Impacto de la fragilidad en la supervivencia intrahospitalaria en pacientes mayores con infección por COVID-19: la importancia de su identificación temprana. Registro Nacional SEMI-COVID / The impact of frailty on intra-hospital survival in older patients with COVID-19 infection: The importance of early identification. SEMI-COVID National Registry

Introducción La evidencia reciente sugiere que la fragilidad puede ser un importante predictor de resultados adversos en personas mayores hospitalizadas por COVID-19. El objetivo de este estudio es determinar el valor pronóstico de la fragilidad en la supervivencia intrahospitalaria de estos pacientes. Métodos Estudio observacional, multicéntrico y de ámbito nacional de pacientes ≥70 años hospitalizados a consecuencia de la COVID-19 en España desde el 1 de marzo hasta el 31 de diciembre de 2020. Los datos de los pacientes se obtuvieron del Registro SEMI-COVID-19 de la Sociedad Española de Medicina Interna. Se utilizó la escala de fragilidad Clínica (CFS, por sus siglas en inglés) para evaluar la fragilidad. El resultado primario fue la supervivencia hospitalaria. Se realizó un modelo de riesgos proporcionales de Cox para evaluar los predictores de supervivencia. Resultados Se incluyeron 1.878 participantes (52% varones y 48% mujeres). Mil trescientos cincuenta y un supervivientes (71,9%) y 527 no supervivientes (28,1%). El grupo de no supervivientes presentaba en comparación con los supervivientes una media de edad superior (83,5 frente a 81 años), más comorbilidades (6,3 frente a 5,3 puntos en el índice de Charlson), mayor grado de dependencia (26,8 frente al 12,4% de pacientes con dependencia severa) y de fragilidad (34,5 frente al 14,7% de pacientes con fragilidad severa), sin embargo, no hubo diferencias en cuanto al sexo. Nuestros resultados muestran que un grado de fragilidad moderado-grave es el principal factor asociado de forma independiente con una menor supervivencia (HR: 2,344; 1,437-3,823; p<0,001 para SFC 5-6 y HR: 3,694; 2,155-6,330; p<0,001 para SFC 7-9. Conclusiones La fragilidad es el principal predictor de resultados adversos en pacientes mayores con COVID-19. El uso de herramientas como la CFS es fundamental para la detección precoz de fragilidad en esta población (AU)

Background Emerging evidence suggests that frailty may be a significant predictor of poor outcomes in older individuals hospitalized due to COVID-19. This study aims to determine the prognostic value of frailty on intrahospital patient survival. Methods This observational, multicenter, nationwide study included patients aged 70 years and older who were hospitalized due to COVID-19 in Spain between March 1 and December 31, 2020. Patient data were obtained from the SEMI-COVID-19 Registry of the Spanish Society of Internal Medicine. Frailty was assessed using the Clinical Frailty Scale. The primary outcome was hospital survival. Cox proportional hazards models were used to assess predictors of survival. Results A total of 1878 participants (52% men and 48% women) were included, with 1351 (71.9%) survivors and 527 (28.1%) non-survivors. The non-survivor group had higher mean age (83.5 vs. 81 years), comorbidities (6.3 vs. 5.3 points on the Charlson index), degree of dependency (26.8% vs. 12.4% severely dependent patients), and frailty (34.5% vs. 14.7% severely frail patients) compared to survivors. However, there were no differences in terms of sex. Our results demonstrate that a moderate–severe degree of frailty is the primary factor independently associated with shorter survival (HR 2.344; 1.437-3.823; p < 0.001 for CFS 5-6 and 3.694; 2.155–6.330; p < 0.001 for CFS 7-9). Conclusion Frailty is the main predictor of adverse outcomes in older patients with COVID-19. The utilization of tools such as the Clinical Frailty Scale is crucial for early detection in this population (AU)

The impact of frailty on intra-hospital survival in older patients with COVID-19 infection: the importance of early identification. SEMI-COVID National Registry.

