Applicability of the STOPP/START criteria to older polypathological patients in a long-term care hospital.

OBJECTIVES: To analyse the applicability of the STOPP/START criteria as a tool to identify patients with potentially inappropriate medications (PIM) during pharmaceutical validation of prescriptions in a long-term care hospital, to identify risk factors for PIM and to characterise the physiological systems and drugs more frequently associated with these PIM. METHODS: An interventional, prospective and longitudinal study was conducted in polypathological patients aged >65 years. Usual pharmaceutical care and the STOPP/START criteria were used to identify PIM and to plan pharmaceutical interventions at admission. At discharge, the discharge summaries were reviewed using the STOPP/START criteria. RESULTS: 112 patients were included. The prevalence of patients with PIM at admission was 76.8%. The STOPP criteria identified a high number of PIM and almost all entailed pharmaceutical intervention. On the other hand, most of the START criteria identified did not entail pharmaceutical intervention. Usual pharmaceutical care detected a different type of PIM; a high percentage of pharmaceutical interventions to resolve them were accepted. At discharge, the prevalence of patients with PIM was 61.3%. At admission, none of the analysed variables was associated with the PIM identified using any of the tools. At discharge STOPP criteria identified a higher percentage of patients with PIM in the geriatric outpatient consultation group. CONCLUSIONS: The prevalence of PIM in older polypathological patients is high. The STOPP criteria are useful for reducing inappropriate prescribing during the pharmaceutical validation process. In contrast, routine incorporation of the START criteria in the pharmaceutical validation may be not necessary in a hospital of this type.

The Effect of Balance Training on Postural Control in Patients with Parkinson's Disease Using a Virtual Rehabilitation System.

OBJECTIVES: Parkinson's disease (PD) is a progressive neurodegenerative disorder characterized by motor clinical alterations among others. Postural problems have serious consequences for patients, not only limiting their daily life but also increasing some risks, like the risk of fall. Inadequate postural control and postural instability is a major problem in PD patients. A Virtual Motor Rehabilitation System (VMR) has been tested in patients with PD in the intervention period. Our purpose was to analyze the evolution of the spatial postural control during the intervention period, to see if there are any changes caused precisely by this intervention. METHODS: Ten people with PD carried out 15 virtual rehabilitation sessions. We tested a groundbreaking system based on Virtual Motor Rehabilitation in two periods of time (baseline evaluation and final evaluation). In the training sessions, the participants performed a customizable treatment using a low-cost system, the Active Balance Rehabilitation system (ABAR). We stored the pressure performed by the participants every five hundredths of a second, and we analyzed the patients' pressure when they maintained their body on the left, on the right, and in the center in sitting position. Our system was able to measure postural control in every patient in each of the virtual rehabilitation sessions. RESULTS: There are no significant differences in the performance of postural control in any of the positions evaluated throughout the sessions. Moreover, the results show a trend to an improvement in all positions. This improvement is especially remarkable in the left/right positions, which are the most important positions in order to avoid problems such as the risk of fall. With regard to the suitability of the ABAR system, we have found outstanding results in enjoyment, success, clarity, and helpfulness. CONCLUSIONS: Although PD is a progressive neurodegenerative disorder, the results demonstrate that patients with PD maintain or even improve their postural control in all positions. We think that the main factor influencing these results is that patients use more of their available cognitive processing to improve their postural control. The ABAR system allows us to make this assumption because the system requires the continuous attention of patients, promoting cognitive processing.

Hematoma subdural agudo en un paciente en tratamiento con apixaban y ácido acetilsalicílico / Acute subdural hematoma in a patient in treatment with apixaban and acetylsalicylic acid

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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