Manejo del dolor oncológico: revisión sistemática y valoración crítica de las guías de práctica clínica / Cancer pain management: systematic review and critical appraisal of clinical practice guidelines

Objetivo. La incidencia del manejo inadecuado del dolor oncológico es muy elevada a pesar de la multitud de guías de práctica clínica creadas. El objetivo es revisar de forma sistemática las guías de práctica clínica actuales sobre el manejo del dolor oncológico, analizar su metodología y contenido de forma crítica, y conocer su calidad y validez. Material y métodos. Revisión sistemática en las principales bases de datos en inglés, francés y español entre 2008 y 2013. Se realizó un análisis de la calidad metodológica con AGREE-II, incluyendo fiabilidad interobservador. Se extrajeron las recomendaciones, clasificándolas por categorías y nivel de evidencia, con el fin de realizar un análisis de la variabilidad entre las guías y de la validez de su contenido. Resultados. Seis guías fueron incluidas en el análisis, existiendo gran variabilidad tanto en la calidad formal y metodológica, como en el contenido y el nivel de evidencia de sus recomendaciones. La guía de Scottish Intercollegiate Guidelines Network fue la mejor valorada en AGREE-II mientras que la de la Sociedad Española de Oncología Médica resultó la peor valorada. La guía del Ministerio de Salud de Malasia fue la que contó con mayor validez, seguida por la Scottish Intercollegiate Guidelines Network. Conclusiones. Las guías actuales para el manejo del dolor en pacientes con cáncer presentan importantes limitaciones en su calidad y contenido. Entre las existentes, se recomiendan las del Ministerio de Salud de Malasia y Scottish Intercollegiate Guidelines Network, mientras que la de la Sociedad Española de Oncología Médica presenta oportunidades de mejora frente a estas (AU)

Objective. Although several clinical practice guidelines have been developed in the last decades, cancer pain management is still deficient. The purpose of this work was to carry out a comprehensive and systematic literature review of current clinical practice guidelines on cancer pain management, and critically appraise their methodology and content in order to evaluate their quality and validity to cope with this public health issue. Materials and methods. A systematic review was performed in the main databases, using English, French and Spanish as languages, from 2008 to 2013. Reporting and methodological quality was rated with the Appraisal of Guidelines, Research and Evaluation II (AGREE-II) tool, including an inter-rater reliability analysis. Guideline recommendations were extracted and classified into several categories and levels of evidence, aiming to analyse guidelines variability and evidence-based content comprehensiveness. Results. Six guidelines were included. A wide variability was found in both reporting and methodological quality of guidelines, as well as in the content and the level of evidence of their recommendations. The Scottish Intercollegiate Guidelines Network guideline was the best rated using AGREE-II, while the Sociedad Española de Oncología Médica guideline was the worst rated. The Ministry of Health Malaysia guideline was the most comprehensive, and the Scottish Intercollegiate Guidelines Network guideline was the second one. Conclusions. The current guidelines on cancer pain management have limited quality and content. We recommend Ministry of Health Malaysia and Scottish Intercollegiate Guidelines Network guidelines, whilst Sociedad Española de Oncología Médica guideline still needs to improve (AU)

[Cancer pain management: Systematic review and critical appraisal of clinical practice guidelines]. / Manejo del dolor oncológico: revisión sistemática y valoración crítica de las guías de práctica clínica.

