El médico clínico ante el paciente en el final de sus días / The clinician and their patient at the end of life

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Reorganization of medical specialization. Beyond the law of management of health professions. / Reorganización de la especialización médica. Más allá de la Ley de Ordenación de Profesiones Sanitarias.

More than 30 years after the creation of postgraduate medical training program in Spain supported by the MIR system, a thorough review of it becomes essential. This was the goal of the LOPS law enacted in 2003. The development of the LOPS is being slow and difficult to enforce, because master lines have to be achieved in order to develop the training of specialists in accordance with internationals standards and, simultaneously, with the reform that is taking place in the undergraduate education. The start up of the medical core will be the cornerstone of this project. The principles of the LOPS provide an opportunity for the training of competent physician in basic general medical practice followed by a progressive specialization supported on a solid foundation. And these principles have to prevail over corporate interests.

Reorganización de la especialización médica. Más allá de la Ley de Ordenación de Profesiones Sanitarias / Reorganization of medical specialization. Beyond the Law of Management of Health Professions

Después de más de 30 años de la creación del programa de formación médica posgraduada en España sustentada por el sistema MIR, se hace imprescindible una revisión a fondo del mismo. Este fue el objetivo de la LOPS promulgada en 2003. Su desarrollo está siendo lento y dificultoso, ya que ha de conseguir unas líneas maestras por las que se desarrolle la formación de especialistas acorde con estándares internacionales y acorde, al mismo tiempo, con la reforma que se está llevando a cabo en la formación de pregrado. La puesta en marcha de la troncalidad médica va a ser la piedra angular de este proyecto. Los principios de la LOPS ofrecen una oportunidad de formar médicos competentes en una práctica general básica, seguida de una especialización progresiva, sobre unos cimientos sólidos. Y estos principios deben prevalecer sobre intereses corporativos (AU)

More than 30 years after the creation of postgraduate medical training program in Spain supported by the MIR system, a thorough review of it becomes essential. This was the goal of the LOPS law enacted in 2003. The development of the LOPS is being slow and difficult to enforce, because master lines have to be achieved in order to develop the training of specialists in accordance with internationals standards and, simultaneously, with the reform that is taking place in the undergraduate education. The start up of the medical core will be the cornerstone of this project. The principles of the LOPS provide an opportunity for the training of competent physician in basic general medical practice followed by a progressive specialization supported on a solid foundation. And these principles have to prevail over corporate interests (AU)

Adherencia terapéutica en la enfermedad crónica: estado de la situación y perspectiva de futuro / Treatment compliance in chronic illness: current situation and future perspectives

Las enfermedades crónicas de larga duración poseen una elevada mortalidad y afectan por igual a ambos sexos. La falta de adherencia a las recomendaciones terapéuticas continúa siendo un obstáculo para mejorar la salud y la calidad de vida de los pacientes, además de conllevar un elevado coste sociosanitario. En este trabajo se desarrolla el concepto «adherencia terapéutica» que engloba tratamientos farmacológicos (cumplimiento terapéutico) y no farmacológicos (grado de coincidencia entre las recomendaciones ofrecidas, como pueden ser cambios en los hábitos de vida y su implantación por el paciente). También se analiza el impacto clínico y sociosanitario de la «adherencia terapéutica», así como las causas de la falta de adherencia y métodos y estrategias para mejorarla. Concluimos que la adherencia terapéutica debe ser un objetivo esencial del sistema sanitario, englobando todos los agentes implicados en la salud del paciente (AU)

Long-term chronic diseases have a high mortality rate around the world, affecting both genders equally. Despite improvements in the diagnosis and treatment of various health problems, lack of treatment compliance remains an obstacle to improving health and patient quality of life, and it carries a high associated socio-healthcare cost. The objectives of this study were to develop the concept of «therapeutic adherence», which includes both pharmacological compliance as well as non-pharmacological (level of agreement and patient involvement, lifestyle changes, etc.) treatments. The study also aimed to establish the clinical and socio-health impact of non-compliance, the reasons for non-compliance, and methods and strategies to improve compliance. The results of this study support therapeutic adherence as an essential goal of the healthcare system that encompasses all stakeholders involved in patient health (AU)

Treatment compliance in chronic illness: Current situation and future perspectives. / Adherencia terapéutica en la enfermedad crónica: estado de la situación y perspectiva de futuro.

