Medical-legal aspects in infectious diseases. / Aspectos medicolegales en las enfermedades infecciosas.

This article reviews the medico-legal aspects associated with infectious diseases, highlighting their complexity and the challenges they pose. Infectious diseases cause not only an increase in morbidity and mortality in the healthcare setting but also involve complex legal issues. Healthcare-Associated Infections (HAIs) represent a growing risk with the increase in invasive procedures and can lead to patient complications and legal claims against healthcare professionals and institutions. The consequences of medical malpractice in this context are discussed, such as diagnostic delays, inappropriate use of treatments, and lack of adequate testing, which can have serious sequelae or even result in the patient's death. The review focuses on highlighting the importance of prevention, considering that healthcare-associated infections can be difficult to avoid, posing complex legal challenges. It concludes that managing infectious diseases and their legal consequences requires careful consideration of clinical practice guidelines, prevention and control strategies, and effective communication with patients. An integrated and evidence-based approach is advocated to address these challenges, emphasizing continuous education, the use of advanced diagnostic technologies, and interdisciplinary collaboration.

Antiviral treatment for SARS-CoV-2 infection in the current situation: a position paper of the Spanish Society of Emergency Medicine (SEMES). / Posicionamiento de la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) ante el tratamiento antiviral frente al SARS-CoV-2 en la situación epidemiológica actual.

SUMMARY: COVID-19 continues to pose a significant threat: mortality stands at nearly twice that of influenza, and the incidence rate is growing as the population's vaccination rate decreases, particularly in Spain and other areas of Europe. Given this situation, it is vitally important know whether medical protocols are consistent and appropriately implemented by health care staff in the interest of preventing possible inefficiency or inequity. Physicians from hospital emergency departments met to study their hospitals' usual clinical practices for managing SARS-CoV-2 infection and to determine their expert opinions on the use of antiviral agents. The participating physicians then reached consensus on evidencebased recommendations for strategies that would optimize emergency treatment.

RESUMEN: Actualmente, la COVID-19 sigue representando una amenaza significativa, con una mortalidad cercana al doble de la ocasionada por la gripe y con una incidencia variable debido a una disminución en la tasa de vacunación de la población, especialmente en el contexto europeo y español. Ante este panorama, es de vital importancia comprobar que los protocolos médicos están consolidados y son debidamente implementados por los profesionales sanitarios, con la finalidad de evitar posibles ineficiencias o inequidades. A través de reuniones con profesionales de urgencias se han observado las prácticas clínicas habituales en los servicios de urgencias hospitalarios para pacientes con infección por SARS-CoV-2, con la finalidad de comprender la perspectiva de estos profesionales acerca del uso de antivirales y, tras un consenso de expertos basados en la evidencia actual, se han generado estas de recomendaciones para poder enfocar estrategias que optimicen el tratamiento de los pacientes en estos servicios.

Diagnóstico y abordaje inicial del niño y adolescente con hipertensión arterial

La hipertensión arterial es uno de los factores de riesgo modificable involucrados en el desarrollo de la enfermedad cardiovascular (ECV). Si bien la prevalencia de HTA en niños es baja (alrededor de un 3.5%) en relación a la prevalencia en el adulto, algunos estudios sugieren que al iniciar en edades pediátricas el riesgo de ECV en la etapa adulta se incrementa, de modo que su detección y manejo temprano contribuiría a disminuir el riesgo de ECV en etapas más avanzadas de la vida. Dado que la ECV se ha constituido en las últimas décadas en la causa individual más frecuentes de morbilidad y mortalidad prematura en adultos a nivel mundial, algunas sociedades pediátricas como la Sociedad Europea de Hipertensión en Niños y Adolescentes (ESH), y la Academia Americana de Pediatría (AAP) se han hecho eco de iniciativas para el manejo de HTA, estableciendo guías prácticas clínicas para su diagnóstico y abordaje oportuEl presente artículo comprende una revisión de la literatura médica respecto a la hipertensión arterial en niños y adolescentes la cual resume las pautas útiles y actualizadas para la evaluación apropiada de la presión arterial y el abordaje inicial de la hipertensión arterial, lo cual incluye las definiciones, técnicas para el diagnóstico establecidas, así como el tratamiento inicial de la hipertensión arterial en niños y adolescentes. (provisto por Infomedic International)

Arterial hypertension is one of the modifiable risk factors involved in the development of cardiovascular disease (CVD). Although the prevalence of hypertension in children is low (around 3.5%) in relation to the prevalence in adults, some studies suggest that when it starts in pediatric age, the risk of CVD in adulthood increases, so that its early detection and management would contribute to reducing the risk of CVD in later stages of life. Given that CVD has become the most frequent single cause of morbidity and premature mortality in adults worldwide in recent decades, some pediatric societies such as the European Society of Hypertension in Children and Adolescents (ESH) and the American Academy of Pediatrics (AAP) have taken initiatives for the management of hypertension, establishing practical clinical guidelines for its diagnosis and timely management. The present article comprises a review of the medical literature regarding hypertension in children and adolescents that summarizes useful and up-to-date guidelines for appropriate blood pressure evaluation and initial management of hypertension, including definitions, established diagnostic techniques, and initial management of hypertension in children and adolescents. (provided by Infomedic International)

The Spanish Scientific Societies before the ESC 2021 guidelines on vascular disease prevention: Generalizing the measurement of albuminuria to identify vascular risk and prevent vascular disease.

