Variations in the definition and perceived importance of positive resection margins in patients with colorectal cancer - an EYSAC international survey.

INTRODUCTION: Microscopically positive resection margins (R1) are associated with poorer outcomes in patients with colorectal cancer. However, different definitions of R1 margins exist. It is unclear to what extent the definitions used in everyday clinical practice differ within and between nations. This study sought to investigate variations in the definition of R1 margins in colorectal cancer and the importance of margin status in clinical decision-making. MATERIALS AND METHODS: A 14-point survey was developed by members of The European Society of Surgical Oncology (ESSO) Youngs Surgeons and Alumni Club (EYSAC) Research Academy targeting all members of the multidisciplinary team (MDT) treating patients with colorectal cancer. The survey was distributed on social media, in ESSO's monthly newsletter and via national societies. RESULTS: In total, 137 responses were received. Most respondents were from Europe (89.7%), with the majority from Denmark (56.9%). Less than 2/3 of respondents defined R1 margins as the presence of viable cancer cells ≤1 mm of the margin. Only 60% reported that subdivisions of R1 margins (primary tumour vs tumour deposit vs metastatic lymph node) are routinely available. More than 20% of respondents reported that pathology reports are not routinely reviewed at MDT meetings. Less than half of respondents considered margin status in decision-making for type and duration of adjuvant chemotherapy in Stage III colon cancer. CONCLUSION: The definitions and perceived clinical importance of microscopically positive margins in patients with colorectal cancer appear to vary. Adoption of an international dataset for pathology reporting may help to standardise current practices.

Meta-analysis of pre-clinical studies on the effects of opioid receptor ligands on food intake, motivation, and choice.

The opioid receptors (OR) regulate food intake. Still, despite extensive pre-clinical research, the overall effects and individual contribution of the mu (MOR), kappa (KOR), and delta (DOR) OR subtypes to feeding behaviors and food intake remain unclear. To address this, we conducted a pre-registered systematic search and meta-analysis of rodent dose-response studies to evaluate the impact of central and peripheral administration of non-selective and selective OR ligands on intake, motivation, and choice of food. All studies had a high bias risk. Still, the meta-analysis confirmed the overall orexigenic and anorexigenic effects of OR agonists and antagonists, respectively. Our results support a larger orexigenic role for central MOR agonists among OR subtypes and that peripheral OR antagonists reduce motivation for and intake of preferred foods. In binary food choice studies, peripheral OR agonists selectively increase the intake of fat-preferred foods; in contrast, they did not increase the intake of sweet carbohydrate-preferred foods. Overall, these data support that OR regulation of intake, motivation, and choice is influenced by food macronutrient composition.

Cardiac safety of dual anti-HER2 blockade with pertuzumab plus trastuzumab in early HER2-positive breast cancer in the APHINITY trial.

BACKGROUND: Trastuzumab increases the incidence of cardiac events (CEs) in patients with breast cancer (BC). Dual blockade with pertuzumab (P) and trastuzumab (T) improves BC outcomes and is the standard of care for high-risk human epidermal growth factor receptor 2 (HER2)-positive early BC patients. We analyzed the cardiac safety of P and T in the phase III APHINITY trial. PATIENTS AND METHODS: Left ventricular ejection fraction (LVEF) ≥ 55% was required at study entry. LVEF assessment was carried out every 3 months during treatment, every 6 months up to month 36, and yearly up to 10 years. Primary CE was defined as heart failure class III/IV and a significant decrease in LVEF (defined as ≥10% from baseline and to <50%), or cardiac death. Secondary CE was defined as a confirmed significant decrease in LVEF, or CEs confirmed by the cardiac advisory board. RESULTS: The safety analysis population consisted of 4769 patients. With 74 months of median follow-up, CEs were observed in 159 patients (3.3%): 83 (3.5%) in P + T and 76 (3.2%) in T arms, respectively. Most CEs occurred during anti-HER2 therapy (123; 77.4%) and were asymptomatic or mildly symptomatic decreases in LVEF (133; 83.6%). There were two cardiac deaths in each arm (0.1%). Cardiac risk factors indicated were age > 65 years, body mass index ≥ 25 kg/m2, baseline LVEF between 55% and <60%, and use of an anthracycline-containing chemotherapy regimen. Acute recovery from a CE based on subsequent LVEF values was observed in 127/155 patients (81.9%). CONCLUSIONS: Dual blockade with P + T does not increase the risk of CEs compared with T alone. The use of anthracycline-based chemotherapy increases the risk of a CE; hence, non-anthracycline chemotherapy may be considered, particularly in patients with cardiovascular risk factors.

