Pancreas units within gastroenterology departments. Organizational and operational standards for a patient-centered service. / Las unidades de páncreas en los servicios de aparato digestivo. Estándares de organización y funcionamiento para un servicio centrado en el paciente.

The Asociación Española de Pancreatología (AESPANC), Asociación Española de Gastroenterología (AEG), and Sociedad Española de Patología Digestiva (SEPD) have developed a consensus document on the standards and recommendations they consider essential for the organization of pancreas units (PUs) within gastroenterology services (GSs) in order to conduct their activities in an efficient, high-quality manner. The consensus document defines PUs and lays down standards relating to their organization, structure, service portfolio, processes, and teaching and research activities. Standards have been categorized as mandatory (requirements to be met to qualify for certification by the scientific societies responsible for the standards) or recommendations. Standards should be updated at most within five years based on the experience gained in Spanish PUs and the advance of knowledge regarding pancreas disease. Development of health outcome indicators, including patient-reported outcome measures (PROMs), is considered a relevant challenge, as is evidence on the association of PU structure and activity standards with health outcomes.

Identificación y cuantificación del efecto fin de semana y festivos en la atención del síndrome coronario agudo en el Sistema Nacional de Salud / The effect of weekends and public holidays on the care of acute coronary syndrome in the Spanish National Health System

Introducción y objetivos Analizar si el ingreso en fin de semana o festivo (IFSF), frente al ingreso en días laborables, influye en el tratamiento (angioplastia, intervención coronaria percutánea [ICP]) y los resultados (mortalidad hospitalaria) de los pacientes hospitalizados por síndrome coronario agudo en el Sistema Nacional de Salud. Métodos Estudio observacional retrospectivo de pacientes ingresados por infarto agudo de miocardio con elevación del segmento ST (IAMCEST) o con síndrome coronario agudo sin elevación del segmento ST (SCASEST) en los hospitales del Sistema Nacional de Salud durante el periodo 2003-2018. Resultados Se seleccionaron 438.987 episodios de IAMCEST y 486.565 de SCASEST, de los cuales fueron IFSF el 28,8 y el 26,1% respectivamente. El IFSF se mostraba como un factor de riesgo de mortalidad hospitalaria en los modelos ajustados por riesgo del IAMCEST (OR=1,05; IC95%, 1,03-1,08; p<0,001) y del SCASEST (OR=1,08; IC95%, 1,05-1,12; p <0,001). La tasa de ICP en el IAMCEST fue más de 2 puntos porcentuales mayor en los pacientes ingresados en días laborables durante el periodo 2003-2011 y similar o incluso más baja en 2012-2018, sin cambios significativos para el SCASEST. El IFSF se mostró como factor de riesgo estadísticamente significativo tanto para el IAMCEST como para el SCASEST. Conclusiones El IFSF puede aumentar el riesgo de muerte hospitalaria en un 5% (IAMCEST) y un 8% (SCASEST). La persistencia del riesgo de mayor mortalidad hospitalaria tras ajustar por la realización de ICP y las demás variables explicativas probablemente indique dficiencias en el tratamiento durante el fin de semana respecto de los días laborables (AU)

Introduction and objectives To analyze whether admission on weekends or public holidays (WHA) influences the management (performance of angioplasty, percutaneous coronary intervention [PCI]) and outcomes (in-hospital mortality) of patients hospitalized for acute coronary syndrome in the Spanish National Health System compared with admission on weekdays. Methods Retrospective observational study of patients admitted for ST-segment elevation myocardial infarction (STEMI) or for non–ST-segment elevation acute coronary syndrome (NSTEACS) in hospitals of the Spanish National Health system from 2003 to 2018. Results A total of 438 987 episodes of STEMI and 486 565 of NSTEACS were selected, of which 28.8% and 26.1% were WHA, respectively. Risk-adjusted models showed that WHA was a risk factor for in-hospital mortality in STEMI (OR, 1.05; 95%CI,1.03-1.08; P < .001) and in NSTEACS (OR, 1.08; 95%CI, 1.05-1.12; P < .001). The rate of PCI performance in STEMI was more than 2 percentage points higher in patients admitted on weekdays from 2003 to 2011 and was similar or even lower from 2012 to 2018, with no significant changes in NSTEACS. WHA was a statistically significant risk factor for both STEMI and NSTEACS. Conclusions WHA can increase the risk of in-hospital death by 5% (STEMI) and 8% (NSTEACS). The persistence of the risk of higher in-hospital mortality, after adjustment for the performance of PCI and other explanatory variables, probably indicates deficiencies in management during the weekend compared with weekdays (AU)

