Assessing the relationship between lipoprotein(a) levels and blood pressure among hypertensive patients beyond conventional measures. An observational study.

High lipoprotein(a) (Lp(a)) levels are associated with an increased risk of arterial hypertension (AHT) and atherosclerotic cardiovascular disease. However, little is known about the detailed profile of AHT based on Lp(a) levels. This observational study focused on elucidating the relationship between Lp(a) concentrations and specific indices obtained from 24-h ambulatory blood pressure (BP) monitoring in hypertensive patients over 18 years of age. We gathered and analyzed data on BP indices along with demographic, epidemiological, clinical, and laboratory variables from 227 hypertensive patients, median age 56 years, including 127 women (56%). After comparing hypertensive patients with Lp(a) levels above and below 125 nmol/L, we found that a 10 mmHg increase in nocturnal systolic BP and all pulse pressure indices (24-h, daytime, and night-time) was associated with an increased risk of high Lp(a) levels by more than 20% and 40%, respectively. Similarly, each 10% increase in the area under the function over time of nocturnal diastolic BP dipping was associated with more than a 30% decrease in the odds of belonging to the elevated Lp(a) levels category. Additionally, Lp(a) levels above 125 nmol/L were associated with higher 24-h, daytime, and night-time systolic BP and pulse pressure load. The relationship between Lp(a) and AHT appears to extend beyond conventional BP measurements, which may be relevant given the prognostic implications of nocturnal BP and pulse pressure indices.

Evolución a largo plazo y factores influyentes de los pacientes que ingresan con FANV en los servicios de Medicina Interna de Galicia / Long-term evolution and influential factors of patients admitted with NVAF in the Internal Medicine services of Galicia

Objectives: The objective of this study was to investigate the longterm evolution and influencing factors of patients with non-valvular atrial fibrillation (NVAF) admitted to internal medicine services. Patients and method: This is an observational and retrospective study of the evolution during five years of the patients admitted, between January-2016 and January-2017, with FANV in the Galician Internal Medicine services. For this end, it was quantified the emergency room visits, hospital admissions and survival. The factors with more influence over these variables were studied. Results: It was included 1.342 patients and followed for 5 years. There were 3.691 hospital admissions, and 8.687 visits to the emergency department (ED). They had a survival of 66,6%, with a median survival of 1.034,57 days. The univariate analysis found that age, antithrombotic treatment at discharge and Barthel's index influenced survival, but not sex. However, in the multivariate analysis only Barthel’s index was found to be independent variable that influence survival. Conclusions: Patients with NVAF admitted to internal medicine services constitute a subpopulation at high risk of hospital readmission and visits to the ED. A change in the model of transition to discharge and outpatient follow-up is necessary, through adapted proactive programs, capable of reducing hospital events and improving the quality of life of these patients and their caregivers. (AU)

Objetivos: Estudiar la evolución a lo largo plazo, así como los factores que influyen en la misma, de la población con fibrilación auricular no valvular (FANV) que ingresa en los servicios de Medicina Interna. Pacientes y método: Estudio observacional y retrospectivo de la evolución durante cinco años, de los pacientes ingresados con FANV en los servicios de Medicina Interna gallegos, entre enero-2016 y enero-2017. Para este fin se cuantificaron las visitas a urgencias, los ingresos hospitalarios y la supervivencia. Se estudiaron los factores que más influyeron en estas variables. Resultados: Se incluyeron 1.342 pacientes y se realizó un seguimiento durante 5 años. Se contabilizaron 3.691 ingresos hospitalarios, y 8.687 visitas al servicio de urgencias (SU). Tuvieron una supervivencia del 66,6%, con una mediana de supervivencia de 1.034,57 días. En el análisis univariante, la edad, el tratamiento antitrombótico al alta y el índice de Barthel influyeron en la supervivencia, no así el sexo. En el análisis multivariante, el índice de Barthel fue la única variable independiente que influyó en la supervivencia. Conclusiones: Los pacientes con FANV ingresados en los servicios de Medicina Interna, suponen una subpoblación de alto riesgo de reingreso hospitalario y visitas al SU. Es necesario un cambio en el modelo de transición al alta y de seguimiento ambulatorio, mediante programas proactivos adaptados, capaces de reducir eventos hospitalarios y mejorar la calidad de vida de estos pacientes y sus cuidadores. (AU)

Atrial fibrillation as a new prognosis factor in chronic patients after hospitalization: the CHRONIBERIA index.