Socio-ecological determinants of rickettsial seroprevalence in a rural community of Yucatán, Mexico.

Rickettsial diseases have seen a re-emergence in the Americas in the last few decades, with concerning morbidity, mortality and economic implications that result from loss of productivity, income, curbs in liberal trade agreements, and reduction in agricultural practices. The aim of this study is to determine the socioecological determinants and seroprevalence for Rickettsia typhi and Rickettsia rickettsii among residents of Teabo, a rural community of Yucatán, Mexico. Sociodemographic data and serum samples were obtained from 180 consenting participants. Antibody titers for R. typhi and R. rickettsii were determined by indirect immunofluorescence assay (IFA). Participants also submitted tick samples collected from their residential area. We conducted logistic regression models to evaluate the association between exposure variables and seroprevalence. Rhipicephalus sanguineus s.l. (37%; n = 65), and Amblyomma cajennense Fabricius (17%; n = 29) were the predominant tick species in peri-domestic areas. Out of the 180 participants, there was significantly higher seroprevalence of R. typhi (n = 77; 46%) compared to R. rickettsii [n = 27, 15%, (p < 0.05)]. Pearson's chi-square test of independence revealed significant differences in R. rickettsii seroprevalence by gender (X2 [n = 175, df = 4, (p < 0.001)] = 180.26), level of education, (X2 [n = 180, df = 4, (p < 0.001)] = 44.0), and by tick species found in residential area, (X2 [n = 180, df = 4, (p = 0.050)] = 9.48). After adjusting for other variables in a logistic regression model, for each unit increase in the number of dogs present in the residential area, there was a 27% increase in the odds of human seroprevalence for R. typhi IgG (AOR = 1.27, 95% CI: 1.01-1.63). Compared to study participants living in residential areas with a 'low' height of vegetation, those living in residential areas with a 'medium' height of vegetation had 2.5 times greater odds of human seroprevalence for R. typhi IgG (AOR = 2.51, 95% CI: 1.19-5.40). Potentially modifiable existing factors in the peri-domestic area may constitute a high-risk source of seroprevalence for rickettsial antibodies among residents of the rural community of Teabo, Yucatán, Mexico.

Postural control strategies are revealed by the complexity of fractional components of COP.

The complexity of the center of pressure (COP) provides important information regarding the underlying mechanisms of postural control. The relationships between COP complexity and balance performance are not fully established and might depend on the task constraints and the filtering decomposition of the COP signal. This study assessed COP complexity under different task constraints and it was assessed if emergent dynamics of COP fluctuations differ according to fractional components of COP related to peripheral or central adjustments. One hundred and sixty-two participants performed two sitting balance tasks. Accuracy was required by following a target that moved in the mediolateral (ML) or in the anteroposterior (AP) axis. Complexity dynamics of COP were addressed through detrended fluctuation analysis (DFA) in the axis constrained by accuracy requirements and in the one nonconstrained. Decomposition of COP components was applied by low-pass, band-pass, and high-pass filters. DFA of low-pass and band-pass components of COP in the constrained axis were small-to-moderately related (r = 0.190-0.237) to balance performance. DFA of the high-pass component of the COP exhibited the opposite relationship (r = -0.283 to -0.453) in both axes (constrained and nonconstrained). This study evidences that COP complexity is linked to better performance. This positive relationship complexity/performance is observed in the low- and mid-frequency components of the COP. These components might be related to central mechanisms of postural control. The lack of relationships between the different frequencies analyzed in the study suggests that they are capturing different components of postural control.NEW & NOTEWORTHY The relationship between the complexity of the center of pressure (COP) and balance performance is not fully established. The task constraints and the filtering decomposition of the COP could influence this relationship. COP complexity is related to a better balance performance only in low frequencies and midfrequencies of the COP. The different frequencies measure different postural control components. Filtering decomposition should be explored in future studies to address the underlying mechanisms of postural control.

