IBD-PODCAST Spain: A Close Look at Current Daily Clinical Practice in IBD Management.

BACKGROUND: Crohn's disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases (IBD) that contributes in part to irreversible bowel damage and long-term complications, reduced quality of life, invalidity, and economic burden. Suboptimal control of IBD is associated with higher healthcare resource utilization (HCRU), impaired quality of life (QoL), and reduced work productivity. AIMS: The IBD-PODCAST study aimed to assess the proportion of IBD patients with suboptimal control and its associated impact. METHODS: IBD-PODCAST is a cross-sectional, multicenter study that aimed to characterize the CD and UC population with optimal or suboptimal control according to the STRIDE-II criteria and patient- and physician-reported measures. Here we present the results of the Spanish cohort (n = 396). RESULTS: A total of 104/196 (53.1%) CD and 83/200 (41.5%) UC patients were found to have suboptimal disease control. Long-term treatment targets according to STRIDE-II were applied in 172 (87.8%) CD and 181 (90.5%) UC patients. 125 of 172 (72.7%) CD and 74 of 181 (40.9%) UC patients were currently treated with targeted immunomodulators. Patients with CD and UC and suboptimal disease control showed impaired QoL, higher HCRU and direct costs, and also loss of work productivity compared to those with optimal control. CONCLUSION: Despite a high rate of targeted immunomodulator therapy, a substantial proportion of IBD patients show suboptimal disease control according to the STRIDE II criteria. Those patients with suboptimal disease control exhibit impaired QoL, less work productivity, and higher HCRU, suggesting that there is considerable need for better treatment approaches in IBD.

Real-world use of mycophenolate mofetil in inflammatory bowel disease: Results from the ENEIDA registry.

BACKGROUND: Studies to evaluate the use of mycophenolate mofetil (MMF) in inflammatory bowel disease (IBD) are limited after the appearance of biological treatments. AIMS: Our primary objective was to evaluate the effectiveness and safety of MMF in IBD. METHODS: IBD patients who had received MMF were retrieved from the ENEIDA registry. Clinical activity as per the Harvey-Bradshaw Index (HBI), partial Mayo score (pMS), physician global assessment (PGA) and C-reactive protein (CRP) were reviewed at baseline, at 3 and 6 months, and at final follow-up. Adverse events and causes of treatment discontinuation were documented. RESULTS: A total of 83 patients were included (66 Crohn's disease, 17 ulcerative colitis), 90% of whom had previously received other immunosuppressants. In 61% of patients systemic steroids were used at initiation of MMF, and in 27.3% biological agents were co-administered with MMF. Overall clinical effectiveness was observed in 64.7% of the population. At the end of treatment, 45.6% and 19.1% of subjects showed remission and clinical response, respectively. MMF treatment was maintained for a median of 28.9 months (IQR: 20.4-37.5). CONCLUSION: Our study suggests, in the largest cohort to date, that MMF may be an effective alternative to thiopurines and methotrexate in IBD.

Diet and microbiome in the beginning of the sequence of gut inflammation.

Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gastrointestinal tract due, at least partially, to an aberrant and excessive mucosal immune response to gut bacteria in genetically-predisposed individuals under certain environmental factors. The incidence of IBD is rising in western and newly industrialized countries, paralleling the increase of westernized dietary patterns, through new antigens, epithelial function and permeability, epigenetic mechanisms (e.g., DNA methylation), and alteration of the gut microbiome. Alteration in the composition and functionality of the gut microbiome (including bacteria, viruses and fungi) seems to be a nuclear pathogenic factor. The microbiome itself is dynamic, and the changes in food quality, dietary habits, living conditions and hygiene of these western societies, could interact in a complex manner as modulators of dysbiosis, thereby influencing the activation of immune cells' promoting inflammation. The microbiome produces diverse small molecules via several metabolic ways, with the fiber-derived short-chain fatty acids (i.e., butyrate) as main elements and having anti-inflammatory effects. These metabolites and some micronutrients of the diet (i.e., vitamins, folic acid, beta carotene and trace elements) are regulators of innate and adaptive intestinal immune homeostasis. An excessive and unhealthy consumption of sugar, animal fat and a low-vegetable and -fiber diet are risk factors for IBD appearance. Furthermore, metabolism of nutrients in intestinal epithelium and in gut microbiota is altered by inflammation, changing the demand for nutrients needed for homeostasis. This role of food and a reduced gut microbial diversity in causing IBD might also have a prophylactic or therapeutic role for IBD. The relationship between dietary intake, symptoms, and bowel inflammation could lead to dietary and lifestyle recommendations, including diets with abundant fruits, vegetables, olive oil and oily fish, which have anti-inflammatory effects and could prevent dysbiosis and IBD. Dietary modulation and appropriate exclusion diets might be a new complementary management for treatment at disease flares and in refractory patients, even reducing complications, hospitalizations and surgery, through modifying the luminal intestinal environment.

