Respiratory syncytial virus: A new era / Virus respiratorio sincitial: un nuevo tiempo

Respiratory syncytial virus (RSV) is a major public health problem that has undergone significant changes in recent years. First of all, it has become easier to diagnose with highly reliable and rapidly available confirmatory tests. This has led to a better understanding of its epidemiology and RSV has gone from being a disease of the pediatric age group, severe only in infants and immunosuppressed children, to being a common disease in people of all ages, particularly important in patients of advanced age or with immunosuppressive diseases. Recent therapeutic and prophylactic advances, both with long-lasting monoclonal antibodies and vaccines, are another reason for satisfaction. For these reasons, the COVID and Emerging Pathogens Committee of the Illustrious Official College of Physicians of Madrid (ICOMEM) has considered it pertinent to review this subject in the light of new knowledge and new resources for dealing with this infection. We have formulated a series of questions that we believe will be of interest not only to members of the College but also to any non-expert in this subject, with a particular focus on the situation of RSV infection in Spain. (AU)

El Virus Respiratorio Sincitial (VRS), es un problema de salud pública de primera magnitud que en años recientes ha experimentado cambios muy importantes. En primer lugar, se ha producido una mayor facilidad diagnóstica con pruebas confirmatorias altamente fiables y rápidamente disponibles. Esto ha permitido conocer mejor su epidemiología y VRS ha pasado de ser una enfermedad de la edad pediátrica, grave sólo en lactantes y niños inmunodeprimidos, a ser una enfermedad común en personas de toda edad, particularmente importante en pacientes de edades avanzadas o con enfermedades que inmunodeprimen. Los avances terapéuticos y profilácticos, recientes, tanto con anticuerpos monoclonales de larga duración como con vacunas, constituyen otro motivo de satisfacción. Por estos motivos, el Comité de COVID y de patógenos emergentes del Ilustre Colegio Oficial de Médicos de Madrid (ICOMEM) ha considerado pertinente revisar este tema, a la luz de los nuevos conocimientos y de los nuevos recursos para afrontar esta infección. Hemos formulado una serie de preguntas que creemos de interés no sólo para los colegiados si no para cualquier persona no experta en este tema, con una vista particular en la situación de la infección por VRS en España. (AU)

COVID -19: On the threshold of the fifth year. The situation in Spain / COVID-19: A las puertas del quinto año

Despite having emerged from pandemic status, the incidence of COVID-19 episodes has recently increased in Spain, including pediatric cases and admissions to Intensive Care Units. Several recombinant variants are circulating among us, particularly XBB arising from two Omicron BA.2 sublineages with mutations in the genes encoding the spicule proteins that could increase binding to the ACE2 receptor and be more prone to immune escape. Faced with these, 3 pharmaceutical companies have developed vaccines adapted to the XBB.1.5 sublineage that are already available for administration in our setting with risks that should not be different from those of previous mRNA vaccines and with clearly favorable benefit/risk ratios. They should be applied to patients with potential for poor COVID-19 evolution and to collectives that have a particular relationship of proximity with them. Their application should be understood not only from a perspective of individual convenience but also from that of collective responsibility. The most convenient seems to be a simultaneous immunization of COVID-19 and influenza in our environment. In the therapeutic aspect, there is little to expect right now from antisera, but the already known antiviral drugs are still available and indicated, although their efficacy will have to be reevaluated due to their impact on populations that are mostly immunized and with a better prognosis than in the past. In our opinion, it is necessary to continue to make a reasonable and timely use of masks and other non-pharmacological means of protection. (AU)

Pese a haber salido de la situación de pandemia, la incidencia de episodios de COVID-19 ha aumentado recientemente en España, incluidos los casos pediátricos y los ingresos en Unidades de Cuidados Intensivos. Circulan entre nosotros diversas variantes recombinantes, particularmente la XBB surgidas de dos sublinajes Omicron BA.2 con mutaciones en los genes que codifican las proteínas de la espícula y que pudieran aumentar la unión al receptor ACE2 y ser más propensas al escape inmune. Frente a ellas, 3 empresas farmacéuticas han elaborado vacunas adaptadas al sublinaje XBB.1.5 que ya se encuentran disponibles para su administración en nuestro medio con riesgos que no deben ser diferentes a los de las vacunas mRNA previas y con relaciones beneficio/riesgos claramente favorables. Deben aplicarse a pacientes con potencial de mala evolución de COVID-19 y a los colectivos que tienen una particular relación de proximidad con ellos. Su aplicación debe ser entendida no sólo desde una perspectiva de conveniencia individual sino desde la de la responsabilidad colectiva. Lo más conveniente parece hacer una inmunización simultánea de COVID-19 y gripe en nuestro medio. En el aspecto terapéutico hay poco que esperar ahora mismo de los antisueros pero siguen estando disponibles e indicados los fármacos antivirales ya conocidos aunque su eficacia tendrá que reevaluarse por su impacto en poblaciones mayoritariamente inmunizadas y con pronóstico mejor que las de tiempos pasados. A nuestro juicio, es necesario seguir haciendo un uso razonable y puntual de mascarillas y otros medios no farmacológicos de protección. (AU)

