ABSTRACT
Introducción y objetivos: Aunque las guías de práctica clínica recomiendan una estrategia invasiva para el infarto agudo de miocardio sin elevación del segmento ST (IAMSEST), en la práctica clínica esta estrategia se infrautiliza en ancianos frágiles. Además estos enfermos habitualmente quedan excluidos de los ensayos clínicos, por lo que la evidencia es escasa. Nuestra hipótesis es que una estrategia invasiva para el anciano con fragilidad y IAMSEST mejorará el pronóstico. Métodos: Se trata de un estudio prospectivo, multicéntrico y aleatorizado que compara una estrategia invasiva frente a una conservadora en ancianos frágiles con IAMSEST. Los criterios de inclusión son: IAMSEST, edad ≥ 70 años y fragilidad definida por al menos 4 criterios de la escala Clinical Frailty Scale. Se aleatorizará a los participantes a una estrategia invasiva (coronariografía y revascularización si se considera anatómicamente indicada) o conservadora (tratamiento médico y coronariografía solo en caso de inestabilidad clínica persistente). El objetivo principal será el número de días vivo fuera del hospital durante el primer año. El objetivo coprincipal será el tiempo hasta la presentación de muerte cardiovascular, reinfarto agudo de miocardio o revascularización tras el alta. El tamaño de la muestra estimado es de 178 pacientes (89 por grupo), asumiendo un incremento del 20% en la proporción de días vivo fuera del hospital con la estrategia invasiva. Resultados: Los resultados del estudio aportarán información novedosa para el tratamiento del anciano frágil con IAMSEST. Conclusiones: Nuestra hipótesis es que una estrategia invasiva mejorará el pronóstico de los pacientes ancianos frágiles con IAMSEST. Si esta hipótesis se confirmara, la situación de fragilidad no debería disuadir al cardiólogo de indicar un tratamiento invasivo. Ensayo registrado en ClinicalTrials.gov (Identificador: NCT03208153)
Introduction and objectives: Although clinical guidelines recommend invasive management in non-ST-segment elevation myocardial infarction (NSTEMI), this strategy is underused in frail elderly patients in the real world. Furthermore, these patients are underrepresented in clinical trials and therefore the evidence is scarce. Our hypothesis is that an invasive strategy will improve prognosis in elderly frail patients with NSTEMI. Methods: This will be a prospective, multicenter, randomized trial, in which the conservative and invasive strategies will be compared in patients meeting all of the following inclusion criteria: NSTEMI diagnosis, age ≥ 70 years, and frailty defined by a category ≥ 4 in the Clinical Frailty Scale. Participants will be randomized to an invasive (coronary angiogram and revascularization if anatomically amenable) or conservative (medical treatment and coronary angiogram only if persistent clinical instability) strategy. The primary endpoint will be the number of days alive out of hospital during the first year. The coprimary endpoint will be the time until the first cardiac event (cardiac death, reinfarction or postdischarge revascularization). We estimate a sample size of 178 patients (89 per arm), considering an increase of 20% in the proportion of days alive out of hospital with the invasive management. Results: The results of this study will add important knowledge to inform the management of frail elderly patients hospitalized with NSTEMI. Conclusions: We hypothesize that the invasive strategy will improve outcomes in frail elderly patients with NSTEMI. If this is confirmed, frailty status should not dissuade physicians from implementing an invasive management strategy. Clinical trial registration: URL: http://www.clinicaltrials.gov .Identifier: NCT03208153
Subject(s)
Humans , Male , Female , Aged , Aged, 80 and over , Non-ST Elevated Myocardial Infarction/therapy , Frailty/complications , Coronary Angiography/statistics & numerical data , Percutaneous Coronary Intervention/methods , Prospective Studies , Frail Elderly/statistics & numerical data , Myocardial Revascularization/statistics & numerical dataABSTRACT
INTRODUCTION AND OBJECTIVES: Although clinical guidelines recommend invasive management in non-ST-segment elevation myocardial infarction (NSTEMI), this strategy is underused in frail elderly patients in the real world. Furthermore, these patients are underrepresented in clinical trials and therefore the evidence is scarce. Our hypothesis is that an invasive strategy will improve prognosis in elderly frail patients with NSTEMI. METHODS: This will be a prospective, multicenter, randomized trial, in which the conservative and invasive strategies will be compared in patients meeting all of the following inclusion criteria: NSTEMI diagnosis, age ≥ 70 years, and frailty defined by a category ≥ 4 in the Clinical Frailty Scale. Participants will be randomized to an invasive (coronary angiogram and revascularization if anatomically amenable) or conservative (medical treatment and coronary angiogram only if persistent clinical instability) strategy. The primary endpoint will be the number of days alive out of hospital during the first year. The coprimary endpoint will be the time until the first cardiac event (cardiac death, reinfarction or postdischarge revascularization). We estimate a sample size of 178 patients (89 per arm), considering an increase of 20% in the proportion of days alive out of hospital with the invasive management. RESULTS: The results of this study will add important knowledge to inform the management of frail elderly patients hospitalized with NSTEMI. CONCLUSIONS: We hypothesize that the invasive strategy will improve outcomes in frail elderly patients with NSTEMI. If this is confirmed, frailty status should not dissuade physicians from implementing an invasive management strategy. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov.Identifier: NCT03208153.