Censo de las Unidades del Dolor en España. Análisis de la estructura organizativa, dotación, cartera de servicios e indicadores de calidad y buenas prácticas / Census Pain Units in Spain. Analysis of organizational structure, staffing, portfolio services and quality indicators

Según el censo existente en la Sociedad Española del Dolor (SED) en febrero de 2012 se contabilizaban 147 Unidades del Dolor. Gracias a la colaboración de la Fundación Signo (fundación que agrupa a los gestores de sanidad), tras cotejar sus ficheros con las direcciones-gerencias de centros hospitalarios públicos y las registradas por el Ministerio de Sanidad en entidades no públicas, se sumaron 36 Unidades a las censadas en la SED, lo que ha permitido identificar un total de 183 Unidades en España. A todas ellas se les solicitó colaborar con una encuesta online hospedada en una hoja web específica, con el objetivo de conocer la dotación y el grado de complejidad de cada una de ellas, así como el cumplimiento de los Estándares de Calidad y Buenas Prácticas de las Unidades del Dolor, editado por el Ministerio de Sanidad en el año 2010. Después de analizar las respuestas se consideraron válidas 143 encuestas, lo que suponía el 80,3 % del total de las Unidades censadas, y por tanto una muestra muy representativa. En este trabajo se analizan los resultados obtenidos en cuanto a la estructura, dotación, cartera de servicios y actividad de cada una de ellas y se contrasta con la tipificación de las Unidades dictada por el Ministerio. Se concluye que es necesario reconsiderar esta clasificación, proponiendo una más acorde con la situación real de las Unidades, que sea fiel reflejo de nuestras fortalezas y debilidades y sirva de referencia y punto de partida para mejorar la atención al dolor en nuestro país. Para validar los resultados obtenidos, una vez recogidas todas las encuestas se realizó una auditoría mediante selección aleatoria de ocho Unidades (5,7 % de las encuestadas), con un grado de coincidencia que oscila entre el 72-100 % en los distintos apartados y un grado de coincidencia global que supera el 86 %, que es el valor medio de veracidad que consideramos para este primer Censo de la Unidades del Dolor en España, con un intervalo de confianza que se sitúa entre el 81 y el 90 % (AU)

According to the census in the existing Spanish Society of Pain (SED) in February 2012 were recorded 147 Units Pain in Spain. Thanks to the collaboration of the Foundation Signo (Foundation which represents health managers), after comparing their files, with directions of hospitals public and institutions non-public registered by the Ministry of Health, 36 units were added to book entries in the SED, which has identified a total of 183 units in Spain. All of them were asked to collaborate with an online survey hosted on a particular web, order to know the crew and the degree of complexity of each, as well as compliance with the Standards Quality and Best Practices of Pain Units, edited by the Ministry of Health in 2010. One hundred and forty-three responses were considered valid surveys which accounted for 80.3 % of all units surveyed, and thus a very representative sample. In this paper are analyzed the results obtained in terms of the structure, endowment portfolio of services and activities of each and contrasted with the definition of the Units issued by the Ministry. We conclude that it is necessary to reconsider this, and propose a classification according to the actual situation Units that would reflect our strengths and weaknesses and serve as a reference and starting point for improving pain care in our country. To validate the results of an audit conducted by random selection of eight units (5.7 % of respondents), with a varying degree of overlap between 72-100 % in the different sections and a degree of overall match exceeding 86 %, which is the average value of truthfulness we consider for the first Census of pain units in Spain, with a confidence interval ranging between 81 and 90 % (AU)

