Hyponatremia is frequent in hospitalized patients, especially in those receiving total parenteral nutrition (TPN). Furthermore, the presence of hyponatremia is associated with increased ...morbimortality in both groups. The goal of this study is to describe the prevalence of hyponatremia developing during TPN in non-critical patients, and identify risk factors for its appearance.
This prospective multicenter study involved 19 Spanish hospitals. Noncritically-ill patients prescribed TPN over a 9-month period were studied. Variables analyzed demographic characteristics, prior comorbidities, drug therapy, PN composition, additional iv fluids, and serum sodium levels.
A total of 543 patients were recruited, 60.2% males. Age: 67 (IR 57–76). Of 466/543 who were eunatremic when starting TPN, 18% developed hyponatremia (serum sodium < 135 mmol/L) during TPN. Independent risk factors identified by logistic regression analysis: female (OR 1.74 95% CI = 1.04–2.92, p = 0.036); severe malnutrition (OR 2.15 95% CI = 1.16–4.35, p = 0.033); opiates (OR 1.97 95% CI = 1.10–3.73, p = 0.036); and nausea/vomiting (OR 1.75 95% CI = 1.04–2.94, p = 0.036).
Previously eunatremic patients frequently develop hyponatremia while receiving TPN. In this group, severe malnutrition is an independent risk factor for hyponatremia, as well as previously described risk factors: opiates, nausea/vomiting, and female gender.
•Total Parenteral Nutrition (TPN) patients are at high risk for development of hyponatremia, with 18% of previously eunatremic patients developing it during TPN.•Severe malnutrition was the most important risk factor for development of hyponatremia during TPN.•The total amount of sodium and liquids administered did not influence the development of hyponatremia during total parenteral nutrition.
Introducción: el escenario de la nutrición enteral domiciliaria (NED) en Murcia, antes de 2010, estaba caracterizado por la gran variabilidad en la consideración del paciente subsidiario de dicha ...prestación, así como por el elevado consumo respecto a otras comunidades autónomas.Objetivos: desarrollar y describir la implementación de una vía clínica de asistencia al paciente subsidiario de NED y analizar el perfil de los pacientes y las características del soporte nutricional.Método: puesta en marcha de la vía clínica en el Área I de salud del Servicio Murciano de Salud (SMS). Diseño observacional y ambispectivo. Análisis de las muestras de NED de adultos del Área I en los años 2010 (NED1) y 2013-14 (NED2), con 345 y 457 casos, respectivamente.Resultados: instrucción nº 4/2012 de 12 de julio, Dirección de Gerencia del SMS, que generaliza la vía clínica a todas las áreas de salud. Aunque la patología más prevalente en ambas muestras fue la neurológica, seguida de la oncológica y la digestiva, hubo diferencias significativas en la distribución. La NED1 presentó un alto porcentaje de casos de pacientes no subsidiarios de prestación. En ambas muestras, la vía más frecuente de administración fue la oral, pero con una tendencia inversa en sonda nasogástrica (SNG) y gastrostomía en NED2, donde las fórmulas específicas también se redujeron.Conclusiones: los perfiles de la NED antes y después de la implantación de la vía clínica difieren significativamente en la patología de base, la vía de administración y el tipo de fórmula utilizada. La vía clínica ha facilitado la racionalización de la prescripción de esta prestación sanitaria.
Introducción: en Murcia, y hasta 2010, la administración de la nutrición enteral domiciliaria (NED) dictaba cumplir la regulación marcada en cuanto a los facultativos con competencias para su ...prescripción. Objetivos: examinar aspectos esenciales de este recurso en el periodo 2007-2010, características de la muestra y evolución del coste, así como perspectivas de futuro. Métodos: estudio del perfil de la población NED en un área de salud específica. Selección de recetas facturadas de productos NED en el conjunto de la Región, clasificación por tipos y análisis de la evolución en importe y en envases para el periodo 2007-2010. Resultados: respecto al perfil de la muestra del Área I de Salud de la Región, la patología, vía de administración y tipo de nutrición más frecuentes resultaron, respectivamente, la enfermedad neurológica, la vía oral y la nutrición no específica. Por otro lado, el gasto sanitario en productos dietoterápicos, en el Servicio Murciano de Salud, aumentó alrededor del 50% entre los años 2007 y 2010. Tanto en envases como en importe, Murcia se sitúa por encima de la media nacional. Conclusiones: el perfil de la muestra no coincide con trabajos publicados en otras regiones. Este dato, junto a la posición de Murcia en gasto dietoterápico, y su evidente tendencia al alza en los años analizados, hace evidente la necesidad de medidas que mejoren la calidad de la NED en la Región de Murcia y, en caso de ser posible, conseguir alcanzar valores nacionales en relación con el consumo medio y el gasto.
The progressive ageing of the population is leading to an increase in multimorbidity and polypharmacy, which in turn may increase the risk of hospitalization and mortality. The enhancement of care ...with information and communications technology (ICT) can facilitate the use of prescription evaluation tools and support system for decision-making (DSS) with the potential of optimizing the healthcare delivery process.