Long-term chronic diseases have a high mortality rate around the world, affecting both genders equally. Despite improvements in the diagnosis and treatment of various health problems, lack of treatment compliance remains an obstacle to improving health and patient quality of life, and it carries a high associated socio-healthcare cost. The objectives of this study were to develop the concept of «therapeutic adherence¼, which includes both pharmacological compliance as well as non-pharmacological (level of agreement and patient involvement, lifestyle changes, etc.) treatments. The study also aimed to establish the clinical and socio-health impact of non-compliance, the reasons for non-compliance, and methods and strategies to improve compliance. The results of this study support therapeutic adherence as an essential goal of the healthcare system that encompasses all stakeholders involved in patient health.

Clinical decisions in patients with diabetes and other cardiovascular risk factors. A statement of the Spanish Society of Internal Medicine / Decisiones clínicas en pacientes con diabetes y otros factores de riesgo cardiovascular. Una declaración de la sociedad española de medicina interna

Although the mortality associated to cardiovascular diseases (CVD) has been reduced in the last decades, CVD remains the main cause of mortality in Spain and they are associated with an important morbidity and a huge economic burden. The increasing prevalence of obesity and diabetes could be slowing down the mortality reduction in Spain. Clinicians have often difficulty making clinical decisions due to the multiple clinical guidelines available. Moreover, in the current context of economic crisis it is critical to promote an efficient use of diagnostic and therapeutic proceedings to ensure the viability of public health care systems. The Spanish Society of Internal Medicine (SEMI) has coordinated a consensus document to answer questions of daily practice with the aim of facilitating physicians’ decision-making in the management of diabetes and cardiovascular risk factors from a cost-efficiency point of view (AU)

Aunque la mortalidad asociada a enfermedades cardiovasculares (ECV) se ha reducido en las últimas décadas, las ECV siguen siendo la causa principal de mortalidad en España y están asociadas a una morbilidad importante y una enorme carga económica. La creciente prevalencia de obesidad y de diabetes podría estar frenando la reducción en la mortalidad en España. Los médicos suelen tener mucha dificultad en la toma de decisiones clínicas debido a las múltiples guías clínicas disponibles. Por otro lado, en el contexto actual de la crisis económica es imprescindible promover un uso eficaz de los procedimientos diagnósticos y terapéuticos para garantizar la viabilidad de los sistemas de salud pública. La Sociedad Española de Medicina Interna (SEMI) ha desarrollado un documento de consenso para responder a las dudas que surgen en la práctica rutinaria con el objetivo de facilitar a los médicos la toma de decisiones en el control de la diabetes y en los factores de riesgo cardiovascular desde el punto de vista de la rentabilidad (AU)

Clinical decisions in patients with diabetes and other cardiovascular risk factors. A statement of the Spanish Society of Internal Medicine.

Although the mortality associated to cardiovascular diseases (CVD) has been reduced in the last decades, CVD remains the main cause of mortality in Spain and they are associated with an important morbidity and a huge economic burden. The increasing prevalence of obesity and diabetes could be slowing down the mortality reduction in Spain. Clinicians have often difficulty making clinical decisions due to the multiple clinical guidelines available. Moreover, in the current context of economic crisis it is critical to promote an efficient use of diagnostic and therapeutic proceedings to ensure the viability of public health care systems. The Spanish Society of Internal Medicine (SEMI) has coordinated a consensus document to answer questions of daily practice with the aim of facilitating physicians' decision-making in the management of diabetes and cardiovascular risk factors from a cost-efficiency point of view.

Competencias básicas de la medicina interna / Core competencies in Internal Medicine

El grupo de trabajo de Competencias del Internista de la Sociedad Española de Medicina Interna (SEMI) expone los principales conocimientos, habilidades y aptitudes que debería poseer todo internista en España. Este listado de competencias representa el núcleo de la Medicina Interna dentro de un escenario futuro de troncalidad de las especialidades en ciencias de la salud(AU)

The working group of the Spanish Society of Internal Medicine (SEMI) on “Competencies of the Internist” has defined the basic medical knowledge, skills and attitudes that all internists in Spain should have. This list of competencies represents the Internal Medicine core curriculum within the context of the future educational framework of medical specialties in Health Sciences(AU)

[Core competencies in internal medicine]. / Competencias básicas de la medicina interna.

The working group of the Spanish Society of Internal Medicine (SEMI) on "Competencies of the Internist" has defined the basic medical knowledge, skills and attitudes that all internists in Spain should have. This list of competencies represents the Internal Medicine core curriculum within the context of the future educational framework of medical specialties in Health Sciences.

[What has changed in the therapeutic strategy for type 2 diabetes mellitus?]. / Qué ha cambiado en la estrategia terapéutica de la diabetes mellitus tipo 2?

