Fortalezas sistémicas y necesidades en atención paliativa domiciliaria: explorando la complejidad / Systemic strengths and needs in palliative home care: exploring complexity

Objetivo Nos proponemos investigar la relación entre las fortalezas sistémicas y el lugar de muerte en atención domiciliaria de pacientes en final de vida. Método Estudio cuantitativo descriptivo longitudinal de pacientes atendidos por un equipo domiciliario de cuidados paliativos. Se analizó la ubicación de la muerte en relación con la complejidad detectada tras la primera valoración domiciliaria usando el modelo de complejidad HexCom. Para la comparación de proporciones utilizamos la prueba de ji cuadrado de Pearson. Resultados Participaron 464 pacientes (74,4% oncológicos), edad media 76,2años (DE: 13,2). El 53% presentaban dependencia funcional total o severa, el 30,8% estaban ya encamados en la primera valoración y el 59,7% fallecieron en domicilio. Las fortalezas influyen en el lugar de muerte, sobre todo la fortaleza del exosistema (equipo) (OR: 4,07 [1,92-8,63]), la del microsistema (tanto la fortaleza del paciente (0,51 [0,28-0,94]) como de cuidador (OR: 3,90 [1,48-10,25]), y la del cronosistema, relativo a la previsión de un curso progresivo (OR: 2,22 [1,37-3,60]). Conclusiones Para mejorar la asistencia a los pacientes en situación de final de vida y sus familias es necesaria una mirada sistémica del morir y de la muerte que incluya tanto necesidades como fortalezas. En este sentido, el marco sistémico propuesto por Bonfrenbrenner puede ser de utilidad para la práctica clínica. (AU)

Objective We aimed to investigate the relationship between systemic strengths and complexity in home care of end-of-life patients. Methods Quantitative descriptive longitudinal study of patients cared for at home by a palliative care team. Place of death was analyzed in relation to complexity, as determined by the HexCom complexity model after the initial home assessment. We used Pearson's chi-square test to analyze the comparison of proportions. Results Forty-six hundred patients (74.4% oncologic) with a mean age of 76.2years (SD 13.2) participated. Fifty-three percent had complete or severe functional dependence, 30.8% were already bedridden in the first assessment, and 59.7% died at home. Strengths influenced place of death, specifically exosystem (team) strength (OR: 4.07 [1.92-8.63]), microsystem (both patient 0.51 [0.28-0.94]) and caregiver (OR: 3.90 [1.48-10.25]), and chronosystem, related to prediction of progressive course (OR: 2.22 [1.37-3.60]). Conclusions To improve care for end-of-life patients and their families, a systemic view of dying and death that includes both needs and strengths is necessary. In this sense, the systemic framework proposed by Bonfrenbrenner can be useful for clinical practice. (AU)

Fortalezas sistémicas y necesidades en atención paliativa domiciliaria: explorando la complejidad / Systemic strengths and needs in palliative home care: exploring complexity

Objetivo Nos proponemos investigar la relación entre las fortalezas sistémicas y el lugar de muerte en atención domiciliaria de pacientes en final de vida. Método Estudio cuantitativo descriptivo longitudinal de pacientes atendidos por un equipo domiciliario de cuidados paliativos. Se analizó la ubicación de la muerte en relación con la complejidad detectada tras la primera valoración domiciliaria usando el modelo de complejidad HexCom. Para la comparación de proporciones utilizamos la prueba de ji cuadrado de Pearson. Resultados Participaron 464 pacientes (74,4% oncológicos), edad media 76,2años (DE: 13,2). El 53% presentaban dependencia funcional total o severa, el 30,8% estaban ya encamados en la primera valoración y el 59,7% fallecieron en domicilio. Las fortalezas influyen en el lugar de muerte, sobre todo la fortaleza del exosistema (equipo) (OR: 4,07 [1,92-8,63]), la del microsistema (tanto la fortaleza del paciente (0,51 [0,28-0,94]) como de cuidador (OR: 3,90 [1,48-10,25]), y la del cronosistema, relativo a la previsión de un curso progresivo (OR: 2,22 [1,37-3,60]). Conclusiones Para mejorar la asistencia a los pacientes en situación de final de vida y sus familias es necesaria una mirada sistémica del morir y de la muerte que incluya tanto necesidades como fortalezas. En este sentido, el marco sistémico propuesto por Bonfrenbrenner puede ser de utilidad para la práctica clínica. (AU)