Subject(s)
Conservative Treatment , Frail Elderly , Non-ST Elevated Myocardial Infarction/therapy , Aged , Coronary Angiography , Humans , Multicenter Studies as Topic , Myocardial Revascularization , Prospective Studies , Randomized Controlled Trials as Topic , Sample Size , Treatment OutcomeABSTRACT
There are discrepancies about whether children who witness and suffer domestic violence (DV) have similar outcomes in terms of psychopathology. This work examines the relationship between different types of exposure to DV and child psychopathology and functional impairment. One hundred and forty-four Spanish children aged from 4 to 17 years and exposed to DV were evaluated using a diagnostic interview and other instruments of psychopathology and functional impairment. The participants were classified in three groups according to the degree of exposure: witness (n = 72), involved (n = 52), and victim (n = 20). According to mothers' self-reports and mother-child combined information, DV equally affects psychopathology and functional impairment regardless of the degree of the exposure. Children's self-reports showed a linear trend to present greater psychopathology as a victim than as a witness. The differential effect of exposure to DV measured in this study depended on the informant, which underlines the importance of obtaining information from the children exposed to violence at home.
Subject(s)
Awareness , Child Behavior Disorders , Crime Victims/psychology , Domestic Violence/psychology , Psychopathology , Adolescent , Child , Child Behavior Disorders/diagnosis , Child Behavior Disorders/etiology , Child Behavior Disorders/psychology , Child, Preschool , Female , Humans , Interviews as Topic , Male , Spain , Surveys and QuestionnairesABSTRACT
La terapia de reperfusión ha supuesto un notable descenso de la morbimortalidad hospitalaria y a largo plazo de los pacientes con infarto agudo de miocardio. En los últimos años, se ha demostrado que la angioplastia es más eficaz que la fibrinolisis siempre que se realice en un intervalo de tiempo adecuado. Sin embargo, la angioplastia primaria no es el tratamiento mayoritariamente utilizado debido a que requiere una infraestructura adecuada y una organización muy eficiente. Para incrementar el uso de la angioplastia primaria y homogeneizar el tratamiento de los pacientes con infarto agudo de miocardio hemos revisado las principales barreras del circuito de la angioplastia primaria. Se describen diferentes estrategias que permiten acortar el tiempo puerta-balón y distintos programas de carácter nacional, regional y local que han facilitado el acceso a la angioplastia primaria y han mejorado los tiempos de reperfusión (AU)
Reperfusion therapy has led to significant reductions in in-hospital and long-term morbidity and mortality in patients with acute myocardial infarction. In recent years, it has been shown that angioplasty is more effective than fibrinolysis if it can be carried out within a short enough timescale. Nevertheless, angioplasty is not widely used because it requires a dedicated infrastructure and highly efficient organization. In order to increase access to primary angioplasty and to standardize treatment for patients with acute myocardial infarction, we carried out a review of the main hurdles to the use of primary angioplasty. This article describes the various strategies available for reducing the door-to-balloon time and reviews national, regional and local programs that have increased access to primary angioplasty and improved the time to reperfusion (AU)
Subject(s)
Humans , Health Strategies , Angioplasty/methods , Myocardial Reperfusion/methods , Myocardial Infarction/diagnosis , Myocardial Infarction/therapy , Myocardial Infarction/surgery , Angioplasty, Balloon, Coronary/instrumentation , Angioplasty, Balloon, Coronary/standardsABSTRACT
The registry contains information collected during 2003 from thirteen Spanish hospitals on the incidence, clinical presentation, initial course, diagnostic imaging, and treatment of anomalous coronary arteries originating in the contralateral coronary sinus. In a total of 23,300 coronary angiograms, 98 anomalous coronary arteries were detected (incidence 0.4%): 46 circumflex coronary arteries (47%), 25 right coronary arteries (25.5%), 10 left main coronary arteries (10.2%), three left anterior descending arteries (3.1%), six single coronary arteries (6.1%), and eight other anomalies (8.2%). The most frequent indication for angiography was angina (43.9%). The initial course of the anomalous coronary artery was not identified in 40.8% of cases. In two patients (2%), diagnostic imaging was used to identify the initial course. Associated atherosclerotic disease was present in 51% of patients. In addition, 18.4% had associated valvular disease, with the aortic valve being affected most often (15.2%). Some 16.3% of patients underwent treatment for the coronary anomaly. The incidence was similar to that observed in other published series, with anomalies in the circumflex coronary artery being diagnosed most frequently. Diagnostic imaging was underused.
