Neuroblastoma in Spain: Linking the national clinical database and epidemiological registries - A study by the Joint Action on Rare Cancers.

PURPOSE: Linkage between clinical databases and population-based cancer registries may serve to evaluate European Reference Networks' (ERNs) activity, by monitoring the proportion of patients benefiting from these and their impact on survival at a population level. To test this, a study targeting neuroblastoma (Nb) was conducted in Spain by the European Joint Action on Rare Cancers. MATERIAL AND METHODS: Subjects: Nb cases, incident 1999-2017, aged < 15 years. Linkage included: Spanish Neuroblastoma Clinical Database (NbCDB) (1217 cases); Spanish Registry of Childhood Tumours (RETI) (1514 cases); and 10 regional population-based registries (RPBCRs) which cover 33% of the childhood population (332 cases). Linkage was semiautomatic. We estimated completeness, incidence, contribution, deficit, and 5-year survival in the databases and specific subsets. RESULTS: National completeness estimates for RETI and NbCDB were 91% and 72% respectively, using the Spanish RPBCRs on International Incidence of Childhood Cancer (https://iicc.iarc.fr/) as reference. RPBCRs' specific contribution was 1.6%. Linkage required manual crossover in 54% of the semiautomatic matches. Five-year survival was 74% (0-14 years) and 90% (0-18 months). CONCLUSIONS: All three databases were incomplete as regards Spain as a whole and should therefore be combined to achieve full childhood cancer registration. A unique personal patient identifier could facilitate such linkage. Most children have access to Nb clinical trials. Consolidated interconnections between the national registry and clinical registries (including ERNs and paediatric oncology clinical groups) should be established to evaluate outcomes.

Principios y deberes en el ejercicio de la dirección médica de los hospitales y centros sanitarios / Principles and duties in the exercise of the medical direction of hospitals and health centers

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Tercer Congreso de la Profesión Médica de Catalunya: consenso sobre los retos del profesionalismo y su impacto en las organizaciones docentes / The Third Congress of the Medical Profession of Catalonia: a consensus on the challenges of professionalism and their impact on medical education organizations

Introducción. En tiempos donde los condicionantes demográficos, epidemiológicos, socioeconómicos y tecnológicos determinan fuertemente la manera en que se ejerce la medicina, foros como el Congreso de la Profesión Médica de Catalunya pueden aportar luz en los nuevos enfoques que exige el profesionalismo médico actual y futuro. Objetivo. Mostrar el proceso y las conclusiones de un consenso, llevado a cabo en la edición 2016 del congreso, acerca de los nuevos retos del profesionalismo y del perfil del médico que la sociedad de las próximas décadas va a necesitar. Sujetos y métodos. Se lleva a cabo un proceso participativo y estructurado de consenso, implementado en tres fases consecutivas: panel de expertos, peer-review telemático y debate intracongresual. Resultados. La participación activa de 21 expertos, de 2.025 aportaciones telemáticas y de 131 delegados congresuales genera un documento de propuestas compartidas que cuenta con índices de aprobación cercanos al 95% y que permite identificar y priorizar los retos percibidos en el profesionalismo y los atributos de los médicos del futuro reciente. Conclusiones. El profesionalismo médico se verá directamente interpelado por las nuevas condiciones sociales y por las nuevas propuestas para los sistemas sanitarios del futuro, donde los elementos de empoderamiento ciudadano, de toma compartida de decisiones clínicas, de prácticas colaborativas y marcos éticos impecables, asociados a una apuesta decidida por posiciones de liderazgo profesional y social del colectivo médico, van a constituir el contexto emergente de la práctica de la medicina, al que las organizaciones docentes deberán adaptarse (AU)