OBJECTIVE: Although several clinical practice guidelines have been developed in the last decades, cancer pain management is still deficient. The purpose of this work was to carry out a comprehensive and systematic literature review of current clinical practice guidelines on cancer pain management, and critically appraise their methodology and content in order to evaluate their quality and validity to cope with this public health issue. MATERIALS AND METHODS: A systematic review was performed in the main databases, using English, French and Spanish as languages, from 2008 to 2013. Reporting and methodological quality was rated with the Appraisal of Guidelines, Research and Evaluation II (AGREE-II) tool, including an inter-rater reliability analysis. Guideline recommendations were extracted and classified into several categories and levels of evidence, aiming to analyse guidelines variability and evidence-based content comprehensiveness. RESULTS: Six guidelines were included. A wide variability was found in both reporting and methodological quality of guidelines, as well as in the content and the level of evidence of their recommendations. The Scottish Intercollegiate Guidelines Network guideline was the best rated using AGREE-II, while the Sociedad Española de Oncología Médica guideline was the worst rated. The Ministry of Health Malaysia guideline was the most comprehensive, and the Scottish Intercollegiate Guidelines Network guideline was the second one. CONCLUSIONS: The current guidelines on cancer pain management have limited quality and content. We recommend Ministry of Health Malaysia and Scottish Intercollegiate Guidelines Network guidelines, whilst Sociedad Española de Oncología Médica guideline still needs to improve.

[Clinical approach to chronic lumbar pain: a systematic review of recommendations included in existing practice guidelines]. / Abordaje clínico del dolor lumbar crónico: síntesis de recomendaciones basadas en la evidencia de las guías de práctica clínica existentes.

This paper presents a systematic review of clinical practice guidelines based on evidence, with explicit recommendations on the treatment of chronic low back pain. The main objective was to analyze their content and provide a synthesis in order to improve the translation of this evidence into practice. The recommendations were analyzed and then classified by treatment; evidence level and strength of recommendation were identified and translated into our gradation system. Eight guidelines met the inclusion criteria. Exercise and back school treatment are shown as the best therapies. Pharmacotherapy is indicated during short periods of time. The guidelines analyzed show similar therapeutic approaches. The recommendations have been synthesized in order to allow clinical selection of the best treatment and avoid bad practices with their corresponding costs, providing a more efficient management of the patient.

Abordaje clínico del dolor lumbar crónico: síntesis de recomendaciones basadas en la evidencia de las guías de práctica clínica existentes / Clinical approach to chronic lumbar pain: a systematic review of recommendations included in existing practice guidelines

Se realizó una revisión sistemática de guías de práctica clínica basadas en evidencia que tuvieran recomendaciones explícitas sobre el tratamiento del dolor lumbar crónico, con el objetivo de analizar su contenido y proveer una síntesis que sirviese para su traslación a la práctica. Las recomendaciones se analizaron y clasificaron según el tipo de tratamiento; se identificó el nivel de evidencia y fuerza de recomendación de las mismas, traduciéndolos a un sistema de gradación común. Ocho guías cumplieron los criterios de inclusión. El ejercicio y la escuela de espalda se perfilan como la terapia más efectiva. La farmacoterapia está indicada durante cortos periodos. Las guías analizadas ofrecen vías de acción similares frente a los principales tratamientos. Se han resumido las recomendaciones de forma clara y estructurada para permitir una elección clínica de los tratamientos más adecuados, evitar gastos y recursos en tratamientos inútiles y una recuperación del paciente más eficiente (AU)

This paper presents a systematic review of clinical practice guidelines based on evidence, with explicit recommendations on the treatment of chronic low back pain. The main objective was to analyze their content and provide a synthesis in order to improve the translation of this evidence into practice. The recommendations were analyzed and then classified by treatment; evidence level and strength of recommendation were identified and translated into our gradation system. Eight guidelines met the inclusion criteria. Exercise and back school treatment are shown as the best therapies. Pharmacotherapy is indicated during short periods of time. The guidelines analyzed show similar therapeutic approaches. The recommendations have been synthesized in order to allow clinical selection of the best treatment and avoid bad practices with their corresponding costs, providing a more efficient management of the patient (AU)

Development and pilot test of a new set of good practice indicators for chronic cancer pain management.