Subject(s)
Coronary Vessel Anomalies , Registries , Sinus of Valsalva/abnormalities , Adolescent , Adult , Age Factors , Aged , Aged, 80 and over , Coronary Angiography , Coronary Artery Disease/epidemiology , Coronary Vessel Anomalies/complications , Coronary Vessel Anomalies/diagnostic imaging , Coronary Vessel Anomalies/epidemiology , Coronary Vessel Anomalies/therapy , Female , Humans , Incidence , Male , Middle Aged , Sex Factors , SpainABSTRACT
Este registro estudió la incidencia, la clínica asociada, el trayecto, los métodos diagnósticos de imagen y el tratamiento de las anomalías coronarias con origen en el seno coronario contralateral en 13 hospitales durante 2003. En 23.300 coronariografías se describieron 98 anomalías (incidencia del 0,4%): 46 circunflejas (47%), 25 coronarias derechas (25,5%), 10 coronarias izquierdas (10,2%), 3 descendentes anteriores (3,1%), 6 coronarias únicas (6,1%) y 8 incluidas en el apartado «otras» (8,2%). El motivo de la coronariografía más frecuente fue la angina (43,9%). El trayecto inicial de la coronaria anómala no fue identificado en el 40,8% de los casos. En 2 pacientes (2%) se emplearon métodos de imagen asociados. El 51% tenía enfermedad coronaria asociada y el 18,4%, valvular; la válvula aórtica era la más afectada (15,2%). El 16,3% recibió tratamiento para la anomalía. Se observó una incidencia similar a la de series previas, y las anomalías de la circunfleja fueron las más frecuentes. Los métodos de imagen asociados para el diagnóstico del trayecto inicial fueron infrautilizados
The registry contains information collected during 2003 from thirteen Spanish hospitals on the incidence, clinical presentation, initial course, diagnostic imaging, and treatment of anomalous coronary arteries originating in the contralateral coronary sinus. In a total of 23,300 coronary angiograms, 98 anomalous coronary arteries were detected (incidence 0.4%): 46 circumflex coronary arteries (47%), 25 right coronary arteries (25.5%), 10 left main coronary arteries (10.2%), three left anterior descending arteries (3.1%), six single coronary arteries (6.1%), and eight other anomalies (8.2%). The most frequent indication for angiography was angina (43.9%). The initial course of the anomalous coronary artery was not identified in 40.8% of cases. In two patients (2%), diagnostic imaging was used to identify the initial course. Associated atherosclerotic disease was present in 51% of patients. In addition, 18.4% had associated valvular disease, with the aortic valve being affected most often (15.2%). Some 16.3% of patients underwent treatment for the coronary anomaly. The incidence was similar to that observed in other published series, with anomalies in the circumflex coronary artery being diagnosed most frequently. Diagnostic imaging was underused
Subject(s)
Male , Female , Adult , Aged , Adolescent , Middle Aged , Aged, 80 and over , Humans , Coronary Vessel Anomalies , Incidence , Sex Factors , Age Factors , Coronary Angiography , Coronary Artery Disease/epidemiology , Coronary Vessel Anomalies/complications , Coronary Vessel Anomalies/epidemiology , Coronary Vessel Anomalies/therapy , SpainABSTRACT
En las últimas décadas ha habido un aumento importante del numero de estudios centrados en los aspectos neuropsicológicos de la esquizofrenia, los cuales han pretendido conocer los déficits cognitivos que presentan los pacientes esquizofrénicos y las consecuencias de estos déficits en su adaptación funcional. El reconocimiento de la importancia de los déficits cognitivos en la esquizofrenia ha generado un creciente interés por la posible modificación de éstos a través de la rehabilitación cognitiva. En este trabajo presentamos los principales déficits neuropsicológicos asociados a la esquizofrenia y las consecuencias de estos