[Maternal and Child Health and Perinatal Mental Health: an area of improvement in Spanish Healthcare]. / Salud materno-infantil y salud mental perinatal: un ámbito de mejora en la sanidad española.

Although the right to enjoy the highest level of mental and physical health that can be achieved is a universal human right, it has not been until very recent stages that mental health has begun to gain the relevance it deserves . Attention to maternal and child health exemplifies the limitations of the Spanish Health Service to offer comprehensive care that includes the dimension of mental health. For years, the main objective has been to combat preventable maternal mortality, practically eradicated in our country thanks to its health benefits . However, the enjoyment of health cannot be limited to achieving the survival of mothers and their babies, and good maternal health necessarily implies good perinatal mental health.

Aunque el derecho al goce del más alto nivel de salud mental y física que se pueda lograr es un derecho humano universal, no ha sido hasta etapas muy recientes que la salud mental ha empezado a cobrar la relevancia que merece . La atención a la salud materno-infantil ejemplifica las limitaciones de la Sanidad española para ofrecer una atención integral que incluya la dimensión de la salud mental. Durante años, el objetivo principal ha sido combatir la mortalidad materna prevenible, prácticamente erradicada en nuestro país gracias a sus prestaciones sanitarias . Sin embargo, el disfrute de la salud no puede limitarse a lograr la supervivencia de las madres y de sus bebés, y una buena salud materna implica, necesariamente, una buena salud mental perinatal.

Agreement between the perception of colon cleansing reported by patients and colon cleansing assessed by a validated colon cleansing scale / Concordancia entre la percepción de limpieza colónica referida por los pacientes y la limpieza colónica evaluada mediante una escala de limpieza validada

Aims Patients’ perception of their cleansing quality can guide strategies to improve cleansing during colonoscopy. There are no studies assessing the agreement between the quality of cleansing perceived by patients and cleansing quality assessed during colonoscopy using validated bowel preparation scales. The main aim of this study was to compare the cleansing quality reported by patients with the quality during colonoscopy using the Boston Bowel Preparation Scale (BBPS). Patients and methods Consecutive patients referred to an outpatient colonoscopy were included. Four drawings representing different degrees of cleansing were designed. Patients chose the drawing that most resembled the last stool. The predictive ability of the patient's perception and agreement between the patient's perception and the BBPS were calculated. A BBPS score of <2 points in any segment was considered inadequate. Results Six hundred and thirty-three patients were included (age: 62.8 ± 13.7 years, male: 53.4%). Overall, 107 patients (16.9%) had inadequate cleansing during colonoscopy, and in 12.2% of cases, the patient's perception was poor. The patient's perception compared to the quality of cleanliness during colonoscopy presented a positive and negative predictive value of 54.6% and 88.3%, respectively. The agreement between patient perception and the BBPS was significant (P < 0.001), although fair (k = 0.37). The results were similar in a validation cohort of 378 patients (k = 0.41). Conclusions The cleanliness perceived by the patient and the quality of cleanliness using a validated scale were correlated, although fair. However, this measure satisfactorily identified patients with adequate preparation. Cleansing rescue strategies may target patients who self-report improper cleaning (AU)

Objetivos La percepción de los pacientes sobre su calidad de limpieza previa a la colonoscopia puede guiar estrategias de rescate para mejorar la limpieza durante la colonoscopia. El objetivo fue evaluar la concordancia entre la calidad de limpieza percibida por los pacientes con la calidad durante la colonoscopia utilizando la escala de preparación colónica de Boston (BBPS). Pacientes y métodos Se incluyeron pacientes consecutivos remitidos a una colonoscopia ambulatoria. Se diseñó un set de 4 imágenes representativas de diferentes grados de limpieza. Los pacientes elegían la imagen que se asemejaba más a la última deposición. Se calculó la concordancia entre la percepción del paciente y la BBPS. Una puntuación de la BBPS < 2 puntos en cualquier segmento se consideró una limpieza inadecuada. Resultados Se incluyeron 633 pacientes. Globalmente, 107 pacientes (16,9%) presentaron una limpieza inadecuada durante la colonoscopia, y en el 12,2% de los casos, la percepción del paciente fue de limpieza inadecuada. La percepción del paciente presentó un valor predictivo positivo y negativo de 54,6 y 88,3%, respectivamente, para predecir la calidad de limpieza mediante la BBPS. La concordancia entre la percepción del paciente y la BBPS fue significativa (p < 0,001), aunque aceptable (k = 0,37). Los resultados fueron similares en una cohorte de validación de 378 pacientes (k = 0,41). Conclusiones Existe concordancia entre la limpieza percibida por el paciente y la calidad de la limpieza mediante una escala validada, aunque esta fue aceptable. Estos resultados sustentan el uso de estrategias de rescate en los pacientes con percepción de una limpieza colónica inadecuada (AU)

Agreement between the perception of colon cleansing reported by patients and colon cleansing assessed by a validated colon cleansing scale.

AIMS: Patients' perception of their cleansing quality can guide strategies to improve cleansing during colonoscopy. There are no studies assessing the agreement between the quality of cleansing perceived by patients and cleansing quality assessed during colonoscopy using validated bowel preparation scales. The main aim of this study was to compare the cleansing quality reported by patients with the quality during colonoscopy using the Boston Bowel Preparation Scale (BBPS). PATIENTS AND METHODS: Consecutive patients referred to an outpatient colonoscopy were included. Four drawings representing different degrees of cleansing were designed. Patients chose the drawing that most resembled the last stool. The predictive ability of the patient's perception and agreement between the patient's perception and the BBPS were calculated. A BBPS score of <2 points in any segment was considered inadequate. RESULTS: Six hundred and thirty-three patients were included (age: 62.8±13.7 years, male: 53.4%). Overall, 107 patients (16.9%) had inadequate cleansing during colonoscopy, and in 12.2% of cases, the patient's perception was poor. The patient's perception compared to the quality of cleanliness during colonoscopy presented a positive and negative predictive value of 54.6% and 88.3%, respectively. The agreement between patient perception and the BBPS was significant (P<0.001), although fair (k=0.37). The results were similar in a validation cohort of 378 patients (k=0.41). CONCLUSIONS: The cleanliness perceived by the patient and the quality of cleanliness using a validated scale were correlated, although fair. However, this measure satisfactorily identified patients with adequate preparation. Cleansing rescue strategies may target patients who self-report improper cleaning. Registration number of the trial: NCT03830489.

Design and validation of an artificial intelligence system to detect the quality of colon cleansing before colonoscopy.

BACKGROUND AND AIMS: Patients' perception of their bowel cleansing quality may guide rescue cleansing strategies before colonoscopy. The main aim of this study was to train and validate a convolutional neural network (CNN) for classifying rectal effluent during bowel preparation intake as "adequate" or "inadequate" cleansing before colonoscopy. PATIENTS AND METHODS: Patients referred for outpatient colonoscopy were asked to provide images of their rectal effluent during the bowel preparation process. The images were categorized as adequate or inadequate cleansing based on a predefined 4-picture quality scale. A total of 1203 images were collected from 660 patients. The initial dataset (799 images), was split into a training set (80%) and a validation set (20%). The second dataset (404 images) was used to develop a second test of the CNN accuracy. Afterward, CNN prediction was prospectively compared with the Boston Bowel Preparation Scale (BBPS) in 200 additional patients who provided a picture of their last rectal effluent. RESULTS: On the initial dataset, a global accuracy of 97.49%, a sensitivity of 98.17% and a specificity of 96.66% were obtained using the CNN model. On the second dataset, an accuracy of 95%, a sensitivity of 99.60% and a specificity of 87.41% were obtained. The results from the CNN model were significantly associated with those from the BBPS (P<0.001), and 77.78% of the patients with poor bowel preparation were correctly classified. CONCLUSION: The designed CNN is capable of classifying "adequate cleansing" and "inadequate cleansing" images with high accuracy.

Salud Mental Perinatal y Reproducción Asistida por Ovodonación: un análisis de la situación actual en España / Perinatal Mental Health and Assisted Reproduction by Oocyte donation: an analysis of the current situation in Spain

Introducción: El número de mujeres que recurren a la ovodonación para lograr la maternidad biológica es cada vez mayor. Esta técnica puede generar conflictos y problemas emocionales en las mujeres que reciben óvulos donados. Se analiza el contexto social, asistencial y legal de la ovodonación en España, así como el papel de la atención de sus dificultades emocionales específicas en Unidades especializadas en Salud Mental Perinatal.Metodología: revisión bibliográfica de la jurisprudencia española y literatura científica especializada en Salud Mental Perinatal.Desarrollo: España es un país líder mundial en número de ovodonaciones, debido a su flexible legislación en materia de reproducción humana, el anonimato legal de las donantes de óvulos y la compensación económica que se ofrece a las mismas. La mayor parte de estos procedimientos se realizan en la red privada, por lo que muchas mujeres no tienen acceso a las Unidades de Salud Mental Perinatal de los sistemas públicos de salud, a pesar de que, en el caso de la ovodonación, la derivación se debe realizar por protocolo. Las mujeres que se plantean la ovodonación presentan con frecuencia sintomatología ansiosa, depresiva y postraumática que debe ser tratada por profesionales especializados. Además, la consulta de Perinatal ofrece un lugar de trabajo terapéutico sobre las cuatro áreas fundamentales de conflicto que pueden sufrir estas mujeres: la maternidad y el duelo genético, el vínculo madre-bebé, la revelación de su origen a las hijas o hijos, y los conflictos éticos.Conclusiones: El retraso de la edad materna y la efectividad de la ovodonación están aumentando el número de mujeres que recurren a la misma. Su asistencia integral debe incluir la atención a las dificultades emocionales que puedan presentar en Unidades de Salud Mental Perinatal. (AU)

Introduction: The number of women who resort to oocyte donation to achieve biological motherhood is constantly increasing. This technique may cause certain conflicts and emotional problems in the women who receive donated oocytes. In this paper, we analyze not only Spain’s oocyte donation social context, but also the healthcare and legal contexts involved. In addition to this, we study the role had by their specific emotional difficulties cared for in specialized Perinatal Mental Health Units.Methodology: A bibliographic review of Spanish jurisprudence and scientific literature specialized in Perinatal Mental Health.Development: Spain is one of the world’s leaders in the number of oocyte donations, due to its flexible legislation on human reproduction, the legal anonymity of oocyte donors and the financial compensa-tions offered to them. These procedures are mostly performed in the private healthcare network, which means that most of the women do not have access to the public health systems’ Perinatal Mental Health Units. However, it must be stressed that in the case of assisted reproduction by oocyte donation, the referral to a perinatal Mental Health unit is required by medical protocol. Women who consider oocyte donation frequently present anxious, depressive and post-traumatic symptoms that must be treated by specialized professionals. In addition to this, the Perinatal Mental Health Units offer a place for therapeutic work on the four fundamental areas of conflict that these women may suffer: motherhood and genetic mourning, the mother-baby bonding process, the disclosure of their origin to their daughters or sons, as well as the ethical conflicts they face. Conclusions: The delay in maternal age and the effectiveness of oocyte donation are leading to an increase in the number of women who resort to it. Their comprehensive assistance must include the due care of the emotional difficulties they may present in Perinatal Mental Health Units. (AU)

Trastorno del espectro autista en menores con superdotación intelectual: descripción de un diagnóstico complejo / Autism Spectrum Disorder among intellectually gifted minors: Description of a complex diagnosis

Introducción: Se pretende analizar las características clínicas de menores con superdotación intelectual y autismo, planteando que la identificación temprana de superdotación no se acompaña de un diagnóstico temprano de TEA.Material y métodosAnálisis descriptivo de una muestra de pacientes (n=8) de 7 a 16 años, con Altas Capacidades identificadas, derivados a una consulta específica de autismo infantil para evaluación diagnóstica.Resultados6 de los pacientes recibieron diagnóstico clínico de TEA. Solo 3 de los pacientes superaron el punto de corte de espectro autista en la evaluación ADOS-2. La edad media de detección de Altas Capacidades fue de 5,88 años, y la de TEA fue de 9,83 años, transcurriendo un tiempo medio de 4,83 años. Todos habían sido evaluados en Servicios de Salud Mental, y 7 habían recibido, al menos, un diagnóstico psiquiátrico previo, así como tratamiento psicofarmacológico.DiscusiónPosiblemente, la superposición de características clínicas de las Altas Capacidades con los síntomas TEA retrase el diagnóstico del segundo cuando se han detectado las primeras, tanto por un fenómeno de enmascaramiento, como por un sesgo de atribución, debido a que la categoría de Altas Capacidades sea mejor aceptada. El deterioro clínicamente significativo de estos pacientes parece agravarse en la adolescencia. La conceptualización incompleta de la neurodivergencia podría estar dificultando a los profesionales clínicos la identificación y clasificación de menores con neurodesarrollos atípicos.ConclusionesLa identificación de una superdotación podría retrasar el diagnóstico de TEA. Se debe ampliar la investigación sobre neurodesarrollo y neurodiversidad, la inteligencia y su relación con el TEA. Es imprescindible la formación específica en neurodesarrollo de psiquiatras infanto-juveniles. (AU)

Introduction: We intend to analyze the clinical characteristics of intellectually gifted minors with autism spectrum disorder (ASD), stating that early identification of giftedness is not linked to an early ASD diagnosis.Material and methodDescriptive analysis in a sample of n=8 patients ages 7 to 16, with identified giftedness refered to a medical consultation specialized in infantile autism for a diagnostic evaluation.Results6 of the latter referred patients received an ASD clinical diagnosis. Only 3 of the patients were above the cut-off point for autism spectrum on the ADOS-2 evaluation. The average age of detection was 5’88 for Giftedness and 9’83 for ASD, with an average time of 4’83 years elapsed in between. All of them had been previously evaluated in Mental Health Services and 7 had received at least one previous psychiatric diagnosis, as well as psycho-pharmacological treatment.DiscussionIt is possible that the superimposition between the clinical characteristics of Giftedness and ASD symptoms may delay the latter’s diagnosis when the previous have been detected, be it due to a masking phenomenon, an attribution bias, or that the Giftedness category is better accepted. This patients significant clinical deterioration seems to worsen during adolescence. The uncompleted conceptualization of neuro-divergence may be hampering the clinicians ability to identify and classify minors with an atypical neurodevelopment.ConclusionsGiftedness identification may delay ASD diagnosis. We must improve investigation about neuro-development and neuro-diversity, as well as intelligence and its connection to ASD. Child and Adolescent psychiatrists’ specific training in neuro-development is therefore essential. (AU)

¿Mantenimiento o retirada? Pericarditis en un paciente en tratamiento con clozapina: a propósito de un caso / To persist or to withdraw? Pericarditis in a patient undergoing treatment with clozapine: report of a clinical case

Introducción: La pericarditis inducida por clozapina es un cuadro raro, pero potencialmente grave para cuya resolución se recomienda la discontinuación del tratamiento con clozapina. Presentación del caso Se trata de un varón de 17 años en tratamiento con clozapina por el fracaso de 3 líneas antipsicóticas previas, con una buena respuesta terapéutica, que 2 meses después del inicio del fármaco desarrolla un cuadro de pericarditis. En la evaluación multidisciplinar, se decide conjuntamente con la familia el tratamiento de la pericarditis, manteniendo clozapina en dosis menores, con la resolución de la misma y conservando la estabilidad psicopatológica. Discusión La miocarditis y pericarditis inducidas por clozapina son efectos adversos graves que aparecen en su mayoría en el primer mes de tratamiento. La actitud generalizada frente a la pericarditis inducida por clozapina es su retirada. Esta retirada puede plantear un dilema ético y debe ser valorada cuidadosamente, ya que el riesgo de descompensación psiquiátrica y pérdida de la calidad de vida debe ser tenido en cuenta. Conclusión Este caso resalta la importancia de realizar un balance riesgo/beneficio en cada caso complejo, reflejando la encrucijada ética del manejo de los efectos adversos de clozapina, puesto que su retirada puede comprometer negativamente la estabilidad psicopatológica y la calidad de vida del paciente. (AU)

Introduction: Clozapine-induced pericarditis is a rare but potentially serious condition for which discontinuation of clozapine treatment is recommended for resolution. Presentation of the case A 17-year-old male under treatment with clozapine due to failure of three previous antipsychotic lines, with good therapeutic response, who two months after starting the drug developed pericarditis. Discussion Clozapine-induced myocarditis and pericarditis are serious adverse effects that appear mostly in the first month of treatment. The generalized attitude towards clozapine-induced pericarditis is its withdrawal. This withdrawal may pose an ethical dilemma and should be carefully assessed, as the risk of psychiatric decompensation and loss of quality of life should be taken into account. Conclusion This case highlights the importance of performing a risk/benefit balance in each complex case, reflecting the ethical conflict of the management of clozapine adverse effects, since its withdrawal may negatively compromise the patient's psychopathological stability and quality of life. (AU)

An Enhanced High-Volume Preparation for Colonoscopy Is Not Better Than a Conventional Low-Volume One in Patients at Risk of Poor Bowel Cleansing: A Randomized Controlled Trial.

Objective: We tested the hypothesis that an enhanced bowel preparation strategy (EBS) improves colonic cleansing in patients at high risk for inadequate bowel cleansing (HRI). Methods: This prospective randomized clinical trial included consecutive HRI patients referred for outpatient colonoscopy between February and October 2019. HRI was considered if patients scored >1.225 according to a previously validated bowel-cleansing predictive score. HRI patients were randomized (1:1) to a low-volume conventional bowel cleansing strategy (CBS) (1-day low residue diet (LRD) plus 2 L of polyethylene glycol (PEG) plus ascorbic acid) or to an EBS (3-day LRD plus 10 mg oral bisacodyl plus 4 L PEG). The Boston Bowel Preparation Scale (BBPS) was used to assess the quality of cleanliness. Intention-to-treat (ITT) and per protocol (PP) analyses were performed. A sample size of 130 patients per group was estimated to reach a 15% difference in favor of EBP. Results: A total of 253 HRI patients were included (mean age 69.8 ± 9.5 years, 51.8% women). No statistically significant differences were found in the BBPS scale between the two groups in the ITT analysis (CBS 76.8% vs. EBS 79.7%, P = 0.58) or PP analysis (CBS 78% vs. EBS 84.3%, P = 0.21), risk difference 2.9% (95% CI-7.26 to 39.16) in the ITT analysis, or risk difference 6.3% (95% CI-3.48 to 16.08) in PP analysis. No differences in preparation tolerance, compliance, adverse effects, or colonoscopy findings were found. Conclusion: EBS is not superior to CBS in hard-to-prepare patients. (EUDRACT: 2017-000787-15, NCT03830489). Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03830489.

Maternidad e identidad materna: deconstrucción terapéutica de narrativas / Maternity and maternal identity: therapeutic deconstruction of narratives

La identidad se construye en la infancia mediante la interacción entre el sujeto y el ambiente, y se va transformando a lo largo de la vida en función de las experiencias del individuo, las relaciones interpersonales y los discursos culturales predominantes. Históricamente, un constructo de repercusión fundamental en la generación de la identidad ha sido el concepto binario de género masculino/femenino, que suponía la asignación de roles sociales diferenciados a hombres y mujeres. En la mujer, la maternidad implica el nacimiento de una nueva identidad a menudo ligada a narrativas rígidas respecto a la “buena madre,” heredadas de los modelos de socialización tradicionales y patriarcales, que entran en conflicto con otros discursos de realización personal. Las dificultades para adecuar las propias decisiones a la narrativa de la “buena madre” generan síntomas de ansiedad, impotencia y frustración en las mujeres, y han propiciado un importante debate social con opiniones encontradas respecto a los modelos de crianza y cuidados de los hijos. En esta revisión, se propone una guía de exploración y abordaje terapéutico narrativo para ayudar a las mujeres que atendemos en la consulta a cuestionar los discursos sociales que les provocan malestar emocional y validar su toma de decisiones respecto a las distintas formas de crianza y maternidad. (AU)

Identity is built during childhood through the interaction of subjects with their environment and circumstances, and is subsequently modified during their lifetime depending on their different individual experiences, the interpersonal relationships they establish, and the predominant cultural discourse. Historically, we can define the binary concept of “gender”, male/female, as a fundamental factor of identity building that assigns very different social roles to different individuals depending on them being categorized as male or female. To women, maternity implies the birth of a new identity, which is traditionally linked to fairly strong pre-established cultural narratives about what a “good mother” is. This is, in turn, related to the traditional patterns of socialisation, which may spark a conflict against other cultural discourses centred around personal fulfilment. The difficulties that arise when trying to accommodate their self-decisions to the “good mother” narrative may generate anxiety symptoms, a sense of helplessness, and frustration among women. This struggle has propitiated and encouraged an important social debate with very opposing views about child rearing, nurturing, and care. In this revision paper, we propose a guide for exploration and management based on narrative therapy to help women we assist in our medical practice to question the social discourses that generate such emotional uneasiness and to validate their own decisions regarding the different approaches to child-bearing and rearing. (AU)

Efectos de la bromocriptina sobre la apetencia cocaínica bajo un modelo de doble alternativa de elección en animales / Efects of the bromocriptine on appetite cocaine

Empleando un modelo de doble alternativa de elección: droga VS. alimento en perros sometidos a un cocainismo experimental, se encuentra que los animales tienden a elegir la droga a pesar de la administración de bromocriptina. Los resultados obtenidos viabilizan la propuesta de una prevalencia del condicionamiento clásico de señales en la instauración de la adicción cocaínica, al cual estaría asociado un condicionamiento operante de señales para el mantenimiento del comportamiento adictivo