The 2021 guidelines on the prevention of vascular disease (VD) in clinical practice published by the European Society of Cardiology (ESC) and supported by 13 other European scientific societies recognize the key role of screening for chronic kidney disease (CKD) in the prevention of VD. Vascular risk in CKD is categorized based on measurements of estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (ACR). Thus, moderate CKD is associated with a high vascular risk and severe CKD with a very high vascular risk requiring therapeutic action, and there is no need to apply other vascular risk scores when vascular risk is already very high due to CKD. Moreover, the ESC indicates that vascular risk assessment and the subsequent decision algorithm should start with measurement of eGFR and ACR. To optimize the implementation of the ESC 2021 guidelines on the prevention of CVD in Spain, we consider that: 1) Urine testing for albuminuria using ACR should be part of the clinical routine at the same level as blood glucose, cholesterolemia, and GFR estimation when these are used to make decisions on CVD risk. 2) Spanish public and private health services should have the necessary means and resources to optimally implement the ESC 2021 guidelines for the prevention of CVD in Spain, including ACR testing.

GALIPDIA study: Reaching lipid targets in a population with type 2 diabetes (T2DM) from the Northwest of Spain.

AIM: To assess the degree of compliance with the European ESC/EAS 2016 and 2019 dyslipidaemia guidelines in patients with type 2 diabetes mellitus (T2DM). METHODS: Multicentre retrospective cross-sectional study, conducted in 380 adults with T2DM and dyslipidaemia in 7 Spanish health areas. INCLUSION CRITERIA: minimum follow-up of one year in Endocrinology Units, at least one visit in 2020 and a lipid profile measurement in the last 3 months. EXCLUSION CRITERIA: familial hypercholesterolaemia, recent hospitalisation, active oncological pathology and dialysis. RESULTS: According to the 2016 and 2019 guidelines the majority of patients were classified as being at very high cardiovascular risk (86.8% vs. 72.1%, respectively). LDL-c compliance was adequate in 62.1% of patients according to the 2016 guidelines and 39.7% according to the 2019 guidelines (p<0.001). Clinical conditions such as history of cardiovascular disease and therapy-related aspects (use of statins, especially high-potency statins, combination therapies and good adherence) were significantly associated with greater achievement of lipid targets. CONCLUSION: There is a discrepancy between dyslipidaemia guideline recommendations and the reality of lipid control in patients with T2DM, despite most of these patients being at very high cardiovascular risk. Strategies to optimise lipid-lowering treatments need to be implemented.

Experiencia formadora con cuatro guías de buenas prácticas clínicas de la registered nurses' association of ontario

El presente artículo trata sobre la implementación de cuatro guías elaboradas por la Registered Nurses' Association of Ontario (Canadá) en la enseñanza de pregrado de la Carrera de Enfermería de la Universidad de Chile, proceso que se enmarca en el primer convenio establecido entre la Universidad de Chile y esta asociación. El acuerdo instaurado entre ambas instituciones promovió la incorporación de las guías: Valoración y Selección de Accesos Vasculares, Atención a las Familias, Establecimiento de Relación Terapéutica, y Valoración y Manejo del Dolor, al plan de formación de la Carrera de Enfermería, proceso liderado por docentes asesores de cada una de las guías a través de diversas estrategias pedagógicas y didácticas, demostrando un aporte significativo de este material al aprendizaje de los estudiantes de enfermería de la institución académica.

This article describes the implementation of four guidelines developed by the Registered Nurses' Association of Ontario for undergraduate nursing education at the Universidad de Chile, a process that is part of the first agreement reached between the University of Chile and the Registered Nurses' Association of Ontario. The agreement established between both institutions helped incorporate the following guidelines: Assessment and Selection of Vascular Accesses, Family Care, Establishment of Therapeutic Relationship, and Assessment and Management of Pain, into the training plan of the nursing program, a process led by the faculty advisors of each of the guidelines through various pedagogical and didactic strategies, demonstrating a significant contribution of this material to the learning process of the nursing students.