Quiste óseo aneurismático de localización vertebral / Aneurysmal bone cyst of vertebral location

El quiste óseo aneurismático (QOA) representa el 9% de los tumores óseos benignos. Es una lesión ósea pseudotumoral, formada por pequeños canales llenos de sangre separados por tabiques de tejido conectivo. Tiene su mayor prevalencia en adolescentes, con un ligero predominio femenino. La localización más frecuente es la metáfisis de los huesos largos (50% de los casos) seguida de la columna vertebral. La presentación clínica es variable y a veces puede ser inespecífica, pero en casos de dolor y tumefacción ósea en adolescentes debemos sospechar esta patología. Es por ello por lo que debemos estar atentos a los signos de alarma del dolor de espalda. El diagnóstico se realizará inicialmente mediante pruebas de imagen como la radiografía ósea y la resonancia magnética, en las que se observa una lesión quística expansiva y osteolítica pero circunscrita siendo característico que conserve la cortical, así como la presentación de una lesión multilobulada o en «pompas de jabón» con niveles líquidos. El diagnóstico definitivo se realiza por estudio histológico. Existen distintos abordajes terapéuticos, dependiendo de la lesión. A pesar de no ser maligno, se caracteriza por ser agresivo, por lo que su sospecha en el paciente pediátrico es relevante para un tratamiento precoz y evitar secuelas, que, en ocasiones, como cuando la localización es vertebral, pueden ser irreversibles. Para ilustrar esta patología, presentamos dos casos de localización vertebral en adolescentes (AU)

Aneurysmal bone cysts (ABCs) account for 9% of benign bone tumors. They are tumor-like bone lesions, formed by blood-filled channels separated by connective tissue septa. Their prevalence peaks in adolescence, and they are slightly more common in girls than in boys. They are most commonly found in the metaphysis of long bones (50%) and the posterior spinal elements (12-30%). The symptons can be non-specific, butt his disease should be suspected in adolescents presenting with pain and bone swelling. On radiographs and nuclear magnetic resonance imaging, ABC appears as an expansive, lytic, agressive lesion with a sclerotic rim. Usually, the cortex is intact. They can present as multiloculated lesions with a "soap bubble" appearance and fluid-fluid levels. The definitive diagnosis is based on the histopathological features. There are different approaches to treatment depending on the lesion. Although ABCs are not malignant, they are aggressive, so prompt suspicion in pediatric patients is important for early treatment. We present 2 cases of ABCs involving the spine in adolescents to illustrate this condition. (AU)

Gasto sanitario público y mortalidad por COVID-19 en España y en Europa / Public healthcare expenditure and COVID-19 mortality in Spain and in Europe

