Abordaje multidisciplinarde un paciente con una úlceraperianal asociada a pomadaantihemorroidal / Multidisciplinary approach to a patient with a perianal ulcer associated with hemorrhoidal ointment

Introducción: Hasta la fecha, la manifestación de una úlcera perianalprovocada por una pomada antihemorroidal no se ha descrito confrecuencia. Sin embargo, se ha objetivado un incremento de loscasos durante la pandemia de COVID-19. Caso clínico: Varónde 82 años independiente, que presentó una úlcera perianal de35,8 cm² sin ninguna patología ni enfermedad concomitante queexplicara su causa. La aplicación de criterios de exclusión exhaustivos,incluida una biopsia para rechazar el pioderma gangrenoso,identificó una pomada rectal hemorroidal como la causa de la úlcera.Plan de actuación: La herida curó tras aplicar una intervenciónmultidisciplinaria y una terapia con factores de crecimientoautólogos. Discusión y conclusiones: Este caso ha sido escasamentereportado en la literatura, aunque esta pomada hemorroidal secomercializa desde hace más de 40 años. Se recomienda evaluaciónmédica antes de la prescripción. (AU)

Introduction: Perianal ulcers resulting from the use of hemorrhoidalointments have been rarely reported to date. Nevertheless, therehas been a surge in the number of cases reported during theCOVID-19 pandemic. Case report: An independent 82-year-oldmale experienced a 35,80 cm² perianal ulcer, with no underlyingcondition or concomitant disease that could explain the cause ofthe ulcer. The application of thorough exclusion criteria, including abiopsy to rule out pyoderma gangrenosum, led to the identificationof a hemorrhoidal rectal ointment as the cause. Action plan: Theulcer healed completely when a multidisciplinary intervention and anautologous growth factors advanced therapy were applied. Discussionand conclusions: This case has been scarcely reported in the literature,although this hemorrhoidal ointment has been on the market for over40 years. Medical assessment before prescription and patients’ followup is recommended. (AU)

Individualized Medication Review in Older People with Multimorbidity: A Comparative Analysis between Patients Living at Home and in a Nursing Home.

(1) Background: aging is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. A periodic medication review (MR) in frail older people leads to optimizing medication use. The aims of the study were to perform a comparative analysis of the impact of place of residence (own home versus nursing home) in a cohort of older patients on the characteristics of the baseline therapeutic plan and characteristics of the therapeutic plan after an MR; (2) Methods: Study with paired pre- and post-MR data based on person-centred prescription, with a follow-up assessment at three months. Patients who lived either in their own home or in a nursing home were recruited. We selected patients of 65 years or more with multimorbidity whose General Practitioner identified difficulties with the prescription management and the need for an MR. Each patient's treatment was analysed by applying the Patient-Centred Prescription (PCP) model; (3) Results: 428 patients. 90% presented at least one inappropriate prescription (IP) in both settings. In nursing homes, a higher number of implemented optimization proposals was detected (81.6% versus 65.7% (p < 0.001)). After the MR, nursing-home patients had a greater decrease in their mean number of medications, polypharmacy prevalence, therapeutic complexity, and monthly drug expenditure (p < 0.001); (4) Conclusions: PCP model detected a high number of IP in both settings. However, after an individualized MR, nursing-home patients presented a greater decrease in some pharmacological parameters related to adverse events, such as polypharmacy and therapeutic complexity, compared to those living at home. Nursing homes may be regarded as a highly suitable scenario to carry out a periodic MR, due to its high prevalence of frail people and its feasibility to apply the recommendations of an MR. Prospective studies with a robust design should be performed to demonstrate this quasi-experimental study along with a longitudinal follow-up on clinical outcomes.