A collaborative project in different areas of Spain and Portugal was designed to find out the variables that influence the mortality after discharge and develop a prognostic model adapted to the current healthcare needs of chronic patients in an internal medicine ward. Inclusion criteria were being admitted to an Internal Medicine department and at least one chronic disease. Patients' physical dependence was measured through Barthel index (BI). Pfeiffer test (PT) was used to establish cognitive status. We conducted logistic regression and Cox proportional hazard models to analyze the influence of those variables on one-year mortality. We also developed an external validation once decided the variables included in the index. We enrolled 1406 patients. Mean age was 79.5 (SD = 11.5) and females were 56.5%. After the follow-up period, 514 patients (36.6%) died. Five variables were identified as significantly associated with 1 year mortality: age, being male, lower BI punctuation, neoplasia and atrial fibrillation. A model with such variables was created to estimate one-year mortality risk, leading to the CHRONIBERIA. A ROC curve was made to determine the reliability of this index when applied to the global sample. An AUC of 0.72 (0.7-0.75) was obtained. The external validation of the index was successful and showed an AUC of 0.73 (0.67-0.79). Atrial fibrillation along with an advanced age, being male, low BI score, or an active neoplasia in chronic patients could be critical to identify high risk multiple chronic conditions patients. Together, these variables constitute the new CHRONIBERIA index.

Efficacy of Telemedicine and At-Home Telemonitoring following Hospital Discharge in Patients with COVID-19.

Aim: This work aims to evaluate the safety and utility of an at-home telemedicine with telemonitoring program for discharged COVID-19 patients. Methods: This is a retrospective cohort study of all patients discharged home in Galicia between 6 March 2020 and 15 February 2021. We evaluated a structured, proactive monitoring program conducted by the ASLAM (Área Sanitaria de Lugo, A Mariña y Monforte de Lemos) Healthcare Area team compared to patients discharged in the rest of the Autonomous Community of Galicia. Results: During the study period, 10,517 patients were hospitalized for COVID-19 and 8601 (81.8%) were discharged. Of them, 738 (8.6%) were discharged in ASLAM and 7863 (91.4%) were discharged in the rest of Galicia. Of those discharged in ASLAM, 475 (64.4%) patients were monitored. Compared to patients in the rest of Galicia, the group monitored via telemedicine had a significantly shorter first hospital stay (p < 0.0001), a lower readmission rate (p = 0.05), and a shorter second hospital stay (p = 0.04), with no differences in emergency department visits or 90-day all-cause mortality. Conclusion: A structured, proactive telemedicine with telemonitoring program for discharged COVID-19 patients is a safe, useful tool that reduces the mean length of hospital stay and readmissions.

Description of multimorbidity clusters of admitted patients in medical departments of a general hospital.

OBJECTIVE: We aim to identify patterns of disease clusters among inpatients of a general hospital and to describe the characteristics and evolution of each group. METHODS: We used two data sets from the CMBD (Conjunto mínimo básico de datos - Minimum Basic Hospital Data Set (MBDS)) of the Lucus Augusti Hospital (Spain), hospitalisations and patients, realising a retrospective cohort study among the 74 220 patients discharged from the Medic Area between 01 January 2000 and 31 December 2015. We created multimorbidity clusters using multiple correspondence analysis. RESULTS: We identified five clusters for both gender and age. Cluster 1: alcoholic liver disease, alcoholic dependency syndrome, lung and digestive tract malignant neoplasms (age under 50 years). Cluster 2: large intestine, prostate, breast and other malignant neoplasms, lymphoma and myeloma (age over 70, mostly males). Cluster 3: malnutrition, Parkinson disease and other mobility disorders, dementia and other mental health conditions (age over 80 years and mostly women). Cluster 4: atrial fibrillation/flutter, cardiac failure, chronic kidney failure and heart valve disease (age between 70-80 and mostly women). Cluster 5: hypertension/hypertensive heart disease, type 2 diabetes mellitus, ischaemic cardiomyopathy, dyslipidaemia, obesity and sleep apnea, including mostly men (age range 60-80). We assessed significant differences among the clusters when gender, age, number of chronic pathologies, number of rehospitalisations and mortality during the hospitalisation were assessed (p<0001 in all cases). CONCLUSIONS: We identify for the first time in a hospital environment five clusters of disease combinations among the inpatients. These clusters contain several high-incidence diseases related to both age and gender that express their own evolution and clinical characteristics over time.

Evaluation of a patient-centered integrated care program for individuals with frequent hospital readmissions and multimorbidity.