BACKGROUND: Emerging evidence suggests that frailty may be a significant predictor of poor outcomes in older individuals hospitalized due to COVID-19. This study aims to determine the prognostic value of frailty on intrahospital patient survival. METHODS: This observational, multicenter, nationwide study included patients aged 70 years and older who were hospitalized due to COVID-19 in Spain between March 1 and December 31, 2020. Patient data were obtained from the SEMI-COVID-19 Registry of the Spanish Society of Internal Medicine. Frailty was assessed using the Clinical Frailty Scale. The primary outcome was hospital survival. Cox proportional hazards models were used to assess predictors of survival. RESULTS: A total of 1,878 participants (52% men and 48% women) were included, with 1,351 (71.9%) survivors and 527 (28.1%) non-survivors. The non-survivor group had higher mean age (83.5 vs. 81 years), comorbidities (6.3 vs. 5.3 points on the Charlson index), degree of dependency (26.8% vs. 12.4% severely dependent patients), and frailty (34.5% vs. 14.7% severely frail patients) compared to survivors. However, there were no differences in terms of sex. Our results demonstrate that a moderate-severe degree of frailty is the primary factor independently associated with shorter survival [HR 2.344 (1.437-3.823; p<0.001) for CFS 5-6 and 3.694 (2.155-6.330; p<0.001) for CFS 7-9]. CONCLUSION: Frailty is the main predictor of adverse outcomes in older patients with COVID-19. The utilization of tools such as the Clinical Frailty Scale is crucial for early detection in this population.

RECALMIN IV. Evolución de la actividad de las unidades de medicina interna del Sistema Nacional de Salud (2008-2021) / RECALMIN IV. Evolution in the activity of internal medicine units of the National Health System (2008-2021)

Objetivos Analizar la estructura, la actividad y los resultados de los servicios y unidades de medicina interna (UMI) del Sistema Nacional de Salud (SNS). Analizar los retos para la especialidad y realizar propuestas de políticas de mejora. Comparar los resultados de la encuesta RECALMIN 2021 con las anteriores oleadas de encuestas a las UMI (2008, 2015, 2017, 2019). Material y métodos Estudio descriptivo transversal entre las UMI en hospitales generales de agudos del SNS con datos referidos a 2020, comparándolos con los anteriores estudios. Las variables de estudio fueron recogidas mediante un cuestionario ad hoc. Resultados Entre 2014 y 2020 aumentó la frecuentación hospitalaria y las altas dadas por las UMI (promedio anual de 4 y 3,8%, respectivamente), así como las tasas interconsultas hospitalarias y primeras consultas (promedio anual: 2,1% en ambos casos). En 2020 aumentaron notablemente las consultas no presenciales. La mortalidad ajustada por riesgo y la estancia hospitalaria no mostraron cambios significativos en 2013-2020. Los progresos en la implantación de buenas prácticas y de una atención sistemática al paciente crónico complejo fueron escasos. Una constante en las encuestas RECALMIN es la variabilidad entre UMI en recursos y actividad, sin encontrarse diferencias estadísticamente significativas en relación con los resultados. Conclusiones Existe un notable margen de mejora en el funcionamiento de las UMI. La reducción de la variabilidad no justificada en la práctica clínica y las desigualdades en los resultados en salud deben ser un reto para los responsables de las UMI y para la Sociedad Española de Medicina Interna (AU)

Aims This work aims to analyze the structure, activity, and outcomes of internal medicine units and departments (IMU) of the Spanish National Health System (SNHS) and to analyze the challenges for the specialty and propose policies for improvement. It also aims to compare the results from the 2021 RECALMIN survey with IMU surveys from previous years (2008, 2015, 2017, 2019). Methods This work is a cross-sectional, descriptive study of IMUs in acute care general hospitals of the SNHS that compares data from 2020 with previous studies. The study variables were collected through an ad hoc questionnaire. Results Between 2014 and 2020, hospital occupancy and discharges by IMU increased (annual mean of 4% and 3.8%, respectively), as did hospital cross-consultation and initial consultation rates (2.1% in both cases). E-consultations increased notably in 2020. Risk-adjusted mortality and length of hospital stay did not show significant changes from 2013-2020. Progress in the implementation of good practices and systematic care for complex chronic patients was limited. A consistent finding in RECALMIN surveys was the variability among IMUs in terms of resources and activity, though no statistically significant differences were found in regard to outcomes. Conclusions There is considerable room for improvement in the operation of IMUs. The reduction in unjustified variability in clinical practice and inequities in health outcomes are a challenge for IMU managers and the Spanish Society of Internal Medicine (AU)

RECALMIN IV. Evolution in the activity of internal medicine units of the National Health System (2008-2021).

