[Health-related quality of life in patients consuming benzodiazepine]. / Calidad de vida relacionada con la salud en pacientes consumidores de benzodiacepinas.

OBJECTIVE: To describe the health-related quality of life (HRQoL) in benzodiazepine users and to verify whether there is an association with the characteristics of the treatment, its effectiveness, and the sociodemographic variables. DESIGN: Descriptive cross-sectional study. LOCATION: Family medicine consultations. PARTICIPANTS: Four hundred and fifty 2patients over 18 years of age consuming benzodiazepines or similar drugs. MAIN MEASUREMENTS: HRQoL was assessed using the EuroQol5-D questionnaire. Other variables: symptoms of anxiety or insomnia, sociodemographic variables and characteristics of the treatment. RESULTS: The mean score in health status was 62.80 (95% CI: 60.69-64.86), lower in people without studies (59.27±21.97 SD; P=.004) and lower social category (60.02±21.27 SD; P<.001). Regarding the social rate (EQ index), a mean score of 0.6025 (95% CI: 0.5659-0.6391) was obtained, higher in people with higher education (0.6577±0.3574 SD; P=.001), plus social category (0.7286±0.3381 SD; P<.001) and age less than 65 years (0.6603±0.3426 SD; P<.001). The variables that were associated with the value of the EQ index by means of multiple regression were absence of anxiety/insomnia, belonging to higher social classes, age less than 65 years and less consumption of anxiolytics/hypnotics. CONCLUSIONS: Patients who use benzodiazepines show, despite treatment, a moderate HRQL, lower than that obtained in the general population or in primary care patients. The situation is more favorable in the youngest, in those who do not present anxiety/insomnia, in those belonging to higher social classes and when the consumption of drugs is lower.

[Bibliometric map of research carried out in Primary Care in Spain during the period 2013-2017]. / Mapa bibliométrico de la investigación realizada en atención primaria en España durante el periodo 2013-2017.

OBJECTIVE: To describe the Spanish scientific production of primary care during 2013-2017 and analyze their geographical distribution, impact factor, areas of research and involvement of different institutional sectors. DESIGN: Observational study bibliometric. PARTICIPANTS: The study focused on publications indexed in Medline. MAIN MEASUREMENTS: Journal and year of publication, first/last author, workplace and autonomous community. Later, articles were classified according to their content. The impact factor was obtained from the basis of bibliometric analysis Journal Citation Reports. RESULTS: Using search criteria, were selected 980 documents. The transiency rate was 78,8%. The highest proportion of articles (43.2%) came from health centers, but we observed an increase of the articles from units or research institutes (14.9% in 2013, 19.1% in 2017). Of the total, 63.3% were classified as "clinical aspects", 19.3% were published in the journal Atención Primaria, 40.6% in foreign journals and 72.4% in journals with impact factor, being this proportion significantly lower (p <0.001) in those coming from health centers (59.6%) or teaching units/management/health services (70.0%) with respect to those originated in research units/institutes (93.1%) or in universities (89.0%). In relation to population (articles/100.000 inhab.), the most productive communities were Cataluña (4.2), Aragón (3.9), e Islas Baleares (3.3). CONCLUSIONS: In primary care publications there is great diversity in both research areas such as in journals where published. Most are from health centers, treat clinical aspects and published in Spanish journals. Differences in the volume of scientific production between regions are observed.

[PAPPS GdT Major 2020 Update]. / Actualización PAPPS GdT Mayor 2020.

In this update, we have introduced new topics that we believe are of vital importance in the major areas, such as the revision of walking aids, as well as recommendations on nutrition and social isolation. Recommendations on deprescribing, fragility, mild cognitive impairment, and dementia have already been presented in previous updates.

Effectiveness of physical exercise in the treatment of depression in older adults as an alternative to antidepressant drugs in primary care.