Managing patients with multimorbidity and frequent hospital readmissions is a challenge. Integrated care programs that consider their needs and allow for personalized care are necessary for their early identification and management. This work aims to describe these patients' clinical characteristics and evaluate a program designed to reducing readmissions. This prospective study analyzed all patients with ≥ 3 admissions to a medical department in the previous year who were included in the Internal Medicine Department chronic care program at the Lucus Augusti University Hospital (Lugo, Spain) between April 1, 2019 and April 30, 2021. A multidimensional assessment, personalized care plan, and proactive follow-up with a case manager nurse were provided via an advanced hospital system. Clinical and demographic variables and data on healthcare system use were analyzed at 6 and 12 months before and after inclusion. Descriptive and survival analyses were performed. One hundred sixty-one patients were included. Program participants were elderly (mean 81.4 (SD 11) years), had multimorbidity (10.2 (3) chronic diseases) and polypharmacy (10.6 (3.5) drugs), frequently used the healthcare system, and were highly complex. Most were included for heart failure. The program led to significant reductions in admissions and emergency department visits (p = .0001). A total of 44.7% patients died within 1 year. The PROFUND Index showed good predictive ability (p = .013), with high values associated with mortality (RR 1.15, p = .001). Patients with frequent hospital readmissions are highly complex and need special care. A personalized integrated care program reduced admissions and allowed for individualized decision-making.

Efficacy of Telemedicine and Telemonitoring in At-Home Monitoring of Patients with COVID-19.

AIM: this work aims to assess if telemedicine and telemonitoring are clinically useful and safe for at-home monitoring of Coronavirus disease 2019 (COVID-19) patients. METHODS: This is a retrospective cohort study of all patients diagnosed with COVID-19 in Galicia (Northwestern Spain) between 26 December 2020 and 15 February 2021. The structured, proactive monitoring via telemonitoring (TELEA) of patients considered to be high-risk in the Lugo, A Mariña, and Monforte Healthcare Area (ASLAM) was evaluated compared to other models in the remaining healthcare areas of Galicia. RESULTS: Of the 47,053 COVID-19 patients, 4384 (9.3%) were in ASLAM. Of them, 1187 (27.1%) were monitored via TELEA, and the rest (3197 in ASLAM and 42,669 in the rest of Galicia) were monitored via other methods. Patients monitored in ASLAM via TELEA were older, consulted in the emergency department less frequently (p = 0.05), were hospitalized less frequently (p < 0.01), had shorter hospital stays (p < 0.0001), and had a lower mortality rate in their first hospitalization (p = 0.03). No at-home life-threatening emergencies were recorded. CONCLUSIONS: these data suggest that, for COVID-19 patients, a care model involving proactive at-home monitoring with telemedicine and telemonitoring is associated with reduced pressure on hospital services and a lower mortality rate.

El hospital en los tiempos del Covid-19: ingresos y mortalidad / Hospital in the time of Covid-19: hospital admissions and mortality

Objetivo: Describir la evolución de los ingresos hospitalarios, en plantas de hospitalización y Cuidados Intensivos, y la mortalidad en el hospital de un área afectada con tasas de incidencia medias por la pandemiaCOVID-19.Métodos: Estudio observacional de todos los ingresos, y fallecimientos, que se produjeron entre los días 1 de marzo y 30 de abril de los años2017, 2018, 2019 y 2020 en un hospital general. Consideramos las00.00 horas del día 14 de marzo como inicio del estado de alarma y separación entre dos periodos: pre-estado de alarma (1-13 de marzo) y estado de alarma (14 de marzo-30 de abril).Resultados: Comparando los meses de marzo-abril de los años 2017,2018 y 2019 frente a 2020 se aprecia un descenso del número de ingresos: 23,33% (Área Médica), 33,46% (Área Quirúrgica) y 38,37% en cuidados intensivos (p<0,0001 en todos los casos). En las Áreas Médica y Quirúrgicas disminuyeron con el inicio del estado de alarma y en Cuidados Intensivos dos semanas más tarde. En el momento de máxima presión los pacientes con COVID-19 ocuparon un 9,8% del total de camas del Centro. En las mismas fechas los fallecidos disminuyeron en las Áreas Médicas y Quirúrgicas un 3,98% y 13,13% respectivamente (p=NS) y se incrementaron levemente (17,59%;p < 0,001) en Cuidados Intensivos. Conclusiones: Tras la instauración del estado de alarma, en un área sanitaria con incidencia media por la pandemia por COVID-19, se redujeron de forma significativa los ingresos hospitalarios sin apreciarse un exceso de mortalidad. (AU)

