episodios de bacteriemia en 227 pacientes. Se realizó LET en 19 pacientes (8,2%). Los pacientes en los que se realizó LET eran de mayor edad (80,7 vs. 72,6 años, p= 0,014), tenían más comorbilidad (índice de Charlson 4,6 vs. 2,1, p<0,001) y con más frecuencia sufrían discapacidad grave (57,9% vs. 18,8%, p<0,001). No se encontró asociación con el sexo, el lugar de adquisición ni con la expresividad clínica de la infección. El foco clínico más frecuente en los casos de LET fue el urinario (42,1%) y predominaron los grampositivos (63,2%). El tratamiento empírico fue precoz en un 73,7%. Todos los pacientes excepto uno fallecieron. Conclusión: La LET se planteó en un número importante de los pacientes con bacteriemia, especialmente en aquellos con más edad, más comorbilidad y mayor dependencia funcional. El conocimiento de sus características diferenciales nos ayuda a comprender la toma de dicha decisión

Introduction: The limitation of therapeutic effort (LTE) depends on medical, ethical and individual factors. We describe the characteristics of patients with bacteremia in which it was decided to limit the therapeutic effort Method: Prospective study of bacteremia in a community hospital in 2011. We collected information regarding patient variable (age, sex, Barthel index, comorbidities, Charlson Index and exogenous factors) as well as regarding the infectious episode (etiology, focus, place of adquisition, clinical expressivity, LTE and hospital mortality). The group in which LTE was performed was compared to the one that was not. Results: We collected 233 episodes of bacteremia in 227 patients. We performed LTE in 19 patients (8.2%). Patients with LTE were older (80.7 vs. 72.6 years, p=.014), had more comorbidity (Charlson index 4.6 vs. 2.1, p<.001 and most frequently were severe dependents (57.9% vs. 18.8%, p<.001). We found no association with sex, place of adquisition or clinical expressivity. The commonest clinical focus in patients with LTE was the urinary (42.1%) and there was a predominance of gram positive bacteria (63.2%). The empirical treatment was started early in 73.7% of cases. All patients except one died. Conclusion: LTE is considered in an important number of patients with bacteremia. They usually are older, with more comorbidity and functional dependence, bad functional basal status and important comorbidity. Knowing their differential characteristics allow us to understand this decision

[Limitation of therapeutic effort in patients with bacteremia]. / Limitación del esfuerzo terapéutico en pacientes con bacteriemia.

INTRODUCTION: The limitation of therapeutic effort (LTE) depends on medical, ethical and individual factors. We describe the characteristics of patients with bacteremia in which it was decided to limit the therapeutic effort. METHOD: Prospective study of bacteremia in a community hospital in 2011. We collected information regarding patient variable (age, sex, Barthel index, comorbidities, Charlson Index and exogenous factors) as well as regarding the infectious episode (etiology, focus, place of adquisition, clinical expressivity, LTE and hospital mortality). The group in which LTE was performed was compared to the one that was not. RESULTS: We collected 233 episodes of bacteremia in 227 patients. We performed LTE in 19 patients (8.2%). Patients with LTE were older (80.7 vs. 72.6 years, p=.014), had more comorbidity (Charlson index 4.6 vs. 2.1, p<.001 and most frequently were severe dependents (57.9% vs. 18.8%, p<.001). We found no association with sex, place of adquisition or clinical expressivity. The commonest clinical focus in patients with LTE was the urinary (42.1%) and there was a predominance of gram positive bacteria (63.2%). The empirical treatment was started early in 73.7% of cases. All patients except one died. CONCLUSION: LTE is considered in an important number of patients with bacteremia. They usually are older, with more comorbidity and functional dependence, bad functional basal status and important comorbidity. Knowing their differential characteristics allow us to understand this decision.

Utilidad del índice PROFUND para predecir la mortalidad a los 4 años en pacientes pluripatológicos / Reliability of the PROFUND index to predict 4-year mortality in polypathological patients