Objetivo Analizar la asociación entre el gasto sanitario público per cápita y la tasa de mortalidad poblacional por COVID-19 en Europa y en España. Material y métodos Se utilizó el coeficiente de correlación de Pearson. Asimismo, se contrastaron los promedios de TMP-COVID-19 entre países y comunidades autónomas con mayor y menor GSPpc que el promedio. Resultados No se halló correlación, en los países europeos, entre el gasto sanitario público per cápita y la tasa de mortalidad poblacional por COVID-19 (r: 0,3; p = 0,14), ni en las comunidades autónomas (r: 0,03; p = 0,91). Tampoco se encontraron diferencias significativas en el contraste de la tasa de mortalidad poblacional por COVID-19 por grupos de gasto sanitario público per capita. Conclusiones La asociación entre «bajo» gasto sanitario público y malos resultados en España en la crisis de la COVID-19 no está sustentada en la evidencia disponible. Los aumentos de financiación de la sanidad pública deberían destinarse a las reformas estructurales para aumentar su eficiencia social (AU)

Objective To analyze the association between public health expenditure per capita and the mortality rate due to COVID-19 in Europe and Spain. Material and methods Pearson's correlation coefficient was used to compare and contrast the mortality rate due to COVID-19 between countries and autonomous communities with higher and lower public health expenditure per capita than the mean. Results No correlation between the public health expenditure per capita and the mortality rate due to COVID-19 (r: 0.3; p = 0.14) was found among European countries or Spain's Autonomous Communities (r: 0.03; p = 0.91). No significant differences were found when comparing the mortality rate due to COVID-19 among the public health expenditure per capita groups. Conclusions The available evidence does not support association between «low» public healthcare expenditure and the poor outcomes observed in Spain during the COVID-19 pandemic. Increased funding for the Spanish National Health System should be earmarked for structural reforms to increase its social efficiency (AU)

Public healthcare expenditure and COVID-19 mortality in Spain and in Europe.

OBJECTIVE: To analyze the association between public health expenditure per capita and the mortality rate due to COVID-19 in Europe and Spain. MATERIAL AND METHODS: Pearson's correlation coefficient was used to compare and contrast the mortality rate due to COVID-19 between countries and autonomous communities with higher and lower public health expenditure per capita than the mean. RESULTS: No correlation between the public health expenditure per capita and the mortality rate due to COVID-19 (r: 0.3; p = 0.14) was found among European countries or Spain's Autonomous Communities (r: 0.03; p = 0.91). No significant differences were found when comparing the mortality rate due to COVID-19 among the public health expenditure per capita groups. CONCLUSIONS: The available evidence does not support association between «low¼ public healthcare expenditure and the poor outcomes observed in Spain during the COVID-19 pandemic. Increased funding for the Spanish National Health System should be earmarked for structural reforms to increase its social efficiency.

[Public healthcare expenditure and COVID-19 mortality in Spain and in Europe]. / Gasto sanitario público y mortalidad por COVID-19 en España y en Europa.

OBJECTIVE: To analyze the association between public health expenditure per capita and the mortality rate due to COVID-19 in Europe and Spain. MATERIAL AND METHODS: Pearson's correlation coefficient was used to compare and contrast the mortality rate due to COVID-19 between countries and autonomous communities with higher and lower public health expenditure per capita than the mean. RESULTS: No correlation between the public health expenditure per capita and the mortality rate due to COVID-19 (r: 0.3; p = 0.14) was found among European countries or Spain's Autonomous Communities (r: 0.03; p = 0.91). No significant differences were found when comparing the mortality rate due to COVID-19 among the public health expenditure per capita groups. CONCLUSIONS: The available evidence does not support association between «low¼ public healthcare expenditure and the poor outcomes observed in Spain during the COVID-19 pandemic. Increased funding for the Spanish National Health System should be earmarked for structural reforms to increase its social efficiency.

The Hospital of the Future in 10 points. / El hospital del futuro en 10 puntos.

Over the course of 2018 and 2019, the Spanish Society of Internal Medicine carried out a project called "The Future Hospital." Based on cumulative knowledge on the Spanish National Health System, this project seeks to transfer the observations on the organization of healthcare in future hospitals made by the Royal College of Physicians in the United Kingdom to the context of the Spanish healthcare system. The project's participants included numerous scientific and medical societies, professional associations in the health sector, and patient associations. This aim of this article is to highlight, in 10 points, predictions that arose from this project that we consider to be the most relevant, reserving the last point for the challenges for the field of internal medicine that can be surmised from these proposals.