Este artigo trata da implementação de quatro guias desenvolvidas pela Associação de Enfermeiros Registrados de Ontário (Canadá) para a educação de enfermagem de graduação na Universidade do Chile, um processo que faz parte do primeiro acordo estabelecido entre Universidade do Chile e a Associação de Enfermeiros Registrados de Ontário. O acordo assinado entre as duas instituições promoveu a incorporação das seguintes guias: Avaliação e Seleção de Acessos Vasculares, Cuidado Familiar, Estabelecimento de Relacionamento Terapêutico e Avaliação e Gerenciamento da Dor, ao plano de treinamento do programa de enfermagem, um processo conduzido pelos orientadores de cada uma das guias através de várias estratégias pedagógicas e didáticas, demonstrando uma contribuição significativa deste material para o aprendizado dos estudantes de enfermagem.

Guía para el diagnóstico, estudio y tratamiento de la infección urinaria: actualización 2022 / Clinical practice guideline for the diagnosis and management of urinary tract infections: 2022 update

En 2015 se publicaron en Archivos Argentinos de Pediatría las "Nuevas recomendaciones frente a las actuales controversias en infección urinaria". Dado que en estos años surgieron evidencias con respecto al diagnóstico, la forma de estudio y el tratamiento de la infección urinaria, el Comité de Nefrología Pediátrica de la Sociedad Argentina de Pediatría decidió actualizar dichas recomendaciones. El objetivo principal es brindar al pediatra las herramientas para realizar un correcto diagnóstico, definir el tratamiento más adecuado, seleccionar a los pacientes que se beneficiarán con la profilaxis antibiótica y decidir cuáles serán los estudios de imágenes necesarios, para evitar intervenciones costosas e invasivas. En estas guías se incluyen, además, los lineamientos para el manejo de niños con infecciones urinarias asociadas a situaciones especiales como la disfunción vesicointestinal, el recién nacido, los portadores de vejiga neurogénica, los receptores de trasplante renal y las infecciones urinarias micóticas.

In 2015, the "New recommendations regarding the current controversies in urinary infection" were published in the Archivos Argentinos de Pediatría. Given the fact that in these past years, new evidence has emerged regarding the diagnosis and treatment of urinary infection, the Pediatric Nephrology Committee of Sociedad Argentina de Pediatría has decided to update these recommendations. The main goal is to provide the pediatrician with the necessary tools to make a correct diagnosis, define the most appropriate treatment, select the patients who will benefit from antibiotic prophylaxis, and decide which imaging studies will be necessary, avoiding costly and invasive interventions. These guidelines also include the management of children with urinary tract infections associated with special situations such as: bladder bowel dysfunction, the newborn, children with neurogenic bladder, kidney transplant patients and fungal urinary tract infections.

Quality Assessment of Clinical Practice Guidelines on the Treatment of Psoriasis Using the AGREE II Tool. / Evaluación de la calidad de guías de práctica clínica para el tratamiento de psoriasis mediante la herramienta AGREE II.

BACKGROUND: Clinical practice guidelines (CPGs) are designed to help health professionals provide patients with excellent medical care. The last critical appraisal of CPGs on the treatment of psoriasis evaluated publications up to 2009, but several new guidelines have been published since and their methodological quality remains unclear. OBJECTIVE: The aim of this study was to systematically evaluate the quality of CPGs on the treatment of psoriasis published between 2010 and 2020 using the Appraisal Guidelines Research and Evaluation II (AGREE II) tool. MATERIAL AND METHODS: We searched for relevant CPGs in MEDLINE, Embase, and LILACS (Latin American and Caribean Health Sciences Literature) as well as in the gray literature. Two reviewers working independently selected the guidelines for analysis and extracted the relevant data. Each guideline was then assessed using the AGREE II instrument by 5 reviewers, also working independently. RESULTS: Nineteen CPGs met the inclusion criteria and most of them had been produced in high-income countries. The mean (SD) domain scores were 84.9% (14.7%) for scope and purpose, 65.5% (19.3%) for stakeholder involvement, 66.7% (15.6%) for rigor of development, 72.8% (16.8%) for clarity of presentation, 46.6% (21.7%) for applicability, and 57.0% (30.4%) for editorial independence. CONCLUSIONS: Although about three-quarters of the CPGs assessed were judged to be of high quality and over half were recommended for use in clinical practice, standards of guideline development need to be raised to improve CPG quality, particularly in terms of applicability and editorial independence, which had the lowest scores in our evaluation.

Optimizing treatment for non muscle-invasive bladder cancer with an app.

