Neurogastroenterology & Motility

Neurogastroenterol Motil (2015)

doi: 10.1111/nmo.12556

Prevalence of irritable bowel syndrome in caregivers of

patients with chronic diseases



IA *
J. M. REMES-TROCHE ,* M. TORRES-AGUILERA ,* V. MONTES-MART
INEZ , V. A. JIM ENEZ-GARC

& F. ROESCH-DIETLEN *
*Digestive Physiology and Gastrointestinal Motility Laboratory, Instituto de Investigaciones Medico Biol

ogicas, Universidad
Veracruzana, Veracruz, Mexico
Department of Internal Medicine, Hospital Regional de Alta Especialidad de Veracruz, Veracruz, Mexico

Key Messages

 Situations with a high emotional burden, such as sexual abuse and posttraumatic stress disorders have been
associated with IBS, and have even been regarded as triggering factors.

 Recent studies have shown that providing long-term care for the chronically ill patient can have a negative
impact, both mentally and physically, on caregivers.

 This is the first study showing that caregivers of chronically ill patients have a high prevalence (49%) of IBS,
and a greater probability of presenting with depression, anxiety, and a worse quality of life.

 Caregiving that involves chronically ill patients should be regarded as another condition associated with IBS.

Abstract
Background Caregivers are an at-risk population for
psychic and physical diseases such as irritable bowel
syndrome (IBS). However, it is not known whether
providing care for the chronically ill patient can be
considered a risk factor for developing IBS. In this
study, our aim was to evaluate the prevalence of IBS
according to the Rome II criteria in a group of
caregivers. Methods A cross-sectional study was conducted through an evaluation of caregivers of chronically ill patients. Subjects completed questionnaires
including the Rome II Modular Questionnaire, the
Hospital Anxiety and Depression Scale, the Zarit
Caregiver Burden Interview (ZCBI) (an instrument
for evaluating the burden experienced by caregivers),
and the irritable bowel syndrome quality of life (IBSQoL) questionnaire. Key Results Ninety-six primary

caregivers (mean age was 43.6  13.7 years and 87%

were women) were evaluated. The mean length of
time providing care was 37.6 months (3288 months).
Forty-seven caregivers (49%) presented with IBS. The
caregivers with IBS had higher scores in the global
ZCBI score (47  8 vs 28  8, p = 0.001) and on the
anxiety and depression scale (p = 0.001) than those
that did not have IBS. A total of 72% were diagnosed
with caregiver stress syndrome; 42 of them had IBS
according to the Rome II questionnaire (60% vs 18%,
p = 0.001, relative risk 3.28, 95% CI: 1.47.4).
Conclusions & Inferences Caregivers of chronically
ill patients have a high prevalence of IBS, which is
associated with depression, anxiety, and poor QoL.

Address for Correspondence

Dr. Jos

e Mar
a Remes-Troche, Laboratorio de Fisiolog
a
Digestiva y Motilidad Gastrointestinal, Instituto de
Investigaciones M

edico Biol

ogicas. Iturbide SN, Colonia
Flores Mag

on, Veracruz CP 91400, Mexico.
Tel: +52 229 2021231; fax: +52 229 9322292;
e-mail: jose.remes.troche@gmail.com, joremes@uv.mx
Received: 17 September 2014
Accepted for publication: 26 February 2015

INTRODUCTION

2015 John Wiley & Sons Ltd

Keywords caregiver, chronic, chronically ill, irritable

bowel syndrome, overload.

Irritable bowel syndrome (IBS) is a heterogeneous

disorder that affects between 10% and 20% of the
population. Due to its high prevalence, the chronicity
of its symptoms, and its impact on quality of life (QoL),
the socioeconomic burden of this disease is very