BACKGROUND: Although currently available evidence suggests that physical exercise can be beneficial for depressed patients and might be comparable to antidepressant treatment, the best way of implementing this recommendation in clinical practice is not known. This study therefore aims to ascertain the non-inferiority of supervised physical exercise to antidepressant drug treatment, in terms of reducing depressive symptoms among patients presenting with clinical criteria of a depressive episode (ICD-10), across a follow-up period of 6 months. METHODS: It will take the form of a randomised clinical trial undertaken in a primary care setting, in which a total of 312 patients over the age of 65 years with clinically significant depression will be randomly assigned to supervised physical exercise programme, or will alternatively receive treatment with antidepressant drugs habitually used in clinical practice. Participants' physical condition will be assessed at baseline, and again at 15 days and 1, 3 and 6 months. The supervised exercise programme will consist of 2 weekly sessions in groups of 10-12 patients across a period of 6 months, in which a sports instructor will train patients to do at least 30 min of regular activity at moderate intensity on an almost daily basis, including aerobic, muscle-strengthening, flexibility, and balance-strengthening exercises. The following will be assessed at regular intervals in both groups: status of depression symptoms; level of physical activity; self-perceived health status; appearance of adverse effects; and adherence to the physical exercise programme or antidepressant treatment. The principal outcome variable will be a reduction in pre-treatment depression-symptom scale scores (Montgomery-Asberg Depression Rating Scale and Geriatric Depression Scale). DISCUSSION: In terms of the number of patients and duration of follow-up, this proposed clinical trial is a project which easily surpasses the few studies on this subject that have been previously conducted on the elderly. Its aim is to provide solid scientific evidence on a therapeutic resource -physical exercise- which has undeniable health benefits and can be applied to certain health problems, such as depressive disorders, which are of great magnitude and considerable socio-economic relevance, and have a significant impact on the quality of life of older adults. TRIAL REGISTRATION: ClinicalTrials.gov NCT03358433 (retrospectively registered on 11/25/2017).

Risk factors related to adjacent segment degeneration: retrospective observational cohort study and survivorship analysis of adjacent unfused segments.

OBJECT: Adjacent segment disease (ASD) has been described as a frequent complication after a lumbar spinal fusion procedure, though its incidence and the factors related to its appearance are not well established. The radiographic signs that identify ASD in unfused segments may be a consequence of biomechanical changes induced by the fusion procedure. This study sought to analyse the incidence of radiographic changes (radiographic ASD) in all adjacent unfused segments, the clinical changes that require a second procedure (clinical ASD), and the risk factors of their appearance evaluated at different follow-up times. METHODS: We conducted a retrospective cohort study of patients fused for degenerative spine disease and instability to analyse ASD risk factors using actuarial estimation, comparison of the Kaplan-Meier survival curves of each variable, and Cox proportional-hazards regression analysis. RESULTS: Among the 263 patients included in the study, radiographic changes were observed in 57.4% and related clinical changes in 20.2%. The univariate analysis showed a higher risk of ASD in patients with smaller post- vs. pre-operative lumbar lordosis (p = .018), diagnosis of lumbar canal stenosis (p = .019), fusion of three or more vs. fewer levels (p = .009) and those fixed with top-loading screws vs. side-connecting screws (p = .001). Cox proportional-hazards regression analysis showed that the use of top-loading pedicle screws and three or more levels of fusion led to a 3- and 2-fold higher risk of degeneration in adjacent unfused segments respectively. CONCLUSIONS: Risk of a second surgical procedure due to clinical changes is 3-fold higher in patients with three or more levels of fusion, and 2.5-fold higher in patients intervened with top-loading pedicle screws.

[Functional status, self-rated health and level of physical activity of patients with osteoarthritis]. / Situación funcional, autopercepción de salud y nivel de actividad física en pacientes con artrosis.

OBJECTIVE: To describe the functional status and self-rated health of patients with osteoarthritis (OA) in Primary Care, and checking their relationship with the level of physical activity and sociodemographic characteristics. DESIGN: Study of prevalence and cross association. SETTING: Primary Care Clinics. PARTICIPANTS: Adult patients with a diagnosis of OA in any joint in their clinical records. Out of a total of 487 selected, 346 (71.0%) took part in the study. MAIN MEASUREMENTS: Functional capacity (WOMAC scale), self-rated quality of life (EuroQol- 5D questionnaire), physical activity (IPAQ questionnaire), number of affected joints, pain level, and sociodemographic characteristics. RESULTS: A mean score of 30.2 (SD: 20.8; CI 95% CI: 28.0 to 32.4) was obtained on the WOMAC scale, with pain, stiffness, and functional capacity scores of 6.5 (SD: 4.8), 1.9 (SD: 2.0), and 21.7 (SD: 15.7), respectively. The score showed a linear trend (P<.001) compared to the level of physical activity, being 41.1 (SD: 19.9) in inactive subjects, 24.3 (SD: 18.7) in subjects with moderate activity, and 22.3 (SD: 19.8) in subjects with intense activity. In the multiple linear regression, the score on the WOMAC scale, as well as that obtained in self-rated health status, maintained their association with physical activity level after adjusting for sociodemographic variables and the number of affected joints. CONCLUSIONS: In patients with OA, pain and functional capacity are the most affected dimensions. Functional status and self-rated health status are higher in active patients, regardless of the number of joints affected and their demographic characteristics.