OBJECTIVES: To evaluate overall and recurrence-progression rate-adjusted concordance of treatment prescription in non-muscle-invasive bladder cancer (NMIBC) of an app based on the best available scientific evidence and the urologist's opinion. METHODS: Development of an app (APPv) specifically designed for the treatment and follow-up of NMIBC and validation of the proposed APPv treatment endpoint by means of a prospective double-blind observational concordance study of related samples in 100 patients with initial or successive histological diagnosis of NMIBC. RESULTS: The treatment prescribed by the urologist agrees with that proposed by the APPv in 64% of cases (kappa index 0.55, P < 0.0001). Regarding low risk, the agreement is 77% (kappa 0.55, P = 0.002), 63% (kappa 0.52, P < 0.0001) for intermediate risk, 17% (kappa 0.143, P = 0.014) in high risk and 66% (kappa 0.71, P = 0.01) for very high risk. Of patients receiving adjuvant intravesical treatment according to APPv, 89.1% remain free of recurrence vs. 61.1% of those with disagreement (P = 0.0004), with a RR 0.46 (95%CI: 0.25-0.86) vs. RR 2.4 (95%CI: 1.5-3.8, P = 0.001). In the APPv-urologist agreement group, 100% of patients are free of progression and 88.9% in the disagreement group (P = 0.004) with a RR 1 vs. RR 1.125 (95%CI: 1-1.26, P = 0.004). CONCLUSIONS: APPv can improve adherence to treatment recommendations according to clinical practice guidelines and health outcomes at NMIBC.

Implementation of clinical practice guidelines: Wishful thinking or reality. Decision algorithm. / Implementación de las guías de práctica clínica: deseo o realidad. Algoritmo de decisión.

The clinical practice guidelines (CPG) have contributed to the dissemination of scientific information that supports decision-making in different clinical situations. CPGs have become more necessary as scientific information has grown, sometimes offering contradictory data, which makes it difficult for the clinician to easily make the most appropriate decision. In this context, the CPGs summarize and simplify the available scientific information, making it available to the doctor who must make the decisions. The publication of a CPG does not mean that it is applied in practice, much less that it is adopted quickly. In fact, despite the improvement in the quality of the CPGs, it is observed that they have not been fully implemented in a large number of cases, which prevents relevant information from ending up being transferred to clinical practice, with the consequent impact on the quality of care. In this article we will briefly review the strategies adopted to ensure that the scientific recommendations contained in the CPGs end up being transferred to patients and, asa consequence, achieving a reduction in the impact of cardiovascular diseases.

Comparison of current guidelines on medical management of stone disease. / Comparación entre guías clínicas en el tratamiento médico de la litiasis.

OBJECTIVE: The objective of this study isto present the content of existing Guidelines on medical management of urinary stone disease. MATERIALS AND METHODS: A search for current Guidelines from national and international urological Associations was performed in Societe International d'Urologie and American Urological Association websites, along with a search in Pubmed/MEDLINE until 30/06/2020. Two authors performed an independent search and data extraction regarding medical management of acute renal colic, medical expulsive treatment, dietary modifications and pharmaceutical interventions for prevention of stone disease recurrence. Quality of Guidelines was assessed by the two reviewers using the AGREE II instrument. RESULTS: Literature search revealed 82 Associations, while eight of them provide recommendations/Guidelines on medical management of stone disease. Non-steroidalanti-inflammatory drugs or paracetamol are the most common 1st line treatment proposed for acute pain management, with opiates following next. Use of a-blockers is also indicated by most Guidelines for facilitating expulsion of distal ureteral stones 5-10 mm, after shockwave or laser lithotripsy or for alleviating stent-related symptoms. Adequate fluid in take, normal dietary calcium consumption and sodium restriction with varying daily limits, are universal dietary modifications from urological Associations on prevention of stone disease. Thiazidesand alkaline citrates are proposed usually for calciumoxalate stone formers with differences in grading of the recommendations, while urinary alkalization with allopurinol or febuxostat as a second line treatment is acommon treatment algorithm for urate stones, but with differences in target urine pH. European and American Urological Association Guidelines, along with National Institute for Health and Care Excellence recommendations were the most highly rated based on AGREE II. CONCLUSIONS: Despite methodological heterogeneity and subjective rating of recommendations, an acceptable degree of consensus was noted on Guidelines regarding medical management of stone disease.