RECALMIN. Four years of growth of the internal medicine units of the Spanish National Health System (2013-2016). / RECALMIN. Cuatro años de evolución de las Unidades de Medicina Interna del Sistema Nacional de Salud (2013-2016).

OBJECTIVES: To compare the structure, resources and activity of the internal medicine units (IMUs) of the Spanish National Health System (SNHS) in 2013 and 2016. To analyse the differences between IMUs in 2016 by hospital size. MATERIAL AND METHODS: We conducted a comparison of 2 descriptive cross-sectional studies of IMUs in general acute care hospitals of the Spanish National Health System, with data referring to 2013 and 2016. The variables were collected via an ad hoc questionnaire (RECALMIN survey). RESULTS: Between 2013 and 2016, the demand for care increased dramatically (with an annual average of 11% in hospital discharges and 16% in first consultations), and comorbidity slightly increased (2%). During this period, the mean productivity of IMUs increased 16.7% (0.6±0.3 vs. 0.7±0.3; P=.09), and the mean stay decreased 10% (9±2.2 vs. 8.1±2.1 days; P=.001). Progress in implementing good practices and systematic care for complex chronic patients was scarce. Both surveys found variability among IMUs and marked differences among IMUs of hospitals of different sizes. CONCLUSIONS: IMUs responded to the increased burden of care they supported during 2013-2016 by improving their efficiency and productivity; however, advances in implementing good practices, including care for chronic complex patients, were scare. The significant variability in the indicators of structure, activity and management models found in 2013 remained in 2016.

RECALMIN II. Eight years of hospitalisation in Internal Medicine Units (2007-2014). What has changed? / RECALMIN II. Ocho años de hospitalización en las Unidades de Medicina Interna (2007-2014). ¿Qué ha cambiado?

OBJECTIVES: To analyse the evolution of care provided by the internal medicine units (IMU) of the Spanish National Health System from 2007 to 2014. MATERIAL AND METHODS: We analysed all discharges from the IMU of the Spanish National Health System in 2007 and 2014, using the Minimum Basic Data Set. We compared the risk factors by episode, mortality and readmissions between the two periods. We prepared specific fits for the risk for mortality and readmissions in heart failure, pneumonia and chronic obstructive pulmonary disease, as well as the Charlson index for all activity. RESULTS: Discharges from the IMU between the two periods increased 14%. The average patient age increased by 2.8 years (71.2±17.1 vs. 74±16.2; p<.001), with a marked increase in comorbidity (Charlson index, 4±3.7 vs. 4.7±3.9; p<.001; 24% increase in risk factors per episode). The adjusted mortality rates decreased slight but significantly, with a slight increase in readmissions. CONCLUSIONS: During the analysed period, there was an increase of almost 3 years in the mean age of patients treated in the IMU of the Spanish National Health System, with a marked increase in comorbidity. These results should lead to a more appropriate assignment of nurse workloads and an increased implementation of good practices in clinical management.

The Internal Medicine of the 21st century: Organizational and operational standards. / La Medicina Interna del siglo xxi: estándares de organización y funcionamiento.

The Spanish Society of Internal Medicine has developed a consensus document on the standards and recommendations that they consider essential to the organisation of internal medicine units for conducting their activities efficiently and with high quality. We defined 3 groups of key processes: the care of acutely ill adult patients, the comprehensive care of complex chronic patients and the examination of a patient with a difficult diagnosis and no organ-specific disease. As support processes, we identified the structure and operation of the Internal Medicine units. As strategic processes, we identified training and research. The main subprocesses are structured below, and we established the standards and recommendations for each of them. Lastly, we proposed resulting workloads. The prepared standards must be reviewed within a maximum of 4 years.

