[Primary and Secondary Prevention of Hip Fragility Fracture in Teruel Health Sector, Aragon, Spain]. / Prevencion primaria y secundaria de la fractura de cadera por fragilidad ósea en la población del sector sanitario Teruel.

OBJECTIVE: Osteoporosis should be prevented, diagnosed and treated, preferably before the fragility fracture occurs. The objective was to analyze primary and secondary interventions carried out in individuals diagnosed with femur fragility fracture at Teruel in 2014. METHODS: Descriptive retrospective study. Variables assessed were sex, age, main health district, place of residence, basal functional situation, diagnosis on osteoporosis, hip or vertebral fracture, loss of height, use of FRAX tool, treatment on discharge, survival and cause of exitus. Student's t-test and ANOVA were used for quantitative variables by categories and regression for linear relationships. RESULTS: 148 patients were included. 123 were women median age was 87 years, 123 (76,4%) were women, 27,4% of the patients were totally or severely dependent for activities of daily living and 33% of them were living in a nursing home. There was a previous history of hip fracture in 10,1%, and one or more vertebral fractures in 10,1%. FRAX® tool was not used in any case. 12,2% of patients had been treated with calcium prior to fracture, 11,5% with vitamin D, and 6,8% of them with antiosteoporotic drugs. Only 52,7% were treated for secondary prevention after discharge. At the end of follow-up, 25,7% of hip fractured patients had died. Median survivorship of deceased patients was 64,5 days. 42,3% of exitus were caused by cardiovascular disease, 23,1% by infection and 11,5% by neoplasms. CONCLUSIONS: Primary pharmacologic prevention and assessment of osteoporosis or risk of fracture are unfrequent in our health district.. Although pharmacologic treatment is prescribed more frequently in Teruel than in other areas after a hip or vertebral fracture, additional measures should be taken in order to improve fragility fracture prevention.

OBJETIVO: La osteoporosis puede y debe prevenirse, diagnosticarse y tratarse, preferentemente antes de que aparezca la fractura por fragilidad. El objetivo fue analizar las intervenciones de prevención primaria y secundaria llevadas a cabo en las personas que sufrieron fractura de cadera por fragilidad en 2014 en el sector sanitario de Teruel. METODOS: Estudio descriptivo transversal. Variables analizadas: sexo, edad, zona básica de salud, residencia, situación funcional basal, antecedente de osteoporosis, fractura de fémur o vertebral, pérdida de estatura, utilización de FRAX, tratamiento al alta, exitus y su causa. Se empleó t-Student y ANOVA para variables cuantitativas por categorías y regresión para relaciones lineales. RESULTADOS: Se incluyó a 148 personas, de las cuales 123 eran mujeres, con una mediana de edad de 87 años, 27,4% tenían dependencia grave o total para las actividades de la vida diaria, 33% estaban institucionalizados. El 10,1% tenían antecedente de fractura de cadera y 10% de fractura vertebral. Constaba diagnóstico de osteoporosis en el 13'7%. En ningún caso se había utilizado la herramienta FRAX®. Habían seguido tratamiento previo con calcio el 12,2%, con vitamina D el 11,5% y con fármacos antiosteoporóticos un 6,8%. Tras la fractura siguió tratamiento para prevención secundaria el 52,7%. A 31/12/2015 había fallecido un 25,7%, con mediana de supervivencia de los fallecidos de 64,5 días, siendo las causas de exitus más frecuentes enfermedad cardiovascular (42,3%), infección (23,1%) y neoplasias (11,5%). CONCLUSIONES: En nuestro sector sanitario es infrecuente la valoración de la osteoporosis y del riesgo de fractura en población de riesgo así como la indicación de medidas farmacológicas de prevención primaria. Aunque la indicación de terapia para la prevención secundaria es superior a la reflejada en la literatura, debemos tomar medidas adicionales para mejorar la prevención de fracturas por fragilidad.