Introduction. In times where demographic, epidemiological, socio-economic and technological conditions strongly determine the way in which medicine is practiced, forums such as the Congress of the Medical Profession of Catalonia can inform on the new approaches required by current and future medical professionalism. Aim. To show the process and the conclusions of a consensus, carried out in the 2016 edition of the Congress, about the new challenges of professionalism and the profile of the physician that the Catalan society will need the next decades. Subjects and methods. A participatory and structured consensus process is implemented in three consecutive phases: expert panel, telematic peer-review and intra-congressional debate. Results. The active participation of 21 experts, 2,025 telematic contributions and 131 congressional delegates generated a document of shared proposals that has approval rates around 95% and that allows the identification and prioritization of the perceived challenges in professionalism and the attributes of physicians for the recent future. Conclusions. Medical professionalism will be directly challenged by the new social conditions and by the proposals for the health systems of the future, where the elements of citizen empowerment, of shared decision-making procedures, of collaborative practices in impeccable ethical frameworks and solid positions of professional and social leadership of doctors will constitute the emerging context of the practice of medicine, to which teaching organizations will have to adapt (AU)

Dual diagnosis among physicians: a clinical perspective.

Co-occurrence of mental disorders and substance use disorders (dual diagnosis) among doctors is a cause of serious concern due to its negative personal, professional, and social consequences. This work provides an overview of the prevalence of dual diagnosis among physicians, suggests a clinical etiological model to explain the development of dual diagnosis in doctors, and recommends some treatment strategies specifically for doctors. The most common presentation of dual diagnosis among doctors is the combination of alcohol use disorders and affective disorders. There are also high rates of self-medication with benzodiazepines, legal opiates, and amphetamines compared to the general population, and cannabis use disorders are increasing, mainly in young doctors. The prevalence of nicotine dependence varies from one country to another depending on the nature of public health policies. Emergency medicine physicians, psychiatrists, and anaesthesiologists are at higher risk for developing a substance use disorder compared with other doctors, perhaps because of their knowledge of and access to certain legal drugs. Two main pathways may lead doctors toward dual diagnosis: (a) the use of substances (often alcohol or self-prescribed drugs) as an unhealthy strategy to cope with their emotional or mental distress and (b) the use of substances for recreational or other purposes. In both cases, doctors tend to delay seeking help once a problem has been established, often for many years. Denial, minimization, and rationalization are common defense mechanisms, maybe because of the social stigma associated with mental or substance use disorders, the risk of losing employment/medical license, and a professional culture of perfectionism and denial of emotional needs or failures. Personal vulnerability interacts with these factors to increase the risk of a dual diagnosis developing in some individuals. When doctors with substance use disorders accept treatment in programs specifically designed for them (Physicians' Health Programs), they show better outcomes than the general population. However, physicians with dual diagnosis have more psychological distress and worse clinical prognosis than those with substance use disorders only. Future studies should contribute to a better comprehension of the risk and protective factors and the evidence-based treatment strategies for doctors with dual diagnosis.

Inpatient physicians and nurses with dual diagnosis: an exploratory study.

OBJECTIVE: This study explored the clinical features of physicians and nurses with dual diagnosis.   METHODS: We conducted a retrospective review of 150 medical records of physicians (n = 120) and nurses (n = 30) admitted from February 2008 to February 2011 to the Barcelona Psychiatric Inpatient Unit for Health Professionals. Routine intake included the Spanish version of the Psychiatric Research Interview for Substance and Mental Disorders (PRISM-IV) and a clinical interview.   RESULTS: The mean age of participants was 48.59 (SD = 8.9) years and 57.3% were male. Patients experienced substance dependence with alcohol (n = 112, 74.7%), sedatives (n = 59, 39.3%), cocaine (n = 24, 16%), other stimulants (n = 15, 10%), and opiates other than heroin (n = 16, 10.7%). About 41% (n = 61) also met criteria for a mental health disorder, mainly major depressive disorder (n = 42, 28%), while 8% (n = 12) had attention deficit hyperactivity disorder. A high proportion of physicians (n = 95, 79.2%) and nurses (n = 25, 83.3%) had nicotine dependence. The most common comorbidity was alcohol dependence and major depressive disorder. No differences were found between groups in the prevalence of substance use disorders, mental health disorders, and dual diagnosis.   CONCLUSIONS: Dual diagnosis is a common condition among inpatient physicians and nurses with substance use disorders and its clinical presentation may be similar in both groups.