Validación del índice de Lattinen para la evaluación del paciente con dolor crónico / No disponible

Fundamentos y objetivo: el índice de Lattinen (IL) es una herramienta muy utilizada para la evaluación del dolor en el mundo hispanoparlante, tanto en la práctica clínica como en trabajos de investigación. Sin embargo, hasta la fecha, no existía en la literatura ninguna validación del cuestionario. El presente estudio pretende abordar la validación del IL al castellano como instrumento de evaluación del dolor crónico. Materiales y métodos: se realizó un estudio multicéntrico, transversal, no intervencionista, incluyendo datos de 283 pacientes con dolor crónico (> 3 meses de duración) en el cual se analizó la validez y fiabilidad del Índice de Lattinen para su validación. En una primera visita, los pacientes cumplimentaron el cuestionario del IL junto con otras escalas habituales de valoración del dolor (Escala Visual Analógica [EVA], Cuestionario de Dolor McGill y tres escalas de Likert para el Consumo de Analgésicos, Grado de Incapacidad y Horas de Sueño), seleccionadas como medidas de referencia o gold standard para el análisis de validez. Un subgrupo de 83 pacientes con características clínicas estables fue citado para retomar las pruebas iniciales en un análisis de Test-Retest para comprobar la estabilidad temporal de las respuestas iniciales. Resultados: se estableció una relación positiva estadísticamente significativa entre la puntuación total obtenida con el IL y el grado de intensidad del dolor, medido a través de la escala EVA. Los distintos ítems del cuestionario, por separado: Intensidad del dolor, Frecuencia del dolor, Consumo de analgésicos, Grado de incapacidad y Horas de sueño; mostraron una correlación entre moderada y alta con las medidas gold standard de referencia equivalentes. Los análisis de consistencia interna y temporal mostraron coeficientes alfa > 0,7 y coeficiente de correlación intraclase > 0,85, respectivamente. Conclusiones: la validez del IL quedó probada tanto para la puntuación global como para las puntuaciones por dimensiones, al correlacionarse estas con las medidas estándar respectivas. Asimismo, se confirmó la fiabilidad del IL a través de los resultados del análisis de consistencia interna y de consistencia temporal, indicativos de una alta homogeneidad de los ítems (AU)

Background and objectives: the Lattinen Index (LI) is a widely used tool for pain assessment in Spanish speaking countries, both in clinical practice and research. Nevertheless, despite its extensive use, no validation of the Spanish language version of the questionnaire has been published yet. This study intends to validate LI as a tool for measuring chronic pain. Materials and methods: a multicentre, cross-sectional, non-interventional study, including 283 chronic pain patients (> 3 months duration), from 6 different centres, was performed. Validity and reliability analysis were performed in order to validate the IL. On a first visit patients completed the IL questionnaire and other conventional pain scales (Visual Analogic Scale [VAS], McGill Pain Questionnaire and three Likert scales evaluating Analgesic Consumption, Functional Ability, and Hours of Sleep), which acted as gold standards validity measurements . A sub-set of 83 patients, with stable clinical characteristics, was asked to retake the initial tests after 15 days, to measure test-retest reliability. Results: a statistically significant positive correlation was found between the total IL score and the degree of pain measured by VAS. The measurements from the individual items in the questionnaire: Pain intensity, Pain frequency, Analgesic consumption, Functional Ability and Hours of Sleep correlated from moderately to strongly, with the respective gold standards measurements. Internal consistency and test-retest assays showed coefficient values of: alpha > 0.7 and intraclass correlation > 0.85, respectively. Conclusions: IL validity was established both for the overall score as for the individual dimensions, proving a correlation with standard measurements. Reliability of IL was demonstrated with the results from internal consistency and test-retest analysis, which indicated a high homogeneity between items (AU)

Código de buena práctica para el control del dolor oncológico / Good practice code for the management of cancer pain

