Advance Care Planning in Spain.

In the last decade in Spain, an important push has been given to the development of health policies that define the framework of action in the care of people with advanced chronic diseases. Respect for the autonomy of the patient, shared decision-making processes and advance care planning (ACP) are recognized into health plans as a key aspect in chronic care, frailty, and palliative care. A few but significant number of institutions, local governments, and healthcare professionals from different regions of Spain have started a rationale and roadmap for a new twist in Spain's theoretical, ethical and policy development, promoting ACP implementation into public health care systems. In 2020, a working group founded in 2017, evolved into the "Spanish Association of Shared Care Planning" (AEPCA). The Shared Care Planning (SCP) concept grows up after the two international consensus Delphi studies in 2017 and pretends to shift from the framework of ACP programs to a person-centred care approach. In the last years, several experiences show how professionals are more sensible and interested on the ACP process, but it cannot be said, for now, that it has taken effect in the global Spanish health system. Even both ACP and SCP are being used simultaneously in Spain, each day more people and autonomous communities embrace renewed concept and foundations of SCP, supporting the work of AEPCA on spreading the value of this process into the care of people who are coping with chronic diseases, vulnerability, and frailty.

Executive summary of the position paper on the use of enteral nutrition in advanced dementia.

Dementia is an increasingly prevalent disease in our environment, with significant health and social repercussions. Despite the available scientific evidence, there is still controversy regarding the use of enteral tube nutrition in people with advanced dementia. This document aims to reflect on the key aspects of advanced dementia, tube nutritional therapy and related ethical considerations, as well as to respond to several frequent questions that arise in our daily clinical practice.

Indicadores de calidad en colonoscopia. Procedimiento de la colonoscopia / Quality indicators in colonoscopy. The colonoscopy procedure

El objetivo del proyecto en el que se inscribe este trabajo es proponer procedimientos e indicadores de calidad y seguridad útiles para facilitar la mejora de la calidad en unidades de Endoscopia Digestiva. En este segundo resultado se proponen procedimientos e indicadores de la colonoscopia. Primero, se ha diseñado un diagrama de los pasos previos y consecutivos a la realización de la colonoscopia. Un grupo de expertos en calidad asistencial y/o endoscopia, bajo el amparo de la Sociedad Española de Patología Digestiva (SEPD), han realizado una revisión cualitativa de la literatura haciendo referencia a la búsqueda de indicadores de calidad en la colonoscopia. Posteriormente, por un procedimiento de análisis por pares se ha hecho la selección y análisis de la literatura seleccionada. Se han identificado un total de 13 indicadores específicos, independientemente de los ya descritos comunes, de los cuales diez son de proceso (uno de preprocedimiento, siete de procedimiento y dos de posprocedimiento) y tres, de resultado. Se ha analizado la calidad de la evidencia de cada uno de ellos aplicando la clasificación utilizada en GRADE (Grading of Recommendations Assessment, Development and Evaluation)

The aim of the project this paper is part of was to propose quality and safety procedures and indicators to facilitate quality improvement in digestive endoscopy units. In this second issue, procedures and indicators are suggested regarding colonoscopy. First, a diagram charting the previous and subsequent steps of colonoscopy was designed. A group of experts in health care quality and/or endoscopy, under the auspices of the Sociedad Española de Patología Digestiva (SEPD), performed a qualitative review of the literature regarding colonoscopy-related quality indicators. Subsequently, using a paired-analysis method, the aforementioned literature was selected and analyzed. A total of 13 specific indicators were found aside of the common markers elsewhere described, ten of which are process-related (one pre-procedure, seven procedure, and two post-procedure markers) while the remaining three are outcome-related. Quality of evidence was assessed for each one of them using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) classification

RECALAD. La asistencia al paciente en las unidades de Aparato Digestivo en el Sistema Nacional de salud. Estudio piloto, 2015 / RECALAD. Patient care at National Health System Digestive Care Units - A pilot study, 2015

Objetivo: elaborar un diagnóstico de situación sobre la asistencia en las unidades de aparato digestivo (UAD) en España. Material y métodos: estudio descriptivo transversal entre las UAD en hospitales generales de agudos del Sistema Nacional de Salud (datos referidos a 2015). Las variables de estudio fueron recogidas mediante un cuestionario sobre su estructura, cartera de servicios, actividad, formación, investigación y buenas prácticas. Asimismo, se analizaron las altas hospitalarias por enfermedades del área de digestivo mediante el Conjunto Mínimo Básico de Datos (2005-2014). Resultados: fueron invitados 209 hospitales, con 55 respuestas (26,3%). El promedio de altas de hospitalización es de 1.139 ± 653 por UAD/año y de 100 ± 66/año por digestólogo dedicado. La tasa de ingresos por mil habitantes y año en UAD en 2014 fue de 280, con una estancia media de 7,4 días. El análisis del CMBD 2005-2014 muestra un progresivo aumento en el número de altas dadas (37% más en 2014 frente a 2005), con una disminución del 28% en la tasa bruta de mortalidad intrahospitalaria (3,7% en 2014) y un ligero descenso (14%) de la estancia media (7,6 días en 2014). Se aprecia notable variabilidad en indicadores de estructura, actividad y resultados. Las tasas de mortalidad y reingresos, así como la estancia media, varían más del 100% entre UAD y existen asimismo notables dispersiones en frecuentación y resultados entre comunidades autónomas. Conclusiones: la encuesta RECALAD 2015 desvela aspectos relevantes sobre la organización, estructura y gestión de las UAD. La notable variabilidad hallada probablemente indica notables diferencias en eficiencia y productividad y, por tanto, un amplio margen de mejora (AU)

