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with the higher scores associated with a low risk of developing pressure ulcers&#46; The final coding of the Norton scale is as follows&#58; very high risk &#40;fewer than 10 points&#41;&#44; high risk &#40;between 10 and 14 points&#41;&#44; moderate risk &#40;between 14 and 18 points&#41; and low risk &#40;more than 18 points&#41;&#46; The Norton scale is well known and is typically applied by nursing staff to assess at-risk patients and establish preventive measures&#46; A recent study evaluated the interobserver concordance of the various domains included in the Norton scale&#46; Among the factors included in the Norton scale&#44; 3 had substantial interobserver variability&#44; 1 had moderate interobserver variability and 1 had very high interobserver variability&#46; However&#44; the overall interobserver concordance in terms of the risk assessment was very high&#44; with a mean value of 0&#46;97 &#40;95&#37; confidence interval &#91;CI&#93; 0&#46;94&#8211;0&#46;98&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The study presented by Diez-Manglano used the Norton scale as a prognostic factor&#44; not for the development of pressure ulcers but rather as a predictor of mortality in patients hospitalized in the internal medicine department&#46; The study included a total of 714 patients hospitalized in a tertiary university hospital and had a 3-year follow-up&#46; The Norton scale showed good predictive capacity for mortality at 1 year&#44; measured by an area under the curve &#40;AUC&#41; of the receiver operating characteristic of 0&#46;76&#46; The study used the assessment of the Norton scale performed by the nursing staff&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">It is well known that socioeconomic advances&#44; technological innovations and improvements in healthcare have increased the population&#39;s life expectancy&#46; As a result&#44; there has been an increase in the rates of patients with chronic disease&#46; Internal medicine departments in Spain currently treat approximately 19&#37; of the population admitted to hospitals&#46; This population is characterized by a mean age of 74 years and a high Charlson comorbidity index&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Since most of these patients have several chronic diseases and a wide range of disability&#44; predicting mortality has considerable significance&#44; because many patients could benefit from an early start of palliative care and social support measures&#46; However&#44; it is not easy for clinicians or managers to identify the start of the terminal phase of a chronic disease&#46; Therefore&#44; patients often undergo unnecessary diagnostic tests and futile treatments&#46; In many cases&#44; the lines between compliance with clinical practice guidelines&#44; nihilism and good clinical practice are difficult to establish&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the last decade&#44; several mortality prediction rules for complex chronic patients have been published&#46; A number of these well-known rules have been published by investigators for the Spanish Society of Internal Medicine and include the PALIAR and PROFUND indices&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#44;6</span></a> For both indices&#44; the patient cohorts included in the studies showed a mortality rate between 35&#37; and 40&#37; during the follow-up&#46; The PALIAR index estimated the mortality at 6 months of 1778 complex chronic patients&#44; and its predictive capacity measured by the AUC was 0&#46;69&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> The PROFUND index estimated the mortality at 1 year of 1632 chronically ill patients and showed a predictive capacity measured by an AUC of 0&#46;73&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> The PROFUND index has been externally validated&#44; and its prognostic capacity has been confirmed&#44; both for patients hospitalized in internal medicine departments<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> and those in cardiology departments&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> The PALIAR and PROFUND indices have the advantage of being developed in Spain and are therefore applicable to the Spanish health system&#46; Although the interobserver assessment of the 2 indices has not been explicitly evaluated&#44; the variables that make up the 2 indices allow for an objective quantification&#46; More recently&#44; Sakhnini et al&#46; published an index that predicts the hospital mortality of patients hospitalized in internal medicine departments&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> The hospital mortality in the study was 7&#46;1&#37;&#46; The prediction model was developed based on a cohort of 7268 patients and confirmed in an independent cohort of 7843 patients treated in a university hospital in Israel&#46; The prediction model used objective&#44; easy-to-collect variables&#44; such as age&#44; mean blood pressure&#44; body mass index&#44; history of hospitalization in the past 3 months&#44; presence of chronic disease &#40;heart failure or cancer&#41; and the use of particular drugs &#40;statins and antiplatelet agents&#41;&#46; The model&#39;s AUC in the independent validation cohort was 0&#46;81&#46; The authors highlighted as limitations of the study that their model was based on retrospective data and that it lacked external validation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">As reported by Diez-Manglano et al&#46; in the present study&#44; the Norton index can be calculated