Estudios protocolizados en neumologia. analisis critico
A critical analysis of protocol directed studies in pneumology
A. Lopez Encuentra
Sección de Neumología. Ciudad Sanitaria de la S. S. 1.° de Octubre. Madrid
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Ros die, O.I. Morales Valentin, F. Perez Benitez, R. Vara Thorbeck" "autores" => array:4 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Ros die" ] 1 => array:2 [ "nombre" => "O.I." "apellidos" => "Morales Valentin" ] 2 => array:2 [ "nombre" => "F." "apellidos" => "Perez Benitez" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Vara Thorbeck" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289615323747?idApp=UINPBA00003Z" "url" => "/03002896/0000001800000002/v1_201509151137/S0300289615323747/v1_201509151137/es/main.assets" ] "es" => array:12 [ "idiomaDefecto" => true "titulo" => "Estudios protocolizados en neumologia. analisis critico" "tieneTextoCompleto" => 0 "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "85" "paginaFinal" => "108" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "A. Lopez Encuentra" "autores" => array:1 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Lopez Encuentra" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Sección de Neumología. Ciudad Sanitaria de la S. S. 1.° de Octubre. Madrid" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "A critical analysis of protocol directed studies in pneumology" ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "1981-02-09" "tieneResumen" => true "resumen" => array:2 [ "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="absec0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Se efectúa un análisis personal de la utilización de los llamados protocolos médicos en neumolo-gía. La problemática de éstos comienza en la misma definición del concepto protocolo. Teniendo en cuenta diversas circunstancias, se podría definir como protocolo médico a un «documento que contiene los acuerdos tomados en junta o asamblea médica».</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estos protocolos médicos pueden ser arbitrariamente clasificados en protocolos de diagnóstico, de clasificación, terapéuticos, de procedimiento diagnóstico y de investigación clínica. Estos últimos, se nutren de los previos, y su utilidad se cifra en alcanzar resultados medibles.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La primera cuestión que se plantea acerca de los protocolos médicos es conocer su presencia como necesaria. <span class="elsevierStyleItalic">La necesidad</span> de poseer protocolos médicos puede venir justificada por diversos motivos. Entre ellos figura el problema de la in-certidumbre diagnóstica o terapéutica, los problemas éticos ante decisiones médicas, la necesidad de elevar y homogeneizar la calidad asisten-cial. la necesidad de poseer códigos de trabajo que sean válidos para diferentes personas o grupos, la necesidad de sumar experiencias de diferente procedencia, y la necesidad de evaluar cuantitativamente el conocimiento médico. Asimismo aparecen otras motivaciones para la génesis del protocolo médico, como es la ausencia-sobrecarga de información médica. La ausencia en libros de texto de guías útiles de actuación ante problemas neumológicos habituales y la excesiva cantidad de información proveniente de otra forma de comunicación científica, fundamentalmente de revistas médicas. El agrupamiento y síntesis del conocimiento existente en un momento dado y en un aspecto concreto es la motivación. en ocasiones, de la realización de un protocolo médico.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Para la <span class="elsevierStyleItalic">realización práctica</span> de estos protocolos médicos es imprescindible una serie de normas básicas. Estas son: 1. Definición y justificación del problema sujeto al protocolo. 2. Revisión bibliográfica del tema en estudio. 3. Necesidad de consenso entre partes. 4. Preparación escrita del protocolo, estimulando la formación de árboles de decisiones, en donde todas las variables que afectan al diagnóstico o a la terapéutica estén contempladas.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Las normas</span> para la realización de estudios de investigación clínica, requieren lo indicado previamente para los otros tipos de protocolo, con un diseño diferente en donde la colaboración con informática es habitualmente necesaria.