Utilidad y seguridad de los ingresos directos a una unidad hospitalaria de agudos de un servicio de geriatría valorados por atención geriátrica en residencias / Utility and safety of direct admission to acute geriatric unit after Nursing Home Geriatric Team assessment

Introducción y objetivo Más de la mitad de los ancianos institucionalizados necesita de una derivación anual a urgencias generando, por su complejidad, un alto uso de recursos y mayor riesgo de eventos adversos. El objetivo del estudio es valorar si la hospitalización directa en una unidad de geriatría de agudos, tras evaluación conjunta del equipo médico de residencia y del geriatra consultor, puede ser una alternativa segura y de utilidad en comparación con la atención en urgencias. Métodos Estudio observacional retrospectivo de los pacientes ingresados en la unidad de geriatría de agudos procedentes de las residencias atendidas por nuestro equipo de atención geriátrica a residencia entre el 01/01/2021 y el 31/12/2021. Se excluyeron los pacientes ingresados de forma programada o con diagnóstico de infección por SARS-CoV-2. Se recogieron variables de la historia clínica (sociodemográficas, clínicas, funcionales, cognitivas). Como variables resultado se registraron mortalidad durante el ingreso, estancia hospitalaria y en urgencias, traslado a urgencias y delirium en las primeras 48h del ingreso, ubicación al alta. Resultados 206 pacientes no COVID ingresaron directamente desde la residencia, 101 derivados desde urgencias (N: 307). Al ingreso el 62,5% presentaba Índice Barthel<40 y el 65% Cruz Roja Mental≥2, con Índice de Charlson ≥3 en el 56,4% de los casos. La mortalidad intrahospitalaria entre los ingresos directos fue del 14,6%, en el grupo derivado de urgencias del 20,8%, p=0,14. La estancia hospitalaria total de los pacientes valorados por atención geriátrica a residencia fue 9,61±6,01 días, mientras en los derivados a urgencias 11,22±5,36 días, p=0,02. Presentaron delirium en las primeras 48h del ingreso, 27,7% de los ingresos directos y 36,6% desde urgencias (p=0,11) (AU)

Background and objective More than half of institutionalized older people need a emergency department visit annually, with high resources consumption and higher risk of adverse events, due to high complexity. Direct admission to Acute Geriatric Unit (AGU), after geriatric consultant and nursing home medical team assessment, could be a safety and effective alternative to emergency department (ED) admission. Methods Retrospective observational study of AGU patients admitted by Nursing Home Geriatric Team between January, 1st and December, 31st, 2021. Planned admissions and SARS-CoV-2 positive patients were excluded. Medical (sociodemographic, clinical, functional and cognitive) records and outcomes data (inpatient mortality, hospital and ED lenght of stay, transfer to ED and delirium within 48h after admission, hospital discharge location) were collected. Results Two hundred and six patients directly admitted, 101 through ED (N 307). 62.5% with Barthel index <40, 65% with dementia, 56.4% with Charlson index ≥3. Inpatient mortality was 14.6% in direct admission, 20.8% in ED referral group, p=0.14. Hospital lenght of stay was 9.61±6.01 days in direct admission, 11.22±5.36 days in ED group, p=0.02. 27.7% of patients with delirium in direct admission and 36.6% in ED group; only one patient was transferred to ED, within 48h after admission. Conclusions Direct admission is a safety and effective alternative to ED referral in institutionalized older people after geriatric assessment, due to no increased mortality, shorter length of stay and hospital cost reduction (AU)

Tuberculosis in Spain: An opinion paper / Tuberculosis en España: Un documento de opinión

This document is the result of the deliberations of the Committee on Emerging Pathogens and COVID-19 of the Il lustrious Official College of Physicians of Madrid (ICOMEM) regarding the current situation of tuberculosis, particularly in Spain. We have reviewed aspects such as the evolution of its incidence, the populations currently most exposed and the health care circuits for the care of these patients in Spain. We have also discussed latent tuberculosis, the reality of extrapul monary disease in the XXI century and the means available in daily practice for the diagnosis of both latent and active forms. The contribution of molecular biology, which has changed the perspective of this disease, was another topic of discussion. The paper tries to put into perspective both the classical drugs and their resistance figures and the availability and indications of the new ones. In addition, the reality of direct observa tion in the administration of antituberculosis drugs has been discussed. All this revolution is making it possible to shorten the treatment time for tuberculosis, a subject that has also been reviewed. If everything is done well, the risk of relapse of tuberculosis is small but it exists. On the other hand, many special situations have been discussed in this paper, such as tuberculosis in pediatric age and tuberculosis as a cause for concern in surgery and intensive care. The status of the BCG vaccine and its present indications as well as the future of new vaccines to achieve the old dream of eradicating this disease have been discussed. Finally, the ethical and medicolegal impli cations of this disease are not a minor issue and our situation in this regard has been reviewed (AU)