Objetivo: Determinar la validez del índice PROFUND para establecer el riesgo de muerte global a los 4 años en pacientes pluripatológicos. Pacientes y métodos: Estudio de cohortes (Medicina Interna y Geriatría) prospectivo y multicéntrico. Se incluyeron pacientes pluripatológicos ingresados entre el 1 de marzo y el 30 de junio de 2011. Se recogieron datos de edad, sexo, si vivían en el domicilio o en una residencia, categorías de pluripatología, índices de Charlson, Lawton-Brody y Barthel, cuestionario de Pfeiffer, escala sociofamiliar de Gijón, delirium, número de fármacos, hemoglobina, creatinina e índice PROFUND. Se realizó un seguimiento durante 4 años. Resultados: Se incluyeron 441 pacientes, 324 de Medicina Interna y 117 de Geriatría, con una edad media de 80,9 (8,7) años, y 245 (55,6%) eran mujeres. Las enfermedades cardiacas (62,7%), neurológicas (41,4%) y respiratorias (37,3%) fueron las más frecuentes. Los pacientes de Geriatría eran de más edad, más dependientes y con más deterioro cognitivo. Al cabo de 4 años habían fallecido 335 (76%) pacientes. Los factores asociados de forma independiente con la mortalidad fueron la edad, la disnea, el índice de Barthel<60, el delirium, las neoplasias avanzadas y haber ingresado 4 o más veces en el último año. El rendimiento del índice PROFUND fue bueno en los pacientes de Medicina Interna y malo en los de Geriatría (0,748, IC 95% 0,689-0,806, p<0,001, y 0,517, IC 95% 0,369-0,666, p=0,818, respectivamente). Conclusiones: El índice PROFUND es útil para predecir la mortalidad global a largo plazo en los pacientes pluripatológicos de Medicina Interna, pero no en los de Geriatría (AU)

Objective: To determine the usefullness of the PROFUND index to assess the risk of global death after 4 years in polypathological patients. Patients and methods: Multicenter prospective cohort (Internal Medicine and Geriatrics) study. Polypathological patients admitted between March 1st and June 30th 2011 were included. For each patient, data concerning age, sex, living at home or in a nursing residence, polypathology categories, Charlson, Barthel and Lawton-Brody indexes, Pfeiffer questionnaire, socio-familial Gijon scale,delirium, number of drugs, hemoglobin and creatinine values were gathered, and the PROFUND index was calculated. The follow-up lasted 4 years. Results: We included 441 patients, 324 from Internal Medicine and 117 from Geriatrics, with a mean age of 80.9 (8.7) years. Of them, 245 (55.6%) were women. Heart (62.7%), neurological (41.4%) and respiratory (37.3%) diseases were the most frequent. Geriatrics inpatients were older and more dependants and presented greater cognitive deterioration. After 4 years, 335 (76%) patients died. Mortality was associated with age, dyspnoea, Barthel index<60,delirium, advanced neoplasia and≥4 admissions in the last year. The area under the curve of the PROFUND index was 0.748, 95% CI 0.689-0.806, P<.001 in Internal Medicine and 0.517, 95% CI 0.369-0.666, P=.818 in Geriatrics patients, respectively. Conclusions: The PROFUND index is a reliable tool for predicting long-term global mortality in polypathological patients from Internal Medicine but not from Geriatrics departments (AU)

[Reliability of the PROFUND index to predict 4-year mortality in polypathological patients]. / Utilidad del índice PROFUND para predecir la mortalidad a los 4 años en pacientes pluripatológicos.

OBJECTIVE: To determine the usefullness of the PROFUND index to assess the risk of global death after 4 years in polypathological patients. PATIENTS AND METHODS: Multicenter prospective cohort (Internal Medicine and Geriatrics) study. Polypathological patients admitted between March 1st and June 30th 2011 were included. For each patient, data concerning age, sex, living at home or in a nursing residence, polypathology categories, Charlson, Barthel and Lawton-Brody indexes, Pfeiffer questionnaire, socio-familial Gijon scale, delirium, number of drugs, hemoglobin and creatinine values were gathered, and the PROFUND index was calculated. The follow-up lasted 4 years. RESULTS: We included 441 patients, 324 from Internal Medicine and 117 from Geriatrics, with a mean age of 80.9 (8.7) years. Of them, 245 (55.6%) were women. Heart (62.7%), neurological (41.4%) and respiratory (37.3%) diseases were the most frequent. Geriatrics inpatients were older and more dependants and presented greater cognitive deterioration. After 4 years, 335 (76%) patients died. Mortality was associated with age, dyspnoea, Barthel index<60, delirium, advanced neoplasia and≥4 admissions in the last year. The area under the curve of the PROFUND index was 0.748, 95% CI 0.689-0.806, P<.001 in Internal Medicine and 0.517, 95% CI 0.369-0.666, P=.818 in Geriatrics patients, respectively. CONCLUSIONS: The PROFUND index is a reliable tool for predicting long-term global mortality in polypathological patients from Internal Medicine but not from Geriatrics departments.

Síndrome coronario agudo. Hiperhomocisteinemia asociada a mutación c677t de la metilentetrahidrofolato reductasa y déficit en la anticoagulación / Acute coronary syndrome. Hyperhomocysteinaemia and methylenetrahydrofolate reductase c677t mutation with failure in the anticoagulation

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