Objective: To describe the evolution of the hospital admissions in the medical and surgical areas and intensive care units and that of the mortality in the hospital of an area affected with average incidence rates of theCOVID-19 pandemic. Methods: Observational study of all admissions in the medical servicesand deaths that were registered between March 1st and April 30th of years 2017, 2018, 2019 and 2020 in a General Hospital. We consider00.00 on March 14th of 2020 as the beginning of the alarm state and as cut-off point between two periods: before the state of alert (March 1-13)and the state of alert (March 14- April 30) Results: Comparing the months of March-April of years 2017, 2018,2019 to 2020 a decrease in the number of admissions can be observed: 23,33% (Medical area), 33,46% (Surgical area) and 38,37% (Intensive Care Units), (p<0,0001 in every case). In the medical and surgical areas decreased with the beginning of state of alert’s official statement andin Intensive Care Units two weeks after. During peak times patients withCOVID-19 took up 9,8% of total beds of the Center. At the same dates fatalities decreased in the medical and surgical areas 3,98% and 13,13%respectively (p=NS) and increased slightly (17,59%; p<0,001) in Intensive Care Units. Conclusions: After the state of alert’s official statement in an health care area with average impact of COVID19 pandemic, hospital admissions dropped significantly without showing an excess in mortality. (AU)

Pandemia por Covid19: otras consecuencias / Covid 19 pandemic: other consequences

Objetivo: Describir la evolución de la demanda en los servicios de urgencias, y los ingresos hospitalarios subsiguientes, en el área médica de un hospital general durante las fases iniciales de la pandemia por COVID19 y tras la declaración del estadio de alarma. Métodos: Estudio observacional de todas las visitas al Servicio de Urgencias de adultos, y de todos los ingresos en los servicios médicos que se generaron, entre los días 1 y 31 de marzo de los años 2017, 2018, 2019 y 2020 en un hospital general. Consideramos las 00.00 horas del día 14 de marzo como el inicio del estado de alarma, y punto de corte entre dos periodos: pre-estado de alarma (días 1 a 13 de marzo) y estado de alarma (días 14 a 31 de marzo). Resultados: Tras la declaración del estado de alarma la asistencia a Urgencias disminuyó un 65,1% y, entre estos pacientes, el porcentaje de ingresos se incrementó un 93,8%. A pesar de ello, el promedio de ingresos por día se redujo un 33%. Sin embargo Medicina Interna (incluyendo área COVID19) tuvo un promedio diario de 10,5 (SD 6,3) pacientes, levemente superior al registrado en años previos. Conclusiones: En las primeras semanas tras la instauración del estado de alarma por la pandemia por COVID19 disminuyó en casi dos tercios la frecuentación a las urgencias hospitalarias y en un tercio los ingresos en todas las áreas de un hospital general. Por el contrario, Medicina Interna (que incluyó ingresos por COVID19) mantuvo los mismos promedios. (AU)

Objective: Describe the evolution of the Emergency Department and the hospital admissions in the medical area of a general hospital during the initial phases of the COVID19 pandemic and after the state of alarm established in Spain. Methodology: Observational study of the patients who were admitted in the Emergency Department and the admissions in medical services from 1st to 31th of March in 2017, 2018, 2019 and 2020 in a general hospital. The beginning of the state of alarm was considered at 00.00 on March 14th of 2020 and a cut-off point is also taken into account between two periods: before the state of alert (March 1st-13th) and the state of alert (March 14th-31th). Results: After the state of alarm, the admission of patients decrease in the Emergency Department by 65.1% and the income in medical areas was increased in 93.8%. Despite this, the average of incomes per day decreased by 33%. However, Internal Medicine (including COVID19 area) had a daily average of 10.5 (SD 6.3) patients, slightly higher than the one registered in previous years. Conclusions: In the first weeks after the state of alarm due to COVID19 pandemic, the attendance in the Emergency Department decreased about two thirds and the incomes in medical areas decreased a third in all areas of a general hospital. On the other hand, Internal Medicine (included COVID-19 area) maintained the same averages. (AU)

El hospital en los tiempos del Covid-19: capacidad de reacción y adaptación / Hospital in times of Covid-19: reaction and adaptation

