Sporadic fasting reduces attentional control without altering overall executive function in a binary classification task.

Diets with intermittent fasting are an efficient method for producing clinically significant weight loss and preventing the development of obesity. However, individuals following intermittent fasting must face the difficulty of avoiding eating when experiencing the feeling of hunger. In this study, we investigated which aspects of executive function were affected following a prolonged period of food deprivation in participants that have never previously undergone intermittent fasting. Twenty-six participants with normal weight performed two binary classification tasks (Stop Signal (SST) and Go/NoGo) after either a 12 h fasting or a nonfasting period in separate sessions. We measured their performance in several underlying decision-making processes, such as response inhibition and attentional control. In line with previous studies, our results revealed that decision-making processes to resolve the classification task were unaffected by fasting. Response inhibition, as indexed by the stop signal reaction time in the SST, remained as well unaltered after food deprivation. Rather, we observed a higher error rate in NoGo trials following a fasting period, which was associated with disrupted attentional control. Overall, these results indicate that when a hunger feeling reaches consciousness, it induces deficits over certain aspects of attentional control. Our findings hint at the importance of structured behavioral change strategies to cope with fasting-induced difficulties in attentional control, to help achieve weight management goals through successful self-monitoring of food intake.

¿Debe la industria farmacéutica participar en la formación médica continuada? / Should the pharmaceutical industry be involved in continuing medical education?

Introducción En julio del 2020 se presentó en el Congreso de los Diputados español una propuesta de ley que proponía que la formación médica continuada se financiase exclusivamente por las Administraciones públicas, prohibiendo la participación privada. Objetivos Recoger la opinión de médicos y farmacéuticos sobre la propuesta de ley, conocer qué piensan acerca de la financiación de la formación médica continuada y su posible conflicto de interés. Métodos Estudio descriptivo transversal a través de una encuesta de opinión, voluntaria y anonimizada, dirigida a médicos y farmacéuticos hospitalarios. Resultados Se analizan 435 encuestas, el 59,8% de mujeres. El 87,6% son facultativos especialistas y el 77,2% pertenece a especialidades médicas. El 55,2% no está de acuerdo con la propuesta de ley. El 92,4% se muestra de acuerdo con que el Estado y las instituciones privadas subvencionen la formación de sus trabajadores. El 54,2% está en desacuerdo con que cada profesional financie su formación, mientras que el 14% está de acuerdo. El 19,8% no se ha sentido cómodo cuando le han financiado un curso o congreso y el 74,5% considera que la participación privada de la financiación no influye en la prescripción. Conclusiones La mayoría de los encuestados no está de acuerdo con una propuesta de ley que pretende prohibir que la industria farmacéutica financie la formación médica continuada. Casi todos se muestran de acuerdo con que el Estado y las instituciones privadas subvencionen la formación de sus trabajadores. En general, los encuestados no detectan conflictos de interés en su relación con la industria (AU)

Introduction In July 2020, a draft bill was introduced in Spain's Congress which proposed that continuing medical education be funded exclusively by the Spanish government, barring involvement from private entities. Aims This work aims to gather physicians’ and pharmacists’ opinions on this draft bill, learn what they think about the funding of continuing medical education and possible conflicts of interest. Methods This work is a descriptive cross-sectional study conducted via voluntary anonymous surveys aimed at physicians and hospital pharmacists. Results Four hundred thirty-five surveys were analyzed, 59.8% of which were from women. Of the respondents, 87.6% were specialist physicians and 77.2% were part of a specialist department. A total of 55.2% did not agree with the draft bill while 92.4% agreed that the government and private institutes should subsidize training for their workers. Furthermore, 52.4% disagreed that each professional should pay for his or her own training while 14% agreed they should. A total of 19.8% have felt uncomfortable when a course or conference has been paid for by another entity and 74.5% believe that the involvement of private entities in funding does not influence prescribing. Conclusions The majority of those surveyed did not agree with a draft bill aimed at prohibiting the pharmaceutical industry from funding continuing medical education. Nearly all agreed that the government and private institutions should fund training for their workers. In general, those surveyed did not find conflicts of interest in their relationship with the industry (AU)

Should the pharmaceutical industry be involved in continuing medical education?