Objectives: To reach a situation diagnosis on the status of patient management at digestive care units (DCUs) in Spain. Material and methods: A cross-sectional descriptive study across DCUs in general acute care hospitals within the Spanish National Health System (data referred to 2015). The study variables were collected with a questionnaire including items on structure, services portfolio, activity, education, research, and good practice. Hospital discharge rates for digestive diseases were also assessed using the minimum basic data set (2005-2014). Results: Two hundred and nine hospitals invited, 55 responders (26.3%). Average discharges from hospital were 1,139 ± 653 per DCU/year, and 100 ± 66 per year per dedicated gastroenterologist. In 2014, admission rate to DCUs per 1,000 population and year was 280, with a mean stay of 7.4 days. The analysis of the MBDS for 2005-2014 reveals a progressive increase in the number of discharges (37% more in 2014 versus 2005), with a 28% decrease in hospital gross mortality rate (3.7% in 2014) and a slightly reduced (14%) mean stay (7.6 days in 2014). Considerable variability may be seen in structure, activity, and results indicators. Mortality and readmission rates, as well as mean stay, vary more than 100% amongst DCUs, and major dispersions also exist in frequentation and results amongst autonomous communities. Conclusions: The RECALAD 2015 survey unveiled relevant aspects related to DCUs organization, structure, and management. The notable variability encountered likely reflects relevant differences in efficiency and productivity, and thus points out there is ample room for improvement (AU)

RECALAD. Patient care at National Health System Digestive Care Units - A pilot study, 2015.

OBJECTIVES: To reach a situation diagnosis on the status of patient management at digestive care units (DCUs) in Spain. MATERIAL AND METHODS: A cross-sectional descriptive study across DCUs in general acute care hospitals within the Spanish National Health System (data referred to 2015). The study variables were collected with a questionnaire including items on structure, services portfolio, activity, education, research, and good practice. Hospital discharge rates for digestive diseases were also assessed using the minimum basic data set (2005-2014). RESULTS: Two hundred and nine hospitals invited, 55 responders (26.3%). Average discharges from hospital were 1,139 ± 653 per DCU/year, and 100 ± 66 per year per dedicated gastroenterologist. In 2014, admission rate to DCUs per 1,000 population and year was 280, with a mean stay of 7.4 days. The analysis of the MBDS for 2005-2014 reveals a progressive increase in the number of discharges (37% more in 2014 versus 2005), with a 28% decrease in hospital gross mortality rate (3.7% in 2014) and a slightly reduced (14%) mean stay (7.6 days in 2014). Considerable variability may be seen in structure, activity, and results indicators. Mortality and readmission rates, as well as mean stay, vary more than 100% amongst DCUs, and major dispersions also exist in frequentation and results amongst autonomous communities. CONCLUSIONS: The RECALAD 2015 survey unveiled relevant aspects related to DCUs organization, structure, and management. The notable variability encountered likely reflects relevant differences in efficiency and productivity, and thus points out there is ample room for improvement.

Eluxadoline en el tratamiento del síndrome de intestino irritable con predominio de diarrea. Punto de vista SEPD / Eluxadoline in the treatment of diarrhea-predominant irritable bowel syndrome. The SEPD perspective

Los trastornos funcionales del tubo digestivo, entre los que se encuentra el síndrome de intestino irritable con predominio de diarrea, constituyen una patología muy prevalente en todo el mundo, con un gran impacto tanto económico como en la calidad de vida de los pacientes, que no cuenta con alternativas terapéuticas completamente satisfactorias. Estas circunstancias han propiciado la investigación de diferentes moléculas con unas dianas terapéuticas más específicas como los receptores opioides. Eluxadoline (Vibercy(R) en Estados Unidos/Truberzi® en Europa, de Allergan) es una molécula agonista con efectos locales mixtos tanto agonista de los receptores opioides μ- y κ- como antagonista del receptor δ-opioide, que fue aprobada en 2015 por la Food and Drug Administration (FDA) y en 2016 por la Agencia Europea del Medicamento (EMA) para su indicación en el síndrome de intestino irritable con predominio de diarrea. Eluxadoline es un fármaco que ofrece, con ventaja sobre los que se utilizan en esta patología, el control tanto de la consistencia de las deposiciones como del dolor abdominal, con una buena tolerancia en la mayoría de los casos y una mejoría en la calidad de vida de estos pacientes, por lo que es una molécula a considerar en el abordaje de esta patología. Como en todo producto de reciente incorporación terapéutica, es de esperar una farmacovigilancia adecuada así como que se vaya generando conocimiento de estudios que nos ofrezcan información sobre diferentes escenarios tales como el tratamiento a demanda, la valoración de la pérdida de respuesta, la utilización del tratamiento como rescate a otras moléculas y la valoración del coste-eficacia del fármaco, para caracterizar y posicionar de una manera más precisa eluxadoline dentro del espectro terapéutico (AU)