J. M. Remes-Troche et al.

Neurogastroenterology and Motility

high.13 Substantial advances have been made in IBS

pathophysiology over the last few years, and even
though its cause is not yet known, the disease is
thought to have a multifactorial etiology in which
various agents interact, producing sensory and motor
alterations within the enteric nervous system.4 Infections,5,6 emotional disorders,7 and diet8,9 are some of
the factors that have been most widely regarded as
probable triggers of IBS symptoms.
In addition to intervening in the pathophysiology of
the disease, psychosocial factors also participate in
symptom exacerbation and/or persistence.10 Covering
a diversity of personality features, IBS patients have
been described as depressive, obsessive, anxiety-ridden,
and neurotic,11 and being individuals who have a lower
tolerance for stress and who are more prone to exhibit
negative behavior.12 According to the American Association of Gastroenterology, IBS patients presenting
with moderate to severe symptoms, together with
associated anxiety and/or depression, tend to seek
medical attention more than those patients with mild
symptoms or with no concomitant psychiatric entities.13,14 Situations with a high emotional burden, such
as sexual abuse516 and posttraumatic stress disorders,17 have been associated with IBS and have even
been regarded as triggering factors.18
Recent studies have shown that providing long-term
care for the chronically ill patient can have a negative
impact, both mentally and physically, on caregivers.19,20 Caregivers are persons that help patients carry
out the functions they can no longer perform on their
own, and at the same time they provide the patients
with the support they need in order to adapt to their
new situation.
Once the adaptation to that new lifestyle is
achieved, caregivers often present with physical and
mental difficulties related to their activity of providing
care that are characterized by feelings of burden, stress,
and sadness; this has been denominated the caregiver
stress syndrome (CSS).1921 Caregiver stress syndrome
is a situation of stress in which there is danger of
overwhelming and exhausting resources, affecting the
physical health and frame of mind of the caregiver, and
modifying his or her thresholds of perception as to the
patients suffering and pain.22,23 In a recent study,
Wong et al. reported that relatives of IBS patients
suffered caregiver stress that was associated with the
severity of the IBS, when compared with healthy
controls.24 In this study, we hypothesize that caregivers are an at-risk population for psychic and physical
diseases like IBS. Therefore, the aims of our study
were: (i) to evaluate the prevalence of IBS according to
the Rome II criteria in a group of caregivers working

with patients with chronic diseases, and (ii) to analyze

the relation of IBS to anxiety, depression, and QoL in
caregivers of chronically ill patients.

METHODS
Population
A cross-sectional study was conducted through an evaluation of
caregivers of chronically ill patients, carried out at the Department of Internal Medicine of the Hospital Regional de Alta
Especialidad de Veracruz and the Institute of Medical and
Biological Research of the Universidad Veracruzana in the Mexican city of Veracruz and the state of the same name, within the
time frame of 1 April 2009 and 31 May 2010.
Consecutive caregivers were invited to voluntarily participate
in the study. The primary caregivers of patients with chronic
degenerative diseases that lived in the patients home and did not
receive remuneration for their activity of providing care were
included. Temporary caregivers were excluded, as were those that
presented with any type of degenerative disease, such as diabetes
mellitus, chronic kidney disease, primary neurologic diseases, and
rheumatologic diseases.
After receiving an explanation of the study protocol and signing
statements of informed consent, all the subjects underwent:
1. An analysis of sociodemographic characteristics: the information pertaining to age, civil status, and occupation of the
subjects, together with the characteristics of the patients they
were caring for, was gathered through a data collection tool.
2. Application of the validated Spanish version of the Rome II
Modular Questionnaire25: this instrument was applied to all
the subjects through direct interview to determine the presence of IBS and its subtypes (IBS with constipation [IBS-C], IBS
with diarrhea [IBS-D], and mixed IBS [IBS-M]). All subjects were
specifically investigated if they had presented with symptoms
consistent with IBS before providing care for their chronically
ill patient.
3. Evaluation of anxiety and depression: all the subjects answered
the self-rating version of the Hospital Anxiety and Depression
Scale questionnaire, an instrument used in the evaluation of
anxiety and depression in situations of stress, which has been
validated in the Mexican population.26 This questionnaire
consists of 14 questions, divided into two subscales of seven
questions each; one subscale measures anxiety in accordance
with the Hamilton scale and the other evaluates depression
based on anhedonia and lack of pleasure. The intensity or
frequency of each answer is evaluated through a Likert scale
(03), with each total subscale score ranging from a possible 0
to 21; a score of 07 is considered normal, 810 inconclusive,
and more than 10 is indicative of significant anxiety and
depression.
4. The Zarit Caregiver Burden Interview (ZCBI)2123 is an instrument for evaluating the burden experienced by caregivers. It
consists of a total of 22 questions that are graded on a Likert
scale (04). The score range is from 0 to 88, and a higher score
indicates a greater burden. A score of 021 is considered null or
minimum burden, 2140 is regarded as moderate burden, 4160
is moderate to severe burden, and a score above 61 represents
severe burden. The questions evaluate three domains: (i)
consequences of care, (ii) interpersonal relation, and (iii) selfefficacy expectations. Caregiver stress syndrome was defined if
subjects had a ZCBI score >21.
5. Quality of life was evaluated through the Spanish version of
the IBS-QoL questionnaire27; it includes a global evaluation