AIMS: This work aims to analyze the structure, activity, and outcomes of internal medicine units and departments (IMU) of the Spanish National Health System (SNHS) and to analyze the challenges for the specialty and propose policies for improvement. It also aims to compare the results from the 2021 RECALMIN survey with IMU surveys from previous years (2008, 2015, 2017, 2019). METHODS: This work is a cross-sectional, descriptive study of IMUs in acute care general hospitals of the SNHS that compares data from 2020 with previous studies. The study variables were collected through an ad hoc questionnaire. RESULTS: Between 2014 and 2020, hospital occupancy and discharges by IMU increased (annual mean of 4% and 3.8%, respectively), as did hospital cross-consultation and initial consultation rates (2.1% in both cases). E-consultations increased notably in 2020. Risk-adjusted mortality and length of hospital stay did not show significant changes from 2013-2020. Progress in the implementation of good practices and systematic care for complex chronic patients was limited. A consistent finding in RECALMIN surveys was the variability among IMUs in terms of resources and activity, though no statistically significant differences were found in regard to outcomes. CONCLUSIONS: There is considerable room for improvement in the operation of IMUs. The reduction in unjustified variability in clinical practice and inequities in health outcomes are a challenge for IMU managers and the Spanish Society of Internal Medicine.

Usefulness of ultrasound-guided core biopsy in thyroid nodules with inconclusive fine-needle aspiration biopsy findings.

OBJECTIVES: To determine the diagnostic performance of ultrasound-guided core-needle biopsy in thyroid nodules after two inconclusive fine-needle aspiration biopsies. To assess the complications of core-needle biopsy. To analyze the reliability of diagnoses obtained with core-needle biopsy. To measure the economic impact of avoiding lobectomies in patients with benign core-needle biopsy findings. MATERIAL AND METHODS: This retrospective study reviewed 195 core-needle biopsies in 178 patients. To determine the reliability of the core-needle biopsy findings, we compared the diagnosis from the core-needle specimen versus the histologic findings in the surgical specimens when core-needle biopsy findings indicated malignancy or follicular proliferation and versus the stability of the nodule on ultrasound follow-up for one year when core-biopsy findings indicated benignity. RESULTS: Core-needle biopsy yielded a diagnosis for 179 (91.7%) nodules, of which 122 (62.5%) were classified as benign, 50 (25.6%) as follicular proliferation, and 7 (3.6%) as malignant. The findings were inconclusive for 16 (8.3%) nodules. Minor complications were observed in 4 (2%) patients; no major complications were observed. The sensitivity of core-needle biopsy for the diagnosis of thyroid cancer was low (42.8%) because the technique was unable to detect capsular or vascular invasion, although the specificity and positive predictive value (PPV) were 100%. However, when we considered histologic findings of malignancy and follicular proliferation positive because both require surgical resection, the sensitivity increased to 97.5% and the PPV decreased to 83.3%. There were 79 nodules with ultrasound follow-up for at least one year; 76 (96.2%) had negative core-needle biopsy findings, and 74 (97.3%) of these remained stable. The negative predictive value (NPV) for malignancy of the benign nodules was 98.6%, although no malignant transformation was observed. Nevertheless, the results of the statistical analysis do not allow us to recommend forgoing ultrasound follow-up in patients with benign core-biopsy findings. The cost savings of avoiding lobectomy in patients with benign nodules and stability of the nodule on ultrasound follow-up for at least one year was about 90%. CONCLUSIONS: Core-needle biopsy of thyroid nodules is effective because it diagnoses more than 90% of nodules with inconclusive findings after fine-needle aspiration biopsy. It is safe if done by experienced professionals. It is reliable because it yields 100% specificity and 100% PPV for malignant nodule, 97.5% sensitivity for the detection of nodules that require surgery, and 98.6% NPV for benign nodules. It is efficient because it reduces the costs of diagnosis compared to lobectomy in benign nodules.