Functional gut disorders, including diarrhea-predominant irritable bowel syndrome, are highly prevalent conditions worldwide that significantly impact health economy and patient quality of life, yet lacking fully satisfactory therapeutic options. These circumstances fostered research on various molecules with more specific therapeutic targets, including opioid receptors. Eluxadoline (Allergan’s Vibercy® in the USA, Truberzi® in Europe) is a locally-acting mixed mu- and kappa-opioid receptor agonist, and delta-opioid receptor antagonist, that was licensed in 2015 by the Food and Drug Administration (FDA) and in 2016 by the European Medicines Agency (EMA) for use in diarrhea-predominant irritable bowel syndrome. Eluxadoline provides, with advantage over the current standard of care, control of both stool consistency and abdominal pain, good tolerability in most cases, and improved quality of life, hence it deserves consideration when approaching a patient with this disorder. As with any recently approved therapy, adequate pharmacovigilance is to be expected, as well as studies to inform on different scenarios such as on-demand therapy, loss of response assessment, use as rescue therapy for other molecules, and cost-effectiveness, to further characterize and more accurately position eluxadoline within the therapeutic spectrum (AU)

Post-Traumatic Stress Disorder and other mental disorders in the general population after Lorca's earthquakes, 2011 (Murcia, Spain): A cross-sectional study.

AIMS: To describe the prevalence and severity of mental disorders and to examine differences in risk among those with and without a lifetime history prior to a moderate magnitude earthquake that took place in Lorca (Murcia, Spain) at roughly the mid-point (on May 11, 2011) of the time interval in which a regional epidemiological survey was already being carried out (June 2010 -May 2012). METHODS: The PEGASUS-Murcia project is a cross-sectional face-to-face interview survey of a representative sample of non-institutionalized adults in Murcia. Main outcome measures are prevalence and severity of anxiety, mood, impulse and substance disorders in the 12 months previous to the survey, assessed using the Composite International Diagnostic Interview (CIDI 3.0). Sociodemographic variables, prior history of any mental disorder and earthquake-related stressors were entered as independent variables in a logistic regression analysis. FINDINGS: A total number of 412 participants (response rate: 71%) were interviewed. Significant differences in 12-month prevalence of mental disorders were found in Lorca compared to the rest of Murcia for any (12.8% vs 16.8%), PTSD (3.6% vs 0.5%) and other anxiety disorders (5.3% vs 9.2%) (p≤ 0.05 for all). No differences were found for 12-month prevalence of any mood or any substance disorder. The two major predictors for developing a 12-month post-earthquake mental disorder were a prior mental disorder and the level of exposure. Other risk factors included female sex and low-average income. CONCLUSIONS: PTSD and other mental disorders are commonly associated with earthquake disasters. Prior mental disorders and the level of exposure to the earthquakes are the most important for the development of a consequent mental disorder and this recognition may help to identify those individuals that may most benefit from specific therapeutic intervention.

Indicadores de calidad en endoscopia digestiva: introducción a los indicadores comunes de estructura, proceso y resultado / Quality indicators in digestive endoscopy: introduction to structure, process, and outcome common indicators

El objetivo general del proyecto en el que se inscribe este trabajo es proponer procedimientos e indicadores de calidad y seguridad útiles para facilitar la mejora de la calidad en unidades de Endoscopia Digestiva. En este primer resultado se proponen procedimientos e indicadores comunes a las pruebas de endoscopia digestiva. Primero, se ha diseñado un diagrama de los pasos previos y consecutivos a la realización de la endoscopia digestiva. Un grupo de expertos en calidad asistencial y/o endoscopia, bajo el amparo de la Sociedad Española de Patología Digestiva, han realizado una revisión cualitativa de la literatura haciendo referencia a la búsqueda de indicadores de calidad en los procedimientos endoscópicos. Posteriormente, por un procedimiento de análisis por pares se ha hecho la selección y análisis de la literatura seleccionada. Se ha identificado un total de 20 indicadores, de los cuales siete son de estructura; once, de proceso (cinco de preprocedimiento, tres de procedimiento y tres de posprocedimiento); y dos, de resultado. Se ha analizado la calidad de la evidencia de cada uno de ellos aplicando la clasificación utilizada en GRADE (Grading of Recommendations Assessment, Development and Evaluation) (AU)

