Cómo el índice pronóstico PPI predice la supervivencia en pacientes oncológicos en situación terminal atendidos en un Equipo de Soporte de Atención Domiciliaria / No disponible

Objetivo: conocer si el índice pronóstico PPI descrito por Morita es capaz de predecir la supervivencia de los pacientes oncológicos en situación terminal atendidos por un ESAD de un Área de Salud de Madrid. Metodología: estudio observacional, longitudinal, prospectivo. Sujetos de estudio: pacientes con el diagnóstico de enfermedad oncológica en situación terminal, derivados al ESAD del Área 7 de Madrid. Variables: recogidas al captar a los pacientes: edad, sexo, localización del tumor, existencia de metástasis, número y localización de las mismas. Recogidas en las visitas semanales hasta el fallecimiento: PPS, estado de la vía oral, disnea de reposo, edema y delirium. Análisis estadístico: Se calcularon sensibilidad y especificidad y se realizó análisis de supervivencia con regresión de Cox. Resultados: se captaron 150 pacientes. El 57% hombres. La edad media de 71,5, DE 12,4. La mediana de supervivencia es de 23 días. Cuando el PPI es mayor de 6, predice en nuestra población una supervivencia menor de 3 semanas con una sensibilidad del 39% y una especificidad de 90%. Cuando el PPI es mayor de 4, predice en nuestra población una supervivencia menor de 6 semanas con una sensibilidad de 48% y una especificidad de 88%. Se identificaron 4 variables predictoras de supervivencia: PPS ≤ 50, vía oral moderada y severamente reducida, disnea de reposo y delirium. Conclusiones: el PPI es un índice pronóstico con una elevada especificidad, pero una baja sensibilidad en nuestra población. Su utilidad en la práctica clínica diaria como método de predicción es baja (AU)

Objective: to know if the PPI (Palliative Prognostic Index), can predict the survival of terminally ill cancer patients attended by a Home Care Support Team. Methodology: observational, prospective study. Were followed up with at least weekly visits until death. We collected the variables: age, sex, tumor's localization and the existence, number and localization of metastases, and the variables that integrate the PPI: PPS (Palliative Performance Status), the state of the oral intake, the presence or not of dyspnea at rest, edema and delirium. Results: 150 patients. The mean age was 71.5. The median of survival was 23 days. A PPI over 6 predicts in our population a survival below 3 weeks with a 39% sensitivity and a 90% specificity. A PPI over 4 predicts a survival below 6 weeks with a 48% sensitivity and a 88% specificity. Conclusions: the PPI is a prognostic index with a high specificity, but a low sensitivity in our population (AU)

Enfermedad celíaca oligosintomática del adulto / Adult oligosymptomatic coeliac disease

La enfermedad celíaca es una patología crónica del intestino delgado, causada por una intolerancia al gluten, en la que hay una lesión característica e inespecífica que conlleva una malabsorción de nutrientes y vitaminas. En el adulto es una entidad infradiagnosticada debido a sus formas atípicas. Es fundamental realizar un diagnóstico precoz, pues la dieta exenta de gluten previene las complicaciones a largo plazo como el linfoma T intestinal y otras neoplasias digestivas, disminuyendo la mortalidad. Presentamos un caso de enfermedad celíaca del adulto oligosintomática en una paciente con antecedente de anemia ferropénica crónica y menorragia, comentamos las alteraciones clínico-nutricionales y la evolución de la paciente (AU)

[Clinical impressions of terminal cancer patients as an estimator of time of survival]. / La impresión clínica como estimador del tiempo de supervivencia en pacientes oncológicos en situación terminal.

OBJECTIVE: To evaluate the relationship between the prognosis of the survival time of terminal cancer patients by doctors and nurses belonging to a Home Care Support Team (HCST) and the actual time of survival found. The first assessment and the last before death were examined. DESIGN: Prospective, descriptive study. SETTING: Area 7 of primary care, Madrid. PARTICIPANTS: Were terminal cancer patients attended by the HCST between February 2001 and August 2002. MAIN MEASUREMENTS: Age, sex, location of the tumour, presence of metastasis, number and location of metastases, real survival time and the time estimated by the doctor and nurse at the first assessment and at the last before death. The quotient of survival time found/survival time estimated was calculated. If it was between 0.67 and 1.33, the prediction was considered correct; < 0.67, optimistic, and >1.33, pessimistic. RESULTS: 121 patients were studied, 57% men, with an average age of 72 +/- 12.8 years. At the first assessment, 30% of doctors' predictions were correct, 40% optimistic and 30% pessimistic. Of nurses' predictions, 40% were correct, 30% optimistic and 30% pessimistic. The intra-class correlation coefficients (ICC) between real and estimated survival times were 0.64 for doctors and 0.54 for nurses. At the final assessment, doctors had 38% correct predictions, 44% optimistic and 18% pessimistic; and nurses had 44% correct, 32% optimistic and 24% pessimistic. The ICCs were 0.83 and 0.84. CONCLUSIONS: The accuracy of professionals' clinical impression was only acceptable at the moment of quantifying the prognosis.

[Effectiveness of a training course in bioethics and of the introduction of a checklist to detect ethical problems in a home care support team]. / Efectividad de un curso de formación en bioética y de la implantación de una checklist en la detección de problemas éticos en un equipo de soporte de atención domiciliaria.

OBJECTIVE: To study the concordance in the number of ethical problems identified in the care of the terminally ill between the members of a home care support team (HCST) and a group of experts before and after a course in bioethics and the introduction of a checklist. DESIGN: Before-and-after intervention study. SETTING: Area 7 of Primary Care, Madrid. PARTICIPANTS: Terminally ill patients attended by the HCST between November 2001 and June 2002. INTERVENTION: Bioethics course and introduction of a checklist. MAIN MEASUREMENTS: Age, sex, basic illness, number of ethical problems identified by the HCST and by the group of experts before and after the intervention. The intraclass correlation coefficient (ICC) for the number of problems identified was calculated in both groups before and after the intervention. RESULTS: 31 cases before and 29 after the intervention were studied. Before the intervention the HCST identified an average of 2.7 +/- 2.3 ethical problems per case; and the group of experts found 11.8 +/- 6.1. The ICC for the number of problems identified was 0.53 (moderate correlation). After the intervention, the HCST identified 5.9 +/- 6.5 ethical problems per case; and the group of experts, 10.7 +/- 7.9. The ICC for the number of problems identified was 0.87 (close correlation). CONCLUSIONS: The course and the introduction of a checklist helped professionals who were not experts in bioethics to detect ethical problems in treating terminally ill patients.

[Adult oligosymptomatic coeliac disease]. / Enfermedad celíaca oligosintomática del adulto.

Coeliac disease is a chronic pathology of the small intestine. The pathogenic mechanism is caused by gluten intolerance. This disease present a characteristic and unspecific injury that causes nutrients and vitamins malabsorption. In adults is an underdiagnosed entity due to atypical forms. To make a premature diagnosis is basic because gluten-free diet prevent the complications after long-term like the intestinal T lymphoma and other digestives malignancies, and decrease the mortality of these patients. We present a case of adult oligosymptomatic coeliac disease in a patient with iron deficiency anaemia and vaginal bleeding. We study the clinic-nutrition and the alterations evolution of the patient.