Objetivo: Describir las repercusiones sobre la hospitalización y las características de los pacientes atendidos en las primeras semanas tras la declaración del estado de alarma durante la pandemia por COVID-19 en un hospital general. Métodos: Estudio observacional de todos los ingresos, en todos servicios hospitalarios, entre los días 1 de marzo y 30 de abril de los años 2017, 2018, 2019 y 2020 en un hospital general. La fuente de información fue el conjunto mínimo básico de datos del centro. Consideramos las 00.00 horas del día 14 de marzo como el inicio del estado de alarma y punto de corte entre dos periodos: previo al estado de alarma (días 1 a 13 de marzo) y estado de alarma (días 14 a 30 de abril). Resultados: Tras la declaración del estado de alarma disminuyó el número de hospitalizaciones (p<0.0001), en un rango entre el 3,5% y el 55,9% con respecto al promedio de los 3 años previos en los diez principales servicios médicos y quirúrgicos de adultos y por todas las modalidades de ingreso (p<0.001). En paralelo se redujo la estancia media ( p<0.001) y se incrementó el porcentaje de ingresados de procedencia urbana (p< 0.01). Si bien la mortalidad global no mostró cambios, si aumentaron los fallecidos en las primeras 24 horas de ingreso hospitalario ( p<0.008). Conclusiones: Este estudio describe los mecanismos de reacción y adaptación de un hospital durante el estado de alarma por la pandemia por COVID-19. Nuestros resultados podrían ayudar a otros centros a diseñar y dimensionar sus preparativos. (AU)

Aim: Describe the patient’s features and the hospital changes during the first weeks of the COVID-19 pandemic alarm in a General Hospital.Method: Observational study that asses all the admissions in the hospital departments between March 1st and April 30th of 2017, 2018, 2019 and 2020 in a General Hospital. The information was obtained from the basic data set of the Center. We consider 00.00 on March 14th of 2020 as the beginning of the alarm state and as cut-off point between two periods: before the state of alert (March 1st-13th) and the state of alert (March 14th- April 30th) Results: After the state of alarm the number of admissions decreased (p< 0,0001) in all kind of admissions (p<0,001) and in the ten medical and surgical services of adults between 3,5% and 55,9% comparing with the main of 3 previous years. At the same time main stay decreased ( p<0,001) and rate of admitted from urban areas increased (p<0,01). Although total mortality did not change, deaths during the first 24 hours after admissions were increased (p<0,008). Conclusions: This study describes surge and adaptation mechanisms of a hospital during state of alert by COVID-19 pandemic. Our results could help other Centers with designing and measuring their preparations. (AU)

Estándares de calidad en un seguimiento a pacientes ancianos con insuficiencia cardiaca e importante comorbilidad

Resumen: Introducción: Los pacientes con insuficiencia cardiaca (IC) seguidos por los servicios de medicina interna son más ancianos y presentan más comorbilidades asociadas. Por ello presentan un riesgo elevado de ingreso hospitalario y de mortalidad. En este estudio se evaluaron los objetivos alcanzados en términos de ingresos, visitas a urgencias y mortalidad, así como la actividad realizada para conseguirlos, en una unidad dirigida a este perfil de pacientes y caracterizada por una atención integral y continuada (programa UMIPIC). Métodos: Se analizaron retrospectivamente los datos de los 329 pacientes con IC atendidos en la unidad de IC, modelo UMIPIC, del servicio de Medicina Interna del Hospital de Lugo. Se recogieron desde enero del 2020, hasta diciembre 2020 los ingresos por IC y totales, las visitas a urgencias por IC y totales, la mortalidad, las consultas realizadas, y los rescates realizados en régimen de hospital de día (HDD). Resultados: Se recogieron 108 ingresos, 40 por IC y 68 por otras causas, 99 visitas a urgencias, 25 por IC y 74 por otras causas. Se produjeron 57 fallecimientos, 37 fueron en el hospital (15 por IC, 12 por otras causas) y 20 fueron extra-hospitalarios. Se realizaron 1179 consultas médico-enfermería, 1554 consultas de enfermería exclusiva y se realizaron 406 tratamientos en HDD. Conclusiones: Los estándares de actividad y resultados conseguidos pueden ser orientativos de la actividad a desarrollar en una unidad de IC modelo UMIPIC.