Objective We aimed to investigate the relationship between systemic strengths and complexity in home care of end-of-life patients. Methods Quantitative descriptive longitudinal study of patients cared for at home by a palliative care team. Place of death was analyzed in relation to complexity, as determined by the HexCom complexity model after the initial home assessment. We used Pearson's chi-square test to analyze the comparison of proportions. Results Forty-six hundred patients (74.4% oncologic) with a mean age of 76.2years (SD 13.2) participated. Fifty-three percent had complete or severe functional dependence, 30.8% were already bedridden in the first assessment, and 59.7% died at home. Strengths influenced place of death, specifically exosystem (team) strength (OR: 4.07 [1.92-8.63]), microsystem (both patient 0.51 [0.28-0.94]) and caregiver (OR: 3.90 [1.48-10.25]), and chronosystem, related to prediction of progressive course (OR: 2.22 [1.37-3.60]). Conclusions To improve care for end-of-life patients and their families, a systemic view of dying and death that includes both needs and strengths is necessary. In this sense, the systemic framework proposed by Bonfrenbrenner can be useful for clinical practice. (AU)

Systemic strengths and needs in palliative home care: exploring complexity.

OBJECTIVE: We aimed to investigate the relationship between systemic strengths and complexity in home care of end-of-life patients. METHODS: Quantitative descriptive longitudinal study of patients cared for at home by a palliative care team. Place of death was analyzed in relation to complexity, as determined by the HexCom complexity model after the initial home assessment. We used Pearson's chi-square test to analyze the comparison of proportions. RESULTS: Forty-six hundred patients (74.4% oncologic) with a mean age of 76.2 years (SD 13.2) participated. Fifty-three percent had complete or severe functional dependence, 30.8% were already bedridden in the first assessment, and 59.7% died at home. Strengths influenced place of death, specifically exosystem (team) strength (OR: 4.07 [1.92-8.63]), microsystem (both patient 0.51 [0.28-0.94]) and caregiver (OR: 3.90 [1.48-10.25]), and chronosystem, related to prediction of progressive course (OR: 2.22 [1.37-3.60]). CONCLUSIONS: To improve care for end-of-life patients and their families, a systemic view of dying and death that includes both needs and strengths is necessary. In this sense, the systemic framework proposed by Bonfrenbrenner can be useful for clinical practice.

Tipología de las heridas atendidas en atención primaria: estudio transversal multicéntrico / Typology of wounds treated in primary care: Multicenter cross-sectional study

Introducción La atención a personas con heridas cutáneas es un importante problema de salud que afecta la calidad de vida de los pacientes y de su familia y tiene un gran impacto socioeconómico. Conocer la situación del problema es el primer paso para el planteamiento de diferentes abordajes sanitarios. En nuestro territorio, desde 2010 no se ha realizado ningún tipo de seguimiento sobre las heridas que tratamos, por lo que planteamos conocer la tipología y las características de las heridas activas en población asistida por atención primaria. Métodos Estudio descriptivo transversal multicéntrico realizado en una zona metropolitana de Cataluña en equipos de atención primaria y en residencias. Los participantes fueron todos los pacientes con heridas activas. Se utilizó un registro realizado por enfermeras referentes del paciente. Se realizó un análisis descriptivo de los datos. Resultados Participaron 1.978 personas, que presentaron 2.471 heridas. La prevalencia global fue del 0,22%. En pacientes domiciliarios la prevalencia fue del 3,58%, y en residencias, del 6,56%. El 46,5% fueron lesiones agudas y el 53,4% crónicas, con un tamaño medio de 3,13cm. De las heridas crónicas, 345 (26,2%) tenían una evolución superior a un año. Las lesiones más prevalentes fueron las úlceras venosas en los equipos de atención primaria y las lesiones por presión categoríaII en los centros residenciales. Conclusiones Los resultados de este estudio presentan una realidad objetiva sobre las lesiones que son atendidas en atención primaria, tanto en centros de atención primaria, en domicilio o en residencias, así como su descripción (AU)

