[Position of the international forum of internal medicine on habits, lifestyle changes and a healthy environment for the prevention of cardiovascular diseases]. / Posicionamiento del foro Internacional de Medicina Interna sobre Hábitos, modificaciones del Estilo de Vida y Ambiente Saludable para la Prevención de Enfermedades Cardiovasculares.

Cardiovascular diseases (CVD), mainly ischemic heart disease and stroke, is the main cause of death worldwide and each year more people die from CVD than from any other cause. These data call for a paradigm shift, where health promotion and cardiovascular prevention will acquire a central role in health policies. From this perspective, dedicating time during the consultation to promoting the acquisition of heart-healthy habits would be indicated in all individuals, regardless of cardiovascular risk classification, the role of the internist being fundamental. This position document from the International Forum of Internal Medicine (FIMI) presents the main indications regarding changes in lifestyle and acquisition of healthy habits to prevent CVD. The different sections will address topics including: nutrition, physical activity, sedentary lifestyle, obesity, smoking, alcohol consumption, sleep, stress, environmental problems related to CVD and specific conditions in women. A section is included about starting CVD promotion and prevention measures at an early age, childhood and adolescence, also mentioning epigenetic aspects related to CVD. Social determinants in CVD are also taken into account, since some of these aspects, such as low socioeconomic level, modify cardiovascular risk and should be taken into account.

Las enfermedades cardiovasculares (ECV), principalmente la cardiopatía isquémica y el accidente cerebrovascular (ACV), constituyen la principal causa de muerte a nivel mundial y cada año mueren más personas por ECV que por cualquier otra causa. Estos datos requieren la necesidad de un cambio de paradigma, en donde la promoción de la salud y la prevención cardiovascular adquieran un papel central en las políticas sanitarias. Desde esta perspectiva, dedicar tiempo durante la consulta en promocionar la adquisición de hábitos cardiosaludables estaría indicado en todos los individuos, independientemente de la clasificación de riesgo cardiovascular, siendo fundamental el rol del médico internista en su función de médico de cabecera. En este documento de posicionamiento del Foro Internacional de Medicina Interna (FIMI) se presentan algunas pautas para recomendar e indicar modificaciones en el estilo de vida y adquisición de hábitos saludables para prevenir la ECV, que tienen el objetivo de ser una herramienta practica para el médico internista. Las diferentes secciones abordaran temas que incluyen: nutrición, actividad física, sedentarismo, obesidad, hábito tabáquico, consumo de alcohol, sueño, estrés, problemas ambientales relacionados a la ECV y condiciones específicas en la mujer. Se incluyó un apartado acerca de comenzar las medidas de promoción y prevención de ECV en edades tempranas, infancia y adolescencia, mencionando además aspectos epigenéticos relacionados a la ECV. Se tienen en cuenta además los determinantes sociales en ECV, ya que algunos de estos aspectos, como el bajo nivel socioeconómico, modifican el riesgo cardiovascular y debieran ser tenidos en cuenta.

Position of the international forum of internal medicine on habits, lifestyle changes and a healthy environment for the prevention of cardiovascular diseases.

Cardiovascular diseases (CVD), mainly ischemic heart disease and stroke, is the main cause of death worldwide and each year more people die from CVD than from any other cause. These data call for a paradigm shift, where health promotion and cardiovascular prevention will acquire a central role in health policies. From this perspective, dedicating time during the consultation to promoting the acquisition of heart-healthy habits would be indicated in all individuals, regardless of cardiovascular risk classification, the role of the internist being fundamental. This position document from the International Forum of Internal Medicine (FIMI) presents the main indications regarding changes in lifestyle and acquisition of healthy habits to prevent CVD. The different sections will address topics including: nutrition, physical activity, sedentary lifestyle, obesity, smoking, alcohol consumption, sleep, stress, environmental problems related to CVD and specific conditions in women. A section is included about starting CVD promotion and prevention measures at an early age, childhood and adolescence, also mentioning epigenetic aspects related to CVD. Social determinants in CVD are also taken into account, since some of these aspects, such as low socioeconomic level, modify cardiovascular risk and should be taken into account.