Aplicabilidad y limitaciones de las pruebas de ejecución funcional en el cribado de fragilidad al alta de un centro de atención intermedia / Applicability and limitations of physical performance tests for frailty screening on discharge from an intermediate care hospital

INTRODUCCIÓN: La fragilidad puede ser detectada con distintas herramientas y en múltiples entornos. Entre los diferentes sistemas de cribado, la velocidad de marcha (VM) y el Timed Up-and- Go (TUG) se postulan como sistemas sencillos y fácilmente aplicables. Existen pocos datos sobre su aplicabilidad en pacientes hospitalizados en centros de atención intermedia. MATERIAL Y MÉTODOS: Estudio descriptivo para determinar la aplicabilidad de la VM y el TUG como herramientas de cribado de fragilidad en un hospital de atención intermedia, así como una estimación de la prevalencia de fragilidad al alta mediante estas pruebas de ejecución funcional. Se consideraron frágiles los pacientes con una VM<1m/s y/o un TUG>12s. Se incluyeron todos pacientes atendidos por la unidad de rehabilitación del centro a lo largo del año 2015. RESULTADOS: Novecientos nueve fueron los pacientes incluidos (edad media de 80,12 años). De estos, solo 205 (22,6%) estaban en condiciones de realizar la VM y TUG en el momento del alta; de estas 205 personas, el 89,8% (VM) y el 92,2% (TUG) presentaban criterios de fragilidad, no habiendo diferencias estadísticamente significativas entre ambas herramientas (p = 0,25). CONCLUSIONES: La utilización de la VM y el TUG para el cribado de fragilidad tiene una aplicabilidad limitada en el entorno de atención intermedia. A pesar de ello, los resultados obtenidos indican una alta prevalencia de fragilidad en este entorno. Serán necesarios más estudios para corroborar estos datos

INTRODUCTION: Frailty screening can be performed with different tools and in multiple settings. Among the different evaluation systems, gait speed (GS) and Timed Up-and-Go (TUG) are postulated as simple and easy to apply systems. There are few data on the prevalence of frailty in intermediate care centre inpatients. MATERIAL AND METHODS: Descriptive study to determine the applicability of GS and TUG as frailty screening tools in an intermediate care hospital, as well as an estimate of frailty prevalence at discharge. Frailty was considered when GS<1m/s and / or TUG>12seconds. The study included all patients attending the rehabilitation unit of the centre throughout 2015. RESULTS: A total of 909 patients were included (mean age of 80.12 years). Only 205 (22.6%) were able to perform GS and TUG at discharge from the rehabilitation unit. Frailty prevalence for this group was between 89.8% (GS) and 92.2% (TUG), with no statistical differences between both tools (P=.25). CONCLUSIONS: The applicability of GS and TUG for frailty screening in intermediate care hospitals is limited. Despite this, the results obtained suggest a high prevalence of frailty. More studies will be necessary to corroborate this data

[Applicability and limitations of physical performance tests for frailty screening on discharge from an intermediate care hospital]. / Aplicabilidad y limitaciones de las pruebas de ejecución funcional en el cribado de fragilidad al alta de un centro de atención intermedia.

INTRODUCTION: Frailty screening can be performed with different tools and in multiple settings. Among the different evaluation systems, gait speed (GS) and Timed Up-and-Go (TUG) are postulated as simple and easy to apply systems. There are few data on the prevalence of frailty in intermediate care centre inpatients. MATERIAL AND METHODS: Descriptive study to determine the applicability of GS and TUG as frailty screening tools in an intermediate care hospital, as well as an estimate of frailty prevalence at discharge. Frailty was considered when GS<1m/s and / or TUG>12seconds. The study included all patients attending the rehabilitation unit of the centre throughout 2015. RESULTS: A total of 909 patients were included (mean age of 80.12 years). Only 205 (22.6%) were able to perform GS and TUG at discharge from the rehabilitation unit. Frailty prevalence for this group was between 89.8% (GS) and 92.2% (TUG), with no statistical differences between both tools (P=.25). CONCLUSIONS: The applicability of GS and TUG for frailty screening in intermediate care hospitals is limited. Despite this, the results obtained suggest a high prevalence of frailty. More studies will be necessary to corroborate this data.