2015 John Wiley & Sons Ltd

Irritable bowel syndrome in caregivers

The mean age of the patients being cared for was

45.7  18.2 years, and 57 (59%) of the patients were
men. Forty-five (45%) of them presented with endstage chronic kidney disease, 19 (20%) with terminal
cancer, 18 (19%) had an incapacitating chronic neurologic disease (Parkinsons disease, cerebrovascular
event, spinal cord injury), 11 (11%) had type 2 diabetes
mellitus with chronic complications (including kidney
failure), and 4 (4%) presented with end-stage AIDS.

and eight subdomains and in this instrument a lower score

indicates a worse quality of life.

Statistical analysis
The nominal variables were described through absolute and
relative frequencies. The continuous variables were analyzed
using means and standard deviation or medians and ranges,
depending on their distribution. A comparative analysis was
carried out between the caregivers that presented with IBS and
those that did not. The Students t-test or MannWhitney U-test
was used for the comparison of two continuous variables, when
appropriate, and the chi-squared test or Fisher exact test was used
for comparing the proportions between two groups, when appropriate. A logistic regression analysis was also performed to look at
the relative effects of the independent variables (age, gender,
occupation, civil status, home setting, length of time taking care
of the patient, level of burden, and Zarit score) on IBS (dependent
variable, yes/no) in the population. Statistical significance was set
at a p < 0.05. The statistical analysis was performed using the
SPSS version 10.0 (SPSS, Inc., Chicago, IL, USA) program. This
study and its protocol and the statements of informed consent
were reviewed by the institutional Research and Ethics Committee, following the bioethical principles of good clinical practice.

Characteristics of the subjects with IBS

In accordance with the Rome II criteria, 47 caregivers
(49%) presented with IBS; 28 subjects had IBS-C (53%),
12 had IBS-D (26%), and 10 had IBS-M (21%). Only 8
(9%) subjects said they had symptoms consistent with
IBS prior to their caregiving activity and they correlated
it with previous stressful events.

Comparison of caregivers with and without IBS

(ZCBI, IBS-QoL, and Hospital Anxiety and
Depression Scale)

RESULTS

There were no differences between the caregivers with

and without IBS with respect to age and the length of
time providing care for their patients (Table 2). There
was a predominance of women among the caregivers
with IBS (91% vs 81%, p = 0.02). The global ZCBI score

Demographic characteristics
Ninety-six primary caregivers with a mean age of
43.6  13.7 years were evaluated; 87% (n = 84) of
them were women. The mean length of time providing
care was 37.6 months (range: 3288 months). Table 1
shows the caregivers relation to their patients, occupation, and civil status.

Table 2 Age, time providing care, and questionnaire scores of subjects

with and without IBS
Table 1 Sociodemographic characteristics of the caregivers of the
chronically ill
Characteristic
Relation
Spouse
Parent
Son or daughter
Sibling
Other relative
Friend
Civil status
Married/Common-law
Single
Widowed
Divorced
Occupation
Homemaker
Employee
Unemployed
Home setting
Urban
Rural

Caregivers
with IBS
(n = 47)

Caregivers
without IBS
(n = 49)

44 (92%)
42  14
32  63

40 (81%)
44  13
37  17

47  12

28  8

0.0001*

25.3  9.6

18.4  9.1

0.004*

4.6  1

4.1  2.3

0.02*

8.2  2.8

6.1  2

0.003*

78  18

87  17

0.01*

11.2  4.6

7.5  4.4

0.0001*

9.5  4.5

7.2  3.8

0.008*

30
22
21
10
10
03

(31.2)
(22.9)
(21.0)
(10.0)
(10.0)
(03.1)

72
15
06
03

(75.0)
(15.6)
(06.2)
(03.1)

Gender
Female (n, %)
Age, years (mean  SD)
Length of time taking
care of the patient,
months (mean  SD)
Global Zarit Score
(mean  SD)
Consequences of
care domain
Interpersonal
relation domain
Self-efficacy
expectation domain
Global IBS-QoL
Score (mean  SD)
Anxiety Score
(mean  SD)
Depression Score
(mean  SD)

59 (61.4)
21 (20.8)
15 (05.2)
62 (64.5)
34 (35.4)

Students t-test, SD: standard deviation.