INTRODUCTION: In July 2020, a draft bill was introduced in Spain's Congress which proposed that continuing medical education be funded exclusively by the Spanish government, barring involvement from private entities. AIMS: This work aims to gather physicians' and pharmacists' opinions on this draft bill, learn what they think about the funding of continuing medical education and possible conflicts of interest. METHODS: This work is a descriptive cross-sectional study conducted via voluntary anonymous surveys aimed at physicians and hospital pharmacists. RESULTS: Four hundred thirty-five surveys were analyzed, 59.8% of which were from women. Of the respondents, 87.6% were specialist physicians and 77.2% were part of a specialist department. A total of 55.2% did not agree with the draft bill while 92.4% agreed that the government and private institutes should subsidize training for their workers. Furthermore, 52.4% disagreed that each professional should pay for his or her own training while 14% agreed they should. A total of 19.8% have felt uncomfortable when a course or conference has been paid for by another entity and 74.5% believe that the involvement of private entities in funding does not influence prescribing. CONCLUSIONS: The majority of those surveyed did not agree with a draft bill aimed at prohibiting the pharmaceutical industry from funding continuing medical education. Nearly all agreed that the government and private institutions should fund training for their workers. In general, those surveyed did not find conflicts of interest in their relationship with the industry.

La albuminuria y la enfermedad polivascular mejoran la capacidad predictiva de los modelos multivariados después de un evento cardiovascular agudo. Cohorte AIRVAG / Albuminuria and polyvascular disease improve multivariate predictive models after an acute cardiovascular event. The AIRVAG cohort

Antecedentes y objetivos: En la enfermedad cardiovascular ateroesclerótica no existe consenso respecto a los instrumentos de estratificación del riesgo en su prevención secundaria. Nuestro objetivo consistía en comparar la capacidad discriminativa de las funciones de riesgo de Framingham, REGICOR, SCORE y REACH y las puntuaciones de riesgo Bohula-TIMI y SMART, así como en evaluar el posible valor añadido de otras variables clínicas en cuanto a la predicción de recurrencias en pacientes con enfermedad cardiovascular. Métodos: Se analizó una cohorte de 269 pacientes con enfermedad cardiovascular establecida (52,8% coronaria, 32% cerebrovascular, 15,2% arteriopatía periférica). Se compararon las funciones de supervivencia de los grupos de riesgo (bajo/intermedio/alto) según los valores de corte de uso habitual de cada función o puntuación y se calcularon las razones de riesgos instantáneos (RRI) correspondientes a cada una mediante regresión de Cox. Se calculó el Δ C de Harrell, el cat-IRN y el cIRN después de añadir nuevos factores predictivos a un modelo base que incluía edad, sexo, colesterol total, tabaquismo activo, hipertensión arterial y diabetes. Resultados: Al cabo de 6 años de seguimiento (mediana de 4,82 años) se habían producido 61 eventos (23%). Los grupos de riesgo alto tuvieron un mayor riesgo de recurrencia: SMART (RRI: 3,17 [1,55-6,5]), Framingham (RRI: 3,08 [1,65-5,75]), REGICOR (RRI: 2,71 [1,39-5,27]), SCORE (RRI: 2,14 [1,01-4,5], REACH (RRI: 5,74 [2,83-11,7]) y B-TIMI (RRI: 3,68 [0,88-15,3]). La enfermedad polivascular (3 territorios, RRI: 5,6 [2,2-14,25]), la albuminuria (RRI: 3,55 [2,06-6,11]) y la insuficiencia cardíaca (RRI: 3,11 [1,34-7,25]) también incrementaron el riesgo. La capacidad discriminativa (índice C de Harrell) fue baja, pero mejoró tras añadir la albuminuria y la enfermedad polivascular. Ambas variables también mejoraron el rendimiento del modelo base (cIRN: 0,326 [0,036; 0,607]) (AU)

