Jorge Calderón

Impact of delirium on short-term mortality in elderly inpatients: a prospective cohort study.

BACKGROUND Delirium is an important problem especially in older medical inpatients. OBJECTIVE The authors asked whether delirium and its duration are associated with higher mortality in a 3-month follow-up period. METHOD In this prospective cohort study, inpatients age 65 and older were assessed every 48 hours with the Confusion Assessment Method. RESULTS Of 542 patients enrolled, 192 (35.4%) developed delirium. After 3 months, mortality in the delirium cohort was 25.9%, and in the nondelirium cohort was 5.8%. Delirium was independently associated with mortality, and increased by 11% for every 48 hours of delirium. CONCLUSION Delirium and increased delirium durations are significantly associated with higher mortality.

Development and validation of a delirium predictive score in older people

BACKGROUND delirium is frequently under diagnosed in older hospitalised patients. Predictive models have not been widely incorporated in clinical practice. OBJECTIVE to develop and validate a predictive score for incident delirium. DESIGN AND SETTING two consecutive observational prospective cohorts (development and validation) in a university affiliated hospital. SUBJECTS inpatients 65 years and older. METHODS in the development cohort patients were assessed within the first 48 h of admission, and every 48 h thereafter, using the confusion assessment method to diagnose delirium and data were collected on comorbidity, illness severity, functional status and laboratory. Delirium predictive score (DPS) was constructed in the development cohort using variables associated with incident delirium in the multivariate analysis (P < 0.05), and then tested in a validation cohort of comparable patients, admitted without delirium. Receiver operating characteristic (ROC) analysis and likelihood ratio (LR) were calculated. RESULTS the development cohort included 374 patients, incident delirium occurred in 25. After multivariate analysis incident delirium was independently associated with lower functional status (Barthel Index) and a proxy for dehydration (elevated urea to creatinine ratio). Using these variables, DPS was constructed with a performance in the ROC curve area of 0.86 (95% CI: 0.82-0.91) and (-) LR = 0.16 and (+) LR = 3.4. The validation cohort included 104 patients and the performance of the score was ROC 0.78 (95% CI: 0.66-0.90). CONCLUSIONS This simple predictive model highlights functional status and a proxy for dehydration as a useful tool for identifying older patients that may benefit from close monitoring and preventive care for early diagnosis of delirium.

Impacto del Delirium en pacientes de edad avanzada hospitalizados: Un estudio prospectivo de cohortes.

BACKGROUND: Delirium is an important problem in older medical inpatients. AIM: To assess if delirium is associated with higher mortality, functional decline or higher rates of readmission or institutionalization in a one year follow-up period. MATERIAL AND METHODS: Prospective cohort study of consecutive patients 65 years and older, admitted to a general hospital medical ward. A psychogeriatric team assessed patients every 48 h using the Confusion Assessment Method (CAM), functionality, acute severity and comorbidity scores. Analysis of one year mortality and telephone functional assessment was performed. RESULTS: Five hundred forty two patients were enrolled and 35.4% had delirium. After one year, mortality was 34.9 and 13% in delirium and non-delirium cohorts, respectively (p < 0.01). After adjustment for covariates, delirium was independently associated with higher mortality, and higher functional decline and institutionalization. No significant differences were seen in readmission rates. CONCLUSIONS: Delirium was significantly associated with higher mortality and functional decline over a one year follow up period in geriatric inpatients.BACKGROUND Delirium is an important problem in older medical inpatients. AIM To assess if delirium is associated with higher mortality, functional decline or higher rates of readmission or institutionalization in a one year follow-up period. MATERIAL AND METHODS Prospective cohort study of consecutive patients 65 years and older, admitted to a general hospital medical ward. A psychogeriatric team assessed patients every 48 h using the Confusion Assessment Method (CAM), functionality, acute severity and comorbidity scores. Analysis of one year mortality and telephone functional assessment was performed. RESULTS Five hundred forty two patients were enrolled and 35.4% had delirium. After one year, mortality was 34.9 and 13% in delirium and non-delirium cohorts, respectively (p < 0.01). After adjustment for covariates, delirium was independently associated with higher mortality, and higher functional decline and institutionalization. No significant differences were seen in readmission rates. CONCLUSIONS Delirium was significantly associated with higher mortality and functional decline over a one year follow up period in geriatric inpatients.

Consejería: propuesta de un método de apoyo al paciente terminal

During the last decades we have witnessed a progressive aging of the general population and a higher prevalence of chronic disease. This fact along with the appearance of infectious diseases like AIDS, anticipates that more patients will benefit from comprehensive palliative care. The objective of this article is to propose a simple, integral and effective method of emotional support to the patient, family and health team in palliative care (PC). PC receives little attention in medical schools, despite the great impact it has on standard health practice and quality of life of patients and their families. Our proposed method, counselling, has been empirically studied and proven to be an effective therapeutic tool in promoting behavioural changes that favour the outcome of many conditions. We believe that it facilitates PC practice, promoting direct conversation and identifying issues that can potentially cause suffering to the patients. It is based on the patient’s autonomy, considers his multiple dimensions, uses and stimulates patient’s own resources and coping strategies, to improve quality of life (Rev Med Chile 2006; 134: 1448-54). (Key words: Aging; Counseling; Palliative care)

Prevalence of emotional symptoms in Chilean oncology patients before the start of chemotherapy: potential of the distress thermometer as an ultra-brief screening instrument.