To assess the effectiveness and cost-effectiveness of the complex intervention MULTIPAP Plus, compared to usual care, in improving prescriptions for young-old patients (65-74 years old) with multimorbidity and polypharmacy in primary care.
This is a pragmatic cluster-randomized clinical trial with a follow-up of 18 months in health centres of the Spanish National Health System. Unit of randomization: family physician. Unit of analysis: patient.
Patients aged 65-74 years with multimorbidity (≥ 3 chronic diseases) and polypharmacy (≥ 5 drugs) during the previous 3 months were included.
n = 1148 patients (574 per study arm).
Complex intervention based on the ARIADNE principles with three components: (1) family physician (FP) training, (2) FP-patient interview, and (3) decision-making support system.
The primary outcome is a composite endpoint of hospital admission or death during the observation period measured as a binary outcome, and the secondary outcomes are number of hospital admission, all-cause mortality, use of health services, quality of life (EQ-5D-5L), functionality (WHODAS), falls, hip fractures, prescriptions and adherence to treatment. Clinical and sociodemographic factors will be explanatory variables.
The main result is the difference in percentages in the final composite endpoint variable at 18 months, with its corresponding 95% CI. Adjustments by the main confounding and prognostic factors will be performed through a multilevel analysis. All analyses will be carried out in accordance to the intention-to-treat principle.
It is important to prevent the cascade of negative health and health care impacts attributable to the multimorbidity-polypharmacy binomial. ICT-enhanced routine clinical practice could improve the prescription process in patient care.
ClinicalTrials.gov NCT04147130 . Registered on 22 October 2019.
Abstract
This article aims to break with two social stereotypes often held about Latinas in Spain. Authors analyze Latinas’ main strengths from a resilient and intersectional approach, to consider ...them holistically within social work interventions. Rather than focusing on Latinas' difficulties, authors point to their multiple strengths and the ability to move forward. The study took place in the province of Tarragona, Catalonia (Spain). A qualitative approach was used. Participants included Latinas living in Tarragona and social workers from the Tarragona social services. The techniques used were nine life stories and 59 semi-open questionnaires with Latinas, and 14 interviews with social workers. The authors identified a fighting attitude and an entrepreneurial and creative spirit as both individual and collective strengths, especially within Latinas' social networks. Latinas did not recognize themselves as victims, nor did they claim to assume that identity. The social workers’ interventions are implemented in a weak welfare system based on a model characterized by a paternalistic and victim-based viewpoint. Adopting approaches such as intersectionality and resilience would allow for the creation of fairer policies, programs, and projects targeted for Latinas, not just in Spain, but in other countries, too.
Introduction: Before 2010, prescribed home enteral nutrition (HEN) in Murcia was characterized by the great variability of the receptor patients,
in addition to a higher use compared with other ...geographical areas.
Objectives: Developing and describing a clinical pathway for attending candidates for HEN, and analyzing their profi le and prescription characteristics.
Methods: Establishment of a clinical pathway for HEN prescription. Bidirectional observational study of the samples of HEN in a specific area
(Health Area I of the Region of Murcia) during 2010 (HEN1) and 2013-14 (HEN2).
Results: An official management statement was established, generalizing the clinical pathway for the rest of the regional areas (Instruction no. 4/2012 of July 12
th). Although most prevalent diseases in both samples were neurological, followed, with a wide spread, by oncological and digestive cases, there was a signifi cant difference regarding distribution. The HEN1 sample showed a great number of no candidate patients according to the management statement. In both samples, the most prevalent route of administration was oral, but with a trend reversal to feeding tube and gastrostomy in HEN2, where the specifi c formulas were also reduced.
Conclusions: The profile of HEN, before and after the deployment of the clinical pathway, changes signifi cantly concerning the main disease, the
route of administration and the formula. It has been proved that there is a need for controlling HEN for an appropriate prescription.
Introduction: malnutrition in patients with neurological disease is very prevalent, worsening their complications and diminishing their quality of life. For that reason, nutritional support can ...provide a reduction in comorbidities. Over the past years, in Murcia (southeast of Spain), a clinical pathway has been stablished in accordance to the National Home Enteral Nutrition guide (HEN) to optimize this resource and reduce the prescription gap. Objective: to analyze the HEN characteristics in neurological patients in an area of Murcia, before and after the adequacy of the national recommendations. Method: observational cross-sectional study. Analysis and comparison of HEN in health area no. 1 in Murcia in 2010 and 2014. Results: the most prevalent cause for HEN was neurological disease. In 2010, oral nutrition was the most used way compared with 2014, when it had changed to enteral nutrition through feeding tube or ostomy. Non-specific formula was the most frequently used in 2010. However, after the establishment of the clinical pathway there was a reduction in specific enteral formula use, specially hypercaloric and hyperproteic. Conclusions: the implementation of a clinical pathway according to the National HEN guide has caused a change in the reality of artificial nutrition in health area no. 1 in Murcia (Spain), which means a standardization of its use under unified criteria made by specialized professionals. Finally, due to these results, this clinical pathway has been generalized to the rest of the region.