Background and aims: There is no consensus regarding risk stratification tools for secondary prevention in atherosclerotic cardiovascular disease. Our aim was to compare the discriminative performance of the Framingham, REGICOR, SCORE, and REACH risk functions and the Bohula-TIMI and SMART risk scores, as well as to assess the potential added value of other clinical variables for the prediction of recurrent events in patients with established vascular disease. Methods: A cohort of 269 patients with established vascular disease (52.8% coronary, 32% cerebrovascular, 15.2% peripheral artery disease) was included. The survival functions of risk groups (low/medium/high) according to commonly used cutoff points for each function/score were compared, and hazard ratios (HR) for each were estimated using Cox regression. We calculated Δ Harrell's C statistic, cat-NRI, and cNRI after adding new predictors to a base model including age, sex, total cholesterol, current smoking status, hypertension, and diabetes. Results: After 6 years of follow-up (median 4.82 years), 61 events occurred (23%). High-risk groups had a higher risk of recurrent event: SMART (HR: 3.17 [1.55-6.5]), Framingham (HR: 3.08 [1.65-5.75]), REGICOR (HR: 2.71 [1.39-5.27]), SCORE (HR: 2.14 [1.01-4.5], REACH (HR: 5.74 [2.83-11.7]), B-TIMI (HR: 3.68 [0.88-15.3]). Polyvascular disease (3 territories HR: 5.6 [2.2-14.25]), albuminuria (HR: 3.55 [2.06-6.11]), and heart failure (HR: 3.11 [1.34-7.25]) also increased risk. Discrimination (Harrell's C) was low but improved after adding albuminuria and polyvascular disease. Both variables also improved the performance of the base model (cNRI: 0.326 [0.036; 0.607]). Conclusions: The Framingham, REGICOR, SCORE, and REACH functions and the B-TIMI and SMART scores showed low yet similar performance in secondary prevention. Albuminuria and polyvascular disease improved the predictive performance of major classical cardiovascular risk factors (AU)

Albuminuria and polyvascular disease improve multivariate predictive models after an acute cardiovascular event. The AIRVAG cohort.

BACKGROUND AND AIMS: There is no consensus regarding risk stratification tools for secondary prevention in atherosclerotic cardiovascular disease. Our aim was to compare the discriminative performance of the Framingham, REGICOR, SCORE, and REACH risk functions and the Bohula-TIMI and SMART risk scores, as well as to assess the potential added value of other clinical variables for the prediction of recurrent events in patients with established vascular disease. METHODS: A cohort of 269 patients with established vascular disease (52.8% coronary, 32% cerebrovascular, 15.2% PAD) was included. The survival functions of risk groups (low/medium/high) according to commonly used cutoff points for each function/score were compared, and hazard ratios for each were estimated using Cox regression. We calculated Δ Harrell's C statistic, cat-NRI, and cNRI after adding new predictors to a base model including age, sex, total cholesterol, current smoking status, hypertension, and diabetes. RESULTS: After six years of follow-up (median 4.82 years), 61 events occurred (23%). High-risk groups had a higher risk of recurrent event: SMART (HR: 3.17 [1.55-6.5]), Framingham (HR: 3.08 [1.65-5.75]), REGICOR (HR: 2.71 [1.39-5.27]), SCORE (HR: 2.14 [1.01-4.5], REACH (HR: 5.74 [2.83-11.7]), B-TIMI (HR: 3.68 [0.88-15.3]). Polyvascular disease (three territories HR: 5.6 [2.2-14.25]), albuminuria (HR: 3.55 [2.06-6.11]), and heart failure (HR: 3.11 [1.34-7.25]) also increased risk. Discrimination (Harrell's C) was low but improved after adding albuminuria and polyvascular disease. Both variables also improved the performance of the base model (cNRI.326 [.036; .607]). CONCLUSIONS: The Framingham, REGICOR, SCORE, and REACH functions and the B-TIMI and SMART scores showed low yet similar performance in secondary prevention. Albuminuria and polyvascular disease improved the predictive performance of major classical cardiovascular risk factors.

