Evaluating patients' satisfaction and preferences with a secondary prevention cardiovascular polypill: the Aurora Study.

Aim: To evaluate the satisfaction, preferences and adherence of patients in secondary cardiovascular prevention treated with the Spanish National Cardiovascular Research Centre cardiovascular polypill compared with patients treated with the separate monocomponents. Methods: Observational, cross-sectional and multicenter study. Satisfaction was evaluated by the Treatment Satisfaction Questionnaire for Medication 9 items, adherence by the Morisky-Green questionnaire and ad-hoc questions were asked regarding patient preferences. Results: Polypill patients reported higher satisfaction than patients treated with the monocomponents (77.3 vs 71.2%; p < 0.0001). 72.8% of patients treated with the monocomponents would prefer to change to the polypill. Patients treated with the polypill had significantly higher adherence than patients treated with the monocomponents (57.7 vs 41.1%; p = 0.0027). Conclusion: Polypill patients show higher satisfaction and better adherence. Most patients receiving the monocomponents would prefer a polypill regime.

Análisis de las características de los pacientes con necesidades paliativas en un servicio de medicina interna / Analysis of the characteristics of patients with palliative needs in an internal medicine service

OBJETIVOS: Analizar la prevalencia de pacientes con necesidad de cuidados paliativos (NCP) en pacientes fallecidos en un servicio de medicina interna (MI), así como las diferencias en la asistencia médica recibida en las últimas 48 h de vida en función de la identificación de situación de "asistencia paliativa" en la historia clínica. MATERIAL Y MÉTODOS: Para el primer objetivo se realizó un estudio observacional, transversal y retrospectivo, incluyendo a todos los pacientes que fallecieron en MI del Hospital Vega Baja entre enero y junio 2017. Se consideró que los pacientes tenían NCP si presentaban un NECPAL CCOMS-ICO(c) positivo y una puntuación en índice PALIAR > 7,5 al ingreso. Entre los pacientes con NCP se realizó un estudio de casos-controles en función de su identificación o no en la historia clínica mediante el código diagnóstico "asistencia paliativa". Se analizaron diferencias relacionadas con la asistencia clínica en las últimas 48 h entre ambos grupos. RESULTADOS: Hubo 120 fallecimientos durante el periodo de estudio, lo que supuso un 12 % de los ingresos en MI. De estos, 98 (82 %) presentaban NCP al ingreso. Predominó la trayectoria de "fragilidad" al final de la vida (43,8 %). Los pacientes del grupo de "asistencia paliativa" fueron expuestos en menor proporción a administración de fluidoterapia intensiva (un 36 % frente a un 93,6 %; p < 0,01), antibioticoterapia intravenosa (un 32 % frente a un 93,6 %; p < 0,01), utilización de ventilación mecánica no invasiva (un 2 % frente a un 17 %, p < 0,01), extracciones analíticas (un 24 % frente a un 100 %, p < 0,01). En este grupo de pacientes se administró en una mayor proporción sedación paliativa en las últimas 48 horas (un 90 % frente a un 29,7 %; p < 0,01). CONCLUSIONES: Una elevada proporción de los pacientes que fallecen en los servicios de MI cumplen criterios de NCP desde el ingreso. La no identificación en la historia clínica se ha asociado a mayor número de maniobras diagnóstico-terapéuticas invasivas y menos utilización de sedación paliativa

OBJECTIVES: To analyse the prevalence of patients in need of palliative care (NPC) among people deceased in an Internal Medicine (IM) service, as well as the diferences in medical care received within the last 48 hours depending on wether the need of palliative care is identified in the medical history or not. MATERIAL AND METHODS: An observational, cross-sectional and retrospective study was conducted for the first objective, including all deceased patients in the hospital Vega Baja IM service between January and June 2017. A NECPAL CCOMS-ICO affirmative response and a score in PALIAR Index greater than 7.5 were considered as need of palliative care. A case-control study was subsequently conducted among the patients in NPC, based on the identification or not of a need of palliative care diagnosis in the medical history. The differences in clinical care over the last 48 hours were analysed between both groups. RESULTS: There were 120 deceases during the study period, which represented 12 % of IM service admissions; 98 of these (82 %) presented with NPC on the day of admission. The end-of-life trajectory "frailty" was predominant (43.8 %). The group of patients identified as in NPC were exposed to a lesser extent to intensive fluid therapy (36 % vs 93 %; p < 0.01), endovenous antibiotic therapy (32 % vs 93.6 %; p < 0.01), use of noninvasive mechanical ventilation (2 % vs 17 %, p < 0.01), and blood tests (24 % vs 100 %, p < 0.01). Moreover, this group was offered palliative sedation in a greater proportion (90% vs 29.7 %; p < 0.01). CONCLUSIONS: A high proportion of deceased patients in IM services meet NPC criteria since admission. Failure to identifiy this in the medical history is associated with a greater number of invasive diagnostic and terapeutic maneuvers, and less use of palliative sedation

Oral anticoagulation in patients with atrial fibrillation and medical non-neoplastic disease in a terminal stage.

