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INTRODUCTION: Older adults with advanced chronic diseases and palliative care needs are more exposed to polypharmacy and use of potentially inappropriate medication, which generates a high risk of adverse events and impaired quality of life. The objective of this study was to describe the frequency of potentially inappropriate medication use among older adults with palliative care needs receiving home care services after hospital discharge. METHODS: Observational cross-sectional study of pharmacy dispensing and electronic health records, of older adults in a home care system and with palliative care needs according to the screening with the NECPAL tool or the PROFUND and/or PALIAR indexes. Dispensed medications during 180 days after admission to home care were analyzed. Medications were classified as potentially inappropriate according to the LESS-CHRON criteria. RESULTS: We included 176 patients, mean age 87.4 years, 67% were women; 73% were pluripathologic patients and 22% had one chronic progressive disease. Mortality at 6 months was 73%. Median frequency of dispensed medications per patient was 9.1 (IQR = 4-9.7). The frequency of potentially inappropriate medication dispensation among patients was 87%, mainly antihypertensives, benzodiazepines and antipsychotics. CONCLUSION: This study observed that dispensation of potentially inappropriate medication among older adults with palliative care needs and home care services is very high. This emphasizes the need for effective patient-centered interventions to prevent inadequate prescription and stimulate de-prescription.

Introducción: Los adultos mayores con enfermedades crónicas avanzadas y necesidad de cuidados paliativos están más expuestos a la polifarmacia y a consumir medicación potencialmente inapropiada, la cual genera un alto riesgo de eventos adversos y alteración de la calidad de vida. El objetivo de este estudio fue describir la frecuencia de consumo de medicación potencialmente inapropiada de adultos mayores con necesidad de cuidados paliativos que ingresaron a cuidados domiciliarios luego de una hospitalización. Métodos: Estudio de corte transversal observacional de registros de dispensación e historias clínicas electrónicas, de adultos mayores en un sistema de cuidados domiciliarios y con necesidades de cuidados paliativos según el rastreo con la herramienta NECPAL, los índices PROFUND y/o PALIAR. Se analizó el consumo de fármacos durante los 180 días posteriores al ingreso a cuidados domiciliarios. Se clasificaron los fármacos como potencialmente inapropiados según criterios de LESS-CHRON. Resultados: Se incluyeron 176 pacientes, edad promedio 87.4 años, 67% mujeres; 78% eran pluripatológicos y 22% presentaban una enfermedad única crónica progresiva. La mortalidad a los 6 meses fue 73%. La mediana de consumo de fármacos por paciente fue 9.1 (RIC = 4-9.7). El 87% consumía medicación potencialmente inapropiada, principalmente antihipertensivos, benzodiacepinas y antipsicóticos. Conclusión: Este estudio observó que los adultos mayores, con necesidad de cuidados paliativos en cuidados domiciliarios, tienen un alto consumo de medicación potencialmente inapropiada. Esto refuerza la necesidad de implementar intervenciones efectivas centradas en el paciente, para prevenir la prescripción inadecuada y estimular la de-prescripción.

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Objetivos: Evaluar la magnitud y la trascendencia de un proceso de estratificación y planificación anticipada de los cuidados y el uso de recursos hospitalarios en pacientes con COVID-19 en un programa de atención integrada para pacientes adultos mayores frágiles en residencias. Material y métodos: Estudio de cohorte prospectiva de pacientes >64 años con COVID-19 en un programa en residencias, desde marzo a septiembre de 2020. Se evaluó la identificación de pacientes con necesidad de abordaje paliativo (NECPAL positivo), la realización de la planificación anticipada del cuidado y su registro visible en la historia clínica electrónica. Se evaluó la utilización de cuidados intensivos. Resultados: Trescientos setenta y cuatro pacientes tuvieron COVID-19: el 88% eran mujeres, mediana de edad 88 años. El 79% tenían necesidades de abordaje paliativo, de los cuales el 68% tenía registrada la planificación anticipada del cuidado (p<0,001) en su historia clínica electrónica. Solamente el 1% de los pacientes con necesidad de abordaje paliativo con criterios de severidad utilizó cuidados intensivos. La mortalidad global fue del 25%. De los fallecidos, el 74% tenían criterios de severidad (p<0,001) y el 90% tenían necesidad de abordaje paliativo (p<0,001). Conclusiones: Realizar un proceso de atención basado en la estratificación e identificación de pacientes con necesidad de abordaje paliativo y la planificación anticipada del cuidado, con registro en un lugar central y visible de la historia clínica electrónica, podría mejorar la calidad y la seguridad de la atención, adecuando los recursos a las necesidades del paciente en todo momento y especialmente en situaciones de emergencia sanitaria. (AU)