Utilidad de la biopsia con aguja gruesa ecoguiada en nódulos tiroideos con punción aspirativa con aguja fina no diagnóstica / Usefulness of ultrasound-guided core biopsy in thyroid nodules with inconclusive fine-needle aspiration biopsy findings

Objetivos: Conocer el rendimiento diagnóstico de la biopsia con aguja gruesa (BAG) ecoguiada en nódulos tiroideos con dos punciones aspirativas con aguja fina (PAAF) previas no diagnósticas. Evaluar complicaciones de la BAG. Analizar la fiabilidad de los diagnósticos obtenidos mediante BAG. Medir el impacto económico de evitar lobectomía tras BAG con resultado benigno. Material y métodos: Revisión retrospectiva de 195 BAG realizadas en 178 pacientes. Las referencias utilizadas para medir la fiabilidad de los resultados de la BAG fueron el análisis de la pieza quirúrgica tras una biopsia con malignidad o proliferación folicular (PF) y la estabilidad ecográfica superior a 1 año tras una BAG benigna. Se compararon costes directos de BAG más seguimiento ecográfico frente al que hubiera tenido realizar lobectomía sin complicaciones en los pacientes con estabilidad ecográfica superior a 1 año tras BAG benigna. Resultados: De los 195 nódulos sometidos a BAG, el resultado fue diagnóstico en 179 (91,7%), incluyendo 122 benignos (62,5%), 50 PF (25,6%) y 7 malignos (3,6%). No fue diagnóstico en 16 nódulos (8,3%). Hubo complicaciones menores en 4 pacientes (2%) y mayores en ninguno. La sensibilidad de la BAG para el diagnóstico de cáncer de tiroides fue baja (42,8%) por su incapacidad para detectar invasión capsular o vascular, aunque con especificidad y valor predictivo positivo (VPP) del 100%. Al considerar los diagnósticos de malignidad y PF como positivos, pues ambos obligan a resección quirúrgica, la sensibilidad ascendió al 97,5%, con descenso al 83,3% del VPP. Hubo 79 nódulos con seguimiento ecográfico superior a 1 año, 76 con BAG benigna (96,2%), de los cuales mostraron estabilidad 74 (97,3%). El valor predictivo negativo (VPN) para malignidad de los nódulos benignos fue del 98,6%, aunque no se detectó ninguna transformación maligna. Sin embargo, el análisis estadístico no permite recomendar la supresión del seguimiento ecográfico tras BAG benigna.(AU)

Objectives: To determine the diagnostic performance of ultrasound-guided core-needle biopsy in thyroid nodules after two inconclusive fine-needle aspiration biopsies. To assess the complications of core-needle biopsy. To analyze the reliability of diagnoses obtained with core-needle biopsy. To measure the economic impact of avoiding lobectomies in patients with benign core-needle biopsy findings. Material and methods: This retrospective study reviewed 195 core-needle biopsies in 178 patients. To determine the reliability of the core-needle biopsy findings, we compared the diagnosis from the core-needle specimen versus the histologic findings in the surgical specimens when core-needle biopsy findings indicated malignancy or follicular proliferation and versus the stability of the nodule on ultrasound follow-up for one year when core-biopsy findings indicated benignity. Results: Core-needle biopsy yielded a diagnosis for 179 (91.7%) nodules, of which 122 (62.5%) were classified as benign, 50 (25.6%) as follicular proliferation, and 7 (3.6%) as malignant. The findings were inconclusive for 16 (8.3%) nodules. Minor complications were observed in 4 (2%) patients; no major complications were observed. The sensitivity of core-needle biopsy for the diagnosis of thyroid cancer was low (42.8%) because the technique was unable to detect capsular or vascular invasion, although the specificity and positive predictive value (PPV) were 100%. However, when we considered histologic findings of malignancy and follicular proliferation positive because both require surgical resection, the sensitivity increased to 97.5% and the PPV decreased to 83.3%. There were 79 nodules with ultrasound follow-up for at least one year; 76 (96.2%) had negative core-needle biopsy findings, and 74 (97.3%) of these remained stable. The negative predictive value (NPV) for malignancy of the benign nodules was 98.6%, although no malignant transformation was observed.(AU)

