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"textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In this issue of <span class="elsevierStyleItalic">Revista Clínica Española</span>, Diez-Manglano et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> published the validity results of the Norton scale for predicting the short, medium and long-term mortality of patients hospitalized in an internal medicine department. 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. The Norton scale evaluates 5 factors: physical state, mental state, activity, mobility and incontinence, each of which is scored from 1 (very poor) to 4 (very good) points. The total score ranges from 5 to 20 points, with the higher scores associated with a low risk of developing pressure ulcers. The final coding of the Norton scale is as follows: very high risk (fewer than 10 points), high risk (between 10 and 14 points), moderate risk (between 14 and 18 points) and low risk (more than 18 points). The Norton scale is well known and is typically applied by nursing staff to assess at-risk patients and establish preventive measures. A recent study evaluated the interobserver concordance of the various domains included in the Norton scale. Among the factors included in the Norton scale, 3 had substantial interobserver variability, 1 had moderate interobserver variability and 1 had very high interobserver variability. However, the overall interobserver concordance in terms of the risk assessment was very high, with a mean value of 0.97 (95% confidence interval [CI] 0.94–0.98).<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, not for the development of pressure ulcers but rather as a predictor of mortality in patients hospitalized in the internal medicine department. The study included a total of 714 patients hospitalized in a tertiary university hospital and had a 3-year follow-up. The Norton scale showed good predictive capacity for mortality at 1 year, measured by an area under the curve (AUC) of the receiver operating characteristic of 0.76. The study used the assessment of the Norton scale performed by the nursing staff.</p><p id="par0015" class="elsevierStylePara elsevierViewall">It is well known that socioeconomic advances, technological innovations and improvements in healthcare have increased the population's life expectancy. As a result, there has been an increase in the rates of patients with chronic disease. Internal medicine departments in Spain currently treat approximately 19% of the population admitted to hospitals. This population is characterized by a mean age of 74 years and a high Charlson comorbidity index.<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, predicting mortality has considerable significance, because many patients could benefit from an early start of palliative care and social support measures. However, it is not easy for clinicians or managers to identify the start of the terminal phase of a chronic disease. Therefore, patients often undergo unnecessary diagnostic tests and futile treatments. In many cases, the lines between compliance with clinical practice guidelines, nihilism and good clinical practice are difficult to establish.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the last decade, several mortality prediction rules for complex chronic patients have been published. 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.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5,6</span></a> For both indices, the patient cohorts included in the studies showed a mortality rate between 35% and 40% during the follow-up. The PALIAR index estimated the mortality at 6 months of 1778 complex chronic patients, and its predictive capacity measured by the AUC was 0.69.<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 0.73.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> The PROFUND index has been externally validated, and its prognostic capacity has been confirmed, both for patients hospitalized in internal medicine departments<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> and those in cardiology departments.<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. Although the interobserver assessment of the 2 indices has not been explicitly evaluated, the variables that make up the 2 indices allow for an objective quantification. More recently, Sakhnini et al. published an index that predicts the hospital mortality of patients hospitalized in internal medicine departments.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> The hospital mortality in the study was 7.1%. 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. The prediction model used objective, easy-to-collect variables, such as age, mean blood pressure, body mass index, history of hospitalization in the past 3 months, presence of chronic disease (heart failure or cancer) and the use of particular drugs (statins and antiplatelet agents). The model's AUC in the independent validation cohort was 0.81. The authors highlighted as limitations of the study that their model was based on retrospective data and that it lacked external validation.</p><p id="par0025" class="elsevierStylePara elsevierViewall">As reported by Diez-Manglano et al. in the present study, the Norton index can be calculated with high reproducibility, both by nursing staff and by physicians, and conducting the index takes no more than 1–2<span class="elsevierStyleHsp" style=""></span>min. The mortality observed by Diez-Manglano et al. during the hospitalization, at 6 months and at 1 year was 11.9%, 28.2% and 34%, respectively. The Norton index's capacity for predicting mortality during hospitalization, at 6 months and at 1 year had AUCs of 0.75, 0.74 and 0.76, respectively. 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. 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.,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> in a study conducted in an Israeli hospital, which included a population of 259 patients with a mean age of 81 years. The hospital mortality was 3.9%, and the mortality at 1 year was 28.6%. Unfortunately, the authors did not assess the prognostic capacity of the Norton index with a receiver operating curve.</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,<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.<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.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p></span>"
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