Resumen de Úlceras cutáneas en pacientes oncológicos con cuidados paliativos de soporte domiciliario
- español
INTRODUCCIÓN. Los Cuidados Paliativos tienen como objetivo mejorar la calidad de vida de los pacientes con patologías oncológicas y no oncológicas en su fase terminal y de sus familiares. La ulceración cutánea (UC), es un problema de salud que afecta a los enfermos que precisan entre otros cuidados, los de soporte domiciliario de cuidados paliativos, agravando su estado e incrementando la carga de cuidados, tanto del personal sanitario como de sus familiares.
OBJETIVO. Conocer la prevalencia e incidencia de las UC en pacientes con patología oncológica terminal atendidos por un equipo de soporte domiciliario y los factores que influyen en su aparición. Estimar el tiempo de supervivencia de estos pacientes y los posibles factores pronósticos.
METODOLOGÍA. Se realiza un estudio de cohortes retrospectivo en pacientes diagnosticados de patología oncológica, tratados por un Equipo de Soporte de Atención Domiciliaria (ESAD) urbano; incluyéndose a todos los pacientes atendidos durante tres años (2010-2012). Se analizaron diversas variables como la presencia de UC, Palliative Performance Scale (PPS), Escala Norton, Escala de Control Nutricional (CONUT) y otras variables que pueden causar deterioro de la piel. Para comparar los diferentes grupos se realizaron múltiples análisis bivariantes (chi-cuadrado, test exacto de Fisher, t de student o U de Mann Whitney). Se estimaron los Odds Ratio (OR) para las variables relacionadas con la prevalencia y los Hazard Ratio (HR) para las relacionadas con incidencia y supervivencia. Se realizaron diversos modelos multivariantes (Regresión Logística y Regresión de Cox) para ajustar los posibles factores de confusión.
RESULTADOS. Se analizaron 510 pacientes (57% hombres y edad media de 72 años). La mediana de seguimiento fue de 24 días, falleciendo un 20% de ellos durante la primera semana tras la derivación. La prevalencia de las UC fue del 37,6% con un IC 95% [34,1%-41,9%], siendo la mayoría de las UC de grado superficial y, en alrededor de un 85 % fueron por decúbito. Se asoció con la presencia de UC: la patología oncológica (p= 0,002), siendo los tumores dermatológicos aquellos que mostraron mayor UC, y la escala Norton (p< 0,001). La incidencia fue del 24,3% con un IC 95% [20,2% - 28,4%] y se asoció durante el tiempo de seguimiento con la presencia de antecedente de sepsis, HR de 2,9, IC 95% [1,1?8,03], (p= 0,01), la escala PPS, HR de 3,2, IC 95% [1,3-8,01], (p= 0,01) y la escala CONUT HR 2,4, IC 95% [1,2?4,9], (p= 0,02). Aquellos pacientes que al ingreso en el ESAD presentaban UC se asociaron con una corta supervivencia. Tiempos largos de seguimiento favorecen la aparición de UC, pero desde el momento de su aparición, disminuye de forma importante el tiempo de supervivencia (p< 0,001). Otras variables que mostraron relación con la supervivencia fueron: la patología oncológica (p= 0,01), siendo los tumores dermatológicos aquellos que presentaron una supervivencia menor; la escala Norton (p< 0,001) y la escala CONUT (p= 0,03).
CONCLUSIONES. Los pacientes derivados al ESAD muestran similares características en cuanto a patología oncológica, género y edad que la población general atendida en otros ámbitos. Uno de los criterios de derivación, es un tiempo estimado de supervivencia inferior a seis meses; en la práctica, la derivación se realiza tardíamente, en estados muy avanzados de la enfermedad. La prevalencia de UC es muy elevada, apareciendo la mayoría de ellas durante seguimiento por el ESAD, presentando una mortalidad precoz tras su aparición. La presencia de UC se relacionó con el tipo de patología oncológica y la escala Norton. La aparición de UC durante el seguimiento por el ESAD se asoció con el antecedente de episodio séptico, la escala PPS y la escala CONUT. El tipo de enfermedad oncológica, la escala Norton y el riesgo de desnutrición (puntuación CONUT), se asociaron con el tiempo de supervivencia durante el seguimiento.