Treatment Satisfaction Among Patients Taking Antidepressant Medication.

This study sought to assess treatment satisfaction among patients on antidepressants, ascertaining whether there might be an association with depressive symptomatology and other variables. Cross-sectional study conducted on 564 adult patients taking antidepressant medication. Satisfaction with antidepressant treatment was assessed using the Assessment of Satisfaction with Antidepressant Treatment Questionnaire (ESTA/Evaluación de la Satisfacción con el Tratamiento Antidepresivo). A moderate negative correlation was observed between satisfaction and intensity of depressive symptoms, as assessed with the Montgomery-Asberg scale. A weak negative correlation was observed between greater satisfaction and less favourable views about taking medication. Satisfaction scale scores were higher among those who took antidepressant medication for 1 year or more versus shorter periods. Most patients reported being satisfied with the antidepressant treatment but the level of satisfaction was higher among those who presented with less marked depressive symptoms, received longer-term treatment and viewed drug treatments favourably. Treatment satisfaction is one of the patient-reported outcome measures that can serve to complement clinical evaluation of depressive disorders.

Effectiveness of three interventions to improve participation in colorectal cancer screening.

BACKGROUND AND OBJECTIVE: Participation in colorectal cancer (CRC) screening varies widely among different countries and different socio-demographic groups. Our objective was to assess the effectiveness of three primary-care interventions to increase CRC screening participation among persons over the age of 50 years and to identify the health and socio-demographic-related factors that determine greater participation. METHODS: We conducted a randomized experimental study with only one post-test control group. A total of 1,690 subjects were randomly distributed into four groups: written briefing; telephone briefing; an invitation to attend a group meeting; and no briefing. Subjects were evaluated 2 years post-intervention, with the outcome variable being participation in CRC screening. RESULTS: A total of 1,129 subjects were interviewed. Within the groups, homogeneity was tested in terms of socio-demographic characteristics and health-related variables. The proportion of subjects who participated in screening was: 15.4% in the written information group (95% confidence interval [CI]: 11.2-19.7); 28.8% in the telephone information group (95% CI: 23.6-33.9); 8.1% in the face-to-face information group (95% CI: 4.5-11.7); and 5.9% in the control group (95% CI: 2.9-9.0), with this difference proving statistically significant (p < 0.001). Logistic regression showed that only interventions based on written or telephone briefing were effective. Apart from type of intervention, number of reported health problems and place of residence remained in the regression model. CONCLUSIONS: Both written and telephone information can serve to improve participation in CRC screening. This preventive activity could be optimized by means of simple interventions coming within the scope of primary health-care professionals.

[Healthy eating and self-perception of health]. / Alimentación saludable y autopercepción de salud.

OBJECTIVES: The aim is to determine whether there is an association between perceived health status, healthy eating and other lifestyles in people over 50 years old. DESIGN: Cross-sectional study. SETTING: 8 Basic Health Zones from the Health Area of Albacete. PARTICIPANTS: A total of 781 subjects, randomly selected by simple random sampling. MAIN MEASUREMENTS: variables: self-rated quality of life (EuroQol 5D), dietary habits (questionnaire on frequency of food consumption), physical activity (IPAQ questionnaire), toxic habits, health problems (International Classification of Primary Care) and sociodemographic characteristics. RESULTS: The mean age was 61.4 years (SD: 6.6) and the proportion of women was 60.1%. On a scale of 0-100 the mean score in the perceived health status was 74.0 (SD: 15.2). This score had a weak correlation with the number of healthy eating criteria (r=0.078; P=.03). A linear trend (P=.001) was observed between exercise intensity and better self-rated health. The score was lower in smokers (70.9±15.6 vs 74.9±15.1 SD; P=.004). In the multiple regression, the number of healthy eating criteria remained an association with the score on perceived health status (P=.04), after adjusting the model for sociodemographic characteristics, number of health problems, and toxic habits. CONCLUSIONS: In people over 50years of age the level of self-rated health is associated with the fulfilment of the criteria of a healthy diet, which is independent of other health habits and main sociodemographic variables.