2015 John Wiley & Sons Ltd

p-value

n (%)

0.02
0.46
0.23

J. M. Remes-Troche et al.

Neurogastroenterology and Motility

was 32.1  3.2. Compared with those that did not

present with IBS, caregivers with IBS had higher scores
in both the global ZCBI scores (47  8 vs 28  8,
p = 0.001) and the three domains (Table 2). Likewise,
the caregivers presenting with burden and IBS had
higher scores for anxiety and depression (p = 0.001;
Table 2).
The majority of subjects with IBS presented with
burden, according to the Zarit scale (42/47, 89%), and
the levels of burden are shown in Table 3. The
presence of moderate to severe burden was greater in
the subjects with IBS than in those that did not present
with IBS (p = 0.0001, Table 3).
In general, the caregivers with IBS had lower scores
in the IBS-QoL than those without IBS (78  18 vs
87  17, p = 0.0001). The caregivers with IBS had
significantly lower scores in all of the domains of the
IBS-QoL questionnaire, except the one related to sexual
activity (Fig. 1). There was a negative correlation

between the global ZCBI and IBS-QoL scores

(r = 0.60, p = 0.001; Fig. 2), and a positive correlation
between the ZCBI score and the scores for anxiety
(r = 0.67, p = 0.001; Fig. 3) and depression (r = 0.58,
p = 0.01; Fig. 4).
In the logistic regression model, female gender and
higher Zarit scores were the only variables with
statistical significance (p = 0.001 and p = 0.049).

22
19
6
2

(45%)
(39%)
(12%)
(4%)

5
17
23
2

(11%)
(36%)
(49%)
(4%)

100
80
40

p-value
0.0001*

20

No burden
Mild burden
Moderate burden
Severe burden

IBS (n = 47)

60

IBS QOL overall

Table 3 Level of burden (according to the ZCBI) between subjects with

and without IBS
No IBS (n = 49)

r = 0.60, p = 0.001

30

*Chi-squared test. No burden = Zarit Caregiver Burden Interview

(ZCBI) of 0-21; Mild burden = ZCBI of 21-40; Moderate burden = ZCBI
of 41-60; and Severe burden = a ZCBI > 61.

40

50
60
70
Zarit score

80

90

Figure 2 Negative correlation between the Zarit score (burden) and

quality of life according to the IBS-QoL.

Figure 1 Mean scores between subjects

with and without IBS according to the IBS
QoL questionnaire.

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Irritable bowel syndrome in caregivers

Table 4 Analysis according to the presence or absence of caregiver

stress syndrome (ZCBI > 21)

10

Gender
Men (n, %)
Women (n, %)
Age (mean  SD)
IBS (n, %)
Civil status (n, %)
Single
Married
Divorced
Widowed
Occupation (n, %)
Homemaker
Employee
Unemployed
Cared-for patient
pathologies (n, %)
Chronic kidney
disease
Cancer
Chronic kidney
disease and diabetes
Neurologic diseases
End-stage AIDS

Anxiety

15

20

r = 0.67, p = 0.001

30

40

50

60
70
Zarit score

80

90

Figure 3 Positive correlation between the Zarit (burden) and anxiety

(HAD) scores.

20

r = 0.58 p = 0.01

Subjects with
caregiver stress
syndrome
(n = 69)

Subjects without
caregiver stress
syndrome
(n = 27)

10 (14%)
59 (86%)
43.02  11
42 (61%)

2 (7%)
25 (93%)
44.07  13.2
5 (18%)

11
52
3
3

p-value

0.34
0.73
0.001*

(16%)
(76%)
(4%)
(4%)

4 (15%)
20 (74%)
0
3 (11%)

0.89
0.89
0.27
0.21

41 (59%)
16 (23%)
12 (18%)

18 (66%)
5 (18%)
4 (14%)

0.51
0.61
0.76

32 (46%)

12 (44%)

0.86

12 (17%)
7 (10%)

7 (26%)
4 (15%)

0.34
0.51

15 (22%)
3 (4%)

3 (11%)
1 (4%)

0.23
0.88

*Chi-square. ZCBI, Zarit Caregiver Burden Interview.