Prevención primaria y secundaria de la fractura de cadera por fragilidad ósea en la población del sector sanitario Teruel / Primary and secondary prevention of hip fragility fracture in Teruel health sector, Aragon, Spain

Fundamentos: La osteoporosis puede y debe prevenirse, diagnosticarse y tratarse, preferentemente antes de que aparezca la fractura por fragilidad. El objetivo fue analizar las intervenciones de prevención primaria y secundaria llevadas a cabo en las personas que sufrieron fractura de cadera por fragilidad en 2014 en el sector sanitario de Teruel. Método: Estudio descriptivo transversal. Variables analizadas: sexo, edad, zona básica de salud, residencia, situación funcional basal, antecedente de osteoporosis, fractura de fémur o vertebral, pérdida de estatura, utilización de FRAX, tratamiento al alta, exitus y su causa. Se empleó t-Student y ANOVA para variables cuantitativas por categorías y regresión para relaciones lineales. Resultados: Se incluyó a 148 personas, de las cuales 123 eran mujeres, con una mediana de edad de 87 años, 27,4% tenían dependencia grave o total para las actividades de la vida diaria, 33% estaban institucionalizados. El 10,1% tenían antecedente de fractura de cadera y 10% de fractura vertebral. Constaba diagnóstico de osteoporosis en el 13’7%. En ningún caso se había utilizado la herramienta FRAX®. Habían seguido tratamiento previo con calcio el 12,2%, con vitamina D el 11,5% y con fármacos antiosteoporóticos un 6,8%. Tras la fractura siguió tratamiento para prevención secundaria el 52,7%. A 31/12/2015 había fallecido un 25,7%, con mediana de supervivencia de los fallecidos de 64,5 días, siendo las causas de exitus más frecuentes enfermedad cardiovascular (42,3%), infección (23,1%) y neoplasias (11,5%). Conclusiones: En nuestro sector sanitario es infrecuente la valoración de la osteoporosis y del riesgo de fractura en población de riesgo así como la indicación de medidas farmacológicas de prevención primaria. Aunque la indicación de terapia para la prevención secundaria es superior a la reflejada en la literatura, debemos tomar medidas adicionales para mejorar la prevención de fracturas por fragilidad (AU)

Background: Osteoporosis should be prevented, diagnosed and treated, preferably before the fragility fracture occurs. The objective was to analyze primary and secondary interventions carried out in individuals diagnosed with femur fragility fracture at Teruel in 2014. Methods: Descriptive retrospective study. Variables assessed were sex, age, main health district, place of residence, basal functional situation, diagnosis on osteoporosis, hip or vertebral fracture, loss of height, use of FRAX tool, treatment on discharge, survival and cause of exitus. Student’s t-test and ANOVA were used for quantitative variables by categories and regression for linear relationships. Results: 148 patients were included. 123 were women median age was 87 years, 123 (76,4%) were women, 27,4% of the patients were totally or severely dependent for activities of daily living and 33% of them were living in a nursing home. There was a previous history of hip fracture in 10,1%, and one or more vertebral fractures in 10,1%. FRAX® tool was not used in any case. 12,2% of patients had been treated with calcium prior to fracture, 11,5% with vitamin D, and 6,8% of them with antiosteoporotic drugs. Only 52,7% were treated for secondary prevention after discharge. At the end of follow-up, 25,7% of hip fractured patients had died. Median survivorship of deceased patients was 64,5 days. 42,3% of exitus were caused by cardiovascular disease, 23,1% by infection and 11,5% by neoplasms. Conclusions: Primary pharmacologic prevention and assessment of osteoporosis or risk of fracture are unfrequent in our health district.. Although pharmacologic treatment is prescribed more frequently in Teruel than in other areas after a hip or vertebral fracture, additional measures should be taken in order to improve fragility fracture prevention (AU)

Predicción de supervivencia en el paciente con cáncer avanzado / Prediction of survival in patients with advanced cancer