El presente documento es el resultado de las deliberacio nes del Comité sobre Patógenos Emergentes y COVID-19 del Ilustre Colegio Oficial de Médicos de Madrid (ICOMEM) en re lación a la situación actual de la tuberculosis, particularmente en España. Hemos revisado aspectos tales como la evolución de su incidencia, las poblaciones actualmente más expuestas y los circuitos sanitarios para la atención a estos pacientes en España. Se ha discutido también la tuberculosis latente, la rea lidad de la enfermedad extrapulmonar en el siglo XXI y los me dios de que en la práctica diaria se dispone para el diagnóstico tanto de las formas latentes como de las activas. La aportación de la biología molecular que ha cambiado la perspectiva de es ta enfermedad ha constituido otro de los temas de debate. El documento trata de poner en perspectiva tanto los fármacos clásicos y sus cifras de resistencia como la disponibilidad e in dicaciones de los nuevos. Junto a esto, se ha discutido la rea lidad de la observación directa en la administración de fárma cos antituberculosos. Toda esta revolución está posibilitando el acortamiento del tiempo de tratamiento de la tuberculosis tema que ha sido igualmente revisado. Si todo se hace bien, el riesgo de recaída de la tuberculosis es pequeño pero existen te. Por otra parte, muchas situaciones especiales han merecido discusión en este documento como por ejemplo la tuberculosis en edad pediátrica y la tuberculosis como causa de preocupa ción en cirugía y cuidados intensivos. Se ha discutido tanto la situación de la vacuna BCG y sus indicaciones presentes, co mo el futuro de nuevas vacunas que permitan alcanzar el viejo sueño de erradicar esta enfermedad. Finalmente, las implica ciones éticas y medicolegales que esta enfermedad plantea no son un tema menor y se ha revisado nuestra situación en este particular (AU)

[Utility and safety of direct admission to acute geriatric unit after Nursing Home Geriatric Team assessment]. / Utilidad y seguridad de los ingresos directos a una unidad hospitalaria de agudos de un servicio de geriatría valorados por atención geriátrica en residencias.

BACKGROUND AND OBJECTIVE: More than half of institutionalized older people need a emergency department visit annually, with high resources consumption and higher risk of adverse events, due to high complexity. Direct admission to Acute Geriatric Unit (AGU), after geriatric consultant and nursing home medical team assessment, could be a safety and effective alternative to emergency department (ED) admission. METHODS: Retrospective observational study of AGU patients admitted by Nursing Home Geriatric Team between January, 1st and December, 31st, 2021. Planned admissions and SARS-CoV-2 positive patients were excluded. Medical (sociodemographic, clinical, functional and cognitive) records and outcomes data (inpatient mortality, hospital and ED lenght of stay, transfer to ED and delirium within 48h after admission, hospital discharge location) were collected. RESULTS: Two hundred and six patients directly admitted, 101 through ED (N 307). 62.5% with Barthel index <40, 65% with dementia, 56.4% with Charlson index ≥3. Inpatient mortality was 14.6% in direct admission, 20.8% in ED referral group, p=0.14. Hospital lenght of stay was 9.61±6.01 days in direct admission, 11.22±5.36 days in ED group, p=0.02. 27.7% of patients with delirium in direct admission and 36.6% in ED group; only one patient was transferred to ED, within 48h after admission. CONCLUSIONS: Direct admission is a safety and effective alternative to ED referral in institutionalized older people after geriatric assessment, due to no increased mortality, shorter length of stay and hospital cost reduction.

Status of Herpes Zoster and Herpes Zoster Vaccines in 2023: A position paper / Situación del herpes zóster y de las vacunas contra el mismo en 2023: Un documento de opinión

Herpes zoster infection (HZ) is an important public health problem due to its high incidence and frequent complications, especially post-herpetic neuropathy . The incidence of HZ increases with age and is more frequent in immunocompromised patients. It is estimated that at least 60,000 people develop HZ each year in Spain.The usual forms of HZ are so clinically characteristic that they do not usually require microbiological confirmation, which is reserved for cases without cutaneous manifestations or with atypical presentation.There are currently two vaccines approved by the regulatory agencies and marketed in Spain to prevent the onset of HZ and its complications. The first (Zostavax®) was marketed by the company MSD and licensed in Europe in 2006 and is a live attenuated virus vaccine that is administered in a single dose, while the second (Shingrix®) is a recombinant vaccine, marketed in 2017 and requires two doses. While the former cannot be administered to immunocompromised persons, the latter can be prescribed to any group of adults.The criteria for the indication and financing of these vaccines have not been uniform in the various autonomous communities of Spain.These and other aspects of HZ have been discussed by a group of experts from the Illustrious Official College of Physicians of Madrid (ICOMEM) whose criteria and opinions are included in this paper. (AU)

La infección por herpes zoster (HZ) es un importante problema de salud pública, por su elevada incidencia y frecuentes complicaciones; en especial la neuropatía post herpética. La incidencia de HZ aumenta con la edad y es más frecuente en inmunodeprimidos. Se calcula que, al menos, 60.000 personas desarrollan HZ cada año en España. Las formas habituales de HZ son tan características clínicamente que no suelen requerir confirmación microbiológica que se reserva para casos sin manifestaciones cutáneas o con manifestaciones atípicas En la actualidad, existen en España dos vacunas aprobadas por las agencias reguladoras y comercializadas para prevenir la aparición de HZ y sus complicaciones. La primera (Zostavax®) fue comercializada por la compañía MSD y autorizada en Europa en 2006 y es una vacuna de virus vivos atenuados que se administra en dosis única, mientras que la segunda (Shingrix®) es una vacuna recombinante, comercializada en 2017 y requiere dos dosis. Mientras la primera no puede ser administrada a inmunodeprimidos, la segunda puede administrarse a cualquier grupo de personas. Los criterios de indicación y de financiación de estas vacunas no han sido uniformes en las diversas comunidades autónomas de España. Estos y otros aspectos sobre HZ han sido discutidos por un grupo de expertos del Ilustre Colegio Oficial de Médicos de Madrid (ICOMEM) cuyo criterio y opinión recogemos en este trabajo. (AU)