Diabetes mellitus is a rapidly evolving area of medicine with the publication of new studies, the introduction of new drugs and a proliferation of clinical practice guidelines, often with subtle differences in the recommended therapeutic approach to patients with this disease. Notable among the extensive information generated on the disease in the last few years is evaluation of the studies with greatest impact on clinical practice in terms of defining glycemic targets and the preferred therapeutic strategy to achieve them. After the disappointing results of intensive glucose control in most patients revealed in the ACCORD, ADVANCE and VADT trials, recent data from the extensions of the UKPDS and STENO-2 trials have shown a new emphasis in the treatment of the disease, highlighting the importance of treatment and optimal glycemic control in the early stages. This strategy confers a long-term benefit on morbidity and mortality through a new concept which has become known as "metabolic memory" or the "legacy effect". Recently introduced drugs with action on the incretin system have been shown to have pleiotropic effects beyond their already confirmed effect on glycemic control, which could lead to their use becoming prioritized in the future. In view of these contributions, both through clinical trials and through data obtained with the new therapies, the overall management of diabetes should be modified. This need for modification is reflected in some of the most recent updates of clinical practice guidelines that incorporate some of these advances.

¿Qué ha cambiado en la estrategia terapéutica de la diabetes mellitus tipo 2? / What has changed in the therapeutic strategy for type 2 diabetes mellitus?

La diabetes mellitus supone actualmente un área de la medicina sujeta a rápida evolución, con nuevos estudios, introducción de nuevos fármacos y proliferación de guías de práctica clínica, a menudo con diversos matices en la orientación terapéutica recomendada en pacientes con diabetes tipo 2. Dentro de la amplia información reciente que se ha venido produciendo el último año sobre esta afección, podría destacarse la valoración de los estudios que han tenido mayor implicación en la práctica clínica a la hora de definir objetivos los glucémicos y la estrategia terapéutica preferible para obtenerlos. Tras la decepción experimentada a la hora de valorar un control intensivo en la mayoría de los pacientes diabéticos, a la luz de los resultados de los estudios ACCORD, ADVANCE y VADT, los recientes datos de las ampliaciones del UKPDS y del STENO-2 han mostrado un nuevo matiz en el tratamiento de la afección, destacando la importancia de un tratamiento y control óptimo glucémico en estadios tempranos, lo que confiere un beneficio a largo plazo en morbimortalidad, en el nuevo concepto que se ha venido a denominar “memoria metabólica” o “ efecto legado” . Los fármacos con acción sobre el sistema incretina, de reciente introducción, están demostrando tener efectos pleiotrópicos, más allá del ya confirmado control glucémico, lo que podría priorizar su empleo en el futuro. Estas aportaciones, tanto mediante ensayos clínicos, como mediante datos obtenidos con las nuevas terapias, obligan a plantear modificaciones en el manejo global de la diabetes y de ello se hacen eco las guías de práctica clínica, algunas de las cuales, en sus versiones más actualizadas, reflejan algunas de estas novedades (AU)

Diabetes mellitus is a rapidly evolving area of medicine with the publication of new studies, the introduction of new drugs and a proliferation of clinical practice guidelines, often with subtle differences in the recommended therapeutic approach to patients with this disease. Notable among the extensive informat ion generated on the disease in the last few years is evaluation of the studies with greatest impact on clinical practice in terms of defining glycemic targets and the preferred therapeut ic strategy to achieve them. After the disappointing results of intensive glucose control in most patients revealed in the ACCORD, ADVANCE and VADT trials, recent data from the extensions of the UKPDS and STENO-2 trials have shown a new emphasis in the treatment of the disease, highlighting the importance of treatment and optimal glycemic control in the early stages. This strategy confers a long-term benefit on morbidity and mortality through a new concept which has become known as “metabolic memory” or the “ legacy effect ”. Recently int roduced drugs with action on the incret in system have been shown to have pleiotropic effects beyond their already confirmed effect on glycemic control, which could lead to their use becoming prioritized in the future. In view of these contribut ions, both through clinical trials and through data obtained with the new therapies, the overall management of diabetes should be modified. This need for modification is reflected in some of the most recent updates of clinical practice guidelines that incorporate some of these advances (AU)

[SEMI, in the Scientific Society of the XXI Century: what we did during 2009 and what we are going to do in 2010]. / SEMI, en la sociedad científica del siglo XXI: lo que hemos hecho en el año 2009 y lo que vamos a hacer en el 2010.