10

DISCUSSION
This study is the first to report the prevalence of IBS in
caregivers of patients with a chronic disease. Caregiving is an activity that causes stress (physical and
psychological) in a population that is highly susceptible to the development of psychosocial disorders.
According to Zarit et al.,28 caregiving burden is defined
as: The extent to which caregivers perceive that
caregiving has had an adverse effect on their emotional,
social, financial, physical, and spiritual functioning.
This definition emphasizes the multidimensional toll
caregiving may exact on care providers and also the fact
that caregiving is an individualized experience.29 Risk
factors for caregiver burden include female gender, low
educational attainment, residing with the care recipient, depression, social isolation, financial stress, higher
number of hours spent caregiving, and lack of choice in
being a caregiver.30
In accordance with the Rome II criteria, in our study,
close to 50% of the subjects taking care of a chronically

Depression

15

(60% vs 18%, p = 0.001, relative risk 3.28, 95% CI:

1.47.4). There were no differences between the subjects that presented with burden and those that did not,
in relation to gender, age, civil status, occupation, or
pathology of the patient in their care (Table 4).

10

20

30

40

50

60

70

Zarit score
Figure 4 Positive correlation between the Zarit (burden) and
depression (HAD) scores.

Analysis according to the prevalence of caregiver

burden
In accordance with the cut-off point of the ZCBI
questionnaire for burden, 69 subjects (72%) were
diagnosed with CSS; 42 of them had IBS according to
the Rome II questionnaire, whereas only five of the
subjects without burden presented with the disease

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J. M. Remes-Troche et al.

Neurogastroenterology and Motility

and economic repercussions, among others, that can

result in the failure of the caregiver to adequately
perform his or her caregiving duties.42,43 Reducing the
burden and improving the well-being of the caretaker
prevent the deterioration of his or her health, which in
turn, reduces the adverse medical events in the
patients receiving the care. Caregiving, even though
stressful, can be emotionally rewarding by strengthening family ties, honoring the past service the caregiver
received from the person now needing care, and saving
family resources.30
As in the majority of studies regarding caregiving,
we found that most of the caregivers were female.
Caregiving worldwide is a womens health issue,
because many more women than men are informal
caregivers.30,44,45 Moreover, in our setting, it is families, not the health and social services, that play the
greatest role in providing continuous care to persons in
need of such services. Several studies from Spain have
shown that it is largely women who assume the
principal role of providing informal care, undertaking
the most difficult and demanding tasks, and dedicating
the largest share of their time to the patient. As a
result, the toll on women is greater, in terms of their
health, quality of life, access to employment and
professional development, social relations, availability
of time for themselves, and economic repercussions.
It is important to mention that the coexistence of
CSS and IBS is a very bad combination, given that
both are situations of stress and present with the
danger of overwhelming and exhausting resources,
affecting the physical health and state of mind of the
caregiver and modifying his or her perception threshold in relation to the suffering and pain of the patient
being cared for.11,23,28 And if the coexistence of worse
quality of life is added, as shown in our study results,
the outcome can be catastrophic. The implications of
our study are important, because the understanding of
novel emotional factors, such as those involved in
caring for a chronically ill patient, can lead the
physician to establish appropriate strategies in an
effort to determine the role and influence of stress in
each case. Furthermore, in these particular cases, the
physician would be more confident in carrying out a
significant mental health intervention through an
interdisciplinary group. One of the methodological
advantages of our study was the fact that it used
scales that were specifically validated for our population, making the results applicable to our clinical
practice.
While our study explores a novel association of
caregiver burden and IBS, there are confounders that
could have affected the results. These include lack of a