¿Cuáles son los conflictos éticos más frecuentes para los internistas españoles? / Which are the most prevalent ethical conflicts for Spanish internists?

Antecedentes y objetivo Los clínicos se enfrentan en su práctica diaria a multitud de conflictos éticos. No hay estudios sobre los tipos de conflictos éticos que se encuentran con más frecuencia y que preocupan más a los clínicos en España. El objetivo de este estudio es describir los conflictos éticos más frecuentes con los que se encuentran los internistas españoles, así como la importancia que los profesionales atribuyen a cada conflicto. Materiales y métodos Estudio observacional transversal a través de una encuesta voluntaria y anónima, dirigida a médicos internistas españoles y distribuida a través de una plataforma ad hoc de la Sociedad Española de Medicina Interna. Resultados Los problemas éticos más frecuentes y relevantes para los internistas españoles son los relacionados con: el final de la vida (decisiones de limitación del esfuerzo terapéutico, uso de tratamientos paliativos, instauración de órdenes de no reanimación cardiopulmonar); los conflictos que se producen en el seno de la relación clínica, bien con familiares o con pacientes, y la toma de decisiones con pacientes incompetentes. Estos resultados son similares a los de otras series anglosajonas y europeas. Los problemas éticos dificultan más la actividad asistencial a los clínicos que perciben con más frecuencia dichos problemas (50,3%) que los que no los perciben (16%). Conclusiones Los conflictos éticos más frecuentes y relevantes entre los internistas españoles son los relacionados con el manejo del final de la vida, seguidos de los derivados de la relación clínica y el manejo de pacientes incompetentes. Es prioritario diseñar programas de formación que permitan abordar y reconocer mejor dichos problemas (AU)

Background and objective Clinicians face a multitude of ethical conflicts in their daily practice. There have been no studies on the types of ethical conflicts encountered most frequently and that are of most concern to clinicians in Spain. The aim of this study is to report the most common ethical conflicts faced by Spanish internists, as well as the importance that the practitioners attribute to each conflict. Materials and Methods Our observational cross-sectional study employed a voluntary and anonymous survey aimed at Spanish medical internists and distributed through an ad hoc platform of the Spanish Society of Internal Medicine. Results The most common and relevant ethical issues for Spanish internists are related to patients’ end of life (decisions limiting therapeutic effort, use of palliative treatments, the establishment of do-not-resuscitate orders), the conflicts arising within the doctor-patient/family relationship, and making decisions with noncompetent patients. These results are similar to those of other English and European series. The ethical problems further complicate the healthcare activity of clinicians who more often notice these problems (50.3%) than those who do not notice them (16%). Conclusions The most common and relevant ethical conflicts among Spanish internists are related to managing patients’ end of life, followed by those related to the doctor-patient relationship and the management of noncompetent patients. It is essential that training programs be designed to better address and recognise these problems (AU)

Do internists know what limitation of therapeutic effort means?

OBJECTIVES: To ascertain whether internists know what limitation of therapeutic effort (LTE) means and whether training in palliative care affects this understanding. METHODS: A survey was administered to Spanish internists on their knowledge of LTE and training in palliative care. RESULTS: A total of 273 respondents completed the survey (mean age, 42±12 years), 80.2% of whom were associates. Some 23.8% of the respondents identified the complete definition of LTE. The most frequently selected responses were "not starting an active treatment" (85.0%) and "withdrawing an active treatment" (65.9%). Forty-three percent of the respondents lacked training in palliative care, 73.3% considered their level of understanding to be good or very good, 62.3% stated that they became anxious when addressing planning for end-of-life care with a patient, and 81.3% stated that they had experienced some conflict with their LTE decisions. CONCLUSIONS: Only 1 of every 4 internists knew the proper definition of LTE, with no association with the level of training in palliative care.