Objectives: To estimate the magnitude and importance of a process of stratification and advance care planning and the use of health resources, among patients in an integrated health care program for frail elderls in nursing homes,that were referred to the hospital with COVID-19. Material and methods: Prospective cohort study of patients >64 years old with COVID-19 infection, in a health care program in nursing homes (from 3/15/2020 to 9/15/2020). The identification of patients with palliative needs, the performing and visible registration in electronic health records of the advance care planning and the use of intensive care were assessed. Results: We included 374 COVID-19 patients. 88% were women, the median age was 88 years old. The 79% were patients with palliative needs, of which 68% had the advance care planning (P<.001) registered in the electronic health record. Only 1% of patients with palliative needs and severity criteria were admitted to the intensive care unit. Overall mortality was 25%. Of those who died, 74% had severity criteria (P<.001) and 90% had palliative needs (P<.001). Conclusions: Carrying out a care process based on identification of patients with palliative needs and advance care planning and a central and visible registration of advance care planning in health records, could improve the quality and safety of care and optimize the use of intensive care health resources at all times and especially in public health emergencies. (AU)

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OBJECTIVES: To estimate the magnitude and importance of a process of stratification and advance care planning and the use of health resources, among patients in an integrated health care program for frail elderls in nursing homes,that were referred to the hospital with COVID-19. MATERIAL AND METHODS: Prospective cohort study of patients >64 years old with COVID-19 infection, in a health care program in nursing homes (from 3/15/2020 to 9/15/2020). The identification of patients with palliative needs, the performing and visible registration in electronic health records of the advance care planning and the use of intensive care were assessed. RESULTS: We included 374 COVID-19 patients. 88% were women, the median age was 88 years old. The 79% were patients with palliative needs, of which 68% had the advance care planning (P<.001) registered in the electronic health record. Only 1% of patients with palliative needs and severity criteria were admitted to the intensive care unit. Overall mortality was 25%. Of those who died, 74% had severity criteria (P<.001) and 90% had palliative needs (P<.001). CONCLUSIONS: Carrying out a care process based on identification of patients with palliative needs and advance care planning and a central and visible registration of advance care planning in health records, could improve the quality and safety of care and optimize the use of intensive care health resources at all times and especially in public health emergencies.

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The aging of the population and the increase in chronic diseases generated the need for care at home for pluripathological patients, who can no longer access outpatient care due to functional and social problems. The use of Electronic Medical Records (EMR) improves continuity of care, simplifies data collection, decreases overhead costs, and reduces mortality in chronically ill patients. The use of an App to check and record data in the EMR during the home visit saves time for professionals and helps to avoid transcription errors. This article shares our experience with the design and implementation of a Mobile Application with EMR functionalities for the Homecare setting of the Hospital Italiano de Buenos Aires network.