The value of telephone consultations during COVID-19 pandemic. An observational study.

BACKGROUND: Many Spanish hospitals converted scheduled in-person visits to telephone visits during the COVID-19 lockdown. There is scarce information about the performance of those visits. AIM: To compare telephone visits during the COVID-19 lockdown period with previous in-person visits. DESIGN: Retrospective descriptive study. METHODS: Telephone visits from 15 March to 31 May 2020 were compared with in-person visits during the same period in 2019. MAIN MEASURES: The proportions of both groups were compared in term of failure to contact patient, requested diagnostic tests/referrals, discharges, admissions and emergency visits within 30-60 days. A sample of patients, and all participating physicians completed surveys. Z-score test was used (statistical significance P<0.05). RESULTS: A total of 5602 telephone visits were conducted. In comparison to in-person visits, telephone visits showed higher rates of visit compliance (95.9% vs. 85.2%, P<0.001) and discharges (22.12% vs. 11.82%; P<0.001), and lower number of ancillary tests and referrals. During the 30- and 60-day periods following the telephone visit, a reduction of 52% and 47% in the combined number of emergency department visits and hospital admissions was observed compared to in-person visits (P<0.01). Of the 120 patients surveyed, 95% were satisfied/very satisfied with the telephone visits. Of the 26 physicians, 84.6% considered telephone visits were useful to prioritize patients. CONCLUSIONS: During health emergencies, previously scheduled outpatient in-person visits can be converted to telephone visits, reducing absenteeism, increasing the rate of discharges and reducing ancillary tests and referrals without increasing the rate of hospital admissions or emergency department visits.

Usefulness of ultrasound-guided core biopsy in thyroid nodules with inconclusive fine-needle aspiration biopsy findings. / Utilidad de la biopsia con aguja gruesa ecoguiada en nódulos tiroideos con punción aspirativa con aguja fina no diagnóstica.

OBJECTIVES: To determine the diagnostic performance of ultrasound-guided core-needle biopsy in thyroid nodules after two inconclusive fine-needle aspiration biopsies. To assess the complications of core-needle biopsy. To analyze the reliability of diagnoses obtained with core-needle biopsy. To measure the economic impact of avoiding lobectomies in patients with benign core-needle biopsy findings. MATERIAL AND METHODS: This retrospective study reviewed 195 core-needle biopsies in 178 patients. To determine the reliability of the core-needle biopsy findings, we compared the diagnosis from the core-needle specimen versus the histologic findings in the surgical specimens when core-needle biopsy findings indicated malignancy or follicular proliferation and versus the stability of the nodule on ultrasound follow-up for one year when core-biopsy findings indicated benignity. RESULTS: Core-needle biopsy yielded a diagnosis for 179 (91.7%) nodules, of which 122 (62.5%) were classified as benign, 50 (25.6%) as follicular proliferation, and 7 (3.6%) as malignant. The findings were inconclusive for 16 (8.3%) nodules. Minor complications were observed in 4 (2%) patients; no major complications were observed. The sensitivity of core-needle biopsy for the diagnosis of thyroid cancer was low (42.8%) because the technique was unable to detect capsular or vascular invasion, although the specificity and positive predictive value (PPV) were 100%. However, when we considered histologic findings of malignancy and follicular proliferation positive because both require surgical resection, the sensitivity increased to 97.5% and the PPV decreased to 83.3%. There were 79 nodules with ultrasound follow-up for at least one year; 76 (96.2%) had negative core-needle biopsy findings, and 74 (97.3%) of these remained stable. The negative predictive value (NPV) for malignancy of the benign nodules was 98.6%, although no malignant transformation was observed. Nevertheless, the results of the statistical analysis do not allow us to recommend forgoing ultrasound follow-up in patients with benign core-biopsy findings. The cost savings of avoiding lobectomy in patients with benign nodules and stability of the nodule on ultrasound follow-up for at least one year was about 90%. CONCLUSIONS: Core-needle biopsy of thyroid nodules is effective because it diagnoses more than 90% of nodules with inconclusive findings after fine-needle aspiration biopsy. It is safe if done by experienced professionals. It is reliable because it yields 100% specificity and 100% PPV for malignant nodule, 97.5% sensitivity for the detection of nodules that require surgery, and 98.6% NPV for benign nodules. It is efficient because it reduces the costs of diagnosis compared to lobectomy in benign nodules.