The general goal of the project wherein this paper is framed is the proposal of useful quality and safety procedures and indicators to facilitate quality improvement in digestive endoscopy units. This initial offspring sets forth procedures and indicators common to all digestive endoscopy procedures. First, a diagram of pre- and post-digestive endoscopy steps was developed. A group of health care quality and/or endoscopy experts under the auspices of the Sociedad Española de Patología Digestiva (Spanish Society of Digestive Diseases) carried out a qualitative review of the literature regarding the search for quality indicators in endoscopic procedures. Then, a paired analysis was used for the selection of literature references and their subsequent review. Twenty indicators were identified, including seven for structure, eleven for process (five pre-procedure, three intra-procedure, three post-procedure), and two for outcome. Quality of evidence was analyzed for each indicator using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification (AU)

A survey-based analysis on endoscopic quality indicators compliance among Spanish endoscopists

Introduction: Endoscopy plays a key role for the diagnosis and management of gastrointestinal disorders. Therefore, quality indicators have been widely proposed in order to optimize endoscopic practice. The aims of this study, promoted by the Spanish Society of Digestive Diseases (SEPD), were to assess the knowledge and compliance to endoscopy quality indicators among Spanish gastroenterologists. Methods: A 31-questionnaire survey was created based on the endoscopy quality indicators proposed by international guidelines. The survey was distributed among Spanish gastroenterologists who are members of the society. Using only fully completed surveys, a descriptive analysis was performed. Those factors related with a suboptimal quality performance were also investigated. Results: A total of 1,543 surveys were sent and 281 (18.2%) were received completed. Based on the answers obtained, the management of 14 (70%) out of 20 assessed quality indicators was poor: 5 (83.3%) out of 6 pre-procedure items, 7 (58.3%) out of 12 intra-procedure items and 2 (100%) out of 2 post-procedure items. Young age, public setting, no colorectal cancer (CRC) screening program at the institution and a low volume of procedures/week are factors related to poorer management of the assessed quality indicators. Conclusions: A significant proportion of Spanish endoscopists do not comply with main endoscopic quality indicators. Factors such as 'young' age, public setting, no colorectal cancer screening program and low volume of procedures/week are related to a poorer management of the assessed quality indicators and should be the target for future formative activities (AU)

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A survey-based analysis on endoscopic quality indicators compliance among Spanish endoscopists.

INTRODUCTION: Endoscopy plays a key role for the diagnosis and management of gastrointestinal disorders. Therefore, quality indicators have been widely proposed in order to optimize endoscopic practice. The aims of this study, promoted by the Spanish Society of Digestive Diseases (SEPD), were to assess the knowledge and compliance to endoscopy quality indicators among Spanish gastroenterologists. METHODS: A 31-questionnaire survey was created based on the endoscopy quality indicators proposed by international guidelines. The survey was distributed among Spanish gastroenterologists who are members of the society. Using only fully completed surveys, a descriptive analysis was performed. Those factors related with a suboptimal quality performance were also investigated. RESULTS: A total of 1,543 surveys were sent and 281 (18.2%) were received completed. Based on the answers obtained, the management of 14 (70%) out of 20 assessed quality indicators was poor: 5 (83.3%) out of 6 pre-procedure items, 7 (58.3%) out of 12 intra-procedure items and 2 (100%) out of 2 post-procedure items. CONCLUSIONS: A significant proportion of Spanish endoscopists do not comply with main endoscopic quality indicators. Factors such as "young" age, public setting, no colorectal cancer screening program and low volume of procedures/week are related to a poorer management of the assessed quality indicators and should be the target for future formative activities.

Utilización del polietilenglicol como tratamiento en el estreñimiento funcional y la impactación fecal / Use of polyethylene glycol in functional constipation and fecal impaction

Objetivo: evaluar analítica y descriptivamente la evidencia publicada hasta la actualidad sobre el uso del polietilenglicol, solo o con electrolitos, en el tratamiento de pacientes con estreñimiento funcional. Metodología: búsqueda en las bases de datos MEDLINE, EMBASE y Cochrane hasta mayo de 2016 de todas las publicaciones que se ajustaran a los siguientes términos: constipation and/or fecal impaction and (PEG or polyethilene or macrogol or movicol or idralax or miralax or transipeg or forlax or golytely or isocolan or mulytely) not colonoscopy. Lectura crítica de los artículos seleccionados (únicamente en inglés o español) clasificando la descripción de los mismos en función de grupos de edad (adulto/ edad pediátrica) y, dentro de ellos, en función de las características de los estudios (evaluación de eficacia frente a placebo, búsqueda de dosis, seguridad, comparación con otros laxantes, estudios observacionales y artículos de revisión monográficos para poletilenglicol o metaanálisis). Resultados: se han seleccionado para análisis descriptivo 58 publicaciones; de ellas, 41 son ensayos clínicos, ocho son estudios observacionales y nueve son revisiones sistemáticas o metaanálisis. Doce ensayos clínicos evalúan la eficacia frente a placebo, ocho frente a lactulosa, seis estudio de dosis, cinco comparan entre sí el polietilenglicol con y sin electrolitos, dos comparan la eficacia con respecto a leche de magnesia y el resto de ensayos evalúan el polietilenglicol comparando con enemas (dos), ispágula (uno), tegaserod (uno), prucaloprida (uno), aceite de parafina (uno), combinaciones de fibras (uno) y Descurainia sophia (uno). Conclusiones: los preparados con polietilenglicol, únicos o asociados a electrolitos, son más eficaces que el placebo en el tratamiento del estreñimiento funcional tanto en adultos como en edad pediátrica con gran seguridad y tolerancia. Constituyen el laxante osmótico más eficaz (superior a la lactulosa) y de primera línea para el tratamiento de esta afección a corto y largo plazo. En la impactación fecal son tan eficaces como los enemas, evitan la necesidad de ingreso hospitalario y son muy bien tolerados por los pacientes (fundamentalmente, en su presentación sin electrolitos) (AU)