ill patient developed symptoms consistent with IBS,

and the probability that this was a consequence of the
generated burden was almost two times greater than
that in subjects that did not develop burden (relative
risk 3.18). We also found that these caregivers had
higher scores for anxiety, depression, and worse quality
of life in practically all the evaluated spheres. Similar
to that reported in other populations, in our study there
was a predominance of primary caregivers that were
direct relatives of the patient, female, and that had no
economic activity.19,23,31 Three main components that
affect these individuals have been identified: the
impact of care, the interpersonal burden, and selfefficacy expectations.23 Recent studies have described
different factors associated with the level of caregiver
burden: the hours of providing care,32 deficient psychosocial support, and a poor work or financial situation23,33; other patient-dependent factors are emotional
state, level of incapacity,32 violent behavior,34 or
urinary incontinence.35 Nevertheless, the relative
importance of these factors is still unclear in relation
to predicting CSS.21,36 There have been reports on
some populations stating that there is no association
between the level or severity of the disease of the
patient and the level of caregiver burden,37,38 just as we
demonstrated in our study.
The only study evaluating CSS and IBS was conducted by Wong et al.24 They analyzed the relatives of
IBS patients and showed that these subjects had higher
Zarit scores than those of a control population, even
higher than caregivers of cancer patients.24 In our
study, the mean ZCBI score was 32.1, but it was 47 in
the caregivers with IBS. Mean ZCBI scores vary
according to the associated pathology; for example, it
was 32.9 in caregivers of patients with dementia,39 52
in caregivers of patients with kidney failure and
hemodialysis,40 and it was as low as 18 in caregivers
of cancer patients.41 This variability may be directly
influenced by the disease; it is known that relatives of
cancer patients have a greater resignation towards and
acceptance of the disease than, for example, those
dealing with patients with kidney failure. The higher
mean in our study could be due to the fact that a large
number of the patients receiving care presented with
end-stage chronic kidney disease. However, other
social and cultural factors that favor greater caregiver
burden in our population cannot be ruled out.
Burden indicates mental exhaustion, anxiety about
providing care, and caregiver health difficulties due to
an accumulation of psychological stress in an individual that does not possess the adequate confrontation
strategies for adapting to the situation. This condition
affects all aspects of the person, with medical, social,

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Irritable bowel syndrome in caregivers

ACKNOWLEDGMENT

control group, prevalence of other functional GI disorders, chronic pain disorders, and psychological disorders in the group with IBS before starting their
caregiving duties, and afterwards. In addition, it is
not known if the IBS symptoms of the caregivers could
be representative of another condition, such as celiac
disease or food intolerances. The study subjects were
recruited at referral centers from different localities,
and from diverse socioeconomic strata, making it
difficult to include an adequate control group. Even
though it appears that the majority of the caregivers
developed symptoms starting from the time they began
to take care of the chronically ill patient, there was an
obvious recall bias that was difficult to eliminate. It is
also important to mention that IBS QoL is a diseasespecific questionnaire, thus non-IBS subjects would be
expected to have lower scores. Finally, despite the fact
that we did not employ a scale for evaluating IBS
severity, we used anxiety and depression scales as
subrogates of more severe disease.
In conclusion, this is the first study showing that
caregivers of chronically ill patients have a high
prevalence (49%) of IBS, which is associated with
depression, anxiety, and poor quality of life. This
association is novel and should be regarded as another
psychological condition associated with IBS.

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2 Gralnek IM, Hays RD, Kilbourne A,
Naliboff B, Mayer EA. The impact of
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3 Creed F, Ratcliffe J, Fernandez L,
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JK. Systematic review and meta-

2015 John Wiley & Sons Ltd

10

11

JM Remes-Troche accepts full responsibility for the conduct of the

study.

FUNDING
This study was funded by an internal grant from the Medical
Biological Research Institute, Universidad Veracruzana, Veracruz,
Mexico.

CONFLICTS OF INTEREST
Jos

e Mar
a Remes-Troche is a member of the Advisory Counsel
for Takeda Pharmaceuticals, Alfa-Wassermann, Almirall, and
Janssen. He has been a speaker for Nycomed- Takeda, Advance
Medical, Endomedica, Astra-Zeneca, and Bristol-Myers-Squibb.
He has received research funding from Sanofi-Pasteur, Asofarma,
and Astra Zeneca. M Torres- Aguilera, V Montes-Mart
nez, VA
Jimen

ez-Garc
a, and F Roesch-Dietlen do not have any conflict of
interest.

AUTHOR CONTRIBUTION
JMR-T contributed to the planning and/or the conducting of the
study, interpreting data, and drafting the manuscript; MT-A, VMM, and VAJ-G contributed to the conducting of the study and to
interpreting data; FR-D contributed to the conducting and drafting
of the manuscript. All authors have approved the final draft
submitted.

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