Abstract: Introduction: Patients with heart failure (HF) followed by internal medicine services are older and have more associated comorbidities. For this reason, they present a high risk of hospital admission and mortality. In this study, the objectives achieved in terms of admissions, emergency room visits and mortality, as well as the activity carried out to achieve them, were evaluated in a unit aimed at this patient profile and characterized by comprehensive and continuous care (UMIPIC program). Methods: The data of the 329 patients with HF treated in the HF unit, model UMIPIC, of the Internal Medicine service of the Hospital de Lugo, were retrospectively analyzed. From January 2020, to December 2020, total and HF admissions, total and HF emergency visits, mortality, consultations made, and rescues performed in a day hospital (HDD) were collected. Results: 108 admissions were collected, 40 for HF and 68 for other causes, 99 visits to the emergency room, 25 for HF and 74 for other causes. There were 57 deaths, 37 were in the hospital (15 due to HF, 12 due to other causes) and 20 were extra-hospital. 1179 medical-nursing consultations were carried out, 1554 exclusive nursing consultations and 406 treatments were carried out in HDD. Conclusions: The activity standards and results achieved can be indicative of the activity to be carried out in an IC model UMIPIC unit.

Resumo: Introdução: Pacientes com insuficiência cardíaca (IC) acompanhados por serviços de medicina interna são mais velhos e apresentam mais comorbidades associadas. Portanto, apresentam alto risco de admissão hospitalar e mortalidade. Neste estudo, os objetivos alcançados em termos de internações, atendimentos de emergência e mortalidade, bem como a atividade desenvolvida para os atingir, foram avaliados numa unidade dirigida a este perfil de doente e caracterizada por um atendimento integral e contínuo (programa UMIPIC). Métodos: Foram analisados ​​retrospectivamente os dados dos 329 pacientes com IC atendidos na unidade de IC, modelo UMIPIC, do serviço de Clínica Médica do Hospital de Lugo. No período de janeiro de 2020 a dezembro de 2020, foram coletadas internações totais e por IC, atendimentos totais e de emergência por IC, mortalidade, consultas realizadas e resgates realizados em regime de hospital-dia (HDD). Resultados: foram coletadas 108 internações, sendo 40 por IC e 68 por outras causas, 99 visitas ao pronto-socorro, 25 por IC e 74 por outras causas. Ocorreram 57 óbitos, 37 foram hospitalares (15 por IC, 12 por outras causas) e 20 extra-hospitalares. Foram realizadas 1179 consultas médico-enfermagem, 1554 consultas exclusivas de enfermagem e 406 atendimentos em HDD. Conclusões: Os padrões de atividade e os resultados alcançados podem ser indicativos da atividade a ser desenvolvida numa unidade IC modelo UMIPIC.

Efectividad de una intervención educativa enfermera en pacientes crónicos complejos / Effectiveness of a nursing training intervention in complex chronic patients

OBJETIVO: Evaluar el efecto de una intervención formativa realizada por enfermeras en pacientes crónicos complejos durante el ingreso hospitalario en un servicio de Medicina Interna. MÉTODO: Ensayo clínico pragmático de una intervención educativa de enfermeras frente a la actuación habitual. Para el grupo de intervención se diseñó un plan de educación en cuidados, personalizado para cada paciente, en función de las necesidades detectadas en una primera entrevista. La intervención se extendió durante el tiempo del ingreso y se dispuso de un teléfono de contacto al alta para la resolución de dudas. RESULTADOS: De entre los 498 pacientes seleccionados inicialmente fueron excluidos 131 por no cumplir los criterios para ser considerados pacientes crónicos complejos o por no detectarse deficiencias en su formación o sus cuidados. Un paciente (0,20%) no aceptó participar y no hubo abandonos. De los 366 participantes, 190 se integraron en el grupo de intervención y 176 en el control. En los primeros 8 días tras el alta, reingresaron 2 (1,05%) pacientes del grupo de intervención y 8 (4,54%) del grupo control (p = 0,05). En los primeros 30 días tras el alta reingresaron 26 (13,70%) y 33 (18,75%), respectivamente (p = 0,10). CONCLUSIONES: Este estudio muestra como una intervención educativa por enfermeras en pacientes crónicos complejos, realizada durante el ingreso hospitalario en unidades de Medicina Interna, puede reducir los reingresos a corto plazo