Doctors admitted to a Physicians' Health Program: a comparison of self-referrals versus directed referrals.

OBJECTIVE: To compare the profile of doctors with mental disorders admitted to a Physicians' Health Program (PHP) depending on their type of referral. DESIGN: Retrospective chart review. METHOD: We analysed 1545 medical records of doctors admitted to the Barcelona PHP (PAIMM) from 1 February 1998 to 31 December 2012. RESULTS: Most doctors (83.2%) were self-referred to the programme. Patients non-self-referred were older ([Formula: see text]=55 vs [Formula: see text]=49.6 years; t=6.96, p<0.01) than those self-referred and there were more men (68.3%) than women (45.8%; OR=0.39; 95% CI 0.29 to 0.52). Self-referrals were more frequent among patients with non-addictive disorders (84.6% vs 15.4%; OR=4.52; 95% CI 3.23 to 28.45). Self-referred patients needed less inpatient admissions (16.8% vs30.9%; OR=2.22; 95% CI 1.63 to 3.01) and the length of their treatment episodes was shorter ([Formula: see text]=24.3 vs [Formula: see text] = 32.4 months; t=3.34; p<0.01). Logistic regression showed a significant model (χ(2)=67.52; df=3; p<0.001). Age, gender and diagnosis were statistically associated with type of referral to the programme. CONCLUSIONS: Type of referral to a PHP may be influenced not only by sick doctors' personal traits but also by each programme's design and how it is perceived by service users. Our findings should be taken into account when designing treatment and preventive interventions for this professional group.

Promoting voluntary help-seeking among doctors with mental disorders.

OBJECTIVES: To explore if the Barcelona Integral Care Program for Doctors with mental disorders (PAIMM, in Catalan) has achieved its goal of enhancing earlier and voluntary help-seeking amongst sick doctors. MATERIAL AND METHODS: We conducted a retrospective chart review of 1363 medical records of physicians admitted to the inpatient and outpatient units of the PAIMM from February 1st, 1998 until December 31st, 2011. The sample was divided into 3 time periods: 1998-2004, 2005-2007 and 2008-2011 (477, 497, and 389 cases, respectively). RESULTS: The mean age at admission decreased (F = 77.57, p < 0.001) from the first period (x = 54.18; SD = 10.28 years) to the last period (x = 44.81; SD = 10.65 years), while voluntary referrals increased from 81.3% to 91.5% (Chi(2) = 17.85, p < 0.001). Mental disorders other than substance use disorders grew from 71% during the 1998-2003 period, to 87.4% (2004-2007), and 83.9% in the last period (Chi2 = 29.01, p < 0.001). Adjustment disorders increased their prevalence, while inpatient treatment progressively represented less of the overall clinical activity. CONCLUSIONS: Sick doctors may feel encouraged to seek help in non-punitive programs specially designed for them and where treatment becomes mandatory only when there is risk or evidence of malpractice.

Synthesis of the HCV protease inhibitor Vaniprevir (MK-7009) using ring-closing metathesis strategy.

A highly efficient synthesis of Vaniprevir (MK-7009) has been accomplished in nine linear steps and 55% overall yield. The key features of this synthesis include a cost-effective synthesis of the isoindoline subunit and efficient construction of the 20-membered macrocyclic core of Vaniprevir (MK-7009) utilizing ring-closing metathesis technology. A high-performing ring-closing metathesis protocol has been achieved by simultaneous slow addition of the ruthenium catalyst (0.2 mol %) and the diene substrate at a concentration of 0.13 M.

Substance abuse in anaesthetists.