with high reproducibility&#44; both by nursing staff and by physicians&#44; and conducting the index takes no more than 1&#8211;2<span class="elsevierStyleHsp" style=""></span>min&#46; The mortality observed by Diez-Manglano et al&#46; during the hospitalization&#44; at 6 months and at 1 year was 11&#46;9&#37;&#44; 28&#46;2&#37; and 34&#37;&#44; respectively&#46; The Norton index&#39;s capacity for predicting mortality during hospitalization&#44; at 6 months and at 1 year had AUCs of 0&#46;75&#44; 0&#46;74 and 0&#46;76&#44; respectively&#46; These AUC values help confirm that the Norton index is an easy-to-apply tool that is often available in the nursing records and is reliable for predicting the vital prognosis of complex chronic patients hospitalized in internal medicine departments&#46; The association between a low score on the Norton index and an increased risk of mortality has also been confirmed by Leshem-Rubino et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> in a study conducted in an Israeli hospital&#44; which included a population of 259 patients with a mean age of 81 years&#46; The hospital mortality was 3&#46;9&#37;&#44; and the mortality at 1 year was 28&#46;6&#37;&#46; Unfortunately&#44; the authors did not assess the prognostic capacity of the Norton index with a receiver operating curve&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The Norton index has also been shown to be a valid prognostic index for predicting mortality in patients with acute myocardial infarction&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> those who undergo transcatheter aortic valve implantation<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> and those who have undergone leg amputations&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> The Norton index has also been used to predict the risk of falls for patients who have experienced hip fractures<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> and to determine the intensity and duration of rehabilitation for patients who have had a stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ena J&#46; Escala de Norton y pron&#243;stico vital&#46; Rev Clin Esp&#46; 2018&#59;218&#58;185&#8211;186&#46;</p>"
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Editorial
Norton scale and vital prognosis
Escala de Norton y pronóstico vital
J. Ena
Servicio de Medicina Interna, Hospital Marina Baixa, Villajoyosa, Alicante, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In this issue of <span class="elsevierStyleItalic">Revista Cl&#237;nica Espa&#241;ola</span>&#44; Diez-Manglano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> published the validity results of the Norton scale for predicting the short&#44; medium and long-term mortality of patients hospitalized in an internal medicine department&#46; The Norton scale was created by Doreen Norton in 1962<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> as a tool to predict the risk of developing pressure ulcers in elderly hospitalized patients&#46; The Norton scale evaluates 5 factors&#58; physical state&#44; mental state&#44; activity&#44; mobility and incontinence&#44; each of which is scored from 1 &#40;very poor&#41; to 4 &#40;very good&#41; points&#46; The total score ranges from 5 to 20 points&#44; with the higher scores associated with a low risk of developing pressure ulcers&#46; The final coding of the Norton scale is as follows&#58; very high risk &#40;fewer than 10 points&#41;&#44; high risk &#40;between 10 and 14 points&#41;&#44; moderate risk &#40;between 14 and 18 points&#41; and low risk &#40;more than 18 points&#41;&#46; The Norton scale is well known and is typically applied by nursing staff to assess at-risk patients and establish preventive measures&#46; A recent study evaluated the interobserver concordance of the various domains included in the Norton scale&#46; Among the factors included in the Norton scale&#44; 3 had substantial interobserver variability&#44; 1 had moderate interobserver variability and 1 had very high interobserver variability&#46; However&#44; the overall interobserver concordance in terms of the risk assessment was very high&#44; with a mean value of 0&#46;97 &#40;95&#37; confidence interval &#91;CI&#93; 0&#46;94&#8211;0&#46;98&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The study presented by Diez-Manglano used the Norton scale as a prognostic factor&#44; not for the development of pressure ulcers but rather as a predictor of mortality in patients hospitalized in the internal medicine department&#46; The study included a total of 714 patients hospitalized in a tertiary university hospital and had a 3-year follow-up&#46; The Norton scale showed good predictive capacity for mortality at 1 year&#44; measured by an area under the curve &#40;AUC&#41; of the receiver operating characteristic of 0&#46;76&#46; The study used the assessment of the Norton scale performed by the nursing staff&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">It is well known that socioeconomic advances&#44; technological innovations and improvements in healthcare have increased the population&#39;s life expectancy&#46; As a result&#44; there has been an increase in the rates of patients with chronic disease&#46; Internal medicine departments in Spain currently treat approximately 19&#37; of the population admitted to hospitals&#46; This population is characterized by a mean age of 74 years and a high Charlson comorbidity index&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Since most of these patients have several chronic diseases and a wide range of disability&#44; predicting