BACKGROUND: Pain is among the most important symptoms in terms of prevalence and cause of distress for cancer patients and their families. However, there is a lack of clearly defined measures of quality pain management to identify problems and monitor changes in improvement initiatives. METHODS: We built a comprehensive set of evidence-based indicators following a four-step model: (1) review and systematization of existing guidelines to list evidence-based recommendations; (2) review and systematization of existing indicators matching the recommendations; (3) development of new indicators to complete a set of measures for the identified recommendations; and (4) pilot test (in hospital and primary care settings) for feasibility, reliability (kappa), and usefulness for the identification of quality problems using the lot quality acceptance sampling (LQAS) method and estimates of compliance. RESULTS: Twenty-two indicators were eventually pilot tested. Seventeen were feasible in hospitals and 12 in all settings. Feasibility barriers included difficulties in identifying target patients, deficient clinical records and low prevalence of cases for some indicators. Reliability was mostly very good or excellent (k > 0.8). Four indicators, all of them related to medication and prevention of side effects, had acceptable compliance at 75%/40% LQAS level. Other important medication-related indicators (i.e., adjustment to pain intensity, prescription for breakthrough pain) and indicators concerning patient-centred care (i.e., attention to psychological distress and educational needs) had very low compliance, highlighting specific quality gaps. CONCLUSIONS: A set of good practice indicators has been built and pilot tested as a feasible, reliable and useful quality monitoring tool, and underscoring particular and important areas for improvement.

Recogida y análisis sistemático de problemas anestésicos intraoperatorios / Systematic collection and analysis of intraoperative anaesthetic-related problems

Objetivo. El objetivo de este estudio fue la recogida sistemática y el análisis de la frecuencia, tipo y severidad de todos los problemas anestésicos intraoperatorios ocurridos en nuestro hospital durante 6 meses. Métodos. Estudio observacional, sistemático, prospectivo y transversal, en el que se estudia el suceso y sus factores de riesgo. Se basó en una recogida de datos rutinaria de todas las anestesias. Incluye anestesia, sedación y analgesia de parto. Las variables recogidas fueron demográficas y de procedimiento, así como una lista de verificación con el tipo de problema y su grado de severidad. Los datos se analizaron mediante los tests de Chi al cuadrado, Fisher, o t de Student, aceptando p<0,05 como significativa. Resultados. La frecuencia de problemas anestésicos intraoperatorios fue de 17,2%, con 1,3 problemas por caso, siendo 9 veces mas frecuentes los problemas con bajo grado de severidad. Durante la anestesia, aparecieron problemas respiratorios en 13, circulatorios en 8, y técnicos en 2 de cada 100 procedimientos. Los factores asociados con los pacientes que presentaron problemas anestésicos se asociaron al uso de la anestesia general, cirugía supraumbilical y mayor riesgo anestésico preoperatorio. Conclusiones. La recogida sistemática de problemas intraoperatorios relacionados con la anestesia, mediante una lista de verificación de problemas y severidad, juega un importante papel en las estrategias de gestión de calidad. El análisis de problemas menores puede ayudar a establecer acciones correctivas antes de la aparición de morbilidad, separando los problemas propios de la cirugía de los de la anestesia(AU)

Objective. The purpose of the study was to systematically collect and analyse the frequency, type and severity of all untoward intraoperative anaesthetic-related problems in a hospital over a 6-month period. Methods. An observational, systematic, prospective, and cross sectional study was conducted on the events and their risk factors. The study is based on a system in which anaesthesia-related data are recorded from all anaesthetic cases on a routine basis, including sedation and obstetric analgesia. The variables were demographic, procedural data, and a checklist with problem type and severity. Data were analysed using chi-square, Fisher's test, or Student's test. A P<.05 was considered statistically significant. Results. The frequency of intraoperative anaesthetic-related problems was 17.2%, with 1.3 anaesthetic problems per case, being 9 times more frequent the adverse effects with low severity grade. During anaesthesia, respiratory problems occurred in 13, circulatory problems in 8, and technical problems in 2 out of every 100 procedures. The factors associated with the patient in whom the anaesthetic problem occurred were: the use of general anaesthesia, supraumbilical surgery, and a higher preoperative anaesthetic risk. Conclusions. Use of a systematic intraoperative anaesthetic-related database with a checklist of problems and severity plays an important part in quality assurance strategies. An analysis of non-fatal problems provides a basis for establishing corrective strategies before significant morbidity occurs, and by separating the surgical and anaesthesia problems(AU)

[Systematic collection and analysis of intraoperative anaesthetic-related problems]. / Recogida y análisis sistemático de problemas anestésicos intraoperatorios.