OBJETIVO: El objetivo de este estudio es presentar el contenido de las guías clínicas existentes enel manejo medico de las litiasis urinarias. MATERIALES Y MÉTODOS: Una búsqueda de las guías clínicas actuales de las asociaciones nacionales e internaciones se realizó en la pagina web de la Societe International d' Urologie y la American Urological Association, junto con una búsque da en Pubmed/Medline hasta el 30 junio 2020. Dos autores realizaron una búsqueda independiente y la extracción de datos en relación al manejo medico del cólico renal agudo, tratamiento medico expulsivo, modificaciones en la dieta e intervenciones farmacológicas para la prevención de la recurrencia en la litiasis. La calidad de las guías se determinó por dos revisores externos utilizando el instrumento AGREE II. RESULTADOS: La búsqueda en la literatura demostró 82 asociaciones, mientras que ocho de estas promueven recomendaciones/guías en el manejo medico de la litiasis. Antiinflamatorios no-esteroideos o paracetamol son los tratamientos de primera línea mas comunes para el manejo del dolor agudo, siendo los opioides el siguiente. El uso de alfa-bloqueantes esta también indicado por la mayoría de las guías para facilitar la expulsión de litiasis del uréter distal de 5 a 10 mm, después de litotricia o después de lasertricia o para aliviar los síntomas relacionados con los catéteres. La ingesta de fluidos adecuada, consumo normal de calcio en la dieta y restricción de sodio con limites variables, son las recomendaciones dietéticas universales de las asociaciones urológicas en la prevención de las litiasis. Tiazidas y citratos alcalinos se proponen para los formadores de litiasis de oxalato cálcico con diferencias en el grado de las recomendaciones, mientras la alcalinización de la orina con alopurinol o febuxostat es la segunda línea de tratamiento en el algoritmo de las litiasis de urato, pero con diferencias en el pH urinario final. Las guías europeas y americanas, junto con las guías del instituto nacional de salud y las recomendaciones care excellence fueron las mejor reportadas en relación a AGREE II.CONCLUSIÓN: A pesar de todo y con la heterogeneidad metodológica y las recomendaciones subjetivas, hay un grado aceptable de consenso en las guías clínicas en relación al manejo medico de la enfermedad litiásica.

Asma en niños: una revisión en torno a los cambios en su tratamiento / Asthma in children: a review of changes in treatment

El asma leve-moderada representa la mayor proporción de niños y adolescentes con asma en el mundo. Durante más de 25 años el tratamiento del asma permaneció invariable en torno al uso de controladores y rescatadores. Recientemente, diversas guías clínicas y sociedades científicas publicaron actualizaciones en torno al tratamiento de los pasos 1, 2 y 3 según GINA; existiendo diferencias y coincidencias entre ellas, a pesar de usar la misma evidencia publicada disponible. Este artículo de revisión se enfoca en tres guías clínicas qué por su popularidad y fácil acceso, son consultadas por diversos profesionales de la salud mostrando los principales cambios introducidos respecto a su edición previa y analizando brevemente la evidencia que existe detrás de estas recomendaciones. Finalmente se presenta un análisis de las principales limitaciones, contradicciones y aspectos aún por resolver.

Mild-moderate asthma represents the highest proportion of children and adolescents with asthma in the world. For more than 25 years, asthma treatment remained unchanged around the use of controllers and relievers. Recently, many clinical guidelines and scientific societies have published updates regarding the treatment of steps 1,2 and 3 according to GINA, with differences and coincidences between them, despite using the same available published evidence. This review article focuses on three clinical guides which, due to their popularity and easy access, are consulted by various health professionals, showing the main changes introduced compared to their previous edition and analyzing briefly the evidence behind these recommendations. Finally, an analysis of the main limitations, contradictions and aspects still to be resolved is presented.

Diverticulitis aguda del colon izquierdo, nivel de consenso y de aplicación de las Guías de Práctica Clínica: entre miembros de la SACP / Left colonic acute diverticulitis. Level of consensus and Clinical Guidelines Implementation: paper to apply for SACP active membership

Contexto y antecedentes: La elaboración e implementación de guías clínicas pretende brindar ayuda en la toma de decisiones respecto de un determinado problema de salud, sintetizando en forma de recomendaciones la mejor evidencia disponible. Con respecto a la diverticulitis aguda, pese a la gran cantidad de guías que se han elaborado, aún hoy se observa un bajo nivel de consenso en varios aspectos de su manejo. Objetivos: Este trabajo representa la primera encuesta que mide el nivel de consenso y la aplicación de guías internacionales sobre el manejo de la diverticulitis aguda entre los miembros de la SACP o entre cualquier otra agrupación médica a nivel nacional. Métodos: Se distribuyó una encuesta online a 313 miembros de la SACP, las respuestas se recolectaron en un período de 2 meses. Resultados: La encuesta obtuvo una tasa de respuesta de 19,5%. Solo 17 enunciados superaron el corte de 70% de nivel de consenso. De ellos, 11 enunciados estuvieron de acuerdo mientras que 2 enunciados estuvieron en desacuerdo con las recomendaciones de las guías internacionales y en los 4 enunciados restantes no pudo valorarse la concordancia debido a falta de respuesta univoca en las guías. Conclusiones: La amplia heterogeneidad en el manejo de la diverticulitis aguda entre los miembros de la SACP junto con la baja evidencia de los trabajos científicos, la pobre metodología empleada en las guías internacionales y la necesidad de contar con datos locales sobre costos y preferencias, hacen evidente la necesidad que en nuestro ámbito se comience a investigar en forma sistematizada para lograr una guía y consenso nacional.