</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">En el estudio protocolizado de la patología neumológica pueden aplicarse modelos matemáticos que reduzcan a números el conocimiento de la sensibilidad o especificidad de un test, o el conocer la probabilidad de que una persona tenga la enfermedad dependiente de que un síntoma. signo o test esté presente o no, o sea positivo o negativo, lo que en teoría facilitaría la decisión médica sobre datos objetivos y favorecería la aparición de protocolos de diagnóstico o tratamientos más rigurosos. La elaboración de este cálculo matemático favorece el conocimiento para cualquier test de los verdaderos negativos, verdaderos positivos, del índice de falsos negativos y de falsos positivos, y de la elaboración matemática del conocimiento de la probabilidad de tener una enfermedad mediante el teorema de Bayes. Esta formulación teórica se ve contrastada con las serias dificultades encontradas en la realización práctica de estos complejos, y no siempre fiables, sistemas de valoración cuantitativa.</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">En la práctica, los protocolos médicos ofrecen respuestas parciales a las necesidades planteadas previamente, y habitualmente proveen, mediante operaciones de consenso, facilidad para obtener criterio en diversas circunstancias.</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Los mayores <span class="elsevierStyleItalic">peligros e inconvenientes</span> de los protocolos son: 1. Disminuir el ejercicio crítico y confiar excesivamente en protocolos. 2. Olvido en la actualización de un protocolo escrito. 3. Intento de trasplantar un protocolo con sus normas y detalles, de un grupo de trabajo a otro, sin ser elaborado o criticado por el que lo recibe. 4. Intentar protocolizarlo todo. 5. Burocracia excesiva. 6. Financiación escasa. 7. Ausencia de espíritu de trabajo cooperativo.</p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">En resumen la opinión ante los protocolos médicos es favorable pero prudente. Tener un protocolo sobre una concreta situación neumológica no resuelve por sí mismo el problema pero favorece su resolución. Un análisis colectivo ante un problema en un paciente concreto puede superar al efectuado en el protocolo escrito, por lo que hay que considerar al protocolo médico, por definición, como un producto inacabado que requiere actualización y análisis permanentes.</p></span>" ] "en" => array:2 [ "titulo" => "Summary" "resumen" => "<span id="absec0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The author presents a personal, critical analysis of the use of medical protocols in pneumology. The first problem encountered lies in the definition of the term «protocol», which, by taking into account different circumstances, might be defined as being «a document stating decisions made by a medical board or meeting». These protocols may then — arbitrarily — be classified as diagnostic, classifying, therapeutic, diagnostic procedure or clinical trial protocols. The clinical trial protocols are in turn, governed by the previous ones and their usefulness is measured by the results obtained of the trial.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The first question to be answered is whether they are truly necessary. The need for a protocol may be justified in several ways: uncertainty as to establishing a firm diagnosis or therapeutic measures; decisions posing ethical problems; the need to improve medical care; working guide lines for several persons or groups; the necessity to summarize experiences from different sources and quantitative evaluation of medical knowledge. Other reasons for a protocol might be the scarcity or even plentitude of information. The textbooks on pneumology do not offer any useful guidelines on the management of common problems, while other publications such as journals offer too much information to be of use for easy reference. The sorting out of existing knowledge on a certain subject may at times be a valid reason for a protocol.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">To establish a medical protocol, certain basic rules are essential: 1) Definition and justification of the reason for the protocol 2) Bibliographic revisión of the literature on the subject 3) unanimity between participants 4) preparation of the protocol in writing, thereby encouraging decisión taking in all branches, creating an all-over view of variables which might influence diagnosis or therapy.</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Clinical trial protocols follow the same guidelines and rules as do the other protocols but with a different design, allowing corraboration of available information.</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A protocol directed study in pneumology can use mathematical models to reduce known sensitivity or specificity of a test to simple numbers, or to calcúlate, when certain signs or symptoms are presented whether there is existing disease; in theory this would aid the correct medical decisions to be taken and would favor the drawing-up of stricter diagnostic and therapeutic protocols. The mathematic calculus is hepful in deciding when test results are true negative, true positive, false negative or false positive, while it may be used with Bayes theorem to deduce the probability of disease being present or not. However, these theoretical possibilities encounter serious difficulties whenever one of these complex, not always reliable systems of quantitative evaluation is attempted.