Many patients with non-neoplastic disease develop atrial fibrillation in advanced stages of their disease. The aim of this study is to determine the factors associated with the use of oral anticoagulants in patients with atrial fibrillation and non-neoplastic medical disease in a terminal stage, and whether their use is associated with a longer survival. Design is prospective, observational, multicentre study. Patients with atrial fibrillation and non-neoplastic disease (severe not reversible organ insufficiency) in a terminal stage were included between February 2009 and September 2010. A 6-month follow-up was carried out. We included 314 patients with a mean (SD) age of 82.6 (7.0) years. Their mean (SD) scores in CHADS2 and ATRIA scales were 3.4 (1.2) and 4.7 (2.0), respectively. Anticoagulants were prescribed to 112 (37.5 %) patients. The use of anticoagulants was associated with age (OR 0.96 95 % CI 0.93-0.99, p = 0.046) and to the Barthel index (OR 1.01 95 % CI 1.00-1.02; p = 0.034). After performing a propensity score matching analysis, 262 patients were included in the survival analysis. After 6 months, 133 (50.8 %) patients were dead. The mortality is higher among patients who are not treated with oral anticoagulants (57.1 vs. 39.4 %; p = 0.006), but it is independently associated only with the Barthel index score (HR 0.99 95 % CI 0.98-1.00; p = 0.039), delirium (HR 1.60, 95 % CI 1.08-2.36; p = 0.018), anorexia (HR 1.58 95 % CI 1.05-2.38; p = 0.027), and with the use of calcium channel blockers (HR 0.50 95 % CI 0.30-0.84; p = 0.009). In patients with atrial fibrillation and non-neoplastic disease in a terminal stage, the use of oral anticoagulants is not independently associated with a higher probability of survival.

Ferric carboxymaltose with or without erythropoietin in anemic patients with hip fracture: a randomized clinical trial.

BACKGROUND: The increasing incidence of osteoporotic hip fracture (HF) has raised the requirements of red blood cell (RBC) transfusions, whereas this scarce resource may cause morbidity and mortality. STUDY DESIGN AND METHODS: This study was a multicenter, randomized, double-blind, clinical trial that aimed to assess efficacy of ferric carboxymaltose (FCM) with or without erythropoietin (EPO) in reducing RBC transfusion in the perioperative period of HF. Participants (patients > 65 years admitted with HF and hemoglobin [Hb] levels of 90-120 g/L) were randomly assigned to receive a preoperative single dose of 1 g of FCM (short intravenous [IV] infusion over 15 min), plus 40,000 IU of subcutaneous EPO (EPOFE arm); versus 1 g of IV FCM plus subcutaneous placebo (FE arm); and versus IV and subcutaneous placebo (placebo arm). Primary endpoint was the percentage of patients who received RBC transfusion, and secondary endpoints were the number of RBC transfusions per patient, survival, hemoglobinemia, and health-related quality of life (HRQoL; by means of Short Form 36 Version 2 questionnaire). RESULTS: A total of 306 patients (85% women, mean age 83 ± 6.5 years) were included. A total of 52, 51.5, and 54% of patients required RBC transfusion in the EPOFE, FE, and placebo arms, respectively, with no significant differences in the number of RBC transfusions per patient, survival, HRQoL, and adverse events among treatment groups. A significant increase in Hb levels was achieved at discharge (102 g/L vs. 97 g/L) and 60 days after discharge (125 g/L vs. 119 g/L) in the EPOFE arm with respect to placebo arm; in addition, a higher rate of patients recovered from anemia in the EPOFE arm with respect to the placebo arm (52% vs. 39%), 60 days after discharge. CONCLUSION: Preoperative treatment with FCM alone or in combination with EPO improved recovery from postoperative anemia, but did not reduce the needs of RBC transfusion in patients with HF.

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)

[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.

Development of a six-month prognostic index in patients with advanced chronic medical conditions: the PALIAR score.