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BACKGROUND: Hospitalization is a moment of extreme vulnerability for frail older adults. There is scarce evidence on the effectiveness of geriatric co-management or transitional care interventions in Latin America. AIMS: To assess whether geriatric co-management combined with an interdisciplinary transitional care intervention could reduce 30-day hospital readmission rate compared to usual care in hospitalized frail older patients in a tertiary hospital in Argentina. METHODS: Single-blinded randomized controlled trial. Usual care treatment arm: all procedures performed during hospitalization were overseen by a senior internal medicine specialist and complied with pre-defined protocols. Patients had access to specialist care if needed, as well as hospital-at-home or home-based primary care services after discharge. Intervention treatment arm: in addition to usual care, a geriatric co-management team performed a comprehensive geriatric assessment during hospitalization, provided tailored recommendations to minimize geriatric syndromes and planned transition of care. A health and social care counselor oversaw continuity of care in patients' homes after discharge. RESULTS: We included 120 participants in each of the intervention and usual care (control) arms. Thirty-day hospital readmissions were 47.7% lower in the intervention arm (18.3% vs 35.0%; P = 0.040); and emergency room visits within the first 6 months after discharge were 27.8% lower (43.3% vs 60.0%; P = 0.010). There was a non-statistically significant decrease in 6-month mortality in the intervention arm (25.0% vs 35.0%; P = 0.124). CONCLUSION: Geriatric co-management of frail older patients during hospitalization combined with an interdisciplinary transitional care intervention reduced 30-day hospital readmissions and emergency visits 6 months after discharge. TRIAL REGISTRATION NUMBER: Trial registration number: RENIS IS003081.

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In this retrospective cohort study in Argentina, risk factors for hospital readmission of older adults, within 72 hours after hospital discharge with home care services, were analyzed. Fifty-three percent of unplanned emergency room visits within 72 hours after hospital discharge resulted in hospital readmissions, 65% of which were potentially avoidable. By multivariate logistic regression, low functionality, pressure ulcers, and age over 83 years predicted hospital readmission among emergency room attendees. It is important to identify and analyze barriers in current home care services and the high-risk population of hospital readmission to improve the strategies to avoid adverse outcomes.

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BACKGROUND: Venous thromboembolic disease (VTE) is higher among patients with cancer. For those undergoing abdominal or pelvic surgery for cancer, it is suggested to extend thromboprophylaxis during 4 weeks with low-molecular-weight heparin over limited-duration of 7 days. There is no published local data from our country about compliance with recommended guidelines of extended prophylaxis (EP) in patients with cancer undergoing surgical procedures. Our aim was to evaluate the adherence rate to extended pharmacological thromboprophylaxis after abdominal-pelvic surgery for cancer, before and after an educational intervention program (EIP) geared toward surgeons. METHODS: Prospective cross-sectional study before and after an EIP aimed for surgeons. All consecutive patients older than 65 years who underwent surgery for abdominal-pelvic neoplasm, at the Hospital Italiano de Buenos Aires, Argentina, between September 2013 and May 2014, were evaluated for inclusion. RESULTS: A total of 120 patients were included, 60 before and 60 after the EIP aimed for surgeons. None of the initial 60 patients received EP, while 13 (21.6%) of 60 patients received prophylaxis for 28 days (all with colon or rectal cancer) after the intervention. There were no bleeding or death during 90 days of follow-up, and there were 7 of 120 VTE events, none in the group receiving extended thromboprophylaxis. CONCLUSION: The EIP for the surgical team significantly improved their adherence but only in the colon-rectal surgeries. The adherence to the recommended guidelines is still low. Reasons could be the subjective perception of elevated bleeding risk and the variable grade of recommendation in different guidelines.