Paciente con deterioro cognitivo y caídas en una consulta de psicogeriatría / Patients with cognitive impairment and falls in a psychogeriatric clinic

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Conducción y demencia: análisis de casos en una unidad de diagnóstico de trastornos cognitivos / Driving and dementia: case analysis in a cognitive disorders diagnostic unit

Objetivo. Determinar las características clínicas de los pacientes con demencia que están conduciendo y analizar cómo se operativiza el cese de la conducción y las dificultades percibidas por el paciente y por la familia. Método. Estudio descriptivo de pacientes evaluados durante 2 años en la consulta de Evaluación de Trastornos Cognitivos del Hospital Universitari de la Santa Creu de Vic (Barcelona) que estaban conduciendo en el momento del diagnóstico. Se registraron datos generales y funcionales de los pacientes, y de forma demorada se realizó un cuestionario a los familiares. Resultados. Se recogieron datos de 40 pacientes (20% de pacientes diagnosticados de demencia); edad media, 77,6 años; 87,5% varones; 90% casos de demencia tipo Alzheimer. El 60% correspondían a la fase inicial de demencia, el 12,5% a la fase inicial-moderada y el 27,5% a la fase moderada. Al año, en el 70,3% de casos se había producido el cese de la conducción. En el 42% de estos, la familia consideró el proceso como complicado. En el 58% de casos, el enfermo no aceptó la decisión. Conclusión. La mayoría de conductores activos en el momento del diagnóstico de demencia son varones con demencia tipo Alzheimer en fase inicial. Al año, un tercio siguen conduciendo. El cese de la conducción puede resultar difícil para pacientes y familiares (AU)

Objective. To determine clinical characteristics of patients with dementia who are currently driving and to analyse the way driving cessation is put into operation and the difficulties identified by patient and family. Method. A descriptive study of patients evaluated during 2 years in a Cognitive Disorders Assessment Clinic in the Hospital Universitari de la Santa Creu de Vic (Barcelona, Spain), who were driving at the time of diagnosis. General and functional patient data were recorded and a questionnaire was later completed by their relatives. Results. Data was collected on a total of 40 patients (20% of patients diagnosed with dementia), with a mean age 77.6 years, 87.5% male, and 90% cases of Alzheimer type dementia. Almost two-thirds (60%) were in early stages of dementia, 12.5% moderate initial-stage, and 27.5% moderate stage. After one year, 70.3% of cases had stopped driving. In 42% of these, the family considered that the process was complicated. In 58% of cases, the patient did not accept the decision. Conclusion. Most active drivers at the time of diagnosis of dementia are men with Alzheimer disease at an early stage. After one year, one third of them were still driving. The driving cessation can be difficult for patients and families (AU)

[Driving and dementia: Case analysis in a cognitive disorders diagnostic unit]. / Conducción y demencia: análisis de casos en una unidad de diagnóstico de trastornos cognitivos.

OBJECTIVE: To determine clinical characteristics of patients with dementia who are currently driving and to analyse the way driving cessation is put into operation and the difficulties identified by patient and family. METHOD: A descriptive study of patients evaluated during 2 years in a Cognitive Disorders Assessment Clinic in the Hospital Universitari de la Santa Creu de Vic (Barcelona, Spain), who were driving at the time of diagnosis. General and functional patient data were recorded and a questionnaire was later completed by their relatives. RESULTS: Data was collected on a total of 40 patients (20% of patients diagnosed with dementia), with a mean age 77.6 years, 87.5% male, and 90% cases of Alzheimer type dementia. Almost two-thirds (60%) were in early stages of dementia, 12.5% moderate initial-stage, and 27.5% moderate stage. After one year, 70.3% of cases had stopped driving. In 42% of these, the family considered that the process was complicated. In 58% of cases, the patient did not accept the decision. CONCLUSION: Most active drivers at the time of diagnosis of dementia are men with Alzheimer disease at an early stage. After one year, one third of them were still driving. The driving cessation can be difficult for patients and families.

Análisis de las defunciones de pacientes con demencia ingresados en una unidad de psicogeriatría / Analysis of dementia patient mortality in a psychogeriatric unit