PURPOSE OF REVIEW: Anaesthesiologists have a significantly higher frequency of substance abuse by a factor of nearly 3 when compared with other physicians. This is still a current problem that must be reviewed. RECENT FINDINGS: Many hypotheses have been formulated to explain why anaesthesiologists appear to be more susceptible to substance abuse than other medical professionals (genetic differences in sensitivity to opioids, stress, the association between chemical dependence and other psychopathology or the second-hand exposure hypothesis). Environmental exposure and sensitization may be an important risk factor in physician addiction. There is a long debate about returning to work for an anaesthetist who has been depending on opioid drugs, and recent debates are discussed. Institutional efforts have been made in many countries and physician health programmes have been developed. SUMMARY: As drug abuse among anaesthesiologists has continued, new studies have been conducted to know the theories about susceptibility. Written substance abuse policies and controls must be taken in place and in all countries.

Effectiveness of a geriatric intervention in primary care: a randomized clinical trial.

OBJECTIVE: To assess the effectiveness of an intervention after comprehensive geriatric assessment (CGA) in reducing morbidity and mortality in patients over 74 years in primary care. METHODS: Randomized controlled trial with 18 months of follow-up. Patients in the control group (CG) followed usual care. Patients in the intervention group (IG) were classified as at risk or non-risk of frailty based on the CGA. Patients at non-risk of frailty in the IG were provided with recommendations about healthy habits and adherence to treatment in group sessions, while patients at risk of frailty were visited individually by a geriatrician. RESULTS: Six hundred and twenty patients were randomized to the IG (49.7%) or to the CG (50.3%), 83.2% completed follow-up. Cox's proportional hazards model showed as covariates the study group (hazard ratio [HR] 0.58; 95% confidence interval [CI] 0.28-1.22), risk of frailty (HR 1.33; 95% CI 0.71-2.51) and the interaction between both (HR 3.08; 95% CI 1.22-7.78). Forty-nine percent of the patients in the IG and 43% in the CG were at risk of frailty at baseline. At the end of the study, 27.9% of the IG and 13.5% of the CG had reversed their initial at risk of frailty status (P = 0.027). Multivariate predictors of reversible risk of frailty were younger age, not being at risk of depression, low consumption of medications and the intervention itself. CONCLUSIONS: A specific intervention in patients over 74 years attended in primary care reduces morbidity and mortality in patients at risk of frailty and increases the proportion of patients that reversed their initial status at risk of frailty.

Evaluation of a urinary incontinence unit for community-dwelling older adults in Barcelona: implementation and improvement of the perceived impact on daily life, frequency and severity of urinary incontinence.

BACKGROUND: Urinary incontinence >(UI) is one of the most important and frequent geriatric syndromes. It is considered a silent but great social problem. Conservative management of UI, in a multidisciplinary and comprehensive approach, has been successful in previous studies, leading to a partial or total remission of the syndrome. AIMS: To investigate the acceptance of a geriatric incontinence unit and the effect of a multidimensional intervention on the improvement of UI regarding frequency, severity and perceived impact on daily life of community-dwelling older adults. METHODOLOGY: Prospective study with a multifactorial intervention with pre-post analyses. 92 patients aged 60 years and over were assessed for UI at an outpatient geriatric unit. They received an individualized conservative treatment and were followed up for 3 months. The International Consultation on Incontinence modular Questionnaire-Short Form (ICIQ-SF) was translated into Catalan. The difference of the perceived impact on the daily life before and 3 months after treatment was used as a primary outcome. The global score and the subscores on frequency and severity were used as secondary outcomes. RESULTS: 77.2% patients had an improvement in their perceived impact of UI on daily life. Concerning the ICIQ-SF global score, 82.6% improved. There was a significant improvement of about 30% in all dimensions measured. Many patients pointed out that being able to talk about the problem with a healthcare professional, in some cases for the first time, was very important to them. CONCLUSIONS: A conservative and multidisciplinary management of UI improved the impact of UI on daily life among comorbid geriatric patients. The Catalan ICIQ-SF was successfully implemented. Outpatient geriatric incontinence units seem to be effective and should be implemented to improve detection and management of this important geriatric syndrome.

El Programa de Atención Integral al Médico Enfermo (PAIME) del Colegio de Médicos de Barcelona / Program for the Integral Care of the Phisician (Paime) of the Official Medicall College of Barcelona, Spain

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