OBJECTIVE: To evaluate whether a training intervention performed by nursing professionals in complex chronic patients, during hospitalisation in an internal medicine service, can modify the pattern of readmissions or reduce their number. METHOD: Pragmatic clinical trial of a nursing training intervention vs. habitual performance. For the intervention group, a training plan in care was designed, personalised for each patient, according to the needs detected in a first interview. The intervention was extended during the time of admission and a contact phone was available after discharge to resolve doubts. RESULTS: Among the 498 patients interviewed initially, 131 were excluded because they were not a complex chronic patient or because they found no deficiencies in their training or care. One patient (.20%) did not agree to participate and there were no dropouts. Of the 366 participants, 190 were included in the intervention group and 176 in the control group. In the first 8 days after discharge, 2 (1.05%) patients from the intervention group and 8 (4.54%) from the control group were re-admitted (p=.05). In the first 30 days after discharge, 26 patients (13.70%) and 33 patients (18.75%) respectively (p=.10) were readmitted. CONCLUSIONS: This study shows how a nursing training intervention during hospitalisation in Internal Medicine in complex chronic patients reduces short-term readmissions

Palliative Sedation in Patients Hospitalized in Internal Medicine Departments.

CONTEXT: Palliative sedation is used to relieve end-of-life refractory symptoms. OBJECTIVE: The objective of this study was to describe the use of palliative sedation in patients who die in internal medicine departments. METHODS: An observational, cross-sectional, retrospective, and multicenter clinical audit study was conducted in 145 hospitals in Spain and Argentina. Each hospital included the first 10 patients who died in the internal medicine department, starting on December 1, 2015. RESULTS: We included 1447 patients, and palliative sedation was administered to 701 patients (48.4%). Having a terminal illness (odds ratio [OR] 2.469, 95% CI 1.971-3.093, P < 0.001) and the length of hospital stay (OR 1.011, 95% CI 1.002-1.021, P = 0.017) were independently associated with the use of palliative sedation. Consent was granted by the families of 582 (83%) patients. The most common refractory symptom was dyspnea, and the most commonly used drugs for sedation were midazolam (77%) and morphine (89.7%). An induction dose was administered in 25.7% of the patients. Rescue doses were scheduled for 70% of the patients, and hydration was maintained in 49.5%. Pain was more common in patients with cancer, whereas dyspnea was more common in those without cancer. Rescue doses were used more often for the patients with cancer (77.8% vs. 67.7%, P = 0.015). Monitoring the palliative sedation with a scale was more frequent in the patients with cancer (23.7% vs. 14.3%, P = 0.008). CONCLUSIONS: Palliative sedation is used more often for terminal patients. There are differences in the administration of palliative sedation between patients with and without cancer.

Effectiveness of a nursing training intervention in complex chronic patients. / Efectividad de una intervención educativa enfermera en pacientes crónicos complejos.

OBJECTIVE: To evaluate whether a training intervention performed by nursing professionals in complex chronic patients, during hospitalisation in an internal medicine service, can modify the pattern of readmissions or reduce their number. METHOD: Pragmatic clinical trial of a nursing training intervention vs. habitual performance. For the intervention group, a training plan in care was designed, personalised for each patient, according to the needs detected in a first interview. The intervention was extended during the time of admission and a contact phone was available after discharge to resolve doubts. RESULTS: Among the 498 patients interviewed initially, 131 were excluded because they were not a complex chronic patient or because they found no deficiencies in their training or care. One patient (.20%) did not agree to participate and there were no dropouts. Of the 366 participants, 190 were included in the intervention group and 176 in the control group. In the first 8 days after discharge, 2 (1.05%) patients from the intervention group and 8 (4.54%) from the control group were re-admitted (p=.05). In the first 30 days after discharge, 26 patients (13.70%) and 33 patients (18.75%) respectively (p=.10) were readmitted. CONCLUSIONS: This study shows how a nursing training intervention during hospitalisation in Internal Medicine in complex chronic patients reduces short-term readmissions.

RECALMIN: The association between management of Spanish National Health Service Internal Medical Units and health outcomes.

OBJECTIVE: To investigate the association between management of Internal Medical Units (IMUs) with outcomes (mortality and length of stay) within the Spanish National Health Service. DESIGN: Data on management were obtained from a descriptive transversal study performed among IMUs of the acute hospitals. Outcome indicators were taken from an administrative database of all hospital discharges from the IMUs. SETTING: Spanish National Health Service. PARTICIPANTS: One hundred and twenty-four acute general hospitals with available data of management and outcomes (401 424 discharges). MAIN OUTCOME MEASURES: IMU risk standardized mortality rates were calculated using a multilevel model adjusted by Charlson Index. Risk standardized myocardial infarction and heart failure mortality rates were calculated using specific multilevel models. Length of stay was adjusted by complexity. RESULTS: Greater hospital complexity was associated with longer average length of stays (r: 0.42; P < 0.001). Crude in-hospital mortality rates were higher at larger hospitals, but no significant differences were found when mortality was risk adjusted. There was an association between nurse workload with mortality rate for selected conditions (r: 0.25; P = 0.009). Safety committee and multidisciplinary ward rounds were also associated with outcomes. CONCLUSIONS: We have not found any association between complexity and intra-hospital mortality. There is an association between some management indicators with intra-hospital mortality and the length of stay. Better disease-specific outcomes adjustments and a larger number of IMUs in the sample may provide more insights about the association between management of IMUs with healthcare outcomes.