¿Saben los internistas qué es la limitación del esfuerzo terapéutico? / Do internists know what limitation of therapeutic effort means?

Objetivos Averiguar si los internistas saben qué es la limitación del esfuerzo terapéutico (LET) y si la formación en cuidados paliativos condiciona dicho conocimiento. Métodos Encuesta a los internistas españoles sobre el conocimiento de la LET y la formación en cuidados paliativos. Resultados Se recibieron 273 encuestas; edad media de los que respondieron 42±12 años; el 80,2% eran adjuntos. El 23,8% identificó la definición completa de la LET; las opciones más escogidas fueron «no iniciar un tratamiento activo» (85,0%) y «retirar un tratamiento activo» (65,9%). El 43% carece de formación en cuidados paliativos, el 73,3% considera que su nivel de conocimiento es bueno o muy bueno, al 62,3% le genera ansiedad afrontar la planificación de cuidados al final de la vida con el paciente y el 81,3% ha tenido algún conflicto con sus decisiones de la LET. Conclusiones Solo 1 de cada 4internistas conoce bien la definición de la LET, sin asociación con el grado de formación en cuidados paliativos (AU)

Objectives To ascertain whether internists know what limitation of therapeutic effort (LTE) means and whether training in palliative care affects this understanding. Methods A survey was administered to Spanish internists on their knowledge of LTE and training in palliative care. Results A total of 273 respondents completed the survey (mean age, 42±12 years), 80.2% of whom were associates. Some 23.8% of the respondents identified the complete definition of LTE. The most frecuently selected responses were «not starting an active treatment»(85.0%) and «withdrawing an active treatment» (65.9%). Forty-three percent of the respondents lacked training in palliative care, 73.3% considered their level of understanding to be good or very good, 62.3% stated that they became anxious when addressing planning for end-of-life care with a patient, and 81.3% stated that they had experienced some conflict with their LTE decisions. Conclusions Only 1 of every 4 internists knew the proper definition of LTE, with no association with level of training in palliative care (AU)

Which are the most prevalent ethical conflicts for Spanish internists? / ¿Cuáles son los conflictos éticos más frecuentes para los internistas españoles?

BACKGROUND AND OBJECTIVE: Clinicians face a multitude of ethical conflicts in their daily practice. There have been no studies on the types of ethical conflicts encountered most frequently and that are of most concern to clinicians in Spain. The aim of this study is to report the most common ethical conflicts faced by Spanish internists, as well as the importance that the practitioners attribute to each conflict. MATERIALS AND METHODS: Our observational cross-sectional study employed a voluntary and anonymous survey aimed at Spanish medical internists and distributed through an ad hoc platform of the Spanish Society of Internal Medicine. RESULTS: The most common and relevant ethical issues for Spanish internists are related to patients' end of life (decisions limiting therapeutic effort, use of palliative treatments, the establishment of do-not-resuscitate orders), the conflicts arising within the doctor-patient/family relationship, and making decisions with noncompetent patients. These results are similar to those of other English and European series. The ethical problems further complicate the healthcare activity of clinicians who more often notice these problems (50.3%) than those who do not notice them (16%). CONCLUSIONS: The most common and relevant ethical conflicts among Spanish internists are related to managing patients' end of life, followed by those related to the doctor-patient relationship and the management of noncompetent patients. It is essential that training programs be designed to better address and recognise these problems.

Do internists know what limitation of therapeutic effort means? / ¿Saben los internistas qué es la limitación del esfuerzo terapéutico?