Background The care of people with skin wounds is an important health problem, that affect the quality of life of patients and their families, and has a great socioeconomic impact. Knowing the situation of the problem is the first step for different health approaches. In our territory since 2010 no type of follow-up has been carried out on the wounds that we are treating, we propose to know the typology and characteristics of active wounds in the population assisted by Primary Care. Methods Multicenter cross-sectional descriptive study carried out in a metropolitan area of Catalonia in Primary Care Teams and residences. Participants were all patients with active wounds. A record made by the patient's referring nurses was used. A descriptive analysis of the data was performed. Results About 1,978 people participated, presenting 2,471 injuries. The overall prevalence was 0.22%. At home patients, the prevalence was 3.58% and in nursing homes, 6.56%. Of all the lesions, 46.5% were acute and 53.4% chronic, the mean size was 3.13cm. Of the chronic wounds, 345 (26.2%) had an evolution of more than 1year. The most prevalent injuries were venous ulcers in Primary Care Teams and categoryII pressure injuries in residential centers. Conclusions The results of this study present an objective reality about the injuries that are treated in primary care, both in Primary Care Centers, homes or residences, as well as their description (AU)

[Typology of wounds treated in primary care: Multicenter cross-sectional study]. / Tipología de las heridas atendidas en atención primaria: estudio transversal multicéntrico.

BACKGROUND: The care of people with skin wounds is an important health problem, that affect the quality of life of patients and their families, and has a great socioeconomic impact. Knowing the situation of the problem is the first step for different health approaches. In our territory since 2010 no type of follow-up has been carried out on the wounds that we are treating, we propose to know the typology and characteristics of active wounds in the population assisted by Primary Care. METHODS: Multicenter cross-sectional descriptive study carried out in a metropolitan area of Catalonia in Primary Care Teams and residences. Participants were all patients with active wounds. A record made by the patient's referring nurses was used. A descriptive analysis of the data was performed. RESULTS: About 1,978 people participated, presenting 2,471 injuries. The overall prevalence was 0.22%. At home patients, the prevalence was 3.58% and in nursing homes, 6.56%. Of all the lesions, 46.5% were acute and 53.4% chronic, the mean size was 3.13cm. Of the chronic wounds, 345 (26.2%) had an evolution of more than 1year. The most prevalent injuries were venous ulcers in Primary Care Teams and categoryII pressure injuries in residential centers. CONCLUSIONS: The results of this study present an objective reality about the injuries that are treated in primary care, both in Primary Care Centers, homes or residences, as well as their description.

Epidemiología de la anemia en adultos: estudio observacional de base poblacional / Epidemiology of anemia in adults: A population based study

Objetivo Determinar la prevalencia de la anemia y las características definitorias de los individuos que la padecen. Diseño Estudio observacional descriptivo de base poblacional. Variables extraídas de la base de datos informatizada de historias clínicas de atención primaria. Emplazamiento El presente estudio se realizó en la región sanitaria Metropolitana Nord, Barcelona. Participantes Pacientes con anemia evaluada mediante hemoglobina durante el año 2019. Criterios inclusión: mayores de 14 años, con determinaciones de hemoglobina por debajo del valor recomendado por la OMS. Criterio exclusión: no realizar seguimiento por la sanidad pública. Mediciones principales Variables demográficas, variables clínicas (fármacos, diagnóstico de anemia, paciente crónico complejo o enfermedad crónica avanzada. Variables consumo de recursos (número de visitas a atención primaria, número de ingresos hospitalarios y número de consultas a urgencias). Las variables demográficas y clínicas se evaluaron mediante frecuencias y porcentajes, media y desviación estándar para las variables cuantitativas. Las características de los diferentes subgrupos se compararon con la t de Student. Resultados La prevalencia de la anemia fue del 3,78%. Media de edad 64,5 años, el 60,8% mujeres. El 15,8% identificados como pacientes crónicos complejos. La hipertensión arterial presente en el 51,46%. El 50,97% fueron anemias ferropénicas. Consultaron al médico de familia 2,25 veces de media y a la enfermera de familia 1,49 veces. De las personas con criterios analíticos de anemia, solo el 46,57% tenían registrado un diagnóstico de anemia. Conclusiones En el territorio estudiado se ha objetivado un infraregistro del diagnóstico de anemia. Se observan diferencias en la caracterización por género y edad (AU)