INTRODUCCIÓN: Con el desarrollo de los Cuidados Paliativos resurge la preocupación por predecir el pronóstico del paciente con la mayor exactitud posible. Muchas decisiones terapéuticas y de cuidados del paciente, dependen de la estimación de su supervivencia. Material y MÉTODO: Se ha realizado una revisión de los trabajos publicados durante los últimos 20 años (desde 1993 al 2013) referentes a pronóstico de supervivencia en cáncer avanzado. RESULTADOS: La estimación clínica de supervivencia, tiende a sobreestimar el pronóstico y debería utilizarse de forma conjunta con otros factores. Se recomienda la opinión de otro médico y repetir las valoraciones en el enfermo. Un estado funcional (Karnofsky, PPS…) bajo, se considera un factor pronóstico fiable para predecir corto tiempo de supervivencia. Algunos signos y síntomas clínicos han demostrado asociación con la esperanza de vida en esta población de PACIENTES: síndrome anorexia-caquexia, disnea, deterioro cognitivo o delirium. Se han estudiado muchas variables de laboratorio asociadas con la esperanza de vida, resultando factores pronósticos independientes: leucocitosis, linfopenia, y proteína C reactiva. Entre las escalas multidimensionales, por el momento, la palliative prognostic (PaP) score que incluye varios factores pronósticos, es la escala recomendada por las guías europeas y españolas, indicando probabilidades de supervivencia a los 30 días. También han mostrado precisión: palliative prognostic pndex (PPI) y cancer prognostic scale (CPS). Otras escalas más nuevas están pendientes de validación en estudios más amplios. Existen nuevos métodos de estimación estadística de supervivencia accesibles desde internet (prognostigram, prognostat…). DISCUSIÓN: La tendencia actual va en la línea de utilizar escalas multidimensionales pronósticas, donde se aúnan diversos parámetros pronósticos. Interesaría comparar entre sí las diferentes escalas y utilizarlas en poblaciones más amplias. CONCLUSIONES: Lo recomendable sería formular un pronóstico individualizado para el paciente, comenzando con un pronóstico generalizado y modificándolo según las observaciones clínicas, valoración funcional, síntomas, analítica y conocimiento de la trayectoria de la enfermedad

INTRODUCTION: With the development in palliative care, there is a resurgence of concern about predicting the patient's prognosis with the best possible accuracy. Many treatment decisions and patient care depends on the prognosis estimation. MATERIALS AND METHODS: A review was performed on the literature related to the main prognosis factors in advanced cancer published within the last 20 years (from 1993 to 2013). RESULTS: The clinical estimation of survival tends to overestimate the prognosis and should be used together with other factors. A second opinion from another doctor and repeated assessments of the patient are recommended. A poor functional state (Karnofsky, PPS. ) is considered an accurate prognosis factor to predicting a short survival time. Some signs and clinical symptoms have been associated with life expectancy in these types of PATIENTS: anorexia-cachexia syndrome, dyspnea, cognitive impairment, or delirium. Many variables associated with life expectancy have undergone laboratory studies, resulting in independent prognostic factors: leukocytosis, lymphopenia, and C reactive protein. For the time being, palliative prognostic (PaP) score, which includes several prognostic factors, is the most recommended system among the multidimensional scales in European and Spanish guidelines indicating the probability of survival within 30 days. Other scales which have also showed precision are: palliative prognostic index (PPI) and cancer prognostic scale (CPS). There are other newer scales awaiting validation in wider studies. New methods of statistical estimation of survival are available on the Internet (prognostigram, prognostat. ). DISCUSSION: The current tendency is to use prognostic multidimensional scales where several prognostic parameters are combined. It would be of interest to compare the different scales, and use them in a wider population. CONCLUSIONS: The best option would be to formulate an individual prognosis for each patient, starting with a generalised prognosis, and modifying it according to clinical observations, functional assessments, symptoms, laboratory tests, and knowledge of the course of the illness

Excessive polypharmacy and survival in polypathological patients.