OBJECTIVES: To ascertain whether internists know what limitation of therapeutic effort (LTE) means and whether training in palliative care affects this understanding. METHODS: A survey was administered to Spanish internists on their knowledge of LTE and the training in palliative care. RESULTS: A total of 273 respondents completed the survey (mean age, 42±12 years), 80.2% of whom were associates. Some 23.8% of the respondents identified the complete definition of LTE. The most often chosen responses were «not starting an active treatment¼(85.0%) and «withdrawing an active treatment¼ (65.9%). Forty-three percent of the respondents lacked training in palliative care, 73.3% considered their level of understanding to be good or very good, 62.3% stated that they became anxious when addressing the planning for end-of-life care with the patient, and 81.3% stated that they had had some conflict with their LTE decisions. CONCLUSIONS: Only 1 of every 4 internists knew the proper definition for LTE, with no association with the level of training in palliative care.

Valoración de la competencia de los pacientes para tomar decisiones / Assessment of patient competence for making decisions

Para que los enfermos puedan tomar decisiones autónomamente (y que se produzca el consentimiento informado) tiene que haber información, comprensión, libertad y voluntariedad, siendo la competencia un prerrequisito para la autonomía. Los clínicos se enfrentan con frecuencia a pacientes incompetentes para tomar decisiones, pero detectan menos de la mitad de los casos y, además, con frecuencia la evaluación de la competencia no es adecuada. Este artículo ofrece unas pautas para la valoración de la competencia en aquellos pacientes en los que existen dudas sobre si están en condiciones para tomar decisiones sobre su salud. El procedimiento se basa en 5pasos: 1) reconocer las situaciones que requieren una valoración de la competencia; 2) evaluación completa de la competencia; 3) correlacionar el grado de competencia con la complejidad de la decisión a tomar; 4) intentar mejorar la competencia del paciente cuando sea posible, y finalmente 5) establecer quién toma la decisión

For patients to be able to make decisions autonomously (and to grant informed consent), they must have information, understanding, freedom and willingness, with competence a prerequisite for autonomy. Clinicians are often faced with patients lacking competence to make decisions but detect less than half of such cases and often inadequately assess the patients' competence. This article offers guidelines for assessing the competence of patients for whom there are doubts about their ability to make decisions concerning their health. The procedure is based on 5 steps: 1) recognising the conditions that require a competence assessment; 2) fully evaluating the competence; 3) correlating the degree of competence with the complexity of the decision; 4) improving the patient's competence when possible; and 5) establishing who will make the decision

Assessment of patient competence for making decisions. / Valoración de la competencia de los pacientes para tomar decisiones.

For patients to be able to make decisions autonomously (and to grant informed consent), they must have information, understanding, freedom and willingness, with competence a prerequisite for autonomy. Clinicians are often faced with patients lacking competence to make decisions but detect less than half of such cases and often inadequately assess the patients' competence. This article offers guidelines for assessing the competence of patients for whom there are doubts about their ability to make decisions concerning their health. The procedure is based on 5 steps: 1) recognising the conditions that require a competence assessment; 2) fully evaluating the competence; 3) correlating the degree of competence with the complexity of the decision; 4) improving the patient's competence when possible; and 5) establishing who will make the decision.

¿Son éticos los objetivos de gestión para los médicos de nuestros hospitales? / Are the management objectives for hospital physicians ethical?

Los objetivos de gestión, en ocasiones, plantean importantes conflictos de valor, hasta el momento poco estudiados. En el presente artículo se analiza qué cuestiones éticas plantean los objetivos operativos de gestión a los médicos que trabajan en hospitales españoles. Estas cuestiones son las siguientes: 1) en el sistema actual se prima la cantidad sobre la calidad, lo que supone una perspectiva de gestión predominantemente economicista; 2) se trata de un sistema jerarquizado, en el que apenas hay participación y en el que los clínicos carecen de capacidad decisoria y 3) los objetivos se centran en actividades desfasadas respecto a la realidad del sistema sanitario actual, por lo que deben ser actualizados considerando, por ejemplo, la cronicidad o la continuidad asistencial. Al analizar estas cuestiones, se realiza una propuesta de elaboración de los objetivos de gestión basada en 3 aspectos: priorizar la calidad asistencial (lo que finalmente repercute en una gestión eficiente), elaborar los objetivos de forma participativa y mixta (con objetivos colectivos e individuales) y diseñar nuevos objetivos acordes con la realidad del actual sistema sanitario. No es complicado poner en práctica esta propuesta, ya que la meta final de los clínicos y de la gerencia es la de proporcionar una asistencia sanitaria óptima