The principal actions carried out by the Spanish Society of Internal Medicine (SEMI) during the last year are reviewed in this work. The projects that are going to be developed immediately in 2010 are also announced. In 2009, it was aimed to improve the communication policy, consolidate and strengthen the structure of the Society with the creation of a permanent committee, stimulate the activities of the strategic Work Groups and the promotion of new organizational models. A new Work Group was established on Internal Medicine in private practice. New projects and initiatives were also designed, such as the project of Hospital Discharge Report, Study of Residents and Internal Medicine in the University. These projects will be established within the next months and they will strengthen us as specialists of prestige. The SEMI is continuing along a positive pathway in its projection, modernization and search for the active participation of its members. The Journal, Revista Clínica Española, official publication of the SEMI, has experienced an important impulse with the new administrative team formed in the year 2009. Our journal should be a key piece in the future of the Society.

SEMI, en la sociedad científica del siglo XXI: lo que hemos hecho en el año 2009 y lo que vamos a hacer en el 2010 / SEMI, in the Scientific Society of the XXI Century: what we did during 2009 and what we are going to do in 2010

En el presente trabajo se revisan las principales acciones que la Sociedad Española de Medicina Interna (SEMI) ha realizado a lo largo del último año. También se anuncian los proyectos de inmediato desarrollo durante el año 2010. En 2009 se persiguió mejorar la política de comunicación, consolidar y agilizar la estructura de la Sociedad con la creación de una comisión permanente, estimular las actividades de los Grupos de Trabajo estratégicos, así como la promoción de nuevos modelos organizativos. Se constituyó un nuevo Grupo de Trabajo sobre Medicina Interna en la práctica privada. Se han diseñado también nuevos proyectos e iniciativas como el proyecto de Informe de Alta Hospitalaria, Estudio MIR y Medicina Interna en la Universidad. Estos proyectos se concretarán en los próximos meses y nos van a fortalecer como especialistas de prestigio. La SEMI continúa un camino positivo en su proyección, modernización y búsqueda de la participación activa de sus miembros. Revista Clínica Española, órgano de expresión de la SEMI, ha experimentado un gran impulso con el nuevo equipo directivo constituido en el año 2009. Nuestra revista debe ser una pieza clave en el futuro de la Sociedad(AU)

The principal actions carried out by the Spanish Society of Internal Medicine (SEMI) during the last year are reviewed in this work. The projects that are going to be developed immediately in 2010 are also announced. In 2009, it was aimed to improve the communication policy, consolidate and strengthen the structure of the Society with the creation of a permanent committee, stimulate the activities of the strategic Work Groups and the promotion of new organizational models. A new Work Group was established on Internal Medicine in private practice. New projects and initiatives were also designed, such as the project of Hospital Discharge Report, Study of Residents and Internal Medicine in the University. These projects will be established within the next months and they will strengthen us as specialists of prestige. The SEMI is continuing along a positive pathway in its projection, modernization and search for the active participation of its members. The Journal, Revista Clínica Española, official publication of the SEMI, has experienced an important impulse with the new administrative team formed in the year 2009. Our journal should be a key piece in the future of the Society(AU)

[European Guidelines on Cardiovascular Disease Prevention in Clinical Practice. Spanish adaptation of the CEIPC 2008]. / Guía Europea de Prevención Cardiovascular en la Práctica Clínica. Adaptación Española del Comité Español Interdisciplinario para la Prevención Cardiovascular (CEIPC) 2008.

We present the Spanish adaptation made by the CEIPC of the European Guidelines on Cardiovascular Disease Prevention (CVD) in Clinical Practice 2008. This guide recommends the SCORE model for risk evaluation. The aim is to prevent premature mortality and morbidity due to CVD through the management of its related risk factors in clinical practice. The guide focuses on primary prevention and emphasizes the role of the nurses and primary care medical doctors in promoting a healthy life style, based on increasing physical activity, change dietary habits, and non smoking. The therapeutic goal is to achieve a Blood Pressure < 140/90 mmHg, but among patients with diabetes, chronic kidney disease, or definite CVD, the objective is <130/80 mmHg. Serum cholesterol should be < 200 mg/dl and cLDL<130 mg/dl, although among patients with CVD or diabetes, the objective is <100 mg/dl (80 mg/dl if feasible in very high-risk patients). Patients with type 2 diabetes and those with metabolic syndrome must lose weight and increase their physical activity, and drugs must be administered whenever applicable, to reach body mass index (BMI) guided and waist circumference objectives. In diabetic type 2 patients, the objective is glycated haemoglobin <7%. Allowing people to know the guides and developing implementation programs, identifying barriers and seeking solutions for them, are priorities for the CEIPC in order to transfer the recommendations established into the daily clinical practice.