Objective: The objective of this study was to evaluate in an analytical and descriptive manner the evidence published so far on the use of polyethylene glycol (PEG), with or without electrolytes, in the management of functional constipation and the treatment of fecal impaction. Methodology: Search on MEDLINE, EMBASE and Cochrane databases until May 2016 of all publications adjusted to the following terms: constipation AND/OR fecal impaction AND (PEG OR polyethylene glycol OR macrogol OR movicol OR idralax OR miralax OR transipeg OR forlax OR golytely OR isocolan OR mulytely) NOT colonoscopy. Critical reading of selected articles (English or Spanish), sorting their description according to group age (adult/pediatric age) and within those, in accordance with study features (efficacy evaluation versus placebo, doses query, safety, comparison with other laxatives, observational studies and monographic review articles of polyethylene glycol or meta-analysis). Results: Fifty-eight publications have been chosen for descriptive analysis; of them, 41 are clinical trials, eight are observational studies and nine are systematic reviews or meta-analysis. Twelve clinical trials evaluate PEG efficacy versus placebo, eight versus lactulose, six are dose studies, five compare polyethylene glycol with and without electrolytes, two compare its efficacy with respect to milk of magnesia, and the rest of the trials evaluate polyethylene glycol with enemas (two), psyllium (one), tegaserod (one), prucalopride (one), paraffin oil (one), fiber combinations (one) and Descurainia sophia (one). Conclusions: Polyethylene glycol with or without electrolytes is more efficacious than placebo for the treatment of functional constipation, either in adults or in pediatric patients, with great safety and tolerability. These preparations constitute the most efficacious osmotic laxatives (more than lactulose) and are the first-line treatment for functional constipation in the short and long-term. They are as efficacious as enemas in fecal impaction, avoid the need for hospital admission and are well tolerated by patients (mainly when administered without electrolytes) (AU)

Use of polyethylene glycol in functional constipation and fecal impaction.

OBJECTIVE: The objective of this study was to evaluate in an analytical and descriptive manner the evidence published so far on the use of polyethylene glycol (PEG), with or without electrolytes, in the management of functional constipation and the treatment of fecal impaction. METHODOLOGY: Search on MEDLINE, EMBASE and Cochrane databases until May 2016 of all publications adjusted to the following terms: constipation AND/OR fecal impaction AND (PEG OR polyethylene glycol OR macrogol OR movicol OR idralax OR miralax OR transipeg OR forlax OR golytely OR isocolan OR mulytely) NOT colonoscopy. Critical reading of selected articles (English or Spanish), sorting their description according to group age (adult/pediatric age) and within those, in accordance with study features (efficacy evaluation versus placebo, doses query, safety, comparison with other laxatives, observational studies and monographic review articles of polyethylene glycol or meta-analysis). RESULTS: Fifty-eight publications have been chosen for descriptive analysis; of them, 41 are clinical trials, eight are observational studies and nine are systematic reviews or meta-analysis. Twelve clinical trials evaluate PEG efficacy versus placebo, eight versus lactulose, six are dose studies, five compare polyethylene glycol with and without electrolytes, two compare its efficacy with respect to milk of magnesia, and the rest of the trials evaluate polyethylene glycol with enemas (two), psyllium (one), tegaserod (one), prucalopride (one), paraffin oil (one), fiber combinations (one) and Descurainia sophia (one). CONCLUSIONS: Polyethylene glycol with or without electrolytes is more efficacious than placebo for the treatment of functional constipation, either in adults or in pediatric patients, with great safety and tolerability. These preparations constitute the most efficacious osmotic laxatives (more than lactulose) and are the first-line treatment for functional constipation in the short and long-term. They are as efficacious as enemas in fecal impaction, avoid the need for hospital admission and are well tolerated by patients (mainly when administered without electrolytes).