Emotional distress (ED) is greater for oncology patients in comparison with the general population, and this has implications for the quality of life of the patient and his/her family, adherence to the treatment, and eventually, survivorship. In general, the detection of these symptoms is low, which explains the need for detection systems appropriate to the clinical reality of the oncology team. The objective of this study is to evaluate for the first time the usefulness of an ultra-brief screening instrument [distress thermometer (DT)], in a group of Chilean oncology patients. A total of 166 outpatients were evaluated at the Cancer Center of the Pontificia Universidad Católica de Chile, before starting chemotherapy. Two screening instruments were applied: Hospital Anxiety and Depression Scale (HADS) and DT. The application of HADS resulted in a prevalence of 32.7% of anxiety symptoms (HADS-A ≥ 8), 15.7% of depression symptoms (HADS-D ≥ 8), and 39.8% had a total score of HADS-T ≥ 11. The DT resulted in the prevalence of 32.5% of distress or ED (DT ≥ 5). The validity of the DT was evaluated as a screening tool in comparison with HADS, observing, in relation to the anxiety scale (HADS-A), a sensitivity of 88.9% and specificity of 78.4% (DT ≥ 4); depression (HADS-D), a sensitivity of 69.2% and specificity of 74.3% (DT ≥ 5); and in relation to the total scale (HADS-T), a sensitivity of 68.2% and specificity of 73.0% (DT ≥ 4). This study demonstrates the elevated prevalence of emotional symptoms in Chilean oncology patients, before the start of chemotherapy, and confirms the potential of the DT as a brief screening instrument with easy application. The DT will allow the clinician to increase the detection threshold in the Chilean oncology population, intervene in a timely manner, and contribute to the comprehensive handling of the oncology patient without affecting the time needed for assistance.

Actualización en lupus neuro-psiquiátrico con énfasis en déficit cognitivo

BACKGROUND: Patients with systemic lupus erythematosus (SLE) suffer from a number of neuropsychiatric (NP) symptoms throughout their disease affecting them both physically and psychologically. We review herein the nomenclature and case definitions for neuropsychiatric lupus syndromes proposed by the American College of Rheumatology in 1999. We emphasize cognitive dysfunction and discuss etiological hypotheses, especially those related to the presence of antineuronal autoantibodies.BACKGROUND Patients with systemic lupus erythematosus (SLE) suffer from a number of neuropsychiatric (NP) symptoms throughout their disease affecting them both physically and psychologically. We review herein the nomenclature and case definitions for neuropsychiatric lupus syndromes proposed by the American College of Rheumatology in 1999. We emphasize cognitive dysfunction and discuss etiological hypotheses, especially those related to the presence of antineuronal autoantibodies.

Prevalencia y evolución de síntomas depresivos en pacientes hospitalizados por infarto agudo al miocardio y su relación con procedimientos de revascularización

BACKGROUND Persistence of depressive symptoms after myocardial infarction (MI) is associated with an adverse outcome. The relationship between depression and Invasive Revascularization Therapy (IRT) is not yet fully understood. AIM To compare the frequency of depressive symptoms and other psychosocial variables among patients with MI, undergoing or not undergoing IRT. MATERIAL AND METHODS Prospective evaluation of 45 patients aged 58 +/- 11 years (87% males) with a diagnosis of MI (Killip I and II). On admission to hospital and at follow up 3 months after discharge, all patients completed the Beck Depression Inventory (BDI), the Zung Anxiety Inventory (ASI), and the Medical Outcomes Study (MOS) social support survey. Depressive symptoms were considered to be present if the BDI score was over 10. RESULTS Thirty seven percent were hypertensive, 15% diabetic and 44% smokers. Sixty four percent of patients underwent IRT (11.1% revascularization surgery and 53.3% coronary angioplasty). Forty four percent of patients scored over 10 in the BDI at baseline assessment and 26.5% at 3 months follow-up (p < 0.01). At baseline BDI score was 10.2 +/- 5.1 and 9.1 +/- 4.4 among patients subjected or not subjected to IRT, respectively (NS). The figures at 3 months of follow up were 9.9 +/- 5.6 and 4.1 +/- 2.5, respectively (p < 0.01). At baseline and three months BDI, anxiety and perceived social support were significantly correlated. CONCLUSIONS Depressive symptoms were frequent after MI in this group of patients, and decreased at follow up only among patients not subjected to IRT.

Neurological soft signs as a marker of cognitive impairment severity in people living with HIV

HIV-associated neurocognitive disorders (HAND) include asymptomatic neurocognitive impairment (ANI), mild neurocognitive disorder (MND) and HIV-associated dementia. Early recognition of HAND is crucial, and usually requires thorough neuropsychological testing. Neurological soft signs (NSS), i.e. minor motor and sensory changes, a common feature in severe psychiatric disorders, may facilitate early diagnosis. NSS were examined using the Heidelberg NSS Scale in 18 patients with ANI, 21 with MND, 28 HIV positive patients without HAND, and 39 healthy controls matched for age, gender, and education. The highest NSS scores were obtained in the MND patients (13.3 ± 10.0, p < 0.0001) followed by those with ANI (11.7 ± 10.6), the HIV positive subjects without neurocognitive deficits (8.0 ± 4.1) and the healthy controls (3.8 ± 3.2). This result was confirmed when age and years of school education were entered as covariates. No significant correlations between NSS and CD4 counts or any other clinical variables were found among the HIV positive groups. Our results demonstrate that NSS are frequently found in both ANI and MND but not HIV positive patients without neurocognitive deficits. NSS may facilitate the screening of HIV positive patients for ANI and MND as an easier and less expensive clinical tool.

Evidence-based practice in Chile

Over the past few decades, the emergence of evidence-based practice medicine (EBP) has allowed a change in the integration of knowledge with policy making and health service development, and Chile has been influenced by EBP with no exemption. In this paper, we will describe the impact of the EBP model at different levels of the Chilean health system, including the development of national clinical guidelines, medical training and in-patient involvement in health awareness.