Management objectives at times create significant value conflicts that have so far been seldom studied. This article analyses the ethical issues created by the operational objectives of management for physicians who work in Spanish hospitals. These issues are as follows: 1) the current system places quantity above quality, which represents a predominantly economist management perspective; 2) the system is hierarchical, lacks participation and deprives clinicians of decision-making authority; 3) the objectives are focused on outdated activities in terms of the current reality of the healthcare system and should therefore be updated considering, for example, chronicity and the continuity of care. After analysing these issues, we created a proposal for developing management objectives based on prioritising quality care (which ultimately results in efficient management), developing objectives in a participatory and mixed manner (with group and individual objectives) and designing new objectives in keeping with the current reality of the healthcare system. Putting this proposal into practice is not complicated because the final goal of clinicians and management is to provide optimal health care

Are the management objectives for hospital physicians ethical? / ¿Son éticos los objetivos de gestión para los médicos de nuestros hospitales?

Management objectives at times create significant value conflicts that have so far been seldom studied. This article analyses the ethical issues created by the operational objectives of management for physicians who work in Spanish hospitals. These issues are as follows: 1) the current system places quantity above quality, which represents a predominantly economist management perspective; 2) the system is hierarchical, lacks participation and deprives clinicians of decision-making authority; 3) the objectives are focused on outdated activities in terms of the current reality of the healthcare system and should therefore be updated considering, for example, chronicity and the continuity of care. After analysing these issues, we created a proposal for developing management objectives based on prioritising quality care (which ultimately results in efficient management), developing objectives in a participatory and mixed manner (with group and individual objectives) and designing new objectives in keeping with the current reality of the healthcare system. Putting this proposal into practice is not complicated because the final goal of clinicians and management is to provide optimal health care.

[Javier Sádaba: A bioethics against suffering]. / Javier Sádaba: una bioética contra el sufrimiento.

The philosopher Javier Sádaba (Portugalete, 1940) is the author of an extensive work in the field of bioethics. It is a procedural bioethics (based on the agreement between the participants, not on absolute truths), casuistry (is based on the analysis of specific problem cases), social (evaluates the context in decision-making), gradual (considers other species, is not "narcissistically human"), and secular (autonomous with respect to religion). Sádaba has also opted for an affirmative bioethics, which seeks to improve the living conditions of humans (in medicine, the quality of life). This is difficult to construct because, for the philosopher, the duty and to establish limits are infinitely easier to elaborate than the specific good and to pursue happiness. In its application to medicine, Sádaba's bioethics focuses on avoiding unnecessary suffering, because suffering does not contribute anything positive and hinders happiness. Likewise, he strives to extract the best of science and open the doors to everything that can bring improvements for the human being, but without ceasing to mention responsibility, because man is capable of the best and the worst. From this perspective, the author is faced with the bioethical issues, leaving the greatest possible margin to freedom of choice.