Can wrecks serve as exploitable surrogate habitats for degraded natural reefs?

Overfishing is a key stressor in many coral reefs, affecting their function and ecosystem services. In the Gulf of California, 50 years of artisanal and recreational fishing have removed most of the largest and most vulnerable fish species, the Espiritu Santo Archipelago (ESA) is a marine protected area (MPA) where artisanal and recreational fishing are allowed in most of the natural reefs, while the artificial reefs (wrecks) are fully protected. An important question under such circumstances is whether artificial reefs can serve as surrogate habitats for the natural reefs. To address this question, we characterized the fish community (species richness, abundance, differences in taxonomic structure) and analyzed the obtained data by multivariate ordination and similarity analysis. The highest species richness was found in the artificial reefs, with total of 83 species, of which 21 species were exclusive. Contrary to the species richness, the total fish abundance was 20% higher at the natural reefs. The fish assemblages of the artificial reefs differ significantly from those of the natural reefs. The natural reefs of the ESA are dominated by few fish species from families of lower trophic levels. In contrast, the studied shipwrecks provide refuge to commercially important fish species (such as Snappers, Triggerfish, Jacks, and Groupers) including threatened species. The different fish compositions on the natural and artificial reefs is likely to be the outcome of differential fishing pressure. The non-fished areas (wrecks) of the ESA may represent a good strategy for reef restoration, enhanced fishing grounds (via spillover) and fishing management. However, the fish community structure of the artificial reefs differs from natural rocky reefs of the ESA, and therefore, should not be considered as surrogate habitats for natural reefs. The results point out the need to reassess the management effectiveness of the natural reefs of the ESA.

Identification through exome sequencing of the first PMM2-CDG individual of Mexican mestizo origin.

Congenital Disorders of Glycosylation (CDG) are scarcely reported from Latin America. We here report on a Mexican mestizo with a multi-systemic syndrome including neurological involvement and a type I transferrin (Tf) isoelectric focusing (IEF) pattern. Clinical exome sequencing (CES) showed known compound missense variants in PMM2 c.422G > A (p.R141H) and c.395 T > C (p.I132T), coding for the phosphomanomutase 2 (PMM2). PMM2 catalyzes the conversion of mannose-6-P to mannose-1-P required for the synthesis of GDP-Man and Dol-P-Man, donor substrates for glycosylation reactions. This is the third reported Mexican CDG patient and the first with PMM2-CDG. PMM2 has been recently identified as one of the top 10 genes carrying pathogenic variants in a Mexican population cohort.

Major liver trauma post-mechanical cardiopulmonary resuscitation-the first reported case of survival with normal cardiovascular and neurological outcome.

Cardiopulmonary resuscitation (CPR) is often conducted with mechanical devices, such as Lund University Cardiac Arrest System in the setting of cardiac arrest during coronary catheterization, to enable effective chest compressions for a prolonged period. Certain injuries from such devices are common such as skin lesions, sternal and rib fractures. Others are rarer, such as visceral injury to the heart, major vessels, lung, liver, spleen and stomach. Major liver injuries have been previously reported but were universally fatal. Here, we report the first case of a capsular liver tear post-mechanical CPR, requiring immediate laparotomy and primary repair, resulting in patient survival with a normal cardiovascular and neurological and outcome.

[Evaluation of compliance with the antibiotic prophylaxis protocol in hysterectomy. Prospective cohort study]. / Evaluación de la adecuación al protocolo de profilaxis antibiótica en histerectomías. Estudio de cohortes prospectivo.