El impacto de las primeras olas pandémicas de la COVID-19 en las personas mayores con demencia / The impact of the first pandemic waves of COVID-19 in older people with dementia

Los pacientes con demencia son de por sí más vulnerables, y se han visto especialmente afectados por el efecto de la pandemia por COVID-19, tanto de manera directa por la propia enfermedad como de manera indirecta por la privación de estimulación cognitiva debido al aislamiento social por el confinamiento.La infección por el virus SARS-CoV-2 ha dado lugar a una gran variedad de síntomas, entre ellos, síntomas neurológicos, siendo uno de los principales el delirium, especialmente en los ancianos con demencia. La afectación del virus sobre el sistema nervioso central ha sido tanto directa, por el neurotropismo del virus, como indirecta, por la inflamación y la hipoxia tisular de origen vascular.Se analizan las diferentes causas que han podido conducir, en las diferentes olas previas a la variante ómicron, al importante aumento de la morbimortalidad en los pacientes con demencia, especialmente en los más mayores.(AU)

Patients with dementia are in themselves more vulnerable, and have been especially affected by the effect of the COVID-19 pandemic, both directly due to the disease itself, and indirectly due to the deprivation of cognitive stimulation due to isolation social due to confinement.SARS-CoV-2 virus infection has given rise to a wide variety of symptoms, including neurological symptoms and especially delirium in the elderly with dementia. The virus has affected the central nervous system, both directly due to the neurotropism of the virus, and indirectly due to inflammation and tissue hypoxia of vascular origin.The different causes that have been able to lead, in the different waves prior to the omicron variant, to the significant increase in morbidity and mortality in patients with dementia, especially the elderly, are analyzed.(AU)

Could olfactory identification be a prognostic factor in detecting cognitive impairment risk in the elderly?

Aging contributes to the deterioration of the olfactory system in humans. Several studies indicate that the olfactory identification test alone may function as a screening test for olfactory dysfunction and they are more feasible to apply in clinical practice. Olfactory identification may be a predictor for cognitive impairment. Multiple studies have considered the use of odor identification as a measure to identify the conversion from normality to mild cognitive impairment or dementia. The objectives were (i) to elucidate the associations between cognitive status and olfactory identification performance in aging; (ii) understand the predictive value of olfactory capacity in identifying subjects with cognitive impairment risk; and (iii) to study how cognitive status and olfactory identification relate with other variables of wellness in aging, such as functional capabilities and clinical measures. For this purpose, a group of 149 participants (77.15 ± 7.29 years; 73 women of 76.7 ± 8 years and 76 men of 77.6 ± 6.52 years) were recruited and were subjected to a sociodemographic questionnaire, a psychological screening tool of general cognitive status, an olfactory identification evaluation, and clinical measures. The participants were divided into groups based on their cutoff scores of previous scientific reports about the Spanish version of Montreal Cognitive Assessment. Our results indicate an age-associated decline in olfactory identification ability and intensity of odor perception. The predictive ability of olfactory identification scores for the risk of mild and severe impairment is around 80%. Olfactory identification decreases with cognitive function. Performance in odor identification is associated with impairment of episodic memory and executive functions. These findings further our current understanding of the association between cognition and olfaction, and support olfactory assessment in screening those at higher risk of dementia.

[The impact of the first pandemic waves of COVID-19 in older people with dementia]. / El impacto de las primeras olas pandémicas de la COVID-19 en las personas mayores con demencia.

Patients with dementia are in themselves more vulnerable, and have been especially affected by the effect of the COVID-19 pandemic, both directly due to the disease itself, and indirectly due to the deprivation of cognitive stimulation due to isolation social due to confinement. SARS-CoV-2 virus infection has given rise to a wide variety of symptoms, including neurological symptoms and especially delirium in the elderly with dementia. The virus has affected the central nervous system, both directly due to the neurotropism of the virus, and indirectly due to inflammation and tissue hypoxia of vascular origin. The different causes that have been able to lead, in the different waves prior to the omicron variant, to the significant increase in morbidity and mortality in patients with dementia, especially the elderly, are analyzed.