Prevalence of hazardous drinking among nursing students.

AIMS: To estimate the frequency of alcohol consumption among nursing students and describe their behaviour patterns in relation to excessive consumption. BACKGROUND: Most alcohol-related problems appear in individuals who indulge in hazardous consumption, with hazardous drinkers constituting a priority in the field of preventive activities. According to previous studies, there is a high proportion of hazardous drinkers among university students. DESIGN: Descriptive cross-sectional study. METHODS: Over the course of the 2012-2013 academic year, we assessed 1060 nursing degree students, ascertaining their socio-demographic characteristics, lifestyle and alcohol consumption by means of the Systematic Alcohol Consumption Interview (Interrogatorio Sistematizado de Consumos Alcohólicos/ISCA) and Alcohol Use Disorders Inventory Test (AUDIT). RESULTS: Hazardous alcohol consumption was observed in 43·4% of students. Moreover, 14·9% of men and 18·7% of women met criteria for hazardous drinkers, without any statistically significant difference between the sexes. The frequency of hazardous drinkers was significantly higher among participants aged under 21 years, those living outside the family nucleus and smokers. CONCLUSION: A considerable proportion of students show evidence of hazardous alcohol consumption and, while there are no sex-related differences, the proportion of hazardous drinkers tends to be higher among the youngest subjects, smokers and persons living outside the family nucleus. Alcohol-prevention activities should envisage greater protection of university settings, particularly where future health professionals are involved.

[The use of social healthcare resources and informal care characteristics care of immobilised homecare patients]. / Utilización de recursos sociosanitarios y características del cuidado informal de los pacientes inmovilizados en atención domiciliaria.

OBJECTIVE: To describe the use of social healthcare resources by immobilised patients and informal care characteristics and the level/degree of satisfaction with home care services. METHOD: Descriptive observational study carried out in primary care. The target group were 369 randomly selected immobilised home care patients in the area of Albacete, Spain. The variables included were: socio-demographic data of the patient and carer; the use of social healthcare resources; perceived social support (DUKE-UNK questionnaire); family function (APGAR questionnaire); nursing care and home care services satisfaction (SATISFAD 10 questionnaire). RESULTS: 66.9% of immobilised homecare patients have high dependency and 18.6% have bedsores. The majority of informal carers are women (83.1%) with an average of 57.7 years of age (DE 15.1). The average intensity of care is 15.7 hours per day (DE 8.5) and the average length of care is 5 years. The average number of visits from nurses per month is 2.1 (DE 2.1), although this measurement is higher in patients with bedsores or multiple diseases. The most widely used social health care resources are telephone care (34.2%) and home care (20.3%), for which 65.6% of immobilised homecare patients receive dependency benefits. Overall satisfaction with home care is of a high degree. CONCLUSION: Musculoskeletal disorders is the main reason for immobilisation in home care patients. Most informal carers are older women. The length and intensity of care is high and the main support comes from healthcare professionals. Patients make limited use of social healthcare resources.

[Bibliometric map of research done in primary care in Spain during the period 2008-2012]. / Mapa bibliométrico de la investigación realizada en atención primaria en España durante el periodo 2008-2012.

OBJECTIVE: To describe the Spanish scientific production of primary care during 2008-2012. DESIGN: Observational study bibliometric. SETTING: Spanish scientific production in primary care. PARTICIPANTS: The study focused on publications indexed in Medline. MAIN MEASUREMENTS: In each record was obtained journal, year of publication, first/last author, workplace and autonomous community. Later, articles were classified according to their content or areas of research. The impact factor was obtained from the basis of bibliometric analysis Journal Citation Reports. RESULTS: Using search criteria, were selected 1,048 documents. The transiency rate was 62.6%. Production increased from 170 papers in 2008 to 291 in 2012. Most (65.7%) came from health centers, but we observed a significant increase (P=.01) of the articles from units or research institutes (5.9% in 2008, 12.0% in 2012). Of the total, 61.6% were classified as «clinical aspects¼, 22.5% were published in the journal Atención Primaria, 80.5% in journals with impact factor and 33.49% in foreign journals, being higher this proportion (P<.001) in units or research institutes (70.5% vs. 29.8%). In relation to population (articles/100.000 inhab.), the most productive communities were Cataluña (4.1), Castilla-La Mancha (3.6), Aragón (3.4) and Navarra (3.4). CONCLUSIONS: In primary care publications there is great diversity in both research areas such as in journals where published. Most are from health centers, treat clinical aspects and published in Spanish journals. Differences in the volume of scientific production between regions are observed.