[RECALMIN. Patient care in the internal medicine units of the Spanish national health system]. / RECALMIN. La atención al paciente en las unidades de Medicina Interna del Sistema Nacional de Salud.

OBJECTIVES: To perform a situation analysis of the care provided by internal medicine units (IMUs) in Spain and to develop, based on this analysis, proposals for improving the quality of care in these units. MATERIAL AND METHODS: A descriptive, cross-sectional study of the IMUs of general acute care hospitals of the Spanish National Health System (SNHS), with data referring to 2013. The study variables were collected via an ad hoc questionnaire. RESULTS: Of the total 260hospitals identified in the SNHS, 142responses were obtained from 139hospitals throughout Spain, which represents 53.5% of the IMUs in the SNHS. The mean number of internists per IMU was 14±8, with a mean rate of 7.2±3.3 internists per 100,000 inhabitants. In 2013, the average number of hospital discharges from the IMU was 2,987±2,066, and those discharged by internists was 232±107. Sixty-one percent of the IMUs had implemented an interconsultation unit, and 41% had implemented a systematic care program for complex chronic patients. Thirty-three percent of the IMUs conducted multidisciplinary rounds, and 60% of these IMUs planned the discharge. CONCLUSIONS: The 2013 RECALMIN survey revealed a number of important aspects of the organisation, structure and management of IMUs. The remarkable variability in the indicators of structure, activity and management probably reflect significant differences in efficiency and productivity, which therefore provide significant room for improvement.

Professional football (soccer) players have a markedly greater skeletal mineral content, density and size than age- and BMI-matched controls.

The total skeletal bone mineral content (BMC), bone mineral density (BMD), bone size, and body composition were measured by dual-energy x-ray absorptiometry (DXA) in all professional male football players of a 1st division team (n = 24) and age- and BMI-matched (n = 22) controls (less than 3 hours of recreational sport activities per week). Average (+/- 1 SD) age of the athletes was 22.6 +/- 2.5 years. Intensive training is conducted during 48 weeks a year for 20-22 hours/week. The length of the registered playing career before the study was 8.2 +/- 2.7 years. Total skeleton BMC was 18.0% (P < 0.001) greater in the football players. The difference resulted from the sum of 5.2% (P < 0.02) increment of bone size and 12.3% (P < 0.001) increment of BMD. The analysis of skeletal subareas revealed that the difference of the BMC and BMD was greater at the level of the pelvis and legs compared with the arms or trunk. The BMC and BMD of the head was equal for both groups. Also, the bone size of the legs and pelvis was significantly greater for the players compared with controls; there was no difference at the level of the arms or head. Within the group of football players the increment of total skeleton BMD was similar in the young players, with less than 7 years of practice (age 20.6 +/- 0.9 years) compared with relative older players (age 24.6 +/- 1.9) with more than 7 years of practice. Lean body mass was significantly greater in the players (63.3 +/- 4.0 kg) compared with the controls (56.7 +/- 3.6, P < 0.001) whereas fat mass was markedly lower (9.4 +/- 2.9 kg versus 14.9 +/- 6.3 kg), P < 0.002). The BMD of the controls was significantly correlated to total weight, height, and lean mass whereas the BMD of the players was only correlated to muscle mass. The calcium intake from dairy products was similar in both groups. The range of calcium intake was wide among the players (184-2519 mg/day) but it was not significantly correlated to BMD (r = 0.03). In conclusion, male professional football players develop a significant increment of BMC as a result of increased bone size and density. This is already present at the end of the second decade and maintained at least to the end of the third decade in active players. As in other high impact loading sports, the effect on area is specific involving mainly the pelvis and legs. The increment was totally unrelated to the calcium intake from dairy products. The fate of the increased BMC after intensive training is discontinued should be assessed. However, if the findings of the present cross-sectional study are supported by detailed longitudinal investigations, the presently reported observations might be important for the prevention of future osteoporotic fractures.