CONTEXT: Efforts in developing useful tools to properly identify the end-of-life trajectory of patients with advanced medical diseases have been made, but the calibration and/or discriminative power of these tools has not been optimal. OBJECTIVES: Our objective was to develop a new, reliable prognostic tool to identify the probability of death within six months in patients with chronic medical diseases. METHODS: This was a multicenter, prospective, observational study in 41 Spanish hospitals, which included 1778 patients with one or more of the following: advanced conditions such as heart failure, respiratory failure, chronic renal failure, chronic liver disease, and/or chronic neurological disease. All patients were followed over six months. Each factor independently associated with death in the derivation cohort (884 patients from eastern areas of Spain) was assigned a prognostic weight, and the score was calculated by summing up the factors. The score's accuracy in the validation cohort (894 patients from western areas of Spain) was assessed by analyzing its calibration and discriminative power; we also calculated sensitivity, specificity, and positive and negative predictive values. RESULTS: Mortality in the derivation/validation cohorts was 37.6%/37.7%, respectively. We identified six independent predictors of mortality (≥85 years, three points; New York Heart Association Class IV/Stage 4 dyspnea on the modified Medical Research Council, 3.5 points; anorexia, 3.5 points; presence of pressure ulcer(s), three points; Eastern Cooperative Oncology Group Performance Status of three or more, four points; and albuminemia ≤2.5g/dL, four points). Mortality in the derivation/validation cohorts according to risk group was 20%/21.5% for patients with zero points; 33%/30.5% for those with 3-3.5 points; 46.3%/43% for those with four to seven points; and 67%/61% for those who reached 7.5 or more points, respectively. The calibration was good (Hosmer-Lemeshow test, P=0.39), as was the discriminative power (area under the receiver operating characteristic curve of 0.69 [0.66-0.72]). The sensitivity (85%), specificity (86%), positive and negative predictive values (64% and 80%, respectively) at 180 days were high. CONCLUSION: The PALIAR score is a precise and reliable tool for identifying the end-of-life trajectory in patients with advanced medical diseases.

Reliability of a short questionnaire for the diagnosis of severe disability in polypathological patients attended in hospital setting.

BACKGROUND: A comprehensive evaluation of polypathological patients (PP) should always include a functional evaluation. For this purpose, a modified version of the Barthel Index (BI) is the most applied questionnaire, and it consists of a 10-variable scale. The aim of this study was to develop a screening and confirmation tool to diagnose high disability with the fewest number of dimensions of the BI as possible. METHOD: This present cross-sectional observational multicentre study included PP attended in 36 Spanish hospitals that were divided into two geographical areas (Western and Eastern). The Western area was considered to be the derivation subgroup of PP, and the Eastern area was the validation subgroup. Complete disability for each item (value of 0) was assessed for the diagnosis of severe disability. Diagnostic validity indices (sensitivity, specificity, negative and positive predictive values [NPV and PPV, respectively], and negative and positive likelihood ratios [NLR and PLR, respectively]) were determined for the derivation subgroup. The dimensions with the best diagnostic validity indices were then used to evaluate the validation subgroup. RESULTS: The analysis included 1521 PP, 753 PP from the Western area and 768 PP from the Eastern area. Needing complete help for bathing showed the highest NPV and lowest NLR in the derivation/validation subgroups (NPV 96.87/95.54, NLR 0.07/0.13). Being disabled for feeding alone showed high PPV and PLR values (PPV 97.97/95.65, PLR 109.25/49.62), as did disability for transfers (PPV 98.48/97.96, PLR 143.36/107.68). In addition, complete disability for feeding and transfers had the best PPV and PLR in both subgroups (PPV 100/100, PLR X/0). CONCLUSIONS: A two-dimension mini-Barthel Index may represent a reliable diagnostic test for severe disability in PP.

[Anticoagulation in polypathological patients with atrial fibrillation]. / Anticoagulación en pacientes pluripatológicos con fibrilación auricular.