Characteristics and temporal pattern of the readmissions of patients with multiple hospital admissions in the medical departments of a general hospital.

INTRODUCTION: Patients with multiple hospital admissions represent a small percentage of total hospitalizations but result in a considerable proportion of the healthcare expenditure. There are no studies that have analyzed their long-term clinical evolution. OBJECTIVES: To study the characteristics, temporal patterns of readmissions and clinical evolution of patients with multiple hospital admission in the long term. METHODS: A retrospective study was conducted of all hospital admissions in the medical area of the Hospital of Lugo (Spain) between January 1, 2000 and December 31, 2012, based on data from the center's minimum basic data set. RESULTS: A total of 139,249 hospital admissions for 62,515 patients were studied. Six hospital admissions were recorded for 6.4% of the patients. The overall mortality rate was 16% (9982 patients). The readmissions rate steadily increased with each new admission, from 48% after the first event to 74.6% after the fifth. The rate of hospital readmission before 30days increased from 18.3% in the second admission to 36.3% in the sixth. The number of chronic diseases increased from 3.1 (SD, 2) in the first hospital admission up to 4.9 (2.8) in the sixth. The Department of Internal Medicine treated a third of all hospital admissions. In the sixth hospitalization, conditions associated with admission in Internal Medicine were CIRS score, age, heart failure, COPD, dementia, diabetes, atrial fibrillation and anemia. CONCLUSIONS: Patients with multiple hospital admissions are complex patients whose temporal pattern of readmissions changes with time, such that each hospital admission constitutes a factor facilitating the next.

Particle repositioning maneuver versus Brandt-Daroff exercise for treatment of unilateral idiopathic BPPV of the posterior semicircular canal: a randomized prospective clinical trial with short- and long-term outcome.

OBJECTIVE: To compare the outcome and probability of recurrence in a series of patients with unilateral idiopathic benign paroxysmal positional vertigo of the posterior canal (PC-BPPV) that were randomly treated by Brandt-Daroff exercise (B-D exercise) or by particle repositioning maneuver (PRM). STUDY DESIGN: Randomized prospective clinical trial. SETTING: Tertiary referral center. PATIENTS: Patients were included in this study if they complained of vertigo and had been diagnosed as having unilateral idiopathic PC-BPPV for at least 1 week before Dix-Hallpike maneuver (DHM), remained for 30 days in the randomly assigned treatment, and had at least 48 months' follow-up. INTERVENTION: Forty-one patients were treated with a single PRM and 40 patients by B-D exercise. MAIN OUTCOME MEASURE: Resolution of benign paroxysmal positional nystagmus on the DHM. The probability of recurrence was also studied. RESULTS: At Day 7, DHM was negative in 80.5% of the PRM-treated patients and in 25% of those treated by B-D exercise (p < 0.001). At Month 1, the differences between both treatment groups remained statistically significant (92.7% in PRM versus 42.5% in the B-D exercise had a negative DHM; p < 0.001). The variable that influenced that DHM became negative was the PRM (RR = 4.8; 95% confidence interval, 2.5-9.2; p < 0.001). The number of recurrences in PRM and B-D exercise were 0.56 ± 0.8 and 0.48 ± 0.8, respectively (p = 0.48). The recurrence rate at 48 months was 35.5% (15/41) in B-D exercise and 36.6% (9/31) in the PRM group (p = 0.62). Although the time interval until the first recurrence was similar (p = 0.44), patients included in the PRM group showed a significantly longer time interval between the first and second recurrence (p = 0.04). CONCLUSION: PRM is more effective treatment and as safe as B-D exercise in the short term for unilateral and idiopathic PC-BPPV, and although it does not reduce the probability of recurrence in the 4-year follow-up period compared with B-D exercise, it may delay the second recurrence's onset in those patients who had already experienced a single recurrence. Our study supports the use of PRM as the treatment of choice in unilateral and idiopathic PC-BPPV, although exercise may be also considered as an alternative treatment in selected cases.