- English
INTRODUCTION. The goal of palliative care is to improve the quality of life of patients who have a serious or life-threatening disease, such as cancer, and their families, during the terminal phase of the illness, combining physical, psychological and spiritual aspects in order to manage the symptoms so that patients may live as actively as possible until death. Cutaneous ulcerations (UC) are a health problem which affects patients who need home support. It may aggravate their prognosis and increase the care load, both for the palliative care specialists and the patient´s families.
OBJECTIVE. The objective of this study is to find out the incidence and prevalence rate of cutaneous ulcerations in terminal cancer patients being supported at home by a palliative care team, and the factors which influence their appearance. As well as estimating the survival time of those patients, and the possible prognostic factors.
METHODS. A three year retrospective cohort study in patients diagnosed with cancer in treatment by an urban Palliative Home Care Team (ESAD) was carried out between the years 2010 and 2012. Different variables were analyzed such us presence of UC (degree of altered skin integrity, etiology of UC), Palliative Performance Scale (PPS), Norton Scale, the tool for Controlling Nutritional Status (CONUT) and several other variables that may cause skin deterioration, such as previous history of: Diabetes Mellitus, Cerebrovascular Accident, Chronic Venous Insufficiency, sepsis and previous treatment with cytostatic drugs. Qualitative variables were described using absolute and relative frequencies and quantitative variables using the mean and standard deviation or median and interquartile range depending on the density function of the frequency distribution. To compare different groups multiple bivariate analysis using chi-square, Fisher exact test, Student t test or Mann Whitney were performed. The odds ratio of the variables related to the prevalence, and Hazard Ratio of variables related to the incidence and survival, along with confidence intervals of 95% were estimated. Various multivariate models (logistic regression and Cox regression) were performed to adjust for potential confounders.
RESULTS. A total of 510 patients were included in the study, of which 57% were male and the average age was 72. The median follow-up was 24 days. 20% of the patients died within a week of being referred to palliative care, and almost 90% of them presented a PPS equal to or less than 50. There was a prevalence of cutaneous ulcerations in 37.6% of cases 95% CI [34,1% – 41,9%]. Most of the cutaneous ulcerations were superficial, and about 85% of the patients presented pressure ulcers. The following factors were linked to the presence of skin ulcers: cancer patients (p= 0,002), of whom the patients affected by skin tumors presented skin ulcers more frequently, and the Norton Scale (p< 0,001), where the lower the score, the greater the development of skin ulcers. The incidence was 24,3%, 95% CI [20,1 – 28,4%] and was associated during the follow-up time with the presence of previous history of sepsis HR de 2,9, IC 95% [1,1 – 8,03], (p= 0,01), the PPS scale HR de 3,2, IC 95% [1,3 - 8,01], (p= 0,01) and the CONUT scale, where higher punctuation, increased risk of skin ulceration, HR 2,4, IC 95% [1,2 – 4,9], (p=0,02). Those patients who presented skin ulcers upon admission to the Palliative Home Care Team had a short survival time. Long follow-up periods increase the incidence of skin ulcers. However, from the moment they appear, the survival time of the patients decreases greatly (p< 0,001). The other factors related to survival time were: cancer patients, of whom those patients affected by skin tumors presented a shorter survival time during the period of home care, and brain tumors, whose patients had a longer survival time; the Norton Scale (p< 0,001), where the higher the risk of skin ulcers, as established by such Scale, the shorter the survival time; and the CONUT scale, which showed that patients with a higher risk of malnutrition presented a shorter survival time.
CONCLUSIONS. The patients referred to the ESAD show similar characteristics with regard to cancerous diseases, gender and age as the rest of the population in general, but patients are included too late in palliative care. The prevalence of UC is very high, appearing most of them during admission in the ESAD and causing premature mortality after their appearance. The presence of UC was associated with the type of cancer pathology and the Norton scale. The appearance of UC during follow the ESAD was associated with: a history of sepsis episode, the PPS, CONUT scale and Norton scale. The type of cancer disease, the Norton scale and risk of malnutrition (CONUT scale) were associated with survival period during follow-up time.