BACKGROUND AND OBJECTIVES: To determine the use of oral anticoagulants in polypathological patients with atrial fibrillation and its influence on mortality and loss of functionality. PATIENTS AND METHODS: Patients with polypathological patient criteria and atrial fibrillation were included in an observational, prospective and multicenter study. Data on demographic, clinical, functional and sociofamilial characteristics, CHADS2 score, levels of hemoglobin, albumin and creatinine, use of oral anticoagulants and survival and functional status at one year were collected. RESULTS: Five hundred and thirty-two (32.6%) of 1,632 polypathological patients had atrial fibrillation. The stroke risk was high in 505 (94.9%), moderate in 24 (4.5%) and low in 3 (0.6%) patients. Oral anticoagulants were used in 61% of patients with CHADS2 score≥2 and in 37.5% with CHADS2 score=1. Oral anticoagulants were less used in older patients, with more functional and cognitive impairment. Heart failure was associated with more use of oral anticoagulants. There was no difference by the presence of hypertension, diabetes, anemia, renal insufficiency or stroke. In multivariate analysis the use of oral anticoagulants was independently associated with lower age, lower cognitive impairment, absence of hepatic disease and with higher stroke risk. The prescription of oral anticoagulants was independently associated with more survival at one year with no influence on functional status. CONCLUSIONS: Oral anticoagulants are underused in polypathological patients with atrial fibrillation despite being associated with more survival.

Ferric carboxymaltose with or without erythropoietin for the prevention of red-cell transfusions in the perioperative period of osteoporotic hip fractures: a randomized contolled trial. The PAHFRAC-01 project.

BACKGROUND: Around one third to one half of patients with hip fractures require red-cell pack transfusion. The increasing incidence of hip fracture has also raised the need for this scarce resource. Additionally, red-cell pack transfusions are not without complications which may involve excessive morbidity and mortality. This makes it necessary to develop blood-saving strategies. Our objective was to assess safety, efficacy, and cost-effictveness of combined treatment of i.v. ferric carboxymaltose and erythropoietin (EPOFE arm) versus i.v. ferric carboxymaltose (FE arm) versus a placebo (PLACEBO arm) in reducing the percentage of patients who receive blood transfusions, as well as mortality in the perioperative period of hip fracture intervention. METHODS/DESIGN: Multicentric, phase III, randomized, controlled, double blinded, parallel groups clinical trial. Patients > 65 years admitted to hospital with a hip fracture will be eligible to participate. Patients will be treated with either a single dosage of i.v. ferric carboxymaltose of 1 g and subcutaneous erythropoietin (40.000 IU), or i.v. ferric carboxymaltose and subcutaneous placebo, or i.v. placebo and subcutaneous placebo. Follow-up will be performed until 60 days after discharge, assessing transfusion needs, morbidity, mortality, safety, costs, and health-related quality of life. Intention to treat, as well as per protocol, and incremental cost-effectiveness analysis will be performed. The number of recruited patients per arm is set at 102, a total of 306 patients. DISCUSSION: We think that this trial will contribute to the knowledge about the safety and efficacy of ferric carboxymaltose with/without erythropoietin in preventing red-cell pack transfusions in patients with hip fracture. CLINICALTRIALS.GOV IDENTIFIER: NCT01154491.

Effects of renin-angiotensin blockers/inhibitors and statins on mortality and functional impairment in polypathological patients.

BACKGROUND: Frail and polypathological patients (PP) are often undertreated with evidence-based cardiovascular drugs, as their benefits are uncertain in this population. OBJECTIVES: To determine the effects of treatment with renin-angiotensin system blockers/inhibitors (ACEI/ARB), statins and/or beta-blockers on survival rates and functional decline in PP with evidence-based clinical indications for treatment with any of these drug families. METHOD: Prospective observational multicentre cohort study with a 12-month follow-up period. We selected PP with any condition of the following: chronic heart failure, coronary heart disease, chronic renal disease, cerebrovascular disease, peripheral artery disease, diabetes mellitus with any visceral involvement, hypertension, and dyslipidaemia. Clinical, functional (Barthel index), socio-familial risk data and drug prescriptions were measured at baseline. Multivariate Cox proportional hazards and logistic regression models were used to identify variables independently associated with survival and functional decline. RESULTS: The analysis included 1260 PP. The mean age was 79±9.5 years. The mortality rate was 34.5%. Statin (aHR 0.671; P=0.001), beta-blocker plus statin (aHR 0.645; P=0.007), ACEI/ARB plus statin (aHR 0.680; P=0.002), or combined ACEI/ARB plus statin plus beta-blocker (aHR 0.541; P=0.000) prescriptions were associated with longer survival times. Additionally, PP whose Barthel index was ≥60 showed a lower risk of disability progression if treated with statins (aOR=0.476; P=0.000), or their combinations, mainly with ACEI/ARB plus beta-blockers (aOR 0.563; P=0.031). CONCLUSIONS: The prescription of statins, alone or in combination with other drugs, may impact the survival and functional decline in polypathological patients. Further prospective blinded randomised assays are needed to confirm these observations.