Objetivo. Determinar las características de los pacientes con demencia fallecidos y describir las condiciones que determinaron la muerte. Material y método. Estudio observacional de los pacientes que murieron en la Unidad de Psicogeriatría del Hospital de la Santa Creu de Vic durante 3 años y medio. Resultados. De 554 ingresos se registró una mortalidad del 14,6% (81 casos). El análisis de los fallecidos mostró que el 67,9% eran mujeres con una edad media de 85,8 años, siendo la demencia más frecuente la tipo Alzheimer (37%) y encontrándose en fase avanzada (CDR3, GDS 6-7) el 72,8% de los casos. Al ingreso se registraron las siguientes características: Mini Mental State Examination (MMSE) 9,5; índice de Barthel (IB) previo de 50,1; IB al ingreso de 17,4, y Neuropsychiatric Inventory (NPI) 31,4. En el momento del ingreso, en un 84% se determinó limitación terapéutica. Del análisis de las condiciones que condujeron a la muerte observamos: en el 74,1% la muerte es consecuencia directa de un episodio gatillo (la infección respiratoria fue el más frecuente); en un 17,3% se produce la muerte por declive progresivo sin claro factor desencadenante y en un 8,6% los pacientes precisaron sedación paliativa por mal control de síntomas. Conclusiones. Los problemas intercurrentes fueron el factor más frecuente asociado a la muerte de los pacientes. La mayoría de los pacientes mueren en fases previas a los criterios establecidos para demencia terminal. En algunos casos los pacientes pueden presentar trastorno de conducta como síntoma refractario(AU)

Aim. To determine the characteristics of patients with dementia who died in a psychogeriatric unit, and to describe the conditions that led to their death. Material and methods. Observational study of patients who died in the Psychogeriatric unit of Hospital de la Santa Creu de Vic during a three and a half year period. Results. Of the 554 patients admitted during the study period, we recorded a mortality of 14.6% (81 patients). The analysis of those who died showed that 67.9% were women, with a mean age of 85.8 years, with the most frequent cause being Alzheimer type dementia (37%) and being in an advanced stage (CDR3, GDS 6-7) in 72.8% of cases. On admission the following characteristics were recorded: Mini Mental State Examination (MMSE) 9.5, Barthel Index (BI) prior to entry 50.1, BI on admission 17.4, and Neuropsychiatric Inventory (NPI) 31.4. A therapeutic limitation treatment was determined for 84% of patients on admission. From the analysis of the conditions that lead to death it was noted that: In 74.1% of the patients the death was a direct result of a triggering event (the most frequent being respiratory infection), in 17.3% the death occurred by a gradual decline, with no clear precipitating factor, and in 8.6% of patients palliative sedation was required due to poorly controlled symptoms. Conclusions. Intercurrent problems were the most common factors related to the death of the patients. Most patients died in the stages prior to the established criteria for terminal dementia. In some cases patients may experience disorder behavior as a refractory symptom(AU)

[Analysis of dementia patient mortality in a psychogeriatric unit]. / Análisis de las defunciones de pacientes con demencia ingresados en una unidad de psicogeriatría.

AIM: To determine the characteristics of patients with dementia who died in a psychogeriatric unit, and to describe the conditions that led to their death. MATERIAL AND METHODS: Observational study of patients who died in the Psychogeriatric unit of Hospital de la Santa Creu de Vic during a three and a half year period. RESULTS: Of the 554 patients admitted during the study period, we recorded a mortality of 14.6% (81 patients). The analysis of those who died showed that 67.9% were women, with a mean age of 85.8 years, with the most frequent cause being Alzheimer type dementia (37%) and being in an advanced stage (CDR3, GDS 6-7) in 72.8% of cases. On admission the following characteristics were recorded: Mini Mental State Examination (MMSE) 9.5, Barthel Index (BI) prior to entry 50.1, BI on admission 17.4, and Neuropsychiatric Inventory (NPI) 31.4. A therapeutic limitation treatment was determined for 84% of patients on admission. From the analysis of the conditions that lead to death it was noted that: In 74.1% of the patients the death was a direct result of a triggering event (the most frequent being respiratory infection), in 17.3% the death occurred by a gradual decline, with no clear precipitating factor, and in 8.6% of patients palliative sedation was required due to poorly controlled symptoms. CONCLUSIONS: Intercurrent problems were the most common factors related to the death of the patients. Most patients died in the stages prior to the established criteria for terminal dementia. In some cases patients may experience disorder behavior as a refractory symptom.