OBJECTIVE: The purpose of the study was to systematically collect and analyse the frequency, type and severity of all untoward intraoperative anaesthetic-related problems in a hospital over a 6-month period. METHODS: An observational, systematic, prospective, and cross sectional study was conducted on the events and their risk factors. The study is based on a system in which anaesthesia-related data are recorded from all anaesthetic cases on a routine basis, including sedation and obstetric analgesia. The variables were demographic, procedural data, and a checklist with problem type and severity. Data were analysed using chi-square, Fisher's test, or Student's test. A P<.05 was considered statistically significant. RESULTS: The frequency of intraoperative anaesthetic-related problems was 17.2%, with 1.3 anaesthetic problems per case, being 9 times more frequent the adverse effects with low severity grade. During anaesthesia, respiratory problems occurred in 13, circulatory problems in 8, and technical problems in 2 out of every 100 procedures. The factors associated with the patient in whom the anaesthetic problem occurred were: the use of general anaesthesia, supraumbilical surgery, and a higher preoperative anaesthetic risk. CONCLUSIONS: Use of a systematic intraoperative anaesthetic-related database with a checklist of problems and severity plays an important part in quality assurance strategies. An analysis of non-fatal problems provides a basis for establishing corrective strategies before significant morbidity occurs, and by separating the surgical and anaesthesia problems.

Mechanisms and treatment of cancer cachexia.

According to a recent consensus, cachexia is a complex metabolic syndrome associated with underlying illness and characterised by loss of muscle with or without loss of fat mass. The prominent clinical feature of cachexia is weight loss. Cachexia occurs in the majority of terminal cancer patients and it is responsible for the deaths of 22% of cancer patients. Although body weight is, indeed, an important factor to be taken into consideration in any cachexia treatment, body composition, physical performance and quality of life should be monitored. From the results presented here, one can speculate that a single therapy may not be completely successful in the treatment of cachexia. From this point of view, treatments involving different combinations are more likely to be successful. The objectives of any therapeutical combination are two: an anticatabolic aim directed towards both fat and muscle catabolism and an anabolic objective leading to the synthesis of macromolecules such as contractile proteins.

Situación actual de las unidades del dolor crónico en la Región de Murcia / No disponible

Objetivo: conocer la situación actual, en términos de organización y administración, de las Unidades del Dolor Crónico (UDO) de los hospitales públicos de la Región de Murcia. Material y método: encuesta on-line que exploraba aspectos de estructura y de proceso, dirigida a cada uno de los responsables de las UDO de todos los hospitales públicos del Servicio Murciano de Salud. Resultados: respondieron el 87,5% de las UDO, que representan una cobertura poblacional del 90% de la Región, todas ellas dirigidas por un anestesiólogo, de las que el 85,7% eran multi-disciplinares. Cada UDO realiza una media de 4,6 consultas y 0,75 quirófanos semanales. El 42,8% dedican a la asistencia menos de 8 h a la semana. Con una demora media para primera demanda de 66 días y de 49,2 para las revisiones, siendo la demanda mensual de primeras visitas de 32,5 pacientes. Algunas UDO expresan rechazar ciertos procesos dolorosos. El 42,8% realiza triaje, pero solo el 28,6% utiliza para ello criterios explícitos. Sólo el 28,6% emplea criterios explícitos de derivación, y solo el 57,1% dispone de protocolos de actuación clínica. Conclusiones: las UDO de la Región de Murcia presentan una gran disparidad en accesibilidad, presión asistencial, continuidad en los cuidados, gestión de la demanda y estructura, lo que hace muy difícil la posibilidad de comparación de resultados entre centros, al no disponer de la homogeneidad necesaria en la estructura y en los procesos asistenciales (AU)