El reto de la planificación anticipada de la atención al final de la vida en España / The challenge of advance care planning at the end of life in Spain

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Manejo del problema clínico del estreñimiento con molestias abdominales en adultos. Encuesta nacional en Atención Primaria y Aparato Digestivo / Management of the clinical issue of constipation with abdominal complaints in adults. A national survey of Primary Care physicians and gastroenterologists

El síndrome del intestino irritable y el estreñimiento funcional constituyen un problema de salud relevante y frecuente. Sin embargo, la realidad clínica presenta a un paciente con estreñimiento que se acompaña o no de otras molestias abdominales (dolor, distensión, molestia abdominal) con una frecuencia variable. El objetivo del estudio fue obtener información sobre el volumen de trabajo que suponen los pacientes con estreñimiento y molestias abdominales asociadas, las conductas clínicas predominantes, las necesidades formativas y las posibles ayudas a la práctica diaria tanto en el ámbito de Atención Primaria como en Aparato Digestivo. La conducta clínica de médicos de ambos niveles es globalmente similar, a pesar del diferente nivel asistencial: utilización de tratamientos empíricos y pruebas diagnósticas guiadas por la clínica, con algunas diferencias en la utilización de la colonoscopia (no siempre indicable directamente desde Primaria). En lo referente a las percepciones, cabe destacar que para los médicos de Primaria las medidas generales y los laxantes osmóticos son los mejor valorados; para los médicos de Digestivo, lo son los laxantes osmóticos, las combinaciones de laxantes y la linaclotida. Por otro lado, más de la mitad de todos los encuestados consideran que es bastante difícil diferenciar entre ambos diagnósticos. Finalmente, existen unas notables necesidades formativas autorreconocidas en ambos niveles, además de la exigencia de generar guías y protocolos que ayuden en la práctica clínica a abordar este problema. La fortaleza de este estudio es proporcionar una fotografía conjunta del abordaje médico y de las percepciones del problema del estreñimiento con molestias abdominales desde el punto de vista médico. La autodeclaración (sin validación formal) y la tasa de respuesta con posible sesgo a profesionales más motivados son sus debilidades (AU)

Irritable bowel syndrome and functional constipation represent a relevant and common health issue. However, real-world clinical practice includes patients with constipation who may or may not have other abdominal complaints (pain, bloating, abdominal discomfort) with variable frequency. The goal of the present study was to obtain information on the workload entailed by patients with constipation and associated abdominal complaints, predominant clinical behaviors, education needs, and potential daily practice aids both in Primary Care and gastroenterology settings. The clinical behavior of doctors is generally similar at both levels, despite differences in healthcare approach: use of empiric therapies and clinically guided diagnostic tests, with some differences in colonoscopy use (not always directly accessible from Primary Care). Regarding perceptions, general support and osmotic laxatives are most valued by PC doctors, whereas osmotic laxatives, combined laxatives, and linaclotide are most valued by GE specialists. Furthermore, over half of respondents considered differentiating both diagnoses as challenging. Finally, considerable education needs are self-acknowledged at both levels, as is a demand for guidelines and protocols to help in managing this issue in clinical practice. A strength of this study is its providing a joint photograph of the medical approach and the perceptions of constipation with abdominal discomfort from a medical standpoint. Weaknesses include self-declaration (no formal validation) and a response rate potentially biased by professional motivation (AU)

Guía de Práctica Clínica: Síndrome del intestino irritable con estreñimiento y estreñimiento funcional en adultos / Clinical Practice Guideline: Irritable bowel syndrome with constipation and functional constipation in the adult

En esta Guía de Práctica Clínica analizamos el manejo diagnóstico y terapéutico de pacientes adultos con estreñimiento y molestias abdominales, bajo la confluencia del espectro del síndrome del intestino irritable y el estreñimiento funcional. Ambas patologías están encuadradas en los trastornos funcionales intestinales y tienen una importante repercusión personal, sanitaria y social, afectando a la calidad de vida de los pacientes que las padecen. La primera es el subtipo de síndrome de intestino irritable en el que el estreñimiento es la alteración deposicional predominante junto con dolor abdominal recurrente, hinchazón y distensión abdominal frecuente. El estreñimiento se caracteriza por la dificultad o la escasa frecuencia en relación con las deposiciones, a menudo acompañado por esfuerzo excesivo durante la defecación o sensación de evacuación incompleta. En la mayoría de los casos no tiene una causa orgánica subyacente, siendo considerado un trastorno funcional intestinal. Son muchas las similitudes clínicas y fisiopatológicas entre ambos trastornos, con respuesta similar del estreñimiento a fármacos comunes, siendo la diferencia fundamental la presencia o ausencia de dolor, pero no de un modo evaluable como «todo o nada». La gravedad de estos trastornos depende no sólo de la intensidad de los síntomas intestinales sino también de otros factores biopsicosociales: asociación de síntomas gastrointestinales y extraintestinales, grado de afectación, y formas de percepción y comportamiento. Mediante los criterios de Roma, se diagnostican los trastornos funcionales intestinales. Esta Guía de Práctica Clínica está adaptada a los criterios de Roma IV difundidos a finales de mayo de 2016 y analiza los criterios de alarma, las pruebas diagnósticas y los criterios de derivación entre Atención Primaria y Aparato Digestivo. Asimismo, se revisan todas las alternativas terapéuticas disponibles (ejercicio, ingesta de líquidos, dieta con alimentos ricos en fibra soluble, suplementos de fibra, otros componentes de la dieta, laxantes osmóticos o estimulantes, probióticos, antibióticos, espasmolíticos, esencia de menta, prucaloprida, linaclotida, lubiprostona, biofeedback, antidepresivos, tratamiento psicológico, acupuntura, enemas, neuroestimulación de raíces sacras o cirugía), efectuando recomendaciones prácticas para cada una de ellas (AU)