OBJECTIVE: Health care-related infections are a public health problem, among them surgical site infection (SSI) are the most frequent in hospitals. The objetive of this study was to assess the effect of the compliance to antibiotic prophylaxis protocol on the incidence of surgical site infection in hysterectomized patients. METHODS: A prospective cohort study was carried out between October 2009 and December 2018. The incidence of SSI was studied after a maximum period of 30 days from the moment of surgery. The degree of adequacy of antibiotic prophylaxis in hysterectomy and the effect of its inadequacy on the incidence of infection was evaluated using relative risk (RR) adjusted with a logistic regression model. RESULTS: A total of 1,025 interventions were studied in 1,022 women. The cumulative incidence of SSI was 2,1% (n = 22). The most frequent etiology of infection was Escherichia coli (23.1%) and Proteus mirabilis (23.1%). Antibiotic prophylaxis was indicated in 1,014 interventions (98.9%) being administered in 1,009 of them (99.5%). The adherence to the protocol was 92,5%. The main cause of non-compliance was the time of onset (40.9%), followed by the choice of the antibiotic (35.2%). The effect of inadequate prophylaxis on the incidence of infection was RR = 0.9; 95% CI 0.2-3.9; p> 0.05. CONCLUSIONS: The adequacy of antibiotic prophylaxis was very high, with a low incidence of surgical site infection. No association was found between adequacy of prophylaxis and incidence of infection in hysterectomy. The continuous improvement of epidemiological surveillance in gynecology should be emphasized.

Uso de internet en los pacientes que acuden a consultas externas de pediatría de un hospital general / Internet use in patients atending an ambulatory pediatric facility in a general hospital

INTRODUCCIÓN: La relación médico-paciente asiste a un nuevo paradigma: la búsqueda de información médico-sanitaria por los pacientes, en ocasiones antes o después de acudir a consulta médica. MATERIAL Y MÉTODOS: Estudio transversal, observacional, no experimental. Encuesta en las consultas externas de un hospital general de área a los padres/madres que acudían por primera vez. RESULTADOS: Contestaron 220 progenitores. El 90% disponían de conexión a internet en su domicilio y el 98% en su móvil. Solo el 38% buscaron información antes de acudir y el 25% la buscarían al llegar a su domicilio. El 34% de los encuestados encontró información relacionada con su problema y al 26% les resultó adecuada. Al 38% les hubiera gustado que tras la visita su médico les hubiese recomendado alguna página web de calidad y a un 80% les parecía una buena idea que el servicio de pediatría contase con su propia página web. CONCLUSIÓN: Cada día es más frecuente que los pacientes busquen información médico-sanitaria en internet antes de acudir a consulta y por ello los profesionales sanitarios y los propios servicios deben estar preparados para ofrecer información de calidad por estos medios

INTRODUCTION: The doctor-patient relationship attends a new paradigm: the search for medical-health information by patients, sometimes before or after going to a doctor's office. MATERIAL AND METHODS: Cross-sectional, observational, non-experimental study. Survey in the outpatient clinics of a general area hospital to parents who came for the first time. RESULTS: 220 parents answered. 90% had Internet connection at home and 98% on their mobile. Only 38% sought information before going and 25% would seek it when they arrived at their home. 34% of respondents found information related to their problem and 26% found it appropriate. 38% would have liked that after the visit their doctor had recommended a quality website and 80% thought it was a good idea for the pediatric service to have its own website. CONCLUSIONS: Every day it is more frequent for patients to seek medical-health information on the Internet before going to consultation and for that reason health professionals and the services themselves must be prepared to offer quality information through these means

European Society of Surgical Oncology's strategy for clinical research: Paving the way for a culture of research in cancer surgery.

As part of its mission to promote the best surgical care for cancer patients, the European Society of Surgical Oncology (ESSO) has been developing multiple programmes for clinical research along with its educational portfolio. This position paper describes the different research activities of the Society over the past decade and an action plan for the upcoming five years to lead innovative and high quality surgical oncology research. ESSO proposes to consider pragmatic research methodologies as a complement to randomised clinical trials (RCT), advocates for increased funding and operational support in conducting research and aims to enable young surgeons to be active in research and establish partnerships for translational research activities.