En muchas ocasiones, los pacientes con cáncer no expresan su dolor por miedo a que el médico desvíe su atención hacia este síntoma, en lugar de centrarse en el tratamiento de su enfermedad principal. No obstante, el paciente debe saber que el tratamiento de su dolor no solo no interfiere con la terapia curativa, sino que colabora con ella. Entre los enfermos, es habitual el temor a que el avance de la enfermedad les lleve a situaciones de sufrimiento insostenible que supere todas las posibilidades médicas, pero es nuestro deber ayudarles a ser conscientes de que la medicina ofrece un abanico de terapias capaces de aliviar su dolor y evitar su sufrimiento. Este conocimiento es esencial para aumentar su confianza en el tratamiento y mejorar la relación médico-paciente. Frente a este desafío, SECPAL (Sociedad Española de Cuidados Paliativos), SED (Sociedad Española del Dolor), SEOM (Sociedad Española de Oncología Médica) y SEOR (Sociedad Española de Oncología Radioterápica) unen sus esfuerzos y crean ALIADO (Alianza Contra el Dolor Oncológico), un grupo de trabajo interdisciplinario que nace con el objetivo de concienciar e implicar a todo el colectivo médico en la necesidad de mejorar la calidad de vida del paciente con dolor oncológico. La primera iniciativa de ALIADO en este sentido es la elaboración del Código de buena praxis para el tratamiento del dolor oncológico, que pretende contribuir al avance en el conocimiento y el manejo de estos pacientes (AU)

Patients with cancer often fail to talk about their pain fearing that their doctor might draw his or her attention to that symptom rather than focus on the management of their underlying disease. However, patients should know that pain management will not interfere with their curative therapy but will supplement it. Fear that the advancing disease will lead to unbearable suffering situations beyond medical possibilities is common among patients, and it is our duty to help them become aware tha medicine offers a number of therapies that actually can suppress pain and relieve suffering. This awareness is key to increase trust in therapy and improve doctor-patient relationships. Facing this challenge SECPAL (Sociedad Española de Cuidados Paliativos), SED (Sociedad Española del Dolor), SEOM (Sociedad Española de Oncología Médica), and SEOR (Sociedad Española de Oncología Radioterápica) unite in a joint venture to create ALIADO (Alianza Contra el Dolor Oncológico), an interdisciplinary work team emerging with the goal of raising awareness and involvement among health providers regarding the need for quality of life improvement in cancer patients with pain. In this respect, ALIADO's first initiative is the development of a good practice code for the management of cancer pain in an attempt to contribute to the further understanding and management of these patients (AU)

Creencias, actitudes y percepciones de médicos, farmacéuticos y pacientes acerca de la evaluación y el tratamiento del dolor crónico no oncológico / Beliefs, attitudes and perceptions of physicians, pharmacists and patients regarding the evaluation and treatment of chronic nononcologic pain

Objetivo: conocer las actitudes, creencias, vivencias y opiniones acerca del dolor crónico no oncológico, desde la perspectiva de los profesionales de la salud (médicos y farmacéuticos de oficina de farmacia) y de los pacientes, para profundizar en sus actitudes frente a la elección y dispensación del analgésico, o el seguimiento terapéutico. Material y métodos: diseño: estudio descriptivo, transversal dirigido a 3 poblaciones; se han realizado 3 cuadernos de recogida de datos (CRD) comparables entre sí, y adaptados a cada subgrupo: 316 farmacéuticos y 838 pacientes fueron entrevistados por teléfono, mientras que 697 médicos de 5 especialidades cumplimentaron un CRD autoadministrado. Variables: sociodemográficas en cada grupo, descriptivas del dolor (prevalencia entre sus pacientes, características del dolor [localización, intensidad —escala visual analógica, EVA, de 0 “no dolor” a 10 “máximo dolor tolerable”—, frecuencia, duración, consecuencias y otras]), características acerca del tratamiento analgésico (objetivos, elección de fármacos, prescripción, información ofrecida y recibida, satisfacción y reticencias).Análisis de datos: se realizó un análisis descriptivo de las características de cada grupo, seguido de un análisis de diferencias intergrupo. Resultados: a) médicos: el 60% afirma medir habitualmente el dolor en la consulta, usando la EVA (68%) o escala verbal simple (EVS) (36%). El 47% de los pacientes atendidos semanalmente presenta dolor, de los cuales un 63% tiene dolor no controlado (EVA ≥ 4).El objetivo que persiguen con el tratamiento analgésico es mejorar la calidad de vida del paciente más que el alivio de dolor. Sólo se prescriben opiáceos mayores al 17%, con más frecuencia en las unidades del dolor (UD), donde atienden mayor proporción de pacientes con dolor crónico no oncológico y con intensidades mayores. En las UD son más conscientes de la repercusión del dolor sobre la cotidianeidad del paciente (...) (AU)