Prevalence of transthyretin cardiac amyloidosis in elderly patients diagnosed with heart failure / Prevalencia de amiloidosis cardiaca por transtirretina en pacientes de edad avanzada con diagnóstico de insuficiencia cardiaca

Objective: There is increased interest in studying ATTR-CA, a pathology that primarily affects patients of geriatric age and is frequently underdiagnosed. We aim to establish the prevalence of ATTR-CA in a cohort of patients with a history of HFpEF and to describe its characteristics. Methods: We conducted a prospective observational study. Patients ≥75 years, clinical history of HFpEF, atrial dilation ≥34ml/m2 and left ventricular wall thickening >13mm, were included. Demographic and analytical parameters were collected, and a comprehensive geriatric assessment was performed, along with a transthoracic echocardiogram and cardiac scintigraphy. Finally, telephone follow-up was carried out at 6 and 12 months. Results: 50 patients were recruited, mean age 86±6 years, 54% women. Age and functional class (I–II vs. III–IV) were factors associated with presenting with ATTR-CA. Patients with positive scintigraphy had a median time to admission of 5.2 months (confidence interval [CI] 95% 0–10.9), while in those with negative scintigraphy, it was 12.2 months (95% CI 11.7–12.8); log-rank: p=0.064. Patients with positive scintigraphy had a median time to the combined endpoint (death and readmission) of 1.9 months (95% CI 0–6.1), and patients with negative scintigraphy of 11.9 months (95% CI 11.7–12); log-rank: p=0.027. Conclusions: ATTR-CA appears to be a prevalent etiology in elderly patients within the spectrum of HFpEF. Patients with a diagnosis of ATTR-CA had a shorter time to admission for HF and the combined event of death and admission than patients with a negative result on scintigraphy. (AU)

Objetivo: Existe un interés creciente por el estudio de AC-TTR, siendo esta una patología que afecta fundamentalmente a pacientes de edad avanzada y que es frecuentemente infradiagnosticada. Nuestro objetivo fue establecer la prevalencia de AC-TTR en una cohorte de pacientes con historia de ICFEp y describir sus características. Métodos: Estudio observacional prospectivo. Se incluyeron pacientes ≥75 años, con historia clínica de ICFEp, dilatación auricular ≥34ml/m2 y engrosamiento de la pared del ventrículo izquierdo >13mm. Se recogieron datos analíticos y demográficos, así como de la valoración geriátrica integral y se realizó un ecocardiograma transtorácico y una gammagrafía cardiaca. Finalmente se realizó seguimiento telefónico a los 6 y 12 meses. Resultados: Se incluyó a 50 pacientes, edad media 86±6 años, 54% mujeres. La edad y la clase funcional NYHA (I-II vs. III-IV) se asociaron con mayor riesgo de presentar AC-TTR. Los pacientes con gammagrafía positiva tuvieron una mediana de tiempo al ingreso de 5,2 meses (intervalo de confianza [IC] 95% 0-10,9), frente a aquellos con gammagrafía negativa que fue de 12,2 meses (IC 95% 11,7-12,8); log-rank: p=0,064. Los pacientes con gammagrafía positiva presentaron una mediana de tiempo al evento combinado (muerte y reingreso) de 1,9 meses (IC 95% 0-6,1), mientras que en aquellos con resultado negativo fue de 11,9 meses (IC 95% 11,7-12); log-rank: p=0.027. Conclusiones: La AC-TTR supone una etiología prevalente de insuficiencia cardiaca, dentro del espectro de la ICFEp, en pacientes de edad avanzada. Los individuos con diagnóstico de AC-TTR presentaron un menor tiempo al ingreso por insuficiencia cardiaca y al evento combinado de muerte y reingreso frente a aquellos pacientes con resultado negativo en la gammagrafía. (AU)

Prevalence of transthyretin cardiac amyloidosis in elderly patients diagnosed with heart failure.

OBJECTIVE: There is increased interest in studying ATTR-CA, a pathology that primarily affects patients of geriatric age and is frequently underdiagnosed. We aim to establish the prevalence of ATTR-CA in a cohort of patients with a history of HFpEF and to describe its characteristics. METHODS: We conducted a prospective observational study. Patients ≥75 years, clinical history of HFpEF, atrial dilation ≥34ml/m2 and left ventricular wall thickening >13mm, were included. Demographic and analytical parameters were collected, and a comprehensive geriatric assessment was performed, along with a transthoracic echocardiogram and cardiac scintigraphy. Finally, telephone follow-up was carried out at 6 and 12 months. RESULTS: 50 patients were recruited, mean age 86±6 years, 54% women. Age and functional class (I-II vs. III-IV) were factors associated with presenting with ATTR-CA. Patients with positive scintigraphy had a median time to admission of 5.2 months (confidence interval [CI] 95% 0-10.9), while in those with negative scintigraphy, it was 12.2 months (95% CI 11.7-12.8); log-rank: p=0.064. Patients with positive scintigraphy had a median time to the combined endpoint (death and readmission) of 1.9 months (95% CI 0-6.1), and patients with negative scintigraphy of 11.9 months (95% CI 11.7-12); log-rank: p=0.027. CONCLUSIONS: ATTR-CA appears to be a prevalent etiology in elderly patients within the spectrum of HFpEF. Patients with a diagnosis of ATTR-CA had a shorter time to admission for HF and the combined event of death and admission than patients with a negative result on scintigraphy.

[Evolution of the profile of patients attended by a hospital Geriatric Home Care Unit in the last 20 years]. / Evolución del perfil de las personas mayores atendidas por una unidad de atención domiciliaria especializada en geriatría en los últimos 20 años.