SEOM clinical guideline for treatment of muscle-invasive and metastatic urothelial bladder cancer (2018)

The goal of this article is to provide recommendations about the management of muscle-invasive (MIBC) and metastatic bladder cancer. New molecular subtypes of MIBC are associated with specific clinical-pathological characteristics. Radical cystectomy and lymph node dissection are the gold standard for treatment and neoadjuvant chemotherapy with a cisplatin-based combination should be recommended in fit patients. The role of adjuvant chemotherapy in MIBC remains controversial; its use must be considered in patients with high-risk who are able to tolerate a cisplatin-based regimen, and have not received neoadjuvant chemotherapy. Bladder-preserving approaches are reasonable alternatives to cystectomy in selected patients for whom cystectomy is not contemplated either for clinical or personal reasons. Cisplatin-based combination chemotherapy is the standard first-line protocol for metastatic disease. In the case of unfit patients, carboplatin-gemcitabine should be considered the preferred first-line chemotherapy treatment option, while pembrolizumab and atezolizumab can be contemplated for individuals with high PD-L1 expression. In cases of progression after platinum-based therapy, PD-1/PD-L1 inhibitors are standard alternatives. Vinflunine is another option when anti-PD-1/PD-L1 therapy is not possible. There are no data from randomized clinical trials regarding moving on to immuno-oncology agents

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SEOM clinical guideline for treatment of muscle-invasive and metastatic urothelial bladder cancer (2018).

The goal of this article is to provide recommendations about the management of muscle-invasive (MIBC) and metastatic bladder cancer. New molecular subtypes of MIBC are associated with specific clinical-pathological characteristics. Radical cystectomy and lymph node dissection are the gold standard for treatment and neoadjuvant chemotherapy with a cisplatin-based combination should be recommended in fit patients. The role of adjuvant chemotherapy in MIBC remains controversial; its use must be considered in patients with high-risk who are able to tolerate a cisplatin-based regimen, and have not received neoadjuvant chemotherapy. Bladder-preserving approaches are reasonable alternatives to cystectomy in selected patients for whom cystectomy is not contemplated either for clinical or personal reasons. Cisplatin-based combination chemotherapy is the standard first-line protocol for metastatic disease. In the case of unfit patients, carboplatin-gemcitabine should be considered the preferred first-line chemotherapy treatment option, while pembrolizumab and atezolizumab can be contemplated for individuals with high PD-L1 expression. In cases of progression after platinum-based therapy, PD-1/PD-L1 inhibitors are standard alternatives. Vinflunine is another option when anti-PD-1/PD-L1 therapy is not possible. There are no data from randomized clinical trials regarding moving on to immuno-oncology agents.

This is a call to oncologists for action

Cancer cases are growing in an exponential way, likewise the prices of new cancer drugs. Continuing in this way, in the near future, it will be impossible to provide optimum care for all cancer patients. Therefore, it is important to establish mechanisms that enable the National Health Systems to provide the best options of treatment, either through the elaboration of decision-binding frameworks or through other initiatives that guarantee the best quality care for all oncology patients to overcome, in the best possible way, this difficult illness. Here, we review current proposals that have been established by different cancer organizations worldwide, their similarities, their differences and whether they are helpful in a real clinical setting. Facing present reality and despite these organizations’ huge efforts, these proposals are not being implemented at all and it does not seem feasible that they will in the short run. In the same way, we support and argue why oncologists should have a crucial and a preponderant role to establish the best way of guaranteeing an equal access to the latest oncology care

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Personalized biomarker-based treatment strategy for patients with squamous cell carcinoma of the head and neck: EORTC position and approach.

The molecular landscape of squamous cell carcinoma of the head and the neck (SCCHN) has been characterized and actionable or targetable genomic alterations have been identified. However, targeted therapies have very limited activity in unselected SCCHN, and the current treatment strategy is still based on tumor location and disease stage and not on tumor biology. Trying to select upfront the patients who will benefit from a specific treatment might be a way to improve patients' outcome. With the objective of optimizing the activity of targeted therapies and immunotherapy, we have designed an umbrella biomarker-driven study dedicated to recurrent and/or metastatic SCCHN patients (EORTC-1559-HNCG, NCT03088059). In this article, we review not only the different trial designs for biomarker-driven studies with their respective advantages and opportunities but also the potential pitfalls that led to the design of the EORTC-1559-HNCG protocol. We also discuss the scientific and logistic challenges of biomarker-driven trials.