Resultados de los parámetros de evaluación asistenciales de una unidad de atención intermedia para pacientes con demencia / Care assessment parameters in an intermediate care unit for patients with dementia

Objetivo. Evaluar los resultados asistenciales de nuestra unidad de Psicogeriatría. Material y métodos. Estudio prospectivo de 46 pacientes con demencia ingresados en la unidad de Psicogeriatría entre mayo y agosto del 2008. Se analizó: a) mediana del Neuropsychiatric Inventory al ingreso, a la semana y al alta; b) porcentaje de pacientes procedentes de domicilio y procedentes del hospital de agudos; c) porcentaje de pacientes procedentes del hospital con estancia media inferior o igual a 7 días; d) porcentaje de caídas y restricciones físicas, y e) destino al alta. Las comparaciones entre variables se realizaron con el T-test y el chi-cuadrado. Resultados. Se observaron diferencias estadísticamente significativas entre la mediana del Neuropsychiatric Inventory al ingreso (37,7) y a la semana (13,7) (p<0,001). El 50% de los pacientes procedía de domicilio y el 50% del hospital de agudos, de éstos, el 73,9% tuvo una estancia media en el hospital de procedencia inferior o igual a 7 días. El 19,6% de los pacientes presentó caídas. Se utilizaron restricciones físicas en el 43,5% de los pacientes. Al ingreso se observó un bajo grado de prescripción de benzodiacepinas de vida media larga (6,5%) y neurolépticos típicos (2,2%), y un 6,7% de los pacientes no presentó prescripción de psicofármacos. Un 33% de los pacientes fueron dados de alta sin prescripción de psicofármacos. El porcentaje de nueva institucionalización fue del 43,5%. Conclusiones. Las unidades de Psicogeriatría de media estancia permiten el control de los síntomas psicológicos y conductuales y probablemente optimizan el recurso de los hospitales de agudos(AU)

Objective. To evaluate the care outcomes of a psychogeriatric unit. Material and methods. A prospective study of 46 patients with dementia consecutively admitted to Psychogeriatric Unit between May and August 2008. The parameters analysed were: a) median Neuropsychiatric Inventory (NPI) on admission, after one week and at discharge, b) percentage of patients coming from home or discharged from the acute hospital, c) percentage of patients coming from the acute hospital with an average stay equal or less than 7 days, d) percentages of falls and physical restraints, and e) destination at discharge. Comparisons between variables were performed using t-test and chi-squared. Results. There were a statistically significant difference between the median NPI on admittance (37.7) and after a week (13.7) (p<0.001). Half of the patients came from home and the other half from acute hospital, 73.9% of whom had had an average hospital stay equal or less than 7 days. Falls were reported in 19.6% of patients. Physical restraints were used in 43.5% of patients. On admission there was a low level of prescription of long half-life benzodiazepines (6.5%) and typical neuroleptics (2.2%), and 6.7% of patients had no prescription of psychotropic drugs. At discharge psychotropic drugs were not prescribed in 33% of patients. The institutionalisation rate was 43.5%. Conclusions. Intermediate Psychogeriatric wards enable behavioural symptoms to be controlled (BPSD) and they probably optimize the use of acute hospitals(AU)

[Care assessment parameters in an intermediate care unit for patients with dementia]. / Resultados de los parámetros de evaluación asistenciales de una unidad de atención intermedia para pacientes con demencia.

OBJECTIVE: To evaluate the care outcomes of a psychogeriatric unit. MATERIAL AND METHODS: A prospective study of 46 patients with dementia consecutively admitted to Psychogeriatric Unit between May and August 2008. The parameters analysed were: a) median Neuropsychiatric Inventory (NPI) on admission, after one week and at discharge, b) percentage of patients coming from home or discharged from the acute hospital, c) percentage of patients coming from the acute hospital with an average stay equal or less than 7 days, d) percentages of falls and physical restraints, and e) destination at discharge. Comparisons between variables were performed using t-test and chi-squared. RESULTS: There were a statistically significant difference between the median NPI on admittance (37.7) and after a week (13.7) (p<0.001). Half of the patients came from home and the other half from acute hospital, 73.9% of whom had had an average hospital stay equal or less than 7 days. Falls were reported in 19.6% of patients. Physical restraints were used in 43.5% of patients. On admission there was a low level of prescription of long half-life benzodiazepines (6.5%) and typical neuroleptics (2.2%), and 6.7% of patients had no prescription of psychotropic drugs. At discharge psychotropic drugs were not prescribed in 33% of patients. The institutionalisation rate was 43.5%. CONCLUSIONS: Intermediate Psychogeriatric wards enable behavioural symptoms to be controlled (BPSD) and they probably optimize the use of acute hospitals.