OBJECTIVE: To describe the evolution of the profile of patients attended by a Geriatric Home Care (GHC) Unit and its care activity in the last two decades. METHODS: Data on the historical activity of the AGD Unit from 2001 to 2020, grouped into 5-year periods, were recorded. Sociodemographic, clinical, functional (Functional Red Cross Scale and Barthel index) and mental (Mental Red Cross Scale) variables were collected, baseline and at inclusion to AGD. Also the waiting time until first visit, mean follow-up, origin of referral, destination at the end of the intervention, reason for consultation and cause of functional dependence were also included. A descriptive analysis was performed with the SPSSv.23 program. RESULTS: Ten thousand six hundred fifty-four patients attended in AGD (1 January 2001 to 31 December 2020). A progressive increase in age and in the number of geriatric syndromes was observed. Patients presented higher functional and cognitive decline, and the number of patients living alone and in need of private assistance increased. The duration of the intervention decreases and Primary Care remains the main source and destination at the end of the intervention, with dementia standing out as the main cause for functional dependence. CONCLUSION: The vulnerability of the populations in need of specialised geriatric care is increasing: patients are older, and have more geriatric syndromes, high functional and cognitive decline, and suffer social frailty; more work is needed to address the role of these support units in the community, as well as their coordination with Primary Care teams.

Evolución del perfil de las personas mayores atendidas por una unidad de atención domiciliaria especializada en geriatría en los últimos 20 años / Evolution of the profile of patients attended by a hospital Geriatric Home Care Unit in the last 20 years

Objetivo: Describir la evolución del perfil de pacientes atendidos por una unidad de atención geriátrica domiciliaria (AGD) y su actividad asistencial desde en las últimas dos décadas. Métodos: Se registraron los datos de la actividad histórica de la unidad de AGD desde 2001 hasta 2020, agrupados en quinquenios. Se recogieron variables sociodemográficas, clínicas, funcionales (escala de Cruz Roja funcional e índice de Barthel) y mentales (escala de Cruz Roja mental), en condiciones basales y al inicio de la atención en AGD. También el tiempo de espera hasta la 1.ª visita, la duración de la intervención, la procedencia de los pacientes y el destino al alta junto con el motivo de consulta y el motivo principal de dependencia funcional. Se realizó un análisis descriptivo con el programa SPSS® v.23. Resultados: Diez mil seiscientos cincuenta y cuatro pacientes atendidos en AGD (1-1-2001 hasta el 31-12-2020). Se observa un incremento progresivo de la edad y de síndromes geriátricos. Los pacientes presentan mayor deterioro funcional y mental, aumentando los pacientes que viven solos y la necesidad de ayuda privada. Disminuye la duración de la intervención y atención primaria se mantiene como la principal procedencia y destino al alta, destacando la demencia como principal causa de dependencia funcional. Conclusión: El paciente geriátrico domiciliario, en las últimas dos décadas, es cada vez más vulnerable: de mayor edad, más síndromes geriátricos, mayor dependencia funcional y mental y de gran fragilidad social; se necesitan más trabajos que aborden la función de estas unidades de soporte al manejo de la complejidad en la comunidad, así como su coordinación con los equipos de atención primaria referentes de la atención. (AU)

Objective: To describe the evolution of the profile of patients attended by a Geriatric Home Care (GHC) Unit and its care activity in the last two decades. Methods: Data on the historical activity of the AGD Unit from 2001 to 2020, grouped into 5-year periods, were recorded. Sociodemographic, clinical, functional (Functional Red Cross Scale and Barthel index) and mental (Mental Red Cross Scale) variables were collected, baseline and at inclusion to AGD. Also the waiting time until first visit, mean follow-up, origin of referral, destination at the end of the intervention, reason for consultation and cause of functional dependence were also included. A descriptive analysis was performed with the SPSSv.23 program. Results: Ten thousand six hundred fifty-four patients attended in AGD (1 January 2001 to 31 December 2020). A progressive increase in age and in the number of geriatric syndromes was observed. Patients presented higher functional and cognitive decline, and the number of patients living alone and in need of private assistance increased. The duration of the intervention decreases and Primary Care remains the main source and destination at the end of the intervention, with dementia standing out as the main cause for functional dependence. Conclusion: The vulnerability of the populations in need of specialised geriatric care is increasing: patients are older, and have more geriatric syndromes, high functional and cognitive decline, and suffer social frailty; more work is needed to address the role of these support units in the community, as well as their coordination with Primary Care teams. (AU)

COVID-19: Some unresolved issues / COVID-19: Algunos asuntos no resueltos

Two years after the COVID-19 pandemic, many uncertainties persist about the causal agent, the disease and its future. This document contains the reflection of the COVID-19 working group of the Official College of Physicians of Madrid (ICOMEM) in relation to some questions that remain unresolved. The document includes considerations on the origin of the virus, the current indication for diagnostic tests, the value of severity scores in the onset of the disease and the added risk posed by hypertension or dementia. We also discuss the possibility of deducing viral behavior from the examination of the structure of the complete viral genome, the future of some drug associations and the current role of therapeutic resources such as corticosteroids or extracorporeal oxygenation (ECMO). We review the scarce existing information on the reality of COVID 19 in Africa, the uncertainties about the future of the pandemic and the status of vaccines, and the data and uncertainties about the long-term pulmonary sequelae of those who suffered severe pneumonia. (AU)