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The venous thromboembolic disease (VTD) in adults has a high morbidity and mortality. It can be also associated to disabling chronic conditions. In spite of this, prophylaxis in healthcare assistance is still underused. In this article, the available evidence in thromboprophylaxis was analyzed to offer recommendations (1) or suggestions (2) classified according to different levels of evidence (A, B or C). Different medical scenarios and types of thromboprophylaxis were analyzed. In major orthopedic surgeries low molecular weight heparins, LMWH, inhibitors of the Xa and IIa factors are recommended (1B) to be started during hospitalization and continued for 35 days in hip replacement surgery and for 10 days in total knee replacement surgery. Knee arthroscopy and spine surgery do not require pharmacologic treatment (2B) unless the patient has other risks factors for thrombosis. In such cases, LMWH are recommended. Non-surgical patients who have at least one risk factor should receive LMWH, NFH or fondaparinux (1B) if they are to be bedridden or unable to walk for three or more days. Patients undergoing neurosurgery or with intracranial hemorrhage should receive mechanic prophylaxis (2C), and accordingly they should start LMWH or NFH 24 to 72 hours afterwards (2C). The latter two drugs are recommended for critically ill patients. Patients with low risk for VTD undergoing other type of surgeries should be prescribed with mechanical prophylaxis (2C) and encouraged to walk promptly (2C), while those with high risk should be prescribed with LMWH or NFH (1B or 2C according to bleeding risk factors).

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La enfermedad tromboembólica venosa (ETV) en adultos posee elevada morbimortalidad y puede asociarse a complicaciones crónicas invalidantes. Sin embargo, la adherencia a estándares de cuidado no es óptima. Se analizó la evidencia disponible en tromboprofilaxis y se generaron recomendaciones (1) o sugerencias (2) con diferentes grados de evidencia (A, B o C) para diferentes escenarios y métodos de tromboprofilaxis. En cirugías ortopédicas mayores se recomienda la profilaxis farmacológica con heparinas de bajo peso molecular, HBPM (1B), fondaparinux, dabigatrán y rivaroxaban (1B) que deben iniciarse durante la internación y mantenerse hasta 35 días después de la cirugía de cadera y hasta 10 días posteriores a la artroplastia de rodilla. La artroscopia de rodilla y la cirugía de columna programada no requieren profilaxis farmacológica (2B) salvo que posean factores de riesgo adicionales, en cuyo caso se recomiendan las HBPM. En pacientes con internación clínica y movilidad reducida esperable mayor a tres días, que posean factores de riesgo adicionales, se recomienda tromboprofilaxis con HBPM, HNF o fondaparinux (1B) hasta el alta. Aquellos pacientes neuroquirúrgicos o con HIC deberán recibir inicialmente tromboprofilaxis mecánica (2C) y dependiendo del caso, iniciar HBPM o HNF entre las 24-72 horas posteriores (2C). Estas últimas dos drogas son recomendadas para pacientes críticos. Los pacientes sometidos a cirugías no ortopédicas con bajo riesgo de ETV deberán realizar deambulación precoz (2C) y tromboprofilaxis mecánica (2C), mientras que aquellos en los que el riesgo de ETV sea elevado deberán recibir HBPM y HNF (1B o 2C según su riesgo de sangrado).

The venous thromboembolic disease (VTD) in adults has a high morbidity and mortality. It can be also associated to disabling chronic conditions. In spite of this, prophylaxis in healthcare assistance is still underused. In this article, the available evidence in thromboprophylaxis was analyzed to offer recommendations (1) or suggestions (2) classified according to different levels of evidence (A, B or C). Different medical scenarios and types of thromboprophylaxis were analyzed. In major orthopedic surgeries low molecular weight heparins, LMWH, inhibitors of the Xa and IIa factors are recommended (1B) to be started during hospitalization and continued for 35 days in hip replacement surgery and for 10 days in total knee replacement surgery. Knee arthroscopy and spine surgery do not require pharmacologic treatment (2B) unless the patient has other risks factors for thrombosis. In such cases, LMWH are recommended. Non-surgical patients who have at least one risk factor should receive LMWH, NFH or fondaparinux (1B) if they are to be bedridden or unable to walk for three or more days. Patients undergoing neurosurgery or with intracranial hemorrhage should receive mechanic prophylaxis (2C), and accordingly they should start LMWH or NFH 24 to 72 hours afterwards (2C). The latter two drugs are recommended for critically ill patients. Patients with low risk for VTD undergoing other type of surgeries should be prescribed with mechanical prophylaxis (2C) and encouraged to walk promptly (2C), while those with high risk should be prescribed with LMWH or NFH (1B or 2C according to bleeding risk factors).