Precisión de los criterios definitorios de pacientes con enfermedades médicas no neoplásicas en fase terminal. Proyecto PALIAR / Reliability of different criteria in identifying end-of-life trajectory of patients with chronic medical diseases. PALIAR Project

Introducción. Existe incertidumbre para identificar adecuadamente la trayectoria del final de la vida en pacientes con enfermedades médicas crónicas en fases avanzadas, hecho que dificulta en muchos casos la planificación de servicios y el proceso de transición, de unos objetivos de supervivencia a unos terapéuticos de calidad de vida. Objetivos. Evaluar la sensibilidad, especificidad, valores predictivos positivo y negativo, e índice de validez de los criterios de enfermedad médica terminal del National Hospice Organization estadounidense, la Palliative Prognostic Index y la Eastern Cooperative Oncology Group (ECOG) en pacientes con enfermedades cardíacas, neumológicas, hepáticas, renales y/o neurológicas en estadío avanzado; y construir-validar un índice específico para determinar con mayor certidumbre esta frontera. Métodos. Estudio de cohortes prospectivas multicéntrico con inclusión de pacientes con criterios predefinidos de enfermedad avanzada en órganos comentados. Recogida de datos demográficos, clínico-asistenciales, de estratificación y estadiaje de enfermedad(es), funcionales, analíticos, criterios de la National Hospice Organization, ECOG, valores predictivos positivos y Palliative Prognostic Index; y de la variable final (fallecimiento) a los 180 días de la inclusión. Análisis de sensibilidad, especifidad, valores predictivos positivos, negativos e índice de validez de los criterios de la National Hospice Organization, escala ECOG y Palliative Prognostic Index a los 30, 60, 90, 120, 150 y 180 días. Derivación, si procede, del indice PALIAR, tras análisis multivariante y ponderación de los factores de riesgo (beta del f. riesgo/beta menor del modelo) y posterior validación en cohorte de validación y cohorte histórica PROFUND...(AU)

Introduction. It is a challenge to reliably identify the end-of-life trajectory in patients with advanced-stage chronic medical conditions. This makes advanced supportive care planning and transition from survival to comfort objectives more difficult in these emergent patient populations. Objectives. To evaluate the sensitivity (Se), specificity (Sp), positive predictive values (PPV) and negative (NPV), and validity index (IV) of NHO criteria for terminal medical conditions, PPI and ECOG in patients with advanced heart, lung, liver, kidney and/or neurological diseases, and to build and validate an accurate index to determine this border-line. Methods. A multicentre prospective cohort study, with inclusion of patients with the predefined advanced medical diseases. Demographic, clinical, care, stratification and staging of disease(s), functional, analytical, NHO criteria, ECOG, PPS and PPI data collection; The end-point (death) will be assessed 180 days after inclusion. Analysis of Se, Sp, PPV, NPV, and IV of the NHO criteria, ECOG scale and PPI at 30, 60, 90, 120, 150 and 180 days. Derivation of PALIAR Index, after multivariate analysis and appropriate weighting of risk factors (beta of risk factor/lowest beta of the model), and validation in the validation cohort, and in the historical PROFUND cohort. Results. The project is still ongoing, with 50 investigators from 33 hospitals throughout Spain, who have already included 1138 patients (92.5% during hospital admissions, 51.4% of them are male, with a mean age of 78.5 years). Mean inclusion chronic diseases were 1.4 per patient (44.5% of patients suffered chronic neurological diseases, 38.6% with heart failure, 34.2% with lung diseases, 12% with liver diseases, and 6.5% with renal diseases)...(AU)

[Reliability of different criteria in identifying end-of-life trajectory of patients with chronic medical diseases. PALIAR Project]. / Precisión de los criterios definitorios de pacientes con enfermedades médicas no neoplásicas en fase terminal. Proyecto PALIAR.