[Adherence to patients antidepressant treatment and the factors associated of non-compiance]. / Seguimiento de la adherencia al tratamiento antidepresivo en pacientes que inician su consumo.

OBJECTIVE: To know the adherence to treatment in patients who initiate antidepressant drugs and to analyze the determinant factors of non-compliance, so much clinical as sociodemographic. DESIGN: Prospective longitudinal observational study. LOCATION: Primary Health Care and Mental Health Surgeries of three Castilla-La Mancha Areas. PARTICIPANTS: 185 adults patients who were started in antidepressant treatment were evaluated. MEASUREMENTS: Treatment adherence (test Haynes-Sackett, test Morisky-Green, count of tablets and MEMS), adverse effects, intensity of depressive symptoms, sociodemographic characteristics and other characteristics related to antidepressants or participants. RESULTS: After 6months of beginning antidepressing treatment, 46.9% (95%IC: 36.5-57.3) showed an inadequate fulfilment by pill count method and 28.6% (95%IC: 19.1-38.0) with Morisky-Green's questionnaire. To 15 days the lack of adherence was 48.5% (95%IC: 40.6-56.4) and of 33.5% (95%IC: 26.1-41.0). The 38.4% (95%IC: 31.1-45.7) demonstrated some side effect during the follow-up. Using proportional risk model of Cox the variables related to compliance were: younger age, level of instruction lower than secondary studies, free medicines for pensioner, no psychotherapeutic treatment, consume a fewer antidepressants drugs and a frequency ≤ 3 visits to the family doctor 3 months previous to the study. CONCLUSIONS: The non-compliance of antidepressant treatment in primary care is high from the first weeks after initiating it. The conditioning factors are related to sociodemographic characteristics and other patient characteristics as type of financing of pharmaceutical benefit and frequentness at primary care.

Impact of pregnancy on women's health-related lifestyle habits: Diet, physical activity, alcohol consumption, and smoking.

OBJECTIVES: To explore health-related lifestyles in women before and during pregnancy, and to determine the potential differences between both and the relevant factors. MATERIALS AND METHODS: A cross-sectional observational study including 348 women with a child <5 years of age was conducted in six health areas. The following variables were recorded: sociodemographic (age, educational level, marital status, social class, type of cohabitation, nationality), health-related habits (physical activity, diet, tobacco use, alcohol consumption), health conditions, and medication intake. RESULTS: Four lifestyle habits were compared between the pre-conception and pregnancy periods: diet, physical activity, and alcohol and tobacco use. The proportion of women who consumed alcohol (42.8 % vs 3.4 %) or smoked (19.3 % vs 12.4 %) was significantly higher before conception (p < 0.01). Conversely, the proportion of inactive women was lower before pregnancy, with 23.3 % (CI95%: 18.7-27.9) formerly classified as active versus 35.3 % (CI95%: 30.2-40.5) (p < 0.01). Similarly, adherence to the Mediterranean diet increased during pregnancy (62.9 % vs 75.0 %; p < 0.01). Furthermore, 53.2 % (CI95%: 47.8-58.5) of women reported a change from non-healthy to healthy in at least one of the evaluated habits. Logistic regression analyses revealed the variables associated with a positive change, which were being national Spanish (OR: 6.9) and experiencing the first pregnancy (OR: 1.8). CONCLUSIONS: The lifestyles of women undergo changes between the pre-gestation and pregnancy periods. However, such variations do not affect all health-related habits similarly. A positive change was observed in diet, alcohol consumption, and smoking habit, whereas pregnancy negatively impacted on physical activity and sedentary behaviours.

The attitudes of primary care providers towards screening for colorectal cancer.