PURPOSE: The purpose of this study was to determine whether excessive polypharmacy is associated with a higher survival rate in polypathological patients. PATIENTS AND METHODS: An observational, prospective, and multicenter study was carried out on those polypathological patients admitted to the internal medicine and acute geriatrics departments between March 1 and June 30, 2011. For each patient, data concerning age, sex, comorbidity, Barthel and Lawton-Brody indexes, Pfeiffer's questionnaire, socio-familial Gijon scale, delirium, number of drugs, and number of admissions during the previous year were gathered, and the PROFUND index was calculated. Polypharmacy was defined as the use of ≥ 5 drugs and excessive polypharmacy as the use of ≥ 10. A 1-year long follow-up was carried out. A logistic regression model was performed to analyze the association of variables with excessive polypharmacy and a Cox proportional hazard model to determine the association between polypharmacy and survival. RESULTS: We included 457 polypathological patients. Mean age was 81.0 (8.8) years and 54.5% were women. The mean number of drugs used was 8.2 (3.4). Excessive polypharmacy was directly associated with heart disease [hazard ratio (HR) 2.33 95% CI 1.40-3.87; p =0.001], respiratory disease [HR 1.87 95% CI 1.13-3.09; p = 0.01], peripheral artery disease/diabetes with retinopathy and/or neuropathy [HR 2.02 95% CI 1.17-3.50; p = 0.01], and the number of admissions during the previous year [HR 1.21 96%CI 1.01-1.44; p = 0.04]. It was inversely associated with delirium [HR 0.48 95% CI 0.25-0.91; p = 0.02]. There were no statistical differences regarding the probability of 1-year survival between patients with no polypharmacy, with simple polypharmacy, and with excessive polypharmacy (0.66, 0.60, and 0.57, respectively, p = 0.12). CONCLUSIONS: A greater use of drugs may not be harmful but is also not associated with a higher probability of survival in polypathological patients.

Síndrome del miembro fantasma: aproximación terapéutica mediante el tratamiento espejo. Experiencia de un Servicio de Geriatría / Phantom limb pain syndrome: therapeutic approach using mirror therapy in a Geriatric Department

El descubrimiento de las neuronas espejo da una perspectiva nueva a la rehabilitación neurológica: se postula que la activación de las neuronas espejo en el hemisferio contralateral a una extremidad amputada reduce la actividad de los sistemas que perciben el dolor protopático y permite la reorganización de la corteza somatosensorial. Esta hipótesis abre la posibilidad de considerar el tratamiento espejo no solo como técnica analgésica, sino también como instrumento para una rehabilitación funcional integral en pacientes geriátricos con amputación de miembro inferior. Presentamos los resultados de la aplicación de dicho tratamiento a 3 pacientes ancianos con dolor de miembro fantasma tras la amputación reciente de una pierna(AU)

The clinical use of mirror visual feedback was initially introduced to alleviate phantom pain by restoring motor function through plastic changes in the human primary motor cortex. It is a promising novel technique that gives a new perspective to neurological rehabilitation. Using this therapy, the mirror neuron system is activated and decrease the activity of those systems that perceive protopathic pain, making somatosensory cortex reorganization possible. This paper reports the results of the mirror therapy in three patients with phantom limb pain after recent lower limb amputation, showing its analgesic effects and its benefits as a comprehensive rehabilitation instrument for lower limb amputee geriatric patients(AU)

[Phantom limb pain syndrome: therapeutic approach using mirror therapy in a Geriatric Department]. / Síndrome del miembro fantasma: aproximación terapéutica mediante el tratamiento espejo. Experiencia de un Servicio de Geriatría.