Background: Construction and elaboration of clinical guidelines aim to provide help to decision-taking process about a specific health issue, synthesizing the best available evidence in the form of recommendations. About acute diverticulitis, although many guidelines were published in the last years, even now, there is a low consensus level in many aspects of its management. Aim: This survey is the first one that measures the consensus level and the application of international guidelines, about acute diverticulitis, within the SACP members, or any other medical society in Argentina. Methods: An online survey was distributed to 313 SACP members; the responses were collected over two months. Results: The response rate obtained by the survey was 19,5%. Only 17 statements passed the consensus level of 70%, 11 of them agreed and 2 disagreed with the recommendations of the international guidelines, in the last 4 statements comparison was impossible because the guidelines lacked one single response. Conclusions: The large heterogeneity in the management of acute diverticulitis within the SACP members, along with the low evidence of the scientific publications, the poor methodology used in the guidelines, and the need of local data about costs and preferences, clearly demonstrates the necessity to start to investigate in a systematic way, in order to achieve a national guideline and consensus about acute diverticulitis.

[Recommendations on bladder cancer Management during COVID-19 pandemia: lessons learned and future plans.] / Recomendaciones sobre el manejo del carcinoma de vejiga en situación de pandemia por Covid-19. Experiencia aprendida y preparación para el futuro.

OBJECTIVES: The guidelines and recommendation sof good clinical practice have been disrupted by new and urgent policies, marked by the COVID-19 pandemic. Urothelial carcinoma has a significant prevalence in Spain, whose population has been greatly affected by COVID-19, directly by the disease and indirectly by the confinement. The objective of this work is to offer recommendations on protocols and guidelines adjusted to different phases of the pandemic. MATERIAL AND METHODS: This document on the management of bladder carcinoma is based on few evidence on urological oncological practice during the first months of the pandemic and on the authors' experience in this pathology during the crisis of COVID-19. Hospital experts in infectious disseases and radiology have participated to design a common strategy to reorganize the activity. RESULTS: Different proposals for treatment and follow-up of patients diagnosed with bladder cancer adjusted for oncological risk and the different phases of the pandemic are presented. CONCLUSIONS: The pandemic's spread was unimaginable just a few months ago. Health systems have been shaken by the disease in the most critical phases. It is necessary, at this time, to make an additional effort to develop tools that can facilitate the care of bladder carcinoma and minimize the impact and risks for patients and health professionals in the future.

 OBJETIVOS: Las directrices y recomendaciones de la buena práctica clínica se han visto trastocadas por las nuevas y urgentes prioridades, marcadas po rla pandemia COVID-19. El carcinoma urotelial es una enfermedad de prevalencia significativa en España, cuya población se ha visto muy afectada por la COVID-19, directamente por la enfermedad e indirectamente por el confinamiento. El objetivo de este trabajo es ofrecer recomendaciones sobre protocolos y circuitos asistenciales ajustados a diferentes fases de la pandemia. MATERIAL Y MÉTODOS: El presente documento sobre el manejo del carcinoma vesical, se basa en la escasa evidencia sobre la práctica oncológica urológica durante los primeros meses de la pandemia y en la experiencia de los autores en esta patología durante la crisis del COVID-19. En ella, han participado expertos hospitalarios en patología infecciosa y radiodiagnóstico para diseñar una estrategia común y reorganizar así la actividad. RESULTADOS: Se presentan distintas propuestas de tratamiento y seguimiento de los pacientes diagnosticados de cáncer vesical ajustados al riesgo oncológico en las diferentes fases de la pandemia. CONCLUSIONES: La velocidad de expansión de la pandemia era inimaginable hace solo unos meses. Los sistemas sanitarios se han visto sacudidos por la enfermedad en las fases más críticas. Es necesario, en estos momentos, realizar un esfuerzo más para desarrollar herramientas que puedan facilitar la asistencia del carcinoma vesical y minimizar el impacto y los riesgos para los pacientes y los profesionales de la salud en el futuro.

PCSK9 inhibitors: Ratification of the role of LDL cholesterol in cardiovascular prevention. Towards a convergence of European and North American prevention guidelines? / Inhibidores de PCSK9: ratificación del papel del colesterol LDL en prevención cardiovascular. ¿Hacia la convergencia en las guías de prevención europeas y norteamericanas?