Validation of the PROFUND index to predict early post-hospital discharge mortality.

BACKGROUND: The PROFUND index (PI) is a prognostic scale for polypathological patients at 12 months. The objective of the study was to validate the PI as a predictor of 1-year mortality in a current cohort of polypathological patients and analyse its prognostic usefulness in the short-term (1 month and 3 months) after discharge from Internal Medicine. DESIGN: We conducted a prospective observational study and all polypathological patients discharged from an Internal Medicine Department between 01 March 2016 and 28 February 2017 were enrolled. METHODS: The variables recorded for each patient were age, sex, diseases and diagnostic categories defining patients as polypathological patients, PI at discharge, number of hospital admissions, length of stay, vital status at 1 year, and date and place of death if applicable. Follow-up lasted 1 year from the time of enrolment. RESULTS: Six hundred and ten polypathological patients were enrolled. Mortality was 41% and the patients who died were older, their length of stay was longer and their PI was higher compared with those who survived. The discrimination of the PI for predicting mortality was good, with a C-statistic of 0.718 [95% confidence interval (CI) 0.67-0.76]. In addition, a subgroup of patients with early mortality after discharge was identified, with a C-statistic of 0.74 (95% CI 0.67-0.80) at 30 days and 0.73 (95% CI 0.68-0.78) at 90 days. CONCLUSIONS: The PI is a valid tool for predicting early and 1-year mortality in polypathological patients after discharge from Internal Medicine.

Analysis of patients shared in consultations of internal medicine and other medical specialties. / Análisis de pacientes compartidos en consultas de medicina interna y otras especialidades médicas.

BACKGROUND AND OBJECTIVE: The aging population is resulting in an increasing number of patients with multiple diseases that require treatment by various specialties. We examined the evolution of consultations and of the percentage of patients treated by several medical specialties. METHODS: We analysed internal medicine (IM) consultations and those of other medical specialties in a hospital during 1997, 2007 and 2017 for the general population and for those older than 65 years. RESULTS: Over the course of 20 years, the rate of first IM consultations per 1000 inhabitants increased 44%, and that of other medical specialties increased 137%. The percentage of patients seen by more than one specialty went from 13.8% in 1997 to 32.6% in 2017 and reached 45.5% for those older than 65 years. CONCLUSIONS: The care for populations with growing comorbidity has a major impact on health systems and requires organisational changes for their care.

Care models for polypathological patients. / Modelos de atención al paciente pluripatológico.

Polypathological patients have specific clinical, functional, psychoaffective, social, family and spiritual characteristics. These patients are generally elderly and frail and have frequent decompensations. They frequently use healthcare resources, have significant functional impairment and have a high index of dependence. This results in a significant social impact, high mortality and a high consumption of resources. The current healthcare models have not answered these needs, which causes problems with accessibility to healthcare services, a lack of coordination among these services, a higher probability of adverse events related to polypharmacy and a high consumption of resources. In the past decade, the healthcare models have changed and are characterized by work in multidisciplinary and interlevel teams, patient self-care, the availability of tools for decision making, information and communication systems and prevention. The goal is to have prepared and proactive health teams and an informed and active patient population. The assessment of health results, processes and the costs for these programs is still based on moderate to low evidence. It is therefore not an easy task to determine the type and intensity of interventions or to determine the patient groups that could gain more benefits.