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La enfermedad tromboembólica venosa (ETV) en adultos posee elevada morbimortalidad y puede asociarse a complicaciones crónicas invalidantes. Sin embargo, la adherencia a estándares de cuidado no es óptima. Se analizó la evidencia disponible en tromboprofilaxis y se generaron recomendaciones (1) o sugerencias (2) con diferentes grados de evidencia (A, B o C) para diferentes escenarios y métodos de tromboprofilaxis. En cirugías ortopédicas mayores se recomienda la profilaxis farmacológica con heparinas de bajo peso molecular, HBPM (1B), fondaparinux, dabigatrán y rivaroxaban (1B) que deben iniciarse durante la internación y mantenerse hasta 35 días después de la cirugía de cadera y hasta 10 días posteriores a la artroplastia de rodilla. La artroscopia de rodilla y la cirugía de columna programada no requieren profilaxis farmacológica (2B) salvo que posean factores de riesgo adicionales, en cuyo caso se recomiendan las HBPM. En pacientes con internación clínica y movilidad reducida esperable mayor a tres días, que posean factores de riesgo adicionales, se recomienda tromboprofilaxis con HBPM, HNF o fondaparinux (1B) hasta el alta. Aquellos pacientes neuroquirúrgicos o con HIC deberán recibir inicialmente tromboprofilaxis mecánica (2C) y dependiendo del caso, iniciar HBPM o HNF entre las 24-72 horas posteriores (2C). Estas últimas dos drogas son recomendadas para pacientes críticos. Los pacientes sometidos a cirugías no ortopédicas con bajo riesgo de ETV deberán realizar deambulación precoz (2C) y tromboprofilaxis mecánica (2C), mientras que aquellos en los que el riesgo de ETV sea elevado deberán recibir HBPM y HNF (1B o 2C según su riesgo de sangrado).(AU)

The venous thromboembolic disease (VTD) in adults has a high morbidity and mortality. It can be also associated to disabling chronic conditions. In spite of this, prophylaxis in healthcare assistance is still underused. In this article, the available evidence in thromboprophylaxis was analyzed to offer recommendations (1) or suggestions (2) classified according to different levels of evidence (A, B or C). Different medical scenarios and types of thromboprophylaxis were analyzed. In major orthopedic surgeries low molecular weight heparins, LMWH, inhibitors of the Xa and IIa factors are recommended (1B) to be started during hospitalization and continued for 35 days in hip replacement surgery and for 10 days in total knee replacement surgery. Knee arthroscopy and spine surgery do not require pharmacologic treatment (2B) unless the patient has other risks factors for thrombosis. In such cases, LMWH are recommended. Non-surgical patients who have at least one risk factor should receive LMWH, NFH or fondaparinux (1B) if they are to be bedridden or unable to walk for three or more days. Patients undergoing neurosurgery or with intracranial hemorrhage should receive mechanic prophylaxis (2C), and accordingly they should start LMWH or NFH 24 to 72 hours afterwards (2C). The latter two drugs are recommended for critically ill patients. Patients with low risk for VTD undergoing other type of surgeries should be prescribed with mechanical prophylaxis (2C) and encouraged to walk promptly (2C), while those with high risk should be prescribed with LMWH or NFH (1B or 2C according to bleeding risk factors).(AU)