Objective: to know about the current situation in terms of organization and management of Chronic Pain Clinics (UDO) of public hospitals in the Region of Murcia. Material and methods: on-line questionnaires that explored aspects of structure and process, addressed to each of the heads of the UDO of every public hospitals of Murcia Health Service. Results: the 87.5% of the UDO answered the questions, representing a 90% of population coverage in the region, all of them directed by an anaesthesiologist, 85.7% of which were multi-disciplinary. Each UDO develops an average of 4.6 consults per week and 0.75 operating rooms. 42.8% of them dedicate less than 8 h per week to assistance. With an average delay of 66 days for the first demand and 49.2 days for the reviews, being the monthly demand for the first visits of 32.5 patients. Some UDO expresses rejection to certain painful processes. 42.8% of them make triage, but only 28.6% use explicit criteria for it. Furthermore, only 28.6% use explicit criteria to send patients to another hospital, and only 57.1% have clinical intervention protocols. Conclusions: UDO in the Region of Murcia has a wide disparity in accessibility, workload, continuity of care, demand management and structure, making it very difficult to compare the results between units, due to the lack of the necessary homogeneity in the structure and care processes (AU)

Evaluación antes-después del “hospital sin dolor” / Pain-free hospital audit: a pre-post assessment

OBJETIVOS: Evaluar la mejora obtenida tras la implementación de una Unidad del Dolor Agudo basada en laenfermería (UDABE) en un Hospital de Área, utilizandométodos de control estadístico de procesos.MATERIAL Y MÉTODO: Medimos mensualmente 3 indicadoresde la calidad de la UDABE (prevalencia de dolor, alivio y satisfacción con su manejo). Monitorizamoslos indicadores mediante gráficos P de control estadístico de procesos para conocer su ajuste a los estándares fijados, así como su variabilidad.RESULTADOS: En un año hemos conseguido estabilizarel dolor agudo en todo el hospital en una prevalencia del30%, que el 85% de nuestros pacientes consigan alivioadecuado, y que su satisfacción con el manejo del dolorsea del 90%.CONCLUSIONES: La implementación de una UDABEdiseñada y gestionada con herramientas procedentes delControl de Calidad, produce mejoras significativas,absoluta y relativa, en la prevalencia del dolor, en su alivio, y en la satisfacción de los pacientes (p<0,001), consiguiendo ahorrar en un año, más de 15.000 días de sufrimiento innecesario

OBJECTIVE: To evaluate improvement after implementationof care through a nurse-managed acute pain unit in adistrict hospital, using statistical process control (SPC) methods.MATERIAL AND METHODS: Each month we measured 3acute pain unit quality indicators: pain prevalence, painrelief, and satisfaction with pain management. Theindicators were monitored on P-charts according to SPCprocedures that determine their distribution withincontrol limits and track variability.RESULTS: The hospital prevalence of acute painstabilized at 30% after a year. Eight-five percent ofpatients achieved adequate pain relief and 90% weresatisfied with pain management.CONCLUSIONS: A nurse-managed acute pain unitdesigned and managed with tools for monitoring qualityassurance produces significant absolute and relativeimprovements in the prevalence of pain, pain relief, andpatient satisfaction (P<.001), leading to a savings of 15000 days of unnecessary suffering per year

Monitorización de la calidad en las unidades de dolor / No disponible

No disponible

Administración accidental de remifentanilo epidural y ropivacaina intravenosa / No disponible

No disponible

Anestesia en un niño con Síndrome de Rubinstein-Taybi / Anesthesia for a boy with Rubinstein-Taybi syndrome

No disponible

No disponible

[Pain-free hospital audit: a pre-post assessment]. / Evaluación antes-después del "hospital sin dolor".