Supervivencia a largo plazo del ictus isquémico / Long-term survival of ischemic stroke

Objetivo. El ictus isquémico es una enfermedad vascular grave, cuyo pronóstico a largo plazo no conocemos en toda su dimensión. Hemos estudiado la supervivencia a largo plazo y sus factores pronósticos tras un primer episodio de ictus agudo de origen isquémico (cardioembólico y aterotrombótico). Pacientes y métodos. Estudio de cohortes retrospectivo de pacientes que han requerido ingreso por un primer episodio de ictus isquémico. El ictus se clasificó en aterotrombótico, cardioembólico, lacunar e indeterminado. Los enfermos fueron seguidos durante 10 años. Resultados. Se incluyeron 415 pacientes (varones: 60%), con una edad media de 68,4 años. La media de seguimiento fue de 66 meses (IC del 95%: 24-108 meses). La supervivencia global a los 10 años fue del 55,4% (54,9-55,9) (aterotrombótico, 57,5% vs cardioembólico, 43,7%; p=0,002). En el análisis multivariante las variables relacionadas con la mortalidad fueron la mayor edad, presencia de insuficiencia renal crónica, dislipemia, antecedentes de insuficiencia cardiaca, fibrilación auricular, presentación con hemiplejía, y los signos de isquemia aguda y de edema perilesional en el TAC realizado en el ingreso hospitalario. Se asociaron a un mejor pronóstico la afectación del territorio de la arteria cerebral media derecha y el tratamiento con estatinas. Conclusiones. La supervivencia tras un ictus isquémico a los 10 años es algo superior al 40%, y tiene mejor pronóstico el ictus aterotrombótico que el cardioembólico(AU)

Objective. Ischemic stroke is a serious vascular disease whose long term prognosis in all of its dimensions is not known. We have studied the long-term survival and its predictors after a first episode of acute ischemic stroke (atherothrombotic and cardioembolic). Patients and methods. A retrospective cohort study was made of patients with a first episode of ischemic stroke. The ictus was classified into atherothrombotic, cardioembolic, lacunar and undetermined. Patients were followed up for 10 years. Results. A total of 415 cases (60% men) with mean age of 68.4 years, were included. Mean follow-up was 66 months (95% CI: 24-108 months). Overall survival at 10 years was 55.4% (54.9-55.9) (atherothrombotic, 57.7% vs cardioembolic, 43.7%, P=.002). In the multivariate analysis, variables related to mortality in acute ischemic stroke were age, chronic renal failure, dyslipidemia, history of heart failure, atrial fibrillation (AF), presenting as hemiplegia, signs of acute ischemia and perilesional edema in the brain scan on hospital admission. Involvement of the territory of right middle cerebral artery and treatment with statins were associated to a better prognosis. Conclusions. Survival of patients after ischemic stroke at ten year is over 40%, and atherothrombotic stroke as a better prognosis than cardioembolic one(AU)

[Long-term survival of ischemic stroke]. / Supervivencia a largo plazo del ictus isquémico.

OBJECTIVE: Ischemic stroke is a serious vascular disease whose long term prognosis in all of its dimensions is not known. We have studied the long-term survival and its predictors after a first episode of acute ischemic stroke (atherothrombotic and cardioembolic). PATIENTS AND METHODS: A retrospective cohort study was made of patients with a first episode of ischemic stroke. The ictus was classified into atherothrombotic, cardioembolic, lacunar and undetermined. Patients were followed up for 10 years. RESULTS: A total of 415 cases (60% men) with mean age of 68.4 years, were included. Mean follow-up was 66 months (95% CI: 24-108 months). Overall survival at 10 years was 55.4% (54.9-55.9) (atherothrombotic, 57.7% vs cardioembolic, 43.7%, P=.002). In the multivariate analysis, variables related to mortality in acute ischemic stroke were age, chronic renal failure, dyslipidemia, history of heart failure, atrial fibrillation (AF), presenting as hemiplegia, signs of acute ischemia and perilesional edema in the brain scan on hospital admission. Involvement of the territory of right middle cerebral artery and treatment with statins were associated to a better prognosis. CONCLUSIONS: Survival of patients after ischemic stroke at ten year is over 40%, and atherothrombotic stroke as a better prognosis than cardioembolic one.