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Objetivos: determinar la prevalencia de conocimiento y consumo del cigarrillo electrónico (CE) en personas que asistieron, al menos una vez, a los consultorios del Programa de Control del Tabaco del Hospital Italiano de Buenos Aires para dejar de fumar.Métodos: estudio de corte transversal a través de encuestas administradas telefónicamente o por correo electrónico entre agosto y noviembre de 2011 a una muestra aleatorizada obtenida de la base de datos de quienes consultaron a dicho programa entre enero de 2008 y julio de 2011.Resultados: fueron invitadas 288 personas, de las cuales 81 completaron su encuesta (tasa de respuesta 31.7%). El 71.6% de los respondedores refirió tener conocimiento acerca del cigarrillo electrónico, pero el 74.1% desconocía si los organismos de salud aprobaron su consumo y si este dispositivo puede generarles algún riesgo o beneficio a su salud.Conclusiones: la mayoría de los encuestados desconoce la eficacia, la seguridad y la actual regulación de la comercialización del CE en la Argentina. Es necesario realizar investigaciones que permitan desarrollar un enfoque normativo basado en la evidencia.

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Objetivos: determinar la prevalencia de conocimiento y consumo del cigarrillo electrónico (CE) en personas que asistieron, al menos una vez, a los consultorios del Programa de Control del Tabaco del Hospital Italiano de Buenos Aires para dejar de fumar.Métodos: estudio de corte transversal a través de encuestas administradas telefónicamente o por correo electrónico entre agosto y noviembre de 2011 a una muestra aleatorizada obtenida de la base de datos de quienes consultaron a dicho programa entre enero de 2008 y julio de 2011.Resultados: fueron invitadas 288 personas, de las cuales 81 completaron su encuesta (tasa de respuesta 31.7%). El 71.6% de los respondedores refirió tener conocimiento acerca del cigarrillo electrónico, pero el 74.1% desconocía si los organismos de salud aprobaron su consumo y si este dispositivo puede generarles algún riesgo o beneficio a su salud.Conclusiones: la mayoría de los encuestados desconoce la eficacia, la seguridad y la actual regulación de la comercialización del CE en la Argentina. Es necesario realizar investigaciones que permitan desarrollar un enfoque normativo basado en la evidencia.(AU)

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Introducción: Las cirugías de reemplazo de cadera (RTC) y rodilla (RTR) requieren profilaxis extendida de la trombosis venosa profunda (TVP). Este estudio describe la utilización en la práctica clínica habitual de dabigatrán etexilato (DE) en adultos mayores con RTC y RTR en un sistema de hospitalización a domicilio. Material y métodos: Estudio descriptivo, retrospectivo de cohorte, incluye pacientes posquirúrgicos programados de RTC o RTR bajo cuidados domiciliarios, que recibieron DE (n = 76) o enoxaparina (n = 80). Se indicó DE usando los criterios de selección y dosificación de los estudios RE-NOVATE y RE-MODEL. Se incluyeron como controles históricos los pacientes con enoxaparina 40 mg/d cuando cumplían los mismos criterios de selección que los pacientes con DE. Se analizó la tasa de sangrados, TVP sintomática, reinternaciones y mortalidad durante los 90 días siguientes desde la cirugía. Resultados: Edad promedio del grupo DE 74 (5) años, 74% mujeres. No hubo diferencias significativas en la edad, sexo y tipo de reemplazo entre ambos grupos. Hubo 4 TVP en cada grupo (50% proximales), sin diferencias significativas entre los grupos. Hubo un tromboembolismo pulmonar en el grupo DE y un sangrado mayor en el de enoxaparina. No se produjo ninguna muerte durante el seguimiento (90 días), sin embargo, hubo 2 reinternaciones en el grupo DE. Se describen también los detalles sobre la implementación de DE en nuestra hospitalización a domicilio. Conclusiones: En adultos mayores adecuadamente seleccionados DE sería una opción efectiva de profilaxis para TVP en un sistema de hospitalización a domicilio en la práctica clínica habitual (AU)