Las enfermedades cardiovasculares (ECV), principalmente la cardiopatía isquémica y el accidente cerebrovascular (ACV), constituyen la principal causa de muerte a nivel mundial y cada año mueren más personas por ECV que por cualquier otra causa. Estos datos requieren la necesidad de un cambio de paradigma, en donde la promoción de la salud y la prevención cardiovascular adquieran un papel central en las políticas sanitarias. Desde esta perspectiva, dedicar tiempo durante la consulta en promocionar la adquisición de hábitos cardiosaludables estaría indicado en todos los individuos, independientemente de la clasificación de riesgo cardiovascular, siendo fundamental el rol del médico internista en su función de médico de cabecera. En este documento de posicionamiento del Foro Internacional de Medicina Interna (FIMI) se presentan algunas pautas para recomendar e indicar modificaciones en el estilo de vida y adquisición de hábitos saludables para prevenir la ECV, que tienen el objetivo de ser una herramienta practica para el médico internista. Las diferentes secciones abordaran temas que incluyen: nutrición, actividad física, sedentarismo, obesidad, hábito tabáquico, consumo de alcohol, sueño, estrés, problemas ambientales relacionados a la ECV y condiciones específicas en la mujer. Se incluyó un apartado acerca de comenzar las medidas de promoción y prevención de ECV en edades tempranas, infancia y adolescencia, mencionando además aspectos epigenéticos relacionados a la ECV. Se tienen en cuenta además los determinantes sociales en ECV, ya que algunos de estos aspectos, como el bajo nivel socioeconómico, modifican el riesgo cardiovascular y debieran ser tenidos en cuenta.

The social return on investment of a new approach to heart failure in the Spanish National Health System.

AIMS: We aim to agree on a set of proposals to improve the current management of heart failure (HF) within the Spanish National Health System (SNHS) and apply the social return on investment (SROI) method to measure the social impact that these proposals would generate. METHODS AND RESULTS: A multidisciplinary working team of 16 experts was set up, with representation from the main stakeholders regarding HF: medical specialists (cardiologists, internal medicine physicians, general practitioners, and geriatric physicians), nursing professionals, health management professionals, patients, and informal caregivers. This team established a set of proposals to improve the management of HF according to the main areas of HF care: emergency and hospitalization, primary care, cardiology, and internal medicine. A forecast-type SROI method, with a 1-year time frame, was applied to measure the social impact resulting from the implementation of these proposals. The required investment and social return were estimated and summarized into a ratio indicating how much social return could be generated for each euro invested. Intangible returns were included and quantified through financial proxies. The approach to improve the management of HF consisted of 28 proposals, including the implementation of a case management nurse network, standardization of operational protocols, psychological support, availability of echocardiography machines at emergency departments, stationary units and primary care, early specialist visits after hospital discharge, and cardiac rehabilitation units, among others. These proposals would benefit not only patients and their informal caregivers but also the SNHS. Regarding patients, proposals would increase their autonomy in everyday activities, decrease anxiety, increase psychological and physical well-being, improve pharmacological adherence and self-care, enhance understanding of the disease, delay disease progression, expedite medical assessment, and prevent the decrease in work productivity associated with HF management. Regarding informal caregivers, proposals would increase their quality of life; improve their social, economic, and emotional well-being; and reduce their care burden. The SNHS would benefit from shorter stays of HF patients at intensive care units and reduction of hospitalizations and admissions to emergency departments. The investment needed to implement these proposals would amount to €548m and yield a social return of €1932m, that is, €3.52 for each euro invested. CONCLUSIONS: The current management of HF could be improved by a set of proposals that resulted in an overall positive social return, varying between areas of analysis. This may guide the allocation of healthcare resources and improve the quality of life of patients with HF.

OPENCRONIC Study. Knowledge and Experiences of Spanish Patients and Carers about Chronic Disease.