Objective To determine the prevalence of anemia and the defining characteristics of the individuals who suffer from it. Design Population-based descriptive observational study. Variables extracted from the computerized database of primary care medical records. Setting This study was conducted in the Metropolitana Nord health region, Barcelona. Participants Patients with anemia evaluated by hemoglobin, during the year 2019. Inclusion criteria: older than 14 years, with hemoglobin determinations below the value recommended by the WHO. Exclusion criteria: no follow-up by public health. Main measurements Demographic variables, clinical variables (drugs, diagnosis of anemia, complex chronic patient or advanced chronic disease. Resource consumption variables (number of visits to primary care, number of hospital admissions, and number of visits to the emergency room). The variables demographic and clinical variables were evaluated using frequencies and percentages, mean and standard deviation for quantitative variables. The characteristics of the different subgroups were compared with Student's t-test. Results The prevalence of anemia was 3.78%. Mean age 64.5 years and 60.8% women. 15.8% identified as complex chronic patients. Arterial hypertension present in 51.46%. 50.97 were iron deficiency anemias. They consulted the family doctor 2.25 times on average and the family nurse 1.49. Of the people with analytical criteria for anemia, only 46.57 had a registered diagnosis of anemia. Conclusions In the territory studied, an under-reporting of the diagnosis of anemia has been observed. Differences are observed in the characterization by gender and age (AU)

[Epidemiology of anemia in adults: A population based study]. / Epidemiología de la anemia en adultos: estudio observacional de base poblacional.

OBJECTIVE: To determine the prevalence of anemia and the defining characteristics of the individuals who suffer from it. DESIGN: Population-based descriptive observational study. Variables extracted from the computerized database of primary care medical records. SETTING: This study was conducted in the Metropolitana Nord health region, Barcelona. PARTICIPANTS: Patients with anemia evaluated by hemoglobin, during the year 2019. INCLUSION CRITERIA: older than 14 years, with hemoglobin determinations below the value recommended by the WHO. EXCLUSION CRITERIA: no follow-up by public health. MAIN MEASUREMENTS: Demographic variables, clinical variables (drugs, diagnosis of anemia, complex chronic patient or advanced chronic disease. Resource consumption variables (number of visits to primary care, number of hospital admissions, and number of visits to the emergency room). The variables demographic and clinical variables were evaluated using frequencies and percentages, mean and standard deviation for quantitative variables. The characteristics of the different subgroups were compared with Student's t-test. RESULTS: The prevalence of anemia was 3.78%. Mean age 64.5 years and 60.8% women. 15.8% identified as complex chronic patients. Arterial hypertension present in 51.46%. 50.97 were iron deficiency anemias. They consulted the family doctor 2.25 times on average and the family nurse 1.49. Of the people with analytical criteria for anemia, only 46.57 had a registered diagnosis of anemia. CONCLUSIONS: In the territory studied, an under-reporting of the diagnosis of anemia has been observed. Differences are observed in the characterization by gender and age.

Medición semiautomática de la relación arteriovenosa retiniana como posible marcador de riesgo de infarto cerebral silente en pacientes hipertensos / Semi-automatic measuring of arteriovenous relation as a possible silent brain infarction risk index in hypertensive patients