INTRODUCTION: It is a challenge to reliably identify the end-of-life trajectory in patients with advanced-stage chronic medical conditions. This makes advanced supportive care planning and transition from survival to comfort objectives more difficult in these emergent patient populations. OBJECTIVES: To evaluate the sensitivity (Se), specificity (Sp), positive predictive values (PPV) and negative (NPV), and validity index (IV) of NHO criteria for terminal medical conditions, PPI and ECOG in patients with advanced heart, lung, liver, kidney and/or neurological diseases, and to build and validate an accurate index to determine this border-line. METHODS: A multicentre prospective cohort study, with inclusion of patients with the predefined advanced medical diseases. Demographic, clinical, care, stratification and staging of disease(s), functional, analytical, NHO criteria, ECOG, PPS and PPI data collection; The end-point (death) will be assessed 180 days after inclusion. Analysis of Se, Sp, PPV, NPV, and IV of the NHO criteria, ECOG scale and PPI at 30, 60, 90, 120, 150 and 180 days. Derivation of PALIAR Index, after multivariate analysis and appropriate weighting of risk factors (beta of risk factor/lowest beta of the model), and validation in the validation cohort, and in the historical PROFUND cohort. RESULTS: The project is still ongoing, with 50 investigators from 33 hospitals throughout Spain, who have already included 1138 patients (92.5% during hospital admissions, 51.4% of them are male, with a mean age of 78.5 years). Mean inclusion chronic diseases were 1.4 per patient (44.5% of patients suffered chronic neurological diseases, 38.6% with heart failure, 34.2% with lung diseases, 12% with liver diseases, and 6.5% with renal diseases). Around 69% fulfilled the criteria of polypathological patients (mean Charlson index 3.4), and were prescribed around 8 drugs chronically. Mean Barthel index was 40 points, and 77% of them were dependent on a caregiver. Around 46% were ECOG-PS stage III or IV, and mean PPS score was 45 points. CONCLUSION: The availability of an accurate and powerful tool that could enable us to identify the end-of-life trajectory of these patients could allow us to establish specific intervention strategies for these populations. Therefore, and with these preliminary data, we believe that the PALIAR PROJECT will answer with rigour the questions and objectives of the study.

Etiología de la infección urinaria en Urgencias. Estudio observacional prospectivo / Urinary infection tract in emergency department. A prospective observational study of the causative microorganism

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[Clinical experience with levosimendan in the emergency department of a tertiary care hospital]. / Experiencia clínica con levosimendán en un servicio de urgencias de un hospital de tercer nivel.

The efficacy and safety of levosimendan administration in patients with acute heart failure admitted to intensive care units has been well established. However, no information is available on the drug's beneficial effects in emergency departments. We studied 40 patients with acute heart failure who showed no or only partial improvement after conventional treatment and who received levosimendan during the period 2005-2006. The patients' mean age was 76 (9) years. The most common etiology was ischemic heart disease, and 85% of patients were in New York Heart Association (NYHA) class III or IV. The clinical response was favorable in 82% of patients, while adverse effects occurred in 18%. Some 70% were admitted to the emergency department short-stay unit. These findings indicate that levosimendan can be used safely and effectively in hospital emergency departments.

Experiencia clínica con levosimendán en un servicio de urgencias de un hospital de tercer nivel / Clinical experience with levosimendan in the emergency department of a tertiary care hospital

La eficacia y la seguridad de la administración de levosimendán en las unidades de cuidados intensivos en pacientes con insuficiencia cardiaca aguda está bien establecida, pero no hay pruebas científicas de sus efectos favorables en los servicios de urgencias (SUH). Hemos estudiado a 40 pacientes con insuficiencia cardiaca aguda con ausencia de mejoría o mejoría parcial tras tratamiento convencional a los que se administró levosimendán entre 2005 y 2006. La media de edad fue de 76 ± 9 años. La cardiopatía isquémica fue la etiología más frecuente; el 85% de los pacientes se encontraba en estadio III-IV de la New York Heart Association. La respuesta clínica fue favorable en un 82% de los pacientes y sólo un 18% presentó efectos adversos. El 70% de los pacientes ingresó en la unidad de corta estancia dependiente del SUH. Los resultados obtenidos indican que levosimendán puede utilizarse de forma segura y eficaz en los SUH (AU)

The efficacy and safety of levosimendan administration in patients with acute heart failure admitted to intensive care units has been well established. However, no information is available on the drug's beneficial effects in emergency departments. We studied 40 patients with acute heart failure who showed no or only partial improvement after conventional treatment and who received levosimendan during the period 2005-2006. The patients' mean age was 76 (9) years. The most common etiology was ischemic heart disease, and 85% of patients were in New York Heart Association (NYHA) class III or IV. The clinical response was favorable in 82% of patients, while adverse effects occurred in 18%. Some 70% were admitted to the emergency department short-stay unit. These findings indicate that levosimendan can be used safely and effectively in hospital emergency departments (AU)