Aim: to identify patients’, physicians’ and pharmacists’ attitudes, personal beliefs, experiences and opinions regarding chronic non oncological pain and to determine how these attitudes influence the choice and follow-up of analgesic strategies. Material and methods: design: we performed a descriptive, cross-sectional survey that included three distinct but comparable questionnaires for data collection, adapted to each subgroup: 316 pharmacists and 838 patients were interviewed by telephone, and697 physicians from different specialties completed a self-administered questionnaire. The variables analyzed included sociodemographic data from each group, descriptive pain variables (prevalence of pain among their patients, pain characteristics [e.g. localization, intensity —visual-analog pain scale, VAS, from 0 “no pain” to 10 “maximum tolerable pain”— frequency, duration, consequences, among others]), and questions related to analgesic treatment (objectives, drug choice and prescription, information provided and received on analgesic drugs, and satisfaction and concerns). Data analysis consisted of a descriptive analysis of the characteristics of each group, followed by analysis of intergroup differences. Results: a) physicians: 60% reported that they usually assessed pain intensity in their patients, using VAS (68%) or verbal rating scales (VRS) (36%). Forty-seven percent of the patients attended weekly had pain, which was uncontrolled (VAS score ≥ 4 points) in 63%.The goal of treatment was to improve patients’ quality of life rather than to relieve pain (...) (AU)

Estimulación Medular (EEM) en el tratamiento de la enfermedad vascular periférica. Parte II / Spinal Cord Stimulation for peripheral vascular disease treatment

Las técnicas de neuromodulación suponen un abordaje no destructivo y reversible en el tratamiento del dolor. Su utilización se establece como estrategia de control del dolor no controlable dentro de las directrices de la O.M.S. y como alternativa a otras terapias invasivas menores o neuroablatibas que no han sido eficaces o que están contraindicadas. De entre ellas el uso clínico de la estimulación eléctrica medular (EEM) o neuroestimulación, demuestra día a día su utilidad y eficacia en el tratamiento de diferentes síndromes de dolor crónico. Estudios de Cook y cols en 1.976, ya demostraron en sus trabajos la efectividad de esta técnica en la manifestación clínica del dolor isquémico así como en la arterioesclerosis o vasculopatía diabética, o en el dolor isquémico producido por vasoespasmo periférico, en entidades específicas como la Enfermedad de Buerguer, Esclerodermia o Síndrome de Raynaud. Durante la última década, se ha extendido la utilización de la EEM en la cardiopatía isquémica de carácter intratable (angina de pecho refractaria a tratamientos, síndrome “X”,...) y la patología vascular periférica, objeto de esta revisión. Esta técnica se presenta como una de las principales indicaciones con altos niveles de efectividad (80%), tanto en el aspecto clínico por el alivio sintomático que produce, como en los beneficios isquémicos fisiopatológicos que induce la neuroestimulación (AU)