PROPÓSITO: Evaluar la utilidad de un sistema semiautomático de medición de relación arteriovenosa (RAV) retiniana sobre imágenes retinográficas de pacientes hipertensos en la valoración del riesgo cardiovascular y la detección de isquemia cerebral silente (ICS). MÉTODO: Un total de 976 pacientes de la cohorte Investigating Silent Strokes in Hypertensives: a magnetic resonance imaging study (ISSYS) estudiados mediante resonancia magnética craneal para valorar la presencia o no de ICS fueron invitados a realizar una retinografía para un examen convencional de fondo de ojo y una medición semitautomática del promedio de los calibres vasculares para el cálculo de la relación arteriovenosa (RAV). RESULTADOS: Se analizaron las retinografías de 768 pacientes. Entre las lesiones observadas, solamente se encontró una asociación con la detección de ICS en aquellos pacientes con microaneurismas (OR: 2,50; IC 95%: 1,05-5,98) o una RAV alterada (<0,666) (OR: 4,22; IC 95%: 2,56-6,96). En el análisis de regresión logística multivariante ajustado por edad y sexo, solamente la RAV alterada continuó manifestándose como un factor de riesgo (OR: 3,70; IC 95%: 2,21-6,18). CONCLUSIONES: Los resultados muestran que el análisis semiautomático de la vasculatura retiniana a partir de retinografías tiene el potencial de ser considerado como un factor de riesgo vascular importante en la población hipertensa

OBJECTIVE: To evaluate the usefulness of a semiautomatic measuring system of arteriovenous relation (RAV) from retinographic images of hypertensive patients in assessing their cardiovascular risk and silent brain ischemia (ICS) detection. METHODS: Semi-automatic measurement of arterial and venous width were performed with the aid of Imedos software and conventional fundus examination from the analysis of retinal images belonging to the 976 patients integrated in the cohort Investigating Silent Strokes in Hypertensives: a magnetic resonance imaging study (ISSYS), group of hypertensive patients. All patients have been subjected to a cranial magnetic resonance imaging (RMN) to assess the presence or absence of brain silent infarct. RESULTS: Retinal images of 768 patients were studied. Among the clinical findings observed, association with ICS was only detected in patients with microaneurysms (OR 2.50; 95% CI: 1.05-5.98) or altered RAV (<0.666) (OR: 4.22; 95% CI: 2.56-6.96). In multivariate logistic regression analysis adjusted by age and sex, only altered RAV continued demonstrating as a risk factor (OR: 3.70; 95% CI: 2.21-6.18). CONCLUSIONS: The results show that the semiautomatic analysis of the retinal vasculature from retinal images has the potential to be considered as an important vascular risk factor in hypertensive population

Semi-automatic measuring of arteriovenous relation as a possible silent brain infarction risk index in hypertensive patients. / Medición semiautomática de la relación arteriovenosa retiniana como posible marcador de riesgo de infarto cerebral silente en pacientes hipertensos.

OBJECTIVE: To evaluate the usefulness of a semiautomatic measuring system of arteriovenous relation (RAV) from retinographic images of hypertensive patients in assessing their cardiovascular risk and silent brain ischemia (ICS) detection. METHODS: Semi-automatic measurement of arterial and venous width were performed with the aid of Imedos software and conventional fundus examination from the analysis of retinal images belonging to the 976 patients integrated in the cohort Investigating Silent Strokes in Hypertensives: a magnetic resonance imaging study (ISSYS), group of hypertensive patients. All patients have been subjected to a cranial magnetic resonance imaging (RMN) to assess the presence or absence of brain silent infarct. RESULTS: Retinal images of 768 patients were studied. Among the clinical findings observed, association with ICS was only detected in patients with microaneurysms (OR 2.50; 95% CI: 1.05-5.98) or altered RAV (<0.666) (OR: 4.22; 95% CI: 2.56-6.96). In multivariate logistic regression analysis adjusted by age and sex, only altered RAV continued demonstrating as a risk factor (OR: 3.70; 95% CI: 2.21-6.18). CONCLUSIONS: The results show that the semiautomatic analysis of the retinal vasculature from retinal images has the potential to be considered as an important vascular risk factor in hypertensive population.

[Introducing formative portfolio as a tool for Internal Medicine residents mentoring: review of a pilot project, 2005-2006]. / Introducción del portafolio formativo como instrumento de tutorización de residentes de Medicina Interna: revisión de una experiencia piloto, 2005-2006.