BACKGROUND AND OBJECTIVE: the scientific community supports the appropriateness of colorectal cancer screening, and there is consensus on the need to raise awareness about the significance of prevention among both health care professionals and the population. The goal was to record the attitude of primary care providers towards colorectal cancer screening, as well as the main barriers to both patient and provider participation. METHODS: a cross-sectional, observational study was performed of 511 professionals in Albacete Health District. Variables included views on screening effectiveness and cost-effectiveness, acceptance by providers and patients, barriers to participation, frequency of prevention recommendations, and education needs. RESULTS: most (76 %) considered screening was effective; 85 % said acceptance of fecal occult blood testing was intermediate or high, and 68.2 % this is also the case for colonoscopy when needed; 71.9 % would recommend screening should a population-based program be implemented (currently only 9.7 % recommends this). Correspondence analysis revealed that recommendation is more common when assigned populations are smaller. CONCLUSIONS: most providers consider screening is both effective and acceptable for patients. In today´s situation, where screening is only performed in an opportunistic manner, the proportion of professionals who commonly recommend screening for the mid-risk population is low, especially when assigned populations are huge.

Alcohol Consumption in Nursing Students after the COVID-19 Lockdown.

Excessive alcohol consumption is a major public health issue that can negatively affect behavior among university students. The objective of this study was to estimate the frequency of alcohol consumption in nursing students as well as to describe the pattern of alcohol consumption after COVID-19 lockdown. A descriptive, cross-sectional observational study was carried out, in which 1162 degree-level nursing students were evaluated. Sociodemographic characteristics, lifestyles and levels of physical activity were determined using the International Physical Activity Questionnaire: Short Form (IPAQ-SF), and alcohol consumption was determined using the ISCA (Systematized Alcohol Consumption Questionnaire) and AUDIT (Alcohol Use Disorders Inventory Test) questionnaires. According to the AUDIT questionnaire, 36.7% of the students met the criteria for excessive alcohol consumption (26.8% men vs. 39.9% women; p < 0.001). The prevalence of hazardous drinkers was found to be 10.2% (95% CI 5.6-11.7), with the difference between men and women being statistically significant. The IPAQ-SF questionnaire indicated that 26.1% of students were sedentary. No relationship was observed between alcohol consumption and the level of physical activity. The frequency of hazardous drinkers was significantly higher in women (OR: 2.2) and in smokers (OR: 4.2). In conclusion, approximately 10% of nursing students can be considered hazardous drinkers, with significant differences between the sexes. The percentage is higher in women and in smokers. Strategies should be created that encourage healthy lifestyles, emphasizing preventive activities against excessive alcohol consumption. Furthermore, given the differences in excessive alcohol consumption between men and women, it would be advisable to include the gender perspective in these activities.

Understanding insomnia in older adults.

OBJECTIVE: The aims of this study were to determine the true frequency of primary insomnia (PI), sleep disorder related to another mental disorder (SDMD) and sleep disorder due to a general medical condition (SDMC) in older adults and to establish their differentiating characteristics. METHODS: This is a cross-sectional study. Participants were randomly selected samples of 951 subjects who are 65 years or older. Main measures were as follows: presence (according to DSM-IV-TR diagnostic criteria) of PI, SDMD, SDMC or other sleep disorders, co-morbidity and psychotropic consumption. RESULTS: Of the subjects, 36.1% reported having sleep problems (95% CI: 33.0-39.2) and 37.0% reported regularly consuming a psychotropic drug. The prevalence of PI was 8.9% (95% CI: 7.1-11.0), and according to the criteria for differential diagnosis, the prevalence of SDMD was 9.3% (95% CI: 7.5-11.4) and that of SDMC was 7.0% (95%CI: 5.4-8.9). A higher percentage of PI subjects had problems in falling asleep on most days (52.5%), had frequent night-time awakenings (66.3%) and early awakenings (51.3%). In subjects with any type of insomnia, the variables that showed a statistically significant association were female gender (OR: 2.21), consumption of psychotropic drugs (OR: 1.83), presence of four or more health problems (OR: 1.88) and being single, widowed or divorced (OR: 1.43). CONCLUSIONS: Our results provide a true picture of the prevalence of insomnia in older adults on the basis of diagnostic criteria and indicate that it is a widespread, significant health problem. The peculiarities of PI, SDMD and SDMC need to be appropriately differentiated in clinical practice, and each needs a different approach to obtain the best outcome.