This is a call to oncologists for action.

Cancer cases are growing in an exponential way, likewise the prices of new cancer drugs. Continuing in this way, in the near future, it will be impossible to provide optimum care for all cancer patients. Therefore, it is important to establish mechanisms that enable the National Health Systems to provide the best options of treatment, either through the elaboration of decision-binding frameworks or through other initiatives that guarantee the best quality care for all oncology patients to overcome, in the best possible way, this difficult illness. Here, we review current proposals that have been established by different cancer organizations worldwide, their similarities, their differences and whether they are helpful in a real clinical setting. Facing present reality and despite these organizations' huge efforts, these proposals are not being implemented at all and it does not seem feasible that they will in the short run. In the same way, we support and argue why oncologists should have a crucial and a preponderant role to establish the best way of guaranteeing an equal access to the latest oncology care.

Approaches for the successful isolation and cell culture of American Rickettsia species.

Rickettsia are intracellular vector-borne bacteria, which are the etiologic agent of severe infections that could inflict death to their host. The intracellular behaviour of Rickettsia makes the study of its genetics, proteomics and cellular processes very difficult. Hence, isolation remains an important experimental technique that permits the obtention of important yields of bacteria, useful for a broad range of experiments. Isolation of Rickettsia using passages in animals or embryonated eggs has been described for long time; however, it was until the 1990s that faster and more feasible approaches for cell culture were developed. Current isolation approaches are mainly based on shell vial culture, that varies according to the media, atmosphere or temperature conditions. These variations have allowed the establishment of isolates from different pathogenic and non-pathogenic Rickettsia species, using arthropod, animal or human samples. Purification method of bacteria has also witnessed changes alongside the quantification of its load in the resulting isolates, from the laborious and time consuming plaque assays, to the routinary use of real-time polymerase chain reaction (qPCR), which is faster and more accurate. This review discusses various approaches that have been used for the isolation and purification of different Rickettsia species along with the mention of some successful examples. It indicated that a successful strategy for the isolation of Rickettsia requires a careful selection of media, cell lines and culture conditions which now are not as time consuming as used to be.

The European Organization for Research and Treatment for Cancer (EORTC) strategy for quality assurance in surgical clinical research: Assessment of the past and moving towards the future.

AIMS: Quality assurance (QA) in a surgical trial must be planned and implemented from study development to completion. Elements of quality must be consistently described in a protocols, case report forms (CRFs) and reported in publications. The purpose of this review was to evaluate the most common surgical parameters and how consistently they were described in EORTC study documents where surgery was included. This was the preliminary step in mapping out the challenges of developing a surgical QA strategy in EORTC. METHODS: A systematic review of EORTC surgical protocols from 1980 to 2013 was performed. Two independent reviewers selected and reviewed the protocols. Data extraction was done using a questionnaire developed by EORTC QA committee. The results were compared across the time period. RESULTS: The most common quality parameters described in protocols were surgical technique, definition of resectability, surgical margins and methods of assessing adverse events using the Common Terminology Criteria for Adverse Event (CTCAE). However, these were not consistently reported in publications. A general improvement in the method of protocol development was observed since year 2000 after standardization measures by EORTC. A new surgical chapter template has been proposed. CONCLUSION: There is a need to consistently define and report surgical parameters from protocol development to publication as a first step to QA. A standard surgical chapter in the EORTC protocol template can help address this need. A framework to consistently implement QA for future surgical trials is needed and the rationale for this is described in this review.