The Neuro-modulation technologies are a not destructive and reversible approach in the treatment of the pain. They are used as a strategy for the control of untreatable pain according to the directives of the OMS and as an alternative of other invasive minor or neuroablatives therapies that have been not effective or that are not indicated. Between them the clinical use of spinal cord stimulation (SCS) has demonstrated its usefulness and efficiency in the treatment of different syndromes of chronic pain. Cook’s and cols. in 1.976, demonstrated in their reports the efficiency of this technique in the clinical manifestation of ischemic pain as well as in the arteriosclerosis, diabetic vasculopaty, or in the ischemic pain related with peripheral vasospasm, in specific pathologies as the Buerguer´s disease, Scleroderma or Raynaud´s syndrome. During the last decade, the utilization of the SCS has spread in the ischemic cardiopathy of untreatable character (refractory angina pectoris, syndrome “X”,…) and vascular peripheral pathology, subject of this review. This technique appears as one of the main indications with high levels of efficiency (80%), so much in the clinical aspect for the symptomatic relief as well as in the ischemic physiopatologic benefits that induces the neuro-estimulation (AU)

Regional reference values for some quantities measured with the ADVIA Centaur analyser. A model of co-operation between the in vitro diagnostic industry and clinical laboratories.

This work is a model of co-operation between the in vitro diagnostic industry and clinical laboratories for the production of reference values. Thirteen clinical laboratories having an ADVIA Centaur analyser and representing the majority of the geographical regions of Spain have shared the search for reference individuals and the production of reference values for thyrotropin, free thyroxine, free triiodothyronine, cobalamine and folate concentrations in serum. All the logistic work has been done in co-operation with the Spanish supplier of the ADVIA Centaur analyser. The reference limits produced in the virtual laboratory are derived from the blend of reference values obtained by each laboratory. The multicentre reference limits were estimated according to the recommendations of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC).

Indicaciones de los opioides en el dolor de espalda no neoplásico / No disponible

La mayoría de los pacientes con dolor crónico de espalda van a conseguir alivio con las terapias habituales, gracias a los importantes avances tanto en medios diagnósticos como de tratamiento. Sin embargo, un número pequeño, pero significativo, de pacientes seguirá experimentando dolor crónico a pesar de estas medidas, y en muchos casos precisarán opioides para controlarlo. Este sigue siendo un tema controvertido, y aunque es difícil determinar la relación del beneficio (eficacia) y el riesgo (tolerancia, abuso, adicción), podemos asegurar, según nuestra experiencia, que el beneficio es bueno y el riesgo pequeño. Los opioides estarían indicados en el dolor de espalda crónico severo, refractario a todas las terapias, con un diagnóstico probado, que produzca una reducción significativa de la calidad de vida, siempre que la situación psicosocial del paciente sea estable y el dolor sensible a opioides. Es importante realizar una valoración integral de estos pacientes, y tener en cuenta una serie de consideraciones antes de iniciar una terapia con opioides. La presentación de efectos secundarios, tolerancia, abuso o adicción, no representan un obstáculo para la utilización de este tratamiento. La vía de administración de elección de opioides es la oral, sin embargo la infusión continua espinal, o el fentanilo transdérmico presentan importantes ventajas. La posibilidad de conseguir alivio del dolor y mejorar la funcionalidad y la calidad de vida, justificaría la utilización de opioides en los pacientes con dolor de espalda crónico severo, refractario a todas las terapéuticas (AU)

Most patients with chronic back pain will achieve some relief with the standard therapies, thanks to the major advances both in diagnostic and therapeutic techniques. However, a small but significant number of patients will continue to have chronic pain despite such measures and in many cases they will require opiates for the management of their pain. This is still a controversial issue, and although it is difficult to determine the balance between benefit (effectiveness) and risk (tolerance, abuse, addiction), we can state, based on our experience, that the benefit is good and the risk small. Opiates would be indicated for severe chronic back pain refractory to other therapies, with a proven diagnosis and being the cause of a significant worsening of quality of life, provided that the psychosocial situation of the patient is stable and the pain is sensitive to opiates. It is important to performan integral assessment of such patients and to take into account some considerations before starting an opiate therapy. The development of side effects, tolerance, abuse or addiction is not a barrier for the use of this treatment. The best route of administration for opiates is the oral one; however, spinal continuous infusion or transdermal fentanile provide significant benefits. The ability to achieve immediate pain relief and to improve the functionality and quality of life of the patient, justifies the use of opiates in patients with severe chronic back pain refractory to other therapies (AU)