Introduction: Hip replacement surgery (HRS) and knee replacement surgery (KRS) require long-term deep venous thrombosis (DVT) prophylaxis. This study describes dabigatran etexilate (DE) use in post-surgical older adults who underwent HRS and KRS in a clinical practice setting in a home-care system. Material and methods: A retrospective descriptive cohort study included elective HRS and KRS postsurgical older adults under home care receiving either DE (n=76) or enoxaparin (n=80). DE was indicated by using the same selection criteria and dosing as in the RE-MODEL and RE-NOVATE studies. The enoxaparin 40 mg/day patients were included as historic controls when they met the same selection criteria as DE patients. Symptomatic DVT, bleeding rate, re-admission rate and mortality during the 90-day postsurgical period were analyzed. Results: The mean age of the DE group was 74 (5) years old, with 74% females. There were no significant differences in age, gender and type of replacement between the two groups. There were four DVT in each group (50% proximal), with no significant differences found between groups. There was one pulmonary thromboembolism in the DE group, and one major bleeding in the enoxaparin group. There were no deaths during the 90-day follow-up; however, two re-hospitalizations occurred in the DE group. The details on introducing DE use in our home-care system are also described. Conclusions: In appropriately selected older adults DE seems to be an effective choice for DVT prophylaxis in home-care in a clinical practice setting (AU)

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INTRODUCTION: Hip replacement surgery (HRS) and knee replacement surgery (KRS) require long-term deep venous thrombosis (DVT) prophylaxis. This study describes dabigatran etexilate (DE) use in post-surgical older adults who underwent HRS and KRS in a clinical practice setting in a home-care system. MATERIAL AND METHODS: A retrospective descriptive cohort study included elective HRS and KRS postsurgical older adults under home care receiving either DE (n=76) or enoxaparin (n=80). DE was indicated by using the same selection criteria and dosing as in the RE-MODEL and RE-NOVATE studies. The enoxaparin 40 mg/day patients were included as historic controls when they met the same selection criteria as DE patients. Symptomatic DVT, bleeding rate, re-admission rate and mortality during the 90-day postsurgical period were analyzed. RESULTS: The mean age of the DE group was 74 (5) years old, with 74% females. There were no significant differences in age, gender and type of replacement between the two groups. There were four DVT in each group (50% proximal), with no significant differences found between groups. There was one pulmonary thromboembolism in the DE group, and one major bleeding in the enoxaparin group. There were no deaths during the 90-day follow-up; however, two re-hospitalizations occurred in the DE group. The details on introducing DE use in our home-care system are also described. CONCLUSIONS: In appropriately selected older adults DE seems to be an effective choice for DVT prophylaxis in home-care in a clinical practice setting.

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The venous thromboembolic disease (VTD) in adults has a high morbidity and mortality. It can be also associated to disabling chronic conditions. In spite of this, prophylaxis in healthcare assistance is still underused. In this article, the available evidence in thromboprophylaxis was analyzed to offer recommendations (1) or suggestions (2) classified according to different levels of evidence (A, B or C). Different medical scenarios and types of thromboprophylaxis were analyzed. In major orthopedic surgeries low molecular weight heparins, LMWH, inhibitors of the Xa and IIa factors are recommended (1B) to be started during hospitalization and continued for 35 days in hip replacement surgery and for 10 days in total knee replacement surgery. Knee arthroscopy and spine surgery do not require pharmacologic treatment (2B) unless the patient has other risks factors for thrombosis. In such cases, LMWH are recommended. Non-surgical patients who have at least one risk factor should receive LMWH, NFH or fondaparinux (1B) if they are to be bedridden or unable to walk for three or more days. Patients undergoing neurosurgery or with intracranial hemorrhage should receive mechanic prophylaxis (2C), and accordingly they should start LMWH or NFH 24 to 72 hours afterwards (2C). The latter two drugs are recommended for critically ill patients. Patients with low risk for VTD undergoing other type of surgeries should be prescribed with mechanical prophylaxis (2C) and encouraged to walk promptly (2C), while those with high risk should be prescribed with LMWH or NFH (1B or 2C according to bleeding risk factors).