El alivio del dolor: un derecho humano universal / Pain relief: An universal human right

El dolor es uno de los síntomas que más sufrimiento produce en cualquier enfermedad y constituye un problema básico de salud en todo el mundo. Sin embargo, con frecuencia no recibe el tratamiento adecuado por razones culturales, religiosas, actitudes de la sociedad y de los profesionales sanitarios, así como por motivos políticos y económicos. Desde el punto de vista ético, aliviar el dolor es un derecho del ser humano y una obligación de los profesionales sanitarios. La responsabilidad de los profesionales en lo que respecta a proporcionar un control adecuado del dolor está recogida en el Juramento Hipocrático y en la Declaración de Ginebra, que exige ante todo velar por la salud del paciente. Desde un punto de vista legislativo, la legislación internacional en materia de derechos humanos obliga a los Estadosfirmantes a proteger con todos los recursos a su alcance los derechos que la misma garantiza, sin establecer expresamente el derecho a un alivio adecuado del dolor. Sin embargo, el derecho a la salud lleva implícito el derecho a un adecuado tratamiento del dolor. La Constitución Española de 1978, en su artículo 43, reconoce el derecho a la protección de la salud y por tanto el derecho de los ciudadanos a recibir una asistencia sanitaria adecuada. Así mismo, el artículo 43 incluye que compete a los poderes públicos organizar y tutelar la salud pública a través de medidas preventivas y de las prestaciones y servicios necesarios. Aun no contemplando expresamente el derecho al alivio del dolor, garantiza una adecuada asistencia sanitaria que no puede dejar de lado un tema tan importante como es el tratamiento del dolor. La Organización Mundial de la Salud (OMS) determinó que el alivio del dolor es un derecho fundamental y que incurre en una falta de ética grave aquel profesional de la salud que impida a un ser humano el acceso a la posibilidad de alivio del mismo. La OMS ha dictado los criterios indispensables para un buen control del dolor, entre los que recoge la adecuada formación de los profesionales de la salud y la disponibilidad de fármacos para el tratamiento del dolor. La actitud o comportamiento del que descuida algo o se descuida en algo se denomina 'negligencia'. Se podrían denominar así situaciones en las que no se realiza una terapéutica analgésica adecuada existiendo medios suficientes para hacerlo. Entre las razones que explican esta situación de 'negligencia terapéutica' se encuentra la reticencia a prescribir fármacos opioides debido a un miedo desmesurado a los efectos indeseables de los mismos, la prescripción a dosis inferiores a las analgésicas, a intervalos de dosificación superiores a los recomendados o en pautas a demanda, la administración de menos dosis de los fármacos prescritos por parte de Enfermería en la creencia errónea de que no deben suministrarse los analgésicos pautados cuando el enfermo se encuentra sin dolor y la resignación de los enfermos a sufrir dolor (AU)

Pain is one of the symptoms that more suffering produces in any disease, being a basic health problem worldwide. However, they often do not receive suitable treatment for cultural, religious, societal and health professionals attitudes as well as political and economic reasons. From the ethical point of view relieve pain is a human right and an obligation for health professionals. The responsibility of professionals with regard to providing adequate pain control is contained in the Hippocratic Oath and the Declaration of Geneva that guarantee the patients’ health. From a legislative perspective, international law on human rights forces signatories States to protect with all the resources at its disposal the guaranteed rights without expressly establish the right to adequate pain relief . However, the health right implies the right to an adequate pain management. The article 43 of the Spanish Constitution of 1978 recognizes the right to health protection and therefore the right of citizens to receive adequate health care. Likewise, Article 43 includes a matter for the public authorities to organize and safeguard public health through preventive measures and the necessary benefits and services. Even without specifically contemplating the right to pain relief, an adequate health care cannot ignore an important issue as pain relief. The World Health Organization (WHO), has stated that pain relief is a fundamental right and that incurs in a severe lack of ethic of the health professional who prevents a human from accessing the possibility of pain alleviation. WHO has issued the necessary criteria for a good pain control among which includes appropriate training of health professionals and the availability of drugs for the treatment of pain. The attitude or behavior that neglects something or neglected something is called negligence. They might as well be called situations where there are enough means to perform analgesic therapy and yet it is not done. The reasons for this situation of therapeutic negligence include reluctance to prescribe opioids due to the fear of the undesirable effects of them, prescribing a lower analgesic doses, prescribing drugs at intervals of exceeding the recommended dosage or is demand patterns, delivery by nurses of less doses of the prescribed drug believing that they should not administer the treatment when the patient does not have pain and finally resignation of patients to suffer pain (AU)