Resumen Introducción: la desnutrición en el paciente neurológico presenta una alta prevalencia, aumentando las complicaciones y disminuyendo la calidad de vida. La nutrición artificial minimiza el ...riesgo de malnutrición. En los últimos años, en Murcia, se pone en marcha una vía clínica de adecuación a la Guía Nacional de Nutrición Enteral Domiciliaria (NED) para optimizar este recurso y reducir la variabilidad de prescripción. Objetivo: analizar las características de la NED en el paciente neurológico, de un área de salud de Murcia, antes y después de la adecuación a las directrices nacionales. Método diseño observacional de corte transversal. Análisis y comparación de las muestras NED de adultos del Área 1 de salud de Murcia, en 2010 y 2014. Resultados: la patología más asociada a las prescripciones de NED fue la neurológica. La vía de administración más utilizada fue la oral, aunque desciende en la muestra de 2014 a favor de la sonda de nutrición y ostomía. El tipo de fórmula más usado en 2010 fue la no específica. Tras la vía clínica se reduce el uso de fórmulas específicas, disminuyendo especialmente las fórmulas hiperproteicas y/o hipercalóricas. Conclusiones: la implementación de una vía clínica de adecuación a la Guía Nacional NED ha provocado un cambio en la realidad de este tipo de nutrición artificial en el Área 1 de salud del Servicio Murciano de Salud, consiguiendo normalizar su uso bajo criterios unificados y profesionales especializados. Finalmente, estos logros se han generalizado a toda la región.
In patients receiving total parenteral nutrition (TPN), the frequency of hyponatraemia is high. However, the causes of hyponatraemia in TPN have not been elucidated, although diagnosis is required ...for appropriate therapy. The aim of this study is to describe the aetiology of hyponatraemia in non-critical hospitalised patients receiving TPN.
Prospective multicentre study in 19 Spanish hospitals. Non-critically hyponatraemic patients receiving TPN and presenting hyponatraemia over a 9-month period were studied. Data collected included sex, age, previous comorbidities, and serum sodium levels (SNa) before and following TPN initiation. Parameters for study of hyponatraemia were also included: clinical volaemia, the presence of pain, nausea, gastrointestinal losses, diuretic use, oedema, renal function, plasma and urine osmolality, urinary electrolytes, cortisolaemia, and thyroid stimulating hormone.
162 patients were included, 53.7% males, age 66.4 (SD13.8) years. Volume status was evaluated in 142 (88%): 21 (14.8%) were hypovolaemic, 96 (67.6%) euvolaemic and 25 (17.6%) hypervolaemic. In 111/142 patients the analytical assessment of hyponatraemia was completed. Hypovolaemic hyponatraemia was secondary to GI losses in 10/111 (9%), and to diuretics in 3/111 (2.7%). Euvolaemic hyponatraemia was due to Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) in 47/111 (42.4%), and to physiological stimuli of Arginine Vasopressin (AVP) secretion in 28/111 (25.2%). Hypervolaemic hyponatraemia was induced by heart failure in 19/111 (17.1%), cirrhosis of the liver in 4/111 (3.6%).
SIADH was the most frequent cause of hyponatraemia in patients receiving TPN. The second most frequent cause was physiological stimuli of AVP secretion induced by pain/nausea.
La hiponatremia es una complicación frecuente en pacientes con nutrición parenteral total (NPT). Aunque su diagnóstico es esencial para indicar el tratamiento apropiado, sus causas no han sido evaluadas. El objetivo del presente estudio es describir la etiología de la hiponatremia en pacientes no críticos que reciben NPT.
Estudio multicéntrico prospectivo en 19 hospitales españoles. Se incluyeron pacientes no críticos que recibieron NPT y presentaron hiponatremia durante un periodo de 9meses. Se recogieron datos demográficos, comorbilidades previas, natremia sérica antes y durante la administración de NPT, y parámetros del estudio de hiponatremia: volemia clínica, presencia de dolor/náuseas, pérdidas gastrointestinales, uso de diuréticos, edema, función renal, osmolalidad plasmática y urinaria, iones en orina, cortisolemia y hormona estimulante del tiroides.
Se incluyeron 162 pacientes, 53,7% varones, con una media de edad de 66,4 (DE 13,8) años. La volemia clínica se evaluó en 142 (88%): 21 (14,8%) hipovolémicos, 96 (67,6%) euvolémicos y 25 (17,6%) hipervolémicos. En 111/142 pacientes se completó el estudio bioquímico de hiponatremia. La hiponatremia hipovolémica fue secundaria a pérdidas gastrointestinales en 10/111 (9%) y diuréticos en 3/111 (2,7%). La hiponatremia euvolémica fue por síndrome de secreción inadecuada de la hormona antidiurética (SIADH) en 47/111 (42,4%) y por estímulo fisiológico de arginina-vasopresina (AVP) en 28/111 (25,2%). La hiponatremia hipervolémica fue inducida por insuficiencia cardiaca en 19/111 (17,1%) y por cirrosis hepática en 4/11 (3,6%).
El SIADH fue la causa más frecuente de hiponatremia en pacientes que reciben NPT, seguida del estímulo fisiológico de AVP por dolor/náuseas.
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