Recent educational projects in our country have been trying to introduce professional portfolios as assessment/learning tools on the undergraduate and specialized post-graduate education levels. The approval of a new formative program for the Internal Medicine specialty in an effort to adapt to the present health care needs offers an opportunity to apply these formative and evaluative methodologies in the learning process of future internists. During the 2005-2006 academic year, the Formative Work Group of the Spanish Internal Medicine Society (SEMI) developed a pilot study on portfolio application as a tool for formative assessment and mentoring. This article describes the project of designing, developing, applying and assessing an electronic portfolio for first year Internal Medicine residents. It presents an analysis of the SEMI Portfolio strengths and weaknesses and finally makes suggestions for future development.

Introducción del portafolio formativo como instrumento de tutorización de residentes de Medicina Interna: revisión de una experiencia piloto, 2005-2006 / Introducing formative portfolio as a tool for Internal Medicine residents mentoring: review of a pilot project, 2005-2006

Experiencias recientes en nuestro país tratan deintroducir los portafolios profesionales comoherramientas de evaluación-aprendizaje, tanto anivel de pregrado como en la formaciónespecializada de posgrado. La aprobación del nuevoprograma de la especialidad de Medicina Interna, enun esfuerzo de adaptación a las necesidades de laatención sanitaria actual, ofrece la oportunidad parala aplicación de estas metodologías docentes y deevaluación formativa del proceso de aprendizaje delos futuros internistas. Durante el curso 2005-2006,el Grupo de Formación de la Sociedad Española deMedicina Interna (SEMI) se propuso desarrollar unaexperiencia piloto demostrativa de la aplicación delportafolio como instrumento para la evaluaciónformativa y la tutorización. Este artículo describedicha experiencia de diseño, desarrollo,implantación y evaluación de un portafolio ensoporte electrónico para residentes de MedicinaInterna de primer año de la especialidad, realiza unanálisis de las fortalezas y las debilidades delPortafolio SEMI y, por último, proponerecomendaciones para su futuro desarrollo

Recent educational projects in our country havebeen trying to introduce professional portfolios asassessment/learning tools on the undergraduate andspecialized post-graduate education levels. Theapproval of a new formative program for theInternal Medicine specialty in an effort to adapt tothe present health care needs offers an opportunityto apply these formative and evaluativemethodologies in the learning process of futureinternists. During the 2005-2006 academic year, theFormative Work Group of the Spanish InternalMedicine Society (SEMI) developed a pilot study onportfolio application as a tool for formativeassessment and mentoring. This article describes theproject of designing, developing, applying andassessing an electronic portfolio for first yearInternal Medicine residents. It presents an analysisof the SEMI Portfolio strengths and weaknesses and finally makes suggestions for future development (AU)

El portfolio como instrumento de valoración del residente / The portfolio as a tool to evaluate residents

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[The health problems and needs of chronic home-bound patients]. / Problemas y necesidades de salud de los pacientes crónicos domiciliarios.

AIM: In light of the progressive ageing of the population and the consequent inability of a section of the population to attend health service facilities on their own, this study aims to establish the proportion of this population which could enter a programme of longterm home treatment, to identify their health problems and to assess what services they might require. DESIGN: Descriptive study of a crossover type. SITE. Four Sections of the Primary Care Centre in Andoain (Guipúzcoa). PATIENTS: Criteria of mobility, social and family support, mental state and limitations on daily activities were those considered when including patients in the study. The selection was made by examining clinical histories, long-treatment cards, the number of home alerts and by contacting institutions. MEASUREMENTS AND MAIN RESULTS: A survey of 68 patients in their homes was undertaken. The average age was 81, with a 76.47% majority of women. 41.06% were bed-ridden or in a wheel-chair and 50% suffered severe invalidity. We noted an average of 2.9 pathologies per patient; with cardiovascular problems (26.6%) accounting for the largest number. The average consumption of medicines was 2.83 per patient. CONCLUSIONS: The chronic home-bound patient presents several characteristics: advanced age, little mobility and a high level of invalidity. She/he suffers several pathologies and takes a large number of medicines, which require some level of primary care control. Both this control and any improvement in the quality of life and satisfaction for this type of patient crucially depend on nursing care.