The epidemiological association of cholesterol associated with low density lipoproteins (LDL-c) levels and the development of atherosclerotic vascular disease has been ratified by mendelian randomization studies. Paradoxically, the success of statins led to the underestimation of other lipid-lowering therapies and even the measurement of LDL-c. Recent studies show that the reduction of LDL-c to extraordinarily low levels through absorption inhibition, and, in a particularly intensive manner, with monoclonal antibodies against pro-protein convertase subtilisine Kesine 9 (PCSK9) continues to offer cardiovascular protection. However, the high cost and limited experience with PCSK-9 inhibitors advised a prudent use of them. An appropriate selection of patients most likely to benefit from treatment with PCSK9 inhibitors emerges as the basis for a consensus of international guidelines: the combination of a high absolute vascular risk and a greater expected benefit by the starting LDL-c levels.

Periendoscopic management of antiplatelet therapy: Prospective evaluation of adherence to guidelines.

INTRODUCCIóN: Adherence to guidelines on the periendoscopic management of antiplatelet therapy (APT) has not been analyzed in detail. Our aim was to assess adherence to guidelines in patients referred to our Endoscopy Unit on a case-by-case basis, describing in detail the detected deviations and identifying areas of improvement. PATIENTS AND METHODS: Cross-sectional study of outpatients consecutively scheduled for an unsedated upper or lower gastrointestinal endoscopy between January and June 2015. Patients on anticoagulant therapy were excluded. RESULTS: 675 patients were evaluated, including 91 (13.5%) patients on APT [upper GI endoscopy 25 (27.5%), lower GI endoscopy 66 (72.5%)]. Contrary to the clinical guidelines, aspirin was discontinued in 25 of the 77 patients previously prescribed the drug (32.5%) but this modification was patient's own decision in 11 cases. Most of the apparent deviations in the management of clopidogrel and dual antiplatelet therapy (DAPT) were not true non-adherence cases. The Primary Care physician modified an APT prescribed by another physician in 8 of 9 cases (88.9%), always in cases with aspirin. No relationship was found between the endoscopic procedure's predicted risk of bleeding or the patient's thrombotic risk and modification of therapy. DISCUSSION: In many patients, the peri-procedural management of APT goes against current guidelines, but some of these inconsistencies cannot be considered true deviations from practice. Identified areas for improvement are increasing patient awareness about APT, disseminating the guidelines in Primary Care, and underscoring the significance of thrombotic risk related to APT withdrawal.

Guidelines on the application of the clinical practice guideline on low back pain.

INTRODUCTION: Low back pain is defined as pain in the upper portion of T12 and below the crease of the buttocks and functional limitation. The prevalence of low back pain gradually increases 11.4% per year. In Mexico, the clinical practice guidelines are not followed in handling low back pain, so it is important to systematize medical care more efficient, since resources are scarce. The first level doctor must meet the benchmarks according to patient need, an incomplete anamnesis is performed, inadequate physical examination, misinterpretation of clinical studies, misdiagnosis, ineffective management, and reference to second or third level not justified. OBJECTIVE: To provide recommendations for the implementation of syndromic diagnosis, management of adult carriers of low back pain, and correct reference. Implementation of clinical practice guidelines for low back pain syndrome consists of an assessment of the patient by way of "verification", which evaluates certain signs of symptoms, with a total of 37 items for rating, including the sections of clinical symptomatology, AP X-ray, lateral X-ray, sagittal (optional) and axial magnetic resonance imaging (optional), and pain type. Oriented data quickly and easily, from first contact to a syndromic diagnosis in patients with low back pain.

INTRODUCCIÓN: La lumbalgia se define como el dolor en el área de la porción superior de T12 e inferior al pliegue de los glúteos, y además limitación funcional. La prevalencia de la lumbalgia va aumentando un 11.4% por año. En México no se siguen las guías de práctica clínica en el manejo de las lumbalgias, por lo que es importante sistematizar la atención médica para eficientizar, ya que cada vez los recursos son más escasos. El médico de primer nivel debe conocer los criterios de referencia según la necesidad del paciente. Se realizan una anamnesis incompleta, una exploración física inadecuada, una mala interpretación de los estudios de gabinete, un diagnóstico equivocado, un manejo ineficaz y la referencia a segundo o tercer nivel no justificada. OBJETIVO: Proporcionar recomendaciones para la realización del diagnóstico sindrómico, el manejo de los adultos portadores de lumbalgia y su correcta referencia. La aplicación de las guías de práctica clínica para el síndrome doloroso lumbar consta de una evaluación del paciente a manera de «verificación¼, en la que se evalúan determinados signos o síntomas, con un total de 37 ítems por calificar, incluyendo los apartados de sintomatología clínica, radiografía anteroposterior, radiografía lateral, resonancia magnética sagital (opcional) y axial (opcional), y tipo de dolor. Estos datos orientan de manera rápida y sencilla, desde el primer contacto, a un diagnóstico sindrómico en el paciente con lumbalgia.