Limitación del esfuerzo terapéutico en pacientes hospitalizados en servicios de medicina interna / Limitation of therapeutic effort in patients hospitalised in departments of internal medicine

Introducción. Existe escasa información sobre la limitación del esfuerzo terapéutico (LET) en pacientes ingresados en unidades de hospitalización de medicina interna. Objetivos. Describir las pautas de LET indicadas en los servicios de medicina interna y las características de los pacientes que las reciben. Pacientes y métodos. Estudio observacional descriptivo y retrospectivo de 4 hospitales de la Comunidad de Madrid. Se recogieron datos demográficos, de comorbilidad y las órdenes de LET pautadas en todos los pacientes fallecidos en un periodo de 6 meses. Resultados. Se incluyeron 382 pacientes cuya edad media fue de 85±10 años; 204 eran mujeres (53,4%) y 222 (58,1%) procedían de su domicilio. El 51,1% eran enfermos terminales, el 43,2% tenían demencia moderada/grave y el 95,5% presentaban comorbilidad al menos moderada. En 318 pacientes (83,7%) se realizó algún tipo de LET, siendo las más frecuentes las órdenes de «no reanimación cardiopulmonar» (292 enfermos, 76,4%; IC 95%: 72,1-80,8), «no usar medidas agresivas» (113 pacientes, 16,4%; IC 95%: 13,7-19,4) y «no ingresar en unidad de cuidados intensivos» (102 casos, 14,8%; IC 95%: 12,3-17,7). Conclusiones. La LET es muy frecuente en los pacientes que fallecen en medicina interna. Las pautas más utilizadas son «no reanimación cardiopulmonar» y la expresión poco concreta de «no usar medidas agresivas». Los pacientes son de edad avanzada, con importante comorbilidad, enfermedad terminal y demencia avanzada (AU)

Introduction. There is little information on the limitation of therapeutic effort (LTE) in patients admitted to hospital internal medicine units. Objectives. To describe the indicated LTE regimens in the departments of internal medicine and the characteristics of the patients who undergo them. Patients and methods. An observational, descriptive retrospective study was conducted on 4 hospitals of the Community of Madrid. The study collected demographic and comorbidity data and the LTE orders prescribed for all patients who died during a period of 6 months. Results. The study included 382 patients with a mean age of 85±10 years; 204 were women (53.4%) and 222 (58.1%) came from their homes. Some 51.1% of the patients were terminal, 43.2% had moderate to severe dementia, and 95.5% presented at least moderate comorbidity. Some type of LTE was performed in 318 patients (83.7%); the most common orders were «No cardiopulmonary resuscitation» (292 patients, 76.4%; 95% CI 72.1-80.8), «Do not use aggressive measures» (113 patients, 16.4%; 95% CI 13.7-19.4) and «Do not transfer to an intensive care unit» (102 cases, 14.8%, 95% CI 12.3-17.7). Some type of LTE was performed in 318 patients (83.7%); the most common orders were «No cardiopulmonary resuscitation» (292 patients, 76.4%; 95% CI 72.1-80.8), «Do not use aggressive measures» (113 patients, 16.4%; 95% CI 13.7-19.4) and «Do not transfer to an intensive care unit» (102 cases, 14.8%, 95% CI 12.3-17.7). Conclusions. LTE is common among patients who die in Internal Medicine. The most widely used regimens were «No CPR» and the unspecific statement «Do not use aggressive measures». The patients were elderly and had significant comorbidity, terminal illness and advanced dementia (AU)

[Are we still our patients' keepers?: James Drane's contribution to clinical ethics in the current context]. / ¿Seguimos siendo guardianes de nuestros pacientes?: la contribución de James Drane a la ética clínica actual.

The current article analyzes the figure of the American bioethicist James Drane (1930). Drane not only played a crucial role in the birth of Bioethics in the United States, but was also instrumental in the inception and development of the field in Spain and Latin America. His «sliding scale¼ was the first dynamic tool encouraging a systematic evaluation of a patient's capacity to make healthcare-related decisions. However Drane's major contribution to the field was his application of virtue Ethics to the doctor-patient relationship. His proposal rests on the physician's compromise with the patient in all his/her dimensions. This goal will guide the physician's character and serve as compass, with which to exercise a virtuous practice, since only by exercising these virtues can doctors become truly good.