OBJECTIVE: To evaluate improvement after implementation of care through a nurse-managed acute pain unit in a district hospital, using statistical process control (SPC) methods. MATERIAL AND METHODS: Each month we measured 3 acute pain unit quality indicators: pain prevalence, pain relief, and satisfaction with pain management. The indicators were monitored on P-charts according to SPC procedures that determine their distribution within control limits and track variability. RESULTS: The hospital prevalence of acute pain stabilized at 30% after a year. Eight-five percent of patients achieved adequate pain relief and 90% were satisfied with pain management. CONCLUSIONS: A nurse-managed acute pain unit designed and managed with tools for monitoring quality assurance produces significant absolute and relative improvements in the prevalence of pain, pain relief, and patient satisfaction (P < .001), leading to a savings of 15 000 days of unnecessary suffering per year.

[Pathophysiology of neoplasic cachexia]. / Fisiopatología de la caquexia neoplásica.

The regulation of food intake is mediated by different psicological, gastrointestinal metabolic, nutritional and endocrine mechanisms. The cancer patient suffers from anorexia which results in early saciety and a reduction of appetite. Sometimes, the causes of the anorectic response are derived from the antitumoral treatment (chemotherapy, radiotherapy or immunotherapy), in some cases vomiting resulting in altered food intake. Alterations in the food taste and smell perception in addition to psychological dearrangements might also lead to the anorexia. Sometimes the tumour may play a direct effect when it is localised in either the hypothalamus or the digestive apparatus. However, in the majority of cases the origin of the anorexia associated with cancer cachexia seems to be due to the metabolic alterations induced by tumour burden. Different factors of both humoral and tumoral origin play a role in cancer anorexia. For instance, tumour necrosis factor (TNF-), a cytokine responsible for a great part of the metabolic alterations characteristic of cancer cachexia seems to be involved. In conclusion, the cancer anorexia seems to be more an effect than the cause of the weight loss and in fact the decrease in food intake might take place after weight loss is evident. In any case, the malnutrition associated with a decrease of food intake worsens the cachectic state, favouring a kind of a positive feed-back mechanism that finally leads to the patient's death.

Muscle wasting in cancer and ageing: cachexia versus sarcopenia.

Muscle wasting during cancer and ageing share many common metabolic pathways and mediators. Due to the size of the population involved, both cancer cachexia and ageing sarcopenia may represent targets for future promising clinical investigations. Cancer cachexia is a syndrome characterized by a marked weight loss, anorexia, asthenia and anemia. In fact, many patients who die with advanced cancer suffer from cachexia. The degree of cachexia is inversely correlated with the survival time of the patient and it always implies a poor prognosis. In recent years, age-related diseases and disabilities have become of major health interest and importance. This holds particularly for muscle wasting, also known as sarcopenia that decreases the quality of life of the geriatric population, increasing morbidity and decreasing life expectancy. The cachectic factors (associated with both depletion of fat stores and muscular tissue) can be divided into two categories: of tumour origin and humoural factors. In conclusion, more research should be devoted to the understanding of muscle wasting mediators, both in cancer and ageing, in particular the identification of common mediators may prove as a good therapeutic strategy for both prevention and treatment of wasting both in disease and during healthy ageing.

[Cerebellar hemorrhage after spinal anesthesia]. / Hemorragia cerebelosa tras anestesia subaracnoidea.

Cerebellar hemorrhage is a rare complication of spinal anesthesia. We report a case in a 51-year-old woman with a history of hypertension who underwent uterine dilatation and curettage with spinal anesthesia. During recovery she vomited and complained of headache. Postdural puncture headache was diagnosed. When there was no response to conventional treatment, computed tomography and magnetic resonance scans of the head were performed. The scans confirmed cerebellar hemorrhage due to rupture of a cavernous angioma. The patient recovered fully without surgical decompression. We review the pathogenesis of headache and cerebral hemorrhage after spinal anesthesia and propose differential diagnosis between spontaneous rupture related to hypertension and cerebrospinal fluid hypotension syndrome caused by trauma from lumbar spinal puncture. Patients with prolonged severe headache after spinal anesthesia require neurologic and radiologic monitoring to rule out the possibility of intracranial complications.