In this Clinical Practice Guideline we discuss the diagnostic and therapeutic approach of adult patients with constipation and abdominal complaints at the confluence of the irritable bowel syndrome spectrum and functional constipation. Both conditions are included among the functional bowel disorders, and have a significant personal, healthcare, and social impact, affecting the quality of life of the patients who suffer from them. The first one is the irritable bowel syndrome subtype, where constipation represents the predominant complaint, in association with recurrent abdominal pain, bloating, and abdominal distension. Constipation is characterized by difficulties with or low frequency of bowel movements, often accompanied by straining during defecation or a feeling of incomplete evacuation. Most cases have no underlying medical cause, and are therefore considered as a functional bowel disorder. There are many clinical and pathophysiological similarities between both disorders, and both respond similarly to commonly used drugs, their primary difference being the presence or absence of pain, albeit not in an «all or nothing» manner. Severity depends not only upon bowel symptom intensity but also upon other biopsychosocial factors (association of gastrointestinal and extraintestinal symptoms, grade of involvement, and perception and behavior variants). Functional bowel disorders are diagnosed using the Rome criteria. This Clinical Practice Guideline has been made consistent with the Rome IV criteria, which were published late in May 2016, and discuss alarm criteria, diagnostic tests, and referral criteria between Primary Care and gastroenterology settings. Furthermore, all the available treatment options (exercise, fluid ingestion, diet with soluble fiber-rich foods, fiber supplementation, other dietary components, osmotic or stimulating laxatives, probiotics, antibiotics, spasmolytics, peppermint essence, prucalopride, linaclotide, lubiprostone, biofeedback, antidepressants, psychological therapy, acupuncture, enemas, sacral root neurostimulation, surgery) are discussed, and practical recommendations are made regarding each of them (AU)

Clinical Practice Guideline: Irritable bowel syndrome with constipation and functional constipation in the adult.

In this Clinical Practice Guideline we discuss the diagnostic and therapeutic approach of adult patients with constipation and abdominal complaints at the confluence of the irritable bowel syndrome spectrum and functional constipation. Both conditions are included among the functional bowel disorders, and have a significant personal, healthcare, and social impact, affecting the quality of life of the patients who suffer from them. The first one is the irritable bowel syndrome subtype, where constipation represents the predominant complaint, in association with recurrent abdominal pain, bloating, and abdominal distension. Constipation is characterized by difficulties with or low frequency of bowel movements, often accompanied by straining during defecation or a feeling of incomplete evacuation. Most cases have no underlying medical cause, and are therefore considered as a functional bowel disorder. There are many clinical and pathophysiological similarities between both disorders, and both respond similarly to commonly used drugs, their primary difference being the presence or absence of pain, albeit not in an "all or nothing" manner. Severity depends not only upon bowel symptom intensity but also upon other biopsychosocial factors (association of gastrointestinal and extraintestinal symptoms, grade of involvement, and perception and behavior variants). Functional bowel disorders are diagnosed using the Rome criteria. This Clinical Practice Guideline has been made consistent with the Rome IV criteria, which were published late in May 2016, and discuss alarm criteria, diagnostic tests, and referral criteria between Primary Care and gastroenterology settings. Furthermore, all the available treatment options (exercise, fluid ingestion, diet with soluble fiber-rich foods, fiber supplementation, other dietary components, osmotic or stimulating laxatives, probiotics, antibiotics, spasmolytics, peppermint essence, prucalopride, linaclotide, lubiprostone, biofeedback, antidepressants, psychological therapy, acupuncture, enemas, sacral root neurostimulation, surgery) are discussed, and practical recommendations are made regarding each of them.

Efectos adversos de los inhibidores de la bomba de protones: revisión de evidencias y posicionamiento de la Sociedad Española de Patología Digestiva / Proton-pump inhibitors adverse effects: a review of the evidence and position statement by the Sociedad Española de Patología Digestiva