mortality has considerable significance&#44; because many patients could benefit from an early start of palliative care and social support measures&#46; However&#44; it is not easy for clinicians or managers to identify the start of the terminal phase of a chronic disease&#46; Therefore&#44; patients often undergo unnecessary diagnostic tests and futile treatments&#46; In many cases&#44; the lines between compliance with clinical practice guidelines&#44; nihilism and good clinical practice are difficult to establish&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the last decade&#44; several mortality prediction rules for complex chronic patients have been published&#46; A number of these well-known rules have been published by investigators for the Spanish Society of Internal Medicine and include the PALIAR and PROFUND indices&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#44;6</span></a> For both indices&#44; the patient cohorts included in the studies showed a mortality rate between 35&#37; and 40&#37; during the follow-up&#46; The PALIAR index estimated the mortality at 6 months of 1778 complex chronic patients&#44; and its predictive capacity measured by the AUC was 0&#46;69&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> The PROFUND index estimated the mortality at 1 year of 1632 chronically ill patients and showed a predictive capacity measured by an AUC of 0&#46;73&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> The PROFUND index has been externally validated&#44; and its prognostic capacity has been confirmed&#44; both for patients hospitalized in internal medicine departments<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> and those in cardiology departments&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> The PALIAR and PROFUND indices have the advantage of being developed in Spain and are therefore applicable to the Spanish health system&#46; Although the interobserver assessment of the 2 indices has not been explicitly evaluated&#44; the variables that make up the 2 indices allow for an objective quantification&#46; More recently&#44; Sakhnini et al&#46; published an index that predicts the hospital mortality of patients hospitalized in internal medicine departments&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> The hospital mortality in the study was 7&#46;1&#37;&#46; The prediction model was developed based on a cohort of 7268 patients and confirmed in an independent cohort of 7843 patients treated in a university hospital in Israel&#46; The prediction model used objective&#44; easy-to-collect variables&#44; such as age&#44; mean blood pressure&#44; body mass index&#44; history of hospitalization in the past 3 months&#44; presence of chronic disease &#40;heart failure or cancer&#41; and the use of particular drugs &#40;statins and antiplatelet agents&#41;&#46; The model&#39;s AUC in the independent validation cohort was 0&#46;81&#46; The authors highlighted as limitations of the study that their model was based on retrospective data and that it lacked external validation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">As reported by Diez-Manglano et al&#46; in the present study&#44; the Norton index can be calculated with high reproducibility&#44; both by nursing staff and by physicians&#44; and conducting the index takes no more than 1&#8211;2<span class="elsevierStyleHsp" style=""></span>min&#46; The mortality observed by Diez-Manglano et al&#46; during the hospitalization&#44; at 6 months and at 1 year was 11&#46;9&#37;&#44; 28&#46;2&#37; and 34&#37;&#44; respectively&#46; The Norton index&#39;s capacity for predicting mortality during hospitalization&#44; at 6 months and at 1 year had AUCs of 0&#46;75&#44; 0&#46;74 and 0&#46;76&#44; respectively&#46; These AUC values help confirm that the Norton index is an easy-to-apply tool that is often available in the nursing records and is reliable for predicting the vital prognosis of complex chronic patients hospitalized in internal medicine departments&#46; The association between a low score on the Norton index and an increased risk of mortality has also been confirmed by Leshem-Rubino et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> in a study conducted in an Israeli hospital&#44; which included a population of 259 patients with a mean age of 81 years&#46; The hospital mortality was 3&#46;9&#37;&#44; and the mortality at 1 year was 28&#46;6&#37;&#46; Unfortunately&#44; the authors did not assess the prognostic capacity of the Norton index with a receiver operating curve&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The Norton index has also been shown to be a valid prognostic index for predicting mortality in patients with acute myocardial infarction&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> those who undergo transcatheter aortic valve implantation<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> and those who have undergone leg amputations&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> The Norton index has also been used to predict the risk of falls for patients who have experienced hip fractures<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> and to determine the intensity and duration of rehabilitation for patients who have had a stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ena J&#46; Escala de Norton y pron&#243;stico vital&#46; Rev Clin Esp&#46; 2018&#59;218&#58;185&#8211;186&#46;</p>"
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Article information
ISSN: 22548874
Original language: English
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