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">In practice, medical protocols offers partial answers to some of the questions posed and usually establish, through consensus, criteria valid under different circumstances. The main dangers and inconveniences inherent in protocols are: 1) blind following of the protocol without sufficient critical judgement 2) lack of bringing up to date in wirtten protocols 3) transferring a protocol from one group of workers to another, without it having been either designed or critically analysed by the group receiving the protocol. 4) trying to reduce everything to protocols 5) excess paperwork 6) lack of financing 7) lack of team spirit.</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">In summary, while protocols may be regarded as useful, caution must be exercised. A protocol alone does not solve a definite problem in pneumology, although it may be of help in doing so. The case of a patient is often better served by critical team appraisal than by protocols, thus, the protocol must be defined as an incomplete tool needing constant bringing up-to-date and analysis.</p></span>" ] ] "bibliografia" => array:2 [ "titulo" => "Bibliografia" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:56 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diccionario Ideológico de la Lengua Española" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. Casares" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "1969" "editorial" => "Edit. Gustavo Gili" "editorialLocalizacion" => "Barcelona" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 5 | 10 |
| 2024 October | 37 | 16 | 53 |
| 2024 September | 38 | 16 | 54 |
| 2024 August | 41 | 32 | 73 |
| 2024 July | 42 | 31 | 73 |
| 2024 June | 49 | 16 | 65 |
| 2024 May | 32 | 33 | 65 |
| 2024 April | 42 | 39 | 81 |
| 2024 March | 32 | 24 | 56 |
| 2024 February | 29 | 40 | 69 |
| 2023 March | 8 | 8 | 16 |
| 2023 February | 34 | 23 | 57 |
| 2023 January | 69 | 25 | 94 |
| 2022 December | 36 | 23 | 59 |
| 2022 November | 61 | 16 | 77 |
| 2022 October | 52 | 27 | 79 |
| 2022 September | 48 | 34 | 82 |
| 2022 August | 53 | 36 | 89 |
| 2022 July | 52 | 42 | 94 |
| 2022 June | 25 | 35 | 60 |
| 2022 May | 53 | 30 | 83 |
| 2022 April | 62 | 35 | 97 |
| 2022 March | 49 | 31 | 80 |
| 2022 February | 53 | 24 | 77 |
| 2022 January | 72 | 29 | 101 |
| 2021 December | 29 | 73 | 102 |
| 2021 November | 53 | 31 | 84 |
| 2021 October | 67 | 39 | 106 |
| 2021 September | 49 | 48 | 97 |
| 2021 August | 45 | 32 | 77 |
| 2021 July | 30 | 37 | 67 |
| 2021 June | 35 | 31 | 66 |
| 2021 May | 40 | 16 | 56 |
| 2021 April | 107 | 65 | 172 |
| 2021 March | 87 | 16 | 103 |
| 2021 February | 84 | 22 | 106 |
| 2021 January | 64 | 31 | 95 |
| 2020 December | 50 | 14 | 64 |
| 2020 November | 37 | 23 | 60 |
| 2020 October | 51 | 11 | 62 |
| 2020 September | 68 | 12 | 80 |
| 2020 August | 102 | 17 | 119 |
| 2020 July | 76 | 24 | 100 |
| 2020 June | 21 | 5 | 26 |
| 2020 May | 51 | 22 | 73 |
| 2020 April | 45 | 6 | 51 |
| 2020 March | 58 | 19 | 77 |
| 2020 February | 51 | 29 | 80 |
| 2020 January | 65 | 17 | 82 |
| 2019 December | 43 | 19 | 62 |
| 2019 November | 28 | 11 | 39 |
| 2019 October | 49 | 25 | 74 |
| 2019 September | 57 | 31 | 88 |
| 2019 August | 21 | 14 | 35 |
| 2019 July | 27 | 40 | 67 |
| 2019 June | 21 | 24 | 45 |
| 2019 May | 13 | 23 | 36 |
| 2019 April | 25 | 98 | 123 |
| 2019 March | 12 | 32 | 44 |
| 2019 February | 6 | 20 | 26 |
| 2019 January | 6 | 12 | 18 |
| 2018 December | 8 | 26 | 34 |
| 2018 November | 10 | 26 | 36 |
| 2018 October | 21 | 27 | 48 |
| 2018 September | 13 | 28 | 41 |
| 2018 July | 0 | 1 | 1 |
| 2018 May | 6 | 8 | 14 |
| 2018 April | 18 | 63 | 81 |
| 2018 March | 7 | 44 | 51 |
| 2018 February | 6 | 36 | 42 |
| 2018 January | 8 | 33 | 41 |
| 2017 December | 14 | 24 | 38 |
| 2017 November | 7 | 17 | 24 |
| 2017 October | 9 | 27 | 36 |
| 2017 September | 14 | 22 | 36 |
| 2017 August | 7 | 30 | 37 |
| 2017 July | 6 | 31 | 37 |
| 2017 June | 8 | 40 | 48 |
| 2017 May | 9 | 37 | 46 |
| 2017 April | 12 | 31 | 43 |
| 2017 March | 8 | 31 | 39 |
| 2017 February | 8 | 25 | 33 |
| 2017 January | 4 | 9 | 13 |
| 2016 December | 16 | 18 | 34 |
| 2016 November | 16 | 25 | 41 |
| 2016 October | 24 | 41 | 65 |
| 2016 September | 25 | 35 | 60 |
| 2016 August | 31 | 31 | 62 |
| 2016 July | 23 | 7 | 30 |
| 2016 June | 24 | 15 | 39 |
| 2016 May | 15 | 7 | 22 |
| 2016 April | 10 | 1 | 11 |
| 2016 March | 12 | 0 | 12 |
| 2016 February | 9 | 2 | 11 |
| 2016 January | 27 | 12 | 39 |
| 2015 December | 32 | 24 | 56 |
| 2015 November | 26 | 9 | 35 |
| 2015 October | 6 | 3 | 9 |
| 2015 September | 1 | 0 | 1 |
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