Introducción: en los últimos años, numerosos artículos relacionan el uso de los inhibidores de la bomba de protones (IBP) con posibles efectos adversos serios que han creado cierta alarma social. Objetivo: el objetivo de este trabajo es revisar la literatura de cara a elaborar un documento institucional de posicionamiento de la Sociedad Española de Patología Digestiva (SEPD) sobre la seguridad de los IBP a largo plazo. Material y métodos: se ha realizado una revisión exhaustiva de la literatura orientada a la presentación de conclusiones tras una valoración crítica sobre los siguientes temas: a) indicaciones actuales de los IBP; b) déficit de vitamina B12 y alteraciones neurológicas; c) déficit de magnesio; d) fracturas óseas; e) infecciones entéricas y neumonías; f) interacción con los derivados de las tienopiridinas; y e) complicaciones en pacientes cirróticos. Resultados: las indicaciones actuales de los IBP no han variado en los últimos años y están bien establecidas. No se recomienda la realización de un cribado generalizado de los niveles de vitamina B12 en todos los pacientes tratados de forma crónica con estos medicamentos; sin embargo, sí parece necesario controlar los niveles de magnesio al inicio del tratamiento y monitorizarlos en pacientes con toma de otros fármacos que puedan inducir hipomagnesemia. Existe mayor riesgo de fracturas óseas, aunque no se puede concluir que esta asociación sea causal. La asociación IBP e infección por Clostridium difficile es débil o moderada y el riesgo de neumonía es bajo. En pacientes con riesgo cardiovascular y tratados con derivados de las tienopiridinas -dada la ausencia de evidencias definitivas en relación a posibles interacciones medicamentosasparece que lo prudente sea sopesar adecuadamente los riesgos gastrointestinales y los riesgos cardiovasculares de cada paciente; cuando el riesgo gastrointestinal sea moderado/alto, debemos ejercer una acción terapéutica de prevención efectiva utilizando un IBP. En cirróticos descompensados deben ser indicados con cautela. Conclusiones: los IBP son fármacos seguros y los beneficios de su empleo, tanto a corto como a largo plazo superan los posibles efectos secundarios, siempre que la indicación, dosis y duración sean las adecuadas (AU)

Introduction: In the last few years a significant number of papers have related the use of proton-pump inhibitors (PPIs) to potential serious adverse effects that have resulted in social unrest. Objective: The goal of this paper was to provide a literature review for the development of an institutional position statement by Sociedad Española de Patología Digestiva (SEPD) regarding the safety of long-term PPI use. Material and methods: A comprehensive review of the literature was performed to draw conclusions based on a critical assessment of the following: a) current PPI indications; b) vitamin B12 deficiency and neurological disorders; c) magnesium deficiency; d) bone fractures; e) enteric infection and pneumonia; f) interactions with thienopyridine derivatives; e) complications in cirrhotic patients. Results: Current PPI indications have remained unchanged for years now, and are well established. A general screening of vitamin B12 levels is not recommended for all patients on a PPI; however, it does seem necessary that magnesium levels be measured at therapy onset, and then monitored in subjects on other drugs that may induce hypomagnesemia. A higher risk for bone fractures is present, even though causality cannot be concluded for this association. The association between PPIs and infection with Clostridium difficile is mild to moderate, and the risk for pneumonia is low. In patients with cardiovascular risk receiving thienopyridines derivatives it is prudent to adequately consider gastrointestinal and cardiovascular risks, given the absence of definitive evidence regardin potential drug-drug interactions; if gastrointestinal risk is found to be moderate or high, effective prevention should be in place with a PPI. PPIs should be cautiously indicated in patients with decompensated cirrhosis. Conclusions: PPIs are safe drugs whose benefits outweigh their potential side effects both short-term and long-term, provided their indication, dosage, and duration are appropriate (AU)

Prevalence of Mental Disorders in the South-East of Spain, One of the European Regions Most Affected by the Economic Crisis: The Cross-Sectional PEGASUS-Murcia Project.

BACKGROUND: To describe the lifetime and 12-month prevalence, severity and age of onset distribution of DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) disorders and to explore the association between socio-demographic variables and economic stressors with mental disorders during the economic crisis in the general population of Murcia (Spain). METHODS AND FINDINGS: The PEGASUS-Murcia Project is a cross-sectional face-to-face interview survey of a representative sample of non-institutionalized adults in Murcia administered between June 2010 and May 2012. DSM-IV disorders were assessed by the Composite International Diagnostic Interview (CIDI 3.0). Main outcome measures were lifetime and 12-month prevalence of Anxiety, Mood, Impulse and Substance Disorders, Severity and Age of Onset. Sociodemographic variables and stressful economic life events during the preceding 12 months were entered as independent variables in a logistic regression analysis. A total of 2,621 participants (67.4% response rate) were interviewed, 54.5% female, mean age 48.6 years. Twelve-month prevalence (95%CI) of disorders: anxiety 9.7% (7.6-12.2), mood 6.6% (5.5-8.1), impulse 0.3% (0.1-1.2) and substance use 1.0% (0.4-2.4) disorders. Lifetime prevalence: anxiety 15.0% (12.3-18.1), mood 15.6% (13.5-18.1), impulse 2.4% (1.4-4.0) and substance use 8.3% (6.2-11.0) disorders. Severity among 12-month cases: serious 29.2% (20.8-39.4), moderate 35.6% (24.0-49.1) and mild severity 35.2% (29.5-41.5). Women were 3.7 and 2.5 times more likely than men to suffer 12-month anxiety and mood disorders, respectively. Substance use was more frequent among men. Younger age and lower income were associated with higher prevalence. Respondents exposed to multiple and recent economic stressors had the highest risk of anxiety disorders. CONCLUSIONS: Mental disorders in the adult population of Murcia during the economic crisis were more prevalent and serious than those in previous estimates for Spain. Prevalence was strongly associated with exposure to stressors related to the economic crisis.

Enfermedades crónicas: ¿por qué seguimos esperando a Godot? / Chronic illnesses: why are we still waiting for Godot?

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