Tifus murino como causa de fiebre de duración intermedia / No disponible

No disponible

[Priority of prescribed medication in patients with heart failure in an Internal Medicine Department]. / Prioridad de las prescripciones farmacéuticas a pacientes con insuficiencia cardíaca en un Servicio de Medicina Interna.

BACKGROUND AND OBJECTIVE: Prescriptions provided to elderly patients with comorbidity on hospital discharge are usually complex. This study has aimed to know what proportion of drugs is considered essential by the prescribing doctors and the existing agreement on this qualification. METHODS: Cross-sectional study. SETTING: general acute care hospital. STUDY SUBJECTS: random sample of 60 hospital discharges in patients hospitalized due to heart failure between 2004 to 2006 with 540 prescribed drugs. INTERVENTIONS: independent review by two internal medicine specialists and qualification of each of prescribed drugs as essential, advisable or not indicated. Calculation of the proportion of prescriptions according to priority, global and by therapeutic groups, and of the agreement between reviewers. RESULTS: An average of 9 drugs (statistical deviation [SD] 2.4) and 13.5 daily takings (SD 4.6) by patient were prescribed on hospital discharge. The reviewers considered 68.4% of the prescriptions essential (95% confidence interval [CI], 65.5-71.2), advisable 25% (95% CI, 22.4-27.6) and not indicated 6.6% (95% CI, 5.1-8.1). An inverse relation between number of prescribed drugs and their proportion considered as essential was observed. Global agreement between reviewers in the classification of priority was relatively low: weighed Kappa 0.27 (95% CI, 0.19-0.36). More than 90% of the prescriptions were considered as essential in only 6 of the 15 therapeutic groups prescribed most, and good agreements in the qualification of their priority was only reached in 3 groups. CONCLUSIONS: A considerable proportion of the prescribed medication on hospital discharge in patients with heart failure was not considered essential. Agreement reached between the reviewers in this qualification was low.

[Characteristics of patients with multiple disease hospitalized in Internal Medicine services]. / Características clínicas diferenciales de los enfermos pluripatológicos hospitalizadosen servicios de Medicina Interna.

INTRODUCTION: Know what proportion of patients hospitalized in the Internal Medicine services have multiple diseases. MATERIAL AND METHODS: We analyzed 400 clinical histories of a random sample of patients admitted to 24 Internal Medicine services of Andalusia. We assessed the diagnostic categories present that make it possible to classify patients as having multiple diseases. RESULTS: One hundred sixty eight patients (42%) were considered as having multiple diseases. The most prevalent diseases in these patients are cardiological and diabetes mellitus. The two main variables that determine that one is a multiple disease patient are age and disease causing the admission. DISCUSSION: A significant percentage of the patients admitted to the Medicine services of the Andalusia public hospitals have multiple diseases.

[The practice of Internal Medicine in Andalusia follows the evidence-based medicine basic principles]. / La práctica de la Medicina interna en Andalucía se ajusta a la Medicina basada en la evidencia.

BASIS: To know the proportion of medical interventions carried out in the Services of Internal Medicine of the public hospitals of Andalusia based on randomized clinical trials. PATIENTS AND METHODS: We have analyzed the primary treatments prescribed in a random sample of 326 patients admitted to these Internal Medicine services during 1998. RESULTS: One hundred and forty-three of the 326 treatments analyzed (43.9%) were based in clinical trials and 135 (41.4%) were interventions unanimously accepted by the medical community without being based in clinical trials. CONCLUSIONS: Most of the primary Andalusian treatments prescribed in the Internal Medicine services are evidence-based.