The clinical use of mirror visual feedback was initially introduced to alleviate phantom pain by restoring motor function through plastic changes in the human primary motor cortex. It is a promising novel technique that gives a new perspective to neurological rehabilitation. Using this therapy, the mirror neuron system is activated and decrease the activity of those systems that perceive protopathic pain, making somatosensory cortex reorganization possible. This paper reports the results of the mirror therapy in three patients with phantom limb pain after recent lower limb amputation, showing its analgesic effects and its benefits as a comprehensive rehabilitation instrument for lower limb amputee geriatric patients.

The use of cost per life year gained as a measurement of cost-effectiveness in Spain: a systematic review of recent publications.

OBJECTIVES: The objective of this study was to evaluate the methodological characteristics of cost-effectiveness evaluations carried out in Spain, since 1990, which include LYG as an outcome to measure the incremental cost-effectiveness ratio. METHODS: A systematic review of published studies was conducted describing their characteristics and methodological quality. We analyse the cost per LYG results in relation with a commonly accepted Spanish cost-effectiveness threshold and the possible relation with the cost per quality adjusted life year (QALY) gained when they both were calculated for the same economic evaluation. RESULTS: A total of 62 economic evaluations fulfilled the selection criteria, 24 of them including the cost per QALY gained result as well. The methodological quality of the studies was good (55%) or very good (26%). A total of 124 cost per LYG results were obtained with a mean ratio of 49,529 and a median of 11,490 (standard deviation of 183,080). Since 2003, a commonly accepted Spanish threshold has been referenced by 66% of studies. A significant correlation was found between the cost per LYG and cost per QALY gained results (0.89 Spearman-Rho, 0.91 Pearson). CONCLUSIONS: There is an increasing interest for economic health care evaluations in Spain, and the quality of the studies is also improving. Although a commonly accepted threshold exists, further information is needed for decision-making as well as to identify the relationship between the costs per LYG and per QALY gained.

Recomendaciones en la prevención de reacciones adversas a medicamentos en personas mayores con demencia / Recomendations for the prevention of adverse drug reactions in older adults with dementia

Las personas mayores son uno de los grupos poblacionales de mayor riesgo de reacción adversa a medicamentos (RAM). Su prevalencia media en el anciano es del 30%. La demencia no es un factor de riesgo independiente de RAM pero, sin embargo, es la principal situación que favorece y multiplica todos los factores de riesgo (polifarmacia, comorbilidad, prescripción inadecuada, interacción medicamentosa, edad avanzada y adherencia terapéutica). Se exponen recomendaciones revisadas y consensuadas para prevenir las RAM en las personas mayores, a la vez que las propias de las personas con demencia en relación con el manejo de la comorbilidad y de los síntomas cognitivos, psicológicos y conductuales(AU)

The elderly are one of the groups at greatest risk for adverse drugs reactions (ADR). The mean prevalence of these reactions in this population is 30%. Dementia is not an independent risk factor of ADR, but is the main condition that increases all risk factors (polypharmacy, comorbidity, inappropriate prescribing, drug–drug interactions, advanced age, and treatment adherence). The present article discusses revised and consensual recommendations for the prevention of ADR in the elderly, as well as recommendations specifically for dementia patients in relation to the management of comorbidity and cognitive, behavioral and psychological symptoms(AU)

[Recomendations for the prevention of adverse drug reactions in older adults with dementia]. / Recomendaciones en la prevención de reacciones adversas a medicamentos en personas mayores con demencia.

The elderly are one of the groups at greatest risk for adverse drugs reactions (ADR). The mean prevalence of these reactions in this population is 30%. Dementia is not an independent risk factor of ADR, but is the main condition that increases all risk factors (polypharmacy, comorbidity, inappropriate prescribing, drug-drug interactions, advanced age, and treatment adherence). The present article discusses revised and consensual recommendations for the prevention of ADR in the elderly, as well as recommendations specifically for dementia patients in relation to the management of comorbidity and cognitive, behavioral and psychological symptoms.