Cuando han transcurrido ya dos años de la pandemia de COVID-19 persisten muchas incertidumbres sobre el agente causal, la enfermedad y su futuro. El presente documento contiene la reflexión del grupo de trabajo sobre COVID-19 del Ilustre Colegio Oficial de Médicos de Madrid (ICOMEM) en relación a algunas preguntas que nos parecen sin resolver. El documento incluye reflexiones sobre el origen del virus, la indicación actual de pruebas diagnósticas, el valor de los “scores” de gravedad en el comienzo de la enfermedad y el riesgo añadido que supone la hipertensión o la demencia. Se discute también, la posibilidad de deducir del examen de la estructura del genoma viral completo el comportamiento viral, el futuro de algunas asociaciones de fármacos y el papel actual de recursos terapéuticos como los corticoides o la oxigenación extracorpórea (ECMO). Revisamos la escasa información existente sobre la realidad de la COVID-19 en África, las incertidumbres sobre el futuro de la pandemia y la situación de las vacunas y los datos e incertidumbres sobre las secuelas pulmonares a largo plazo de los que padecieron neumonía grave. (AU)

COVID in Pediatric Age: an opinion paper / COVID en la edad pediátrica: un documento de opinión

The incidence of COVID in pediatrics was underestimated during the first months of the pandemic due to the oligosymptomatic nature of the infection in many children and thescarcity of diagnostic tests applied to this population. It is nowaccepted that children are infected and transmit the diseasein the same way as adults. On the contrary, children have lesssevere and less lethal COVID, probably due to a lower maturityof the child’s immune system, a lower number of ACE2 receptors and the lower presence of comorbidities in this populationgroup.The development of a multisystemic inflammatory syndrome after SARS-CoV-2 infection in children, despite its rarity, is a very serious condition that frequently requires intensivecare. Other less severe post-COVID manifestations have beendescribed in children but are not yet well defined.COVID has had and continues to have a significant psychological impact on the children themselves, on their caregiversand on the exacerbation of pre-existing psychiatric conditions.We apply adult therapeutic principles to children but withvery low levels of evidence. Information on the tolerability of the available medications in this population group is stillscarce. The mortality of COVID in children is very low and generally affects children with significant comorbidities.There are, at present, three vaccines licensed for pediatricuse which are compatible with all other vaccines applicable tochildren.In these circumstances, there has been much speculationabout the indication for vaccination in the pediatric age group,but given its good tolerance, there are clinical and ethical reasons that, in our opinion, justify it. (AU)

La incidencia de COVID en pediatría ha estado infraestimada durante los primeros meses de la pandemia por el carácter oligosintomático de la infección en muchos niños y porla escasez de pruebas diagnósticas aplicadas a esta población.Hoy se admite que los niños se infectan y transmiten la enfermedad igual que los adultos. Por el contrario, los niños tienencuadros clínicos menos graves y letales lo cuál parece relacionado con una menor madurez del sistema inmune del niño,una menor cantidad de receptores ACE2 y la menor presenciade comorbilidades en este grupo de población.El desarrollo de un síndrome inflamatorio multisistémicotras la infección por SARS-CoV-2 en niños, pese a su rareza, esun cuadro muy grave que frecuentemente requiere cuidadosintensivos. Se han descrito otros cuadros post-COVID en niños,menos graves, pero todavía no muy bien definidos.La COVID-19 ha tenido y tiene un importante impacto psicológico en los propios niños, en sus cuidadores y en la exacerbación de cuadros psiquiátricos pre-existentes.Aplicamos a los niños los principios terapéuticos de losadultos pero con niveles muy bajos de evidencia y la toleranciade los medicamentos disponibles en este grupo de poblaciónes todavía mal conocida. La mortalidad de la COVID en niñoses muy baja e incide generalmente en niños con importantescomorbilidades.Hay, en el momento presente, tres vacunas autorizadaspara el uso pediátrico y las vacunas frente a SARS-CoV-2 soncompatibles con el resto de las vacunas aplicables a niños.En estas circunstancias se ha especulado mucho sobre laindicación de vacunación en la edad pediátrica pero dada subuena tolerancia, existen, en nuestra opinión, razones clínicasy éticas que la justifican. (AU)

Safety, Effectiveness, and Immunogenicity 6 Months After BNT162B2 mRNA Vaccine in Frail Nursing Home Residents.