Endoscopic surveillance after colonic polyps and colorrectal cancer resection. 2018 update. / Vigilancia tras resección de pólipos de colon y de cáncer colorrectal. Actualización 2018.

There is limited scientific evidence available to stratify the risk of developing metachronous colorectal cancer after resection of colonic polyps and to determine surveillance intervals and is mostly based on observational studies. However, while awaiting further evidence, the criteria of endoscopic follow-up needs to be unified in our setting. Therefore, the Spanish Association of Gastroenterology, the Spanish Society of Family and Community Medicine, the Spanish Society of Digestive Endoscopy, and the Colorectal Cancer Screening Group of the Spanish Society of Epidemiology, have written this consensus document, which is included in chapter 10 of the "Clinical Practice Guideline for Diagnosis and Prevention of Colorectal Cancer. 2018 Update". Important developments will also be presented as regards the previous edition published in 2009. First of all, situations that require and do not require endoscopic surveillance are established, and the need of endoscopic surveillance of individuals who do not present a special risk of metachronous colon cancer is eliminated. Secondly, endoscopic surveillance recommendations are established in individuals with serrated polyps. Finally, unlike the previous edition, endoscopic surveillance recommendations are given in patients operated on for colorectal cancer. At the same time, it represents an advance on the European guideline for quality assurance in colorectal cancer screening, since it eliminates the division between intermediate risk group and high risk group, which means the elimination of a considerable proportion of colonoscopies of early surveillance. Finally, clear recommendations are given on the absence of need for follow-up in the low risk group, for which the European guidelines maintained some ambiguity.

Executive summary of the GeSIDA/National AIDS Plan consensus document on antiretroviral therapy in adults infected by the human immunodeficiency virus (updated January 2018).

This update to the document on antiretroviral therapy (ART) in adults, which has been prepared jointly by GeSIDA and the Spanish National AIDS Plan for the last two decades, supersedes the document published in 2017.1 The update provides physicians treating HIV-1-infected adults with evidence-based recommendations to guide their therapeutic decisions. The main difference with respect to the previous document concerns recommended initial ART regimens, only three of which are maintained as preferential. All three include dolutegravir or raltegravir, together with emtricitabine/tenofovir alafenamide or abacavir/lamivudine. Other differences concern the section on switching ART in patients with suppressed viral replication, which now includes new two- and three-drug regimens, and the antiretroviral drugs recommended for pregnant women and patients with tuberculosis. A recommendation has also been added for patients who present with acute HIV infection after pre-exposure prophylaxis.

Optimización versus "Switch" temprano en depresión monopolar: Revisión comprensiva acerca de una controversia clínica / Optimization versus early Switching in monopolar depression: A comprehensive review of a clinical controversy

Resumen Lograr la recuperación funcional lo más tempranamente posible en el tratamiento de una depresión monopolar es un desafío que los clínicos de hoy no pueden eludir, pues el retardo en conseguir la remisión sintomática predice mayor número de recaídas y mayor morbimortalidad. Saber cómo escoger, combinar o secuenciar las diferentes estrategias psicofarmacológicas disponibles, como lo son la optimización y el cambio de un antidepresivo son preguntas frecuentes en la práctica cotidiana. Esta revisión comprensiva pretende dilucidar cuándo un clínico deberá optimizar o cambiar un tratamiento antidepresivo en un paciente con un episodio depresivo monopolar que acude a control a las dos a cuatro semanas desde el inicio de su tratamiento, reportando una respuesta parcial al fármaco inicialmente elegido. Analizar adecuadamente los dominios sintomáticos presentes, tener una visión crítica de las guías clínicas imperantes hoy en día y ser enérgico, pero lúcido en esta etapa temprana del tratamiento son, a nuestro juicio, elementos fundamentales para conseguir una recuperación "ad integrum" de nuestros pacientes.

In the current management of monopolar depression, achieving functional recovery as early as possible is a challenge that today's clinicians cannot evade, as the delay in symptom remission predicts a higher number of relapses and increased morbidity and mortality. Knowing how to choose, combine or sequence different psychopharmacological strategies, such as optimization or switching of an antidepressant are frequent questions in everyday clinical practice. This reflective review aims to elucidate when the clinician should optimize or switch an antidepressant treatment in a patient with a monopolar depressive episode that goes to a regular appointment after two to four weeks since the onset of treatment and reports partial response to the initially chosen drug. An adequate analysis of symptomatic domains, having a critical view of contemporary clinical guidelines, and maintaining an active but lucid approach at this early stage of treatment are, in our opinion, fundamental elements for the pursuit of an "ad integrum" recovery.