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The venous thromboembolic disease (VTD) in adults has a high morbidity and mortality. It can be also associated to disabling chronic conditions. In spite of this, prophylaxis in healthcare assistance is still underused. In this article, the available evidence in thromboprophylaxis was analyzed to offer recommendations (1) or suggestions (2) classified according to different levels of evidence (A, B or C). Different medical scenarios and types of thromboprophylaxis were analyzed. In major orthopedic surgeries low molecular weight heparins, LMWH, inhibitors of the Xa and IIa factors are recommended (1B) to be started during hospitalization and continued for 35 days in hip replacement surgery and for 10 days in total knee replacement surgery. Knee arthroscopy and spine surgery do not require pharmacologic treatment (2B) unless the patient has other risks factors for thrombosis. In such cases, LMWH are recommended. Non-surgical patients who have at least one risk factor should receive LMWH, NFH or fondaparinux (1B) if they are to be bedridden or unable to walk for three or more days. Patients undergoing neurosurgery or with intracranial hemorrhage should receive mechanic prophylaxis (2C), and accordingly they should start LMWH or NFH 24 to 72 hours afterwards (2C). The latter two drugs are recommended for critically ill patients. Patients with low risk for VTD undergoing other type of surgeries should be prescribed with mechanical prophylaxis (2C) and encouraged to walk promptly (2C), while those with high risk should be prescribed with LMWH or NFH (1B or 2C according to bleeding risk factors).

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La morbimortalidad asociada a este evento genera ôexceso de mortalidadõ, dependencia, internación en geriátricos y altos costos en los diferentessistemas de salud. El tratamiento de la osteoporosis ha demostrado una disminución de la incidencia de nuevas fracturas y de la tasa de mortalidad.Un bajo porcentaje de la población con fracturas de cadera recibe tratamiento para osteoporosis. Los programas destinados al tratamiento de estospacientes muestran mejoría en las tasas de morbimortalidad. En nuestro hospital un 27% de la población con fractura de cadera recibe tratamiento.El objetivo de este protocolo es implementar un programa multidisciplinario que integra el tratamiento de la osteoporosis, la prevención de las caídas y la seguridad en el hogar para lograr disminuir las tasas de nuevas fracturas, internaciones y mortalidad.Este artículo explicita las intervenciones durante la internación, en domicilio y en el seguimiento ambulatorio. Detalla además la participación delos distintos equipos profesionales.

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Mortalidad a largo plazo y factores predictores en pacientes con fractura de cadera.El objetivo de este estudio fue determinar la mortalidad a largo plazo y los factores que la predicen en pacientes con fractura de cadera. De un estudio de cohorte ambidireccional realizado, se identificaron pacientes pertenecientes a un sistema cerrado de salud, internados por una fractura de cadera durante el año 2006. Se observó a esta población desde la fecha de la fractura hasta la muerte o el 1º de julio de 2009. Asimismo, se determinó la mortalidad y se analizaron los factores que predicen muerte, mediante el método de Kaplan-Meier y el modelo de riesgos proporcionales de Cox. Se incluyeron 124 pacientes (edad promedio de 79,4±8,7 años; 78,5% mujeres) y el tiempo de seguimiento promedio fue 2,33±0,089 años, siendo la pérdida de casos de un 1,6% durante el período. El 16,2% de la población falleció al año y 25,8% durante el seguimiento. La mortalidad difirió entre hombres y mujeres, siendo mayor en hombres, (30,8 vs. 24,5%) durante todo el período. Se identificaron como factores predisponentes independientes de muerte: la edad por año de incremento (HR 1,07, p=0,027), la demencia (HR 2,34, p<0,001 ) y la enfermedad coronaria (HR 2,94, p<0,001). El evento fractura de cadera disminuyó la sobrevida de la población estudiada a mediano y largo plazo.

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