BACKGROUND: Elderly people who reside in long-term care facilities form a frail and vulnerable population, with multiple pathologies and high percentages of cognitive and functional disability. OBJECTIVES: The aims of this study were to assess the safety of vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in frail nursing home residents and to evaluate its effectiveness 6 months after full vaccination. DESIGN: This was an ambispective observational study. SETTING: Residents of a long-term care facility in Madrid, Spain. PARTICIPANTS: One hundred and thirty-seven nursing home residents (81.8% female, mean age 87.77 ± 8.31 years) with high comorbidity (61.3% Charlson Index ≥ 3) and frailty (75% Clinical Frail Scale ≥ 7) who received the BNT162B2 mRNA vaccine. MEASUREMENTS: Safety data were collected to evaluate the type of adverse drug reactions and their duration, severity, and causality. Immunogenicity was tested 6 months after the primary vaccination and effectiveness was evaluated by the incidence of SARS-CoV-2 infection, the number of hospital admissions, and mortality due to coronavirus disease 2019 (COVID-19). RESULTS: Safety: Of the residents, 21.9% had some adverse reaction and 5.8% had a severe or more serious adverse reaction. The most frequent adverse reactions were fatigue (13.1%), pyrexia (12.4%), and headache (7.3%). No association was observed between frailty (including a need for palliative care) and clinical, functional or cognitive status of the participants and the occurrence of adverse events. Immunogenicity and Effectiveness: After 6 months of vaccination, only one case of SARS-CoV-2 infection was confirmed in the vaccinated residents. Most of the nursing home residents presented positive serology (95.2%). Loss of immunogenicity was associated with older age (95.12 ± 3.97 vs. 87.24 ± 8.25 years; p = 0.03) and no previous COVID-19 infection (16.6% vs. 70%; p < 0.001). Binary logistic regression models did not reveal this association. CONCLUSION: The BNT162B2 vaccine is well tolerated and effective in nursing home residents, independently of their clinical, functional, cognitive, or frailty characteristics. For the most part, immunogenicity has been maintained over time, regardless of comorbidity, functional status or frailty.

Coordinación entre atención primaria y un servicio de geriatría, 20 años después / Coordination between primary care and a geriatrics service, 20 years later

Objetivo: Describir la evolución de la actividad asistencial y de la coordinación de un equipo especializado hospitalario (equipo de Atención Geriátrica Domiciliaria-AGD) en el apoyo a atención primaria (AP) para la atención de pacientes geriátricos. Emplazamiento: Antigua área de Salud-5 de la Comunidad de Madrid. Participantes, intervenciones y mediciones principales: Evaluación de los pacientes atendidos en su domicilio a petición de AP por AGD, en 1997-1999 y 20 años después, en 2017-2019. Se registraron variables sociodemográficas, clínicas, funcionales y mentales. También datos asistenciales como el tiempo hasta la primera visita, la estancia media, la procedencia y destino de los pacientes, el motivo de consulta y el motivo principal de discapacidad. Resultados: Se atendieron 524 pacientes (58% del total) solicitados desde AP en 1997-1999 y 1196 (72,2% del total) en 2017-2019. Actualmente se muestra un paciente de mayor edad, más incapacitado física y mentalmente, con mayor prevalencia de síndromes geriátricos y mayor fragilidad social. Ha aumentado la demencia como motivo principal de incapacidad, observándose un incremento de la Valoración Geriátrica Integral (VGI) y del control clínico como motivos principales de derivación. Conclusiones: En nuestro medio, transcurridos 20 años, AGD continúa siendo un importante apoyo para AP en el complejo abordaje de los pacientes ancianos frágiles recluidos en su domicilio, que son cada vez más vulnerables desde el punto de vista clínico, funcional, cognitivo y social. Contribuye en el manejo de los síndromes geriátricos, la deprescripción, los ingresos directos hospitalarios cuando se necesitan sin pasar por urgencias y la disminución en la institucionalización, facilitando el mantenimiento del paciente en su domicilio.(AU)

Objective: To describe the evolution of the care and coordination activity of a specialized hospital team (Geriatric Home Care-AGD team) in support of Primary Care (PC) for the care of geriatric patients. Location: Health-5 area of the Community of Madrid. Participants, interventions and main measurements: Evaluation of patients attended at home at the request of PC by AGD, in 1997-1999 and twenty years later, in 2017-2019. Sociodemographic, clinical, functional and mental variables were recorded. Also care data such as time to first visit, average length of stay, origin and destination of patients, reason for consultation and main reason for disability. Results: 524 patients (58% of the total) requested from AP in 1997-1999 and 1196 (72.2% of the total) in 2017-2019 were attended. Currently we show an older patient, more physically and mentally disabled, with a higher prevalence of geriatric syndromes and greater social fragility. Dementia has increased as the main reason for incapacity, with an increase in Comprehensive Geriatric Assessment and clinical control as the main reasons for referral. Conclusion: sin our setting, after 20 years, AGD continues to be an important support for PC in the complex approach to frail elderly patients confined to their homes, who are increasingly vulnerable from a clinical, functional, cognitive and social point of view. It contributes to the management of geriatric syndromes, deprescription, direct hospital admissions when needed without having to go to the emergency department, and a decrease in institutionalization, facilitating the maintenance of the patient at home.(AU)

Gangrena de Fournier en varón de 89 años: un diagnóstico clínico urgente / Fournier's gangrene in an 89-year-old male: An urgent clinical diagnosis

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Aplicación de «Point-Of-Care-Ultrasound» (POCUS) en Atención Geriátrica a Domicilio (AGD): a propósito de un caso / Application of “Point-Of-Care-Ultrasound” (POCUS) in a Geriatric Home Care (AGD): A case report

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