Background: Chronic diseases are currently the main cause of morbidity and mortality and represent a major challenge to healthcare systems. The objective of this study is to know Spanish public opinion about chronic disease and how it affects their daily lives. Methods: Through a telephone or online survey of 24 questions, data was gathered on the characteristics of the respondents and their knowledge and experiences of chronic diseases. Results: Of the 2522 survey respondents, 325 had a chronic disease and were carers, 1088 had a chronic disease and were not carers, 140 did not have a chronic disease but were carers, and 969 did not have chronic disease and were not carers. The degree of knowledge on these diseases was good or very good for 69.4%, 56.0%, 62.2%, and 46.7%, respectively, for each group. All the groups agreed that chronic diseases mainly affect mood, quality of life and having to make sacrifices. Conclusions: Knowledge about chronic diseases is relatively good, although it can be improved among the Spanish population, especially among patients who report having a chronic disease and play the role of carers. However, it is important to continue maintaining the level of information and training concerning these diseases.

Management of patients with type 2 diabetes and multiple chronic conditions: A Delphi consensus of the Spanish Society of Internal Medicine.

AIMS: To develop consensus-based recommendations for the management of chronic complex patients with type 2 diabetes mellitus using a two round Delphi technique. METHODS: Experts from the Diabetes and Obesity Working Group (DOWG) of the Spanish Society of Internal Medicine (SEMI) reviewed MEDLINE, PubMed, SCOPUS and Cochrane Library databases up to September 2014 to gather information on organization and health care management, stratification of therapeutic targets and therapeutic approach for glucose control in chronic complex patients with type 2 diabetes mellitus. A list of 6 recommendations was created and rated by a panel of 75 experts from the DOWG by email (first round) and by open discussion (second round). A written document was produced and sent back to DOWG experts for clarification purposes. RESULTS: A high degree of consensus was achieved for all recommendations summarized as 1) there is a need to redesign and test new health care programs for chronic complex patients with type 2 diabetes mellitus; 2) therapeutic targets in patients with short life expectancy should be individualized in accordance to their personal, clinical and social characteristics; 3) patients with chronic complex conditions and type 2 diabetes mellitus should be stratified by hypoglycemia risk; 4) age and specific comorbidities should guide the objectives for glucose control; 5) the risk of hypoglycemia should be a key factor when choosing a treatment; and 6) basal insulin analogs compared to human insulin are cost-effective options. CONCLUSION: The assessment and recommendations provided herein represent our best professional judgment based on current data and clinical experience.

Presentation and prognosis of gastric cancer in patients aged 80 years and older.

The aim of this study was to analyze the characteristics of the presentation and prognosis of patients aged >/= 80 who were diagnosed with gastric adenocarcinoma. We have used a retrospective cohort study of 2334 patients diagnosed between 1975 and 1993 in northwestern Spain, 263 (11.3%)of whom were >/= 80 years of age. No differences were observed with respect to patients of a younger age at diagnosis regarding the site of the tumor, extension of the disease, or Laurén's histologic type. However, fewer resections with curative intent were performed in the older group (49.1% vs. 30.1%; p < 0.0001). Among those operated on with curative or palliative intent, at the end of the first month the survival probability was 0.9 and the 0.95% confidence interval (CI 95%) was 0.93-0.97 for patients < 80 years of age and 0.93 (CI 95% 0.89-0.98) for the older group ( p = 0.19). At the end of 5 years of follow-up these probabilities were 0.29 (CI 95% 0.27-0.31) and 0.18 (CI 95% 0.14-0.23), respectively ( p < 0.0001). If we consider only those patients undergoing curative resection, the survival probability for the two groups ( p = 0.4) was not statistically different. In conclusion, although the two groups showed similar characteristics at presentation, patients >/= 80 years of age underwent surgery with curative intent less frequently and their general prognosis was worse. Our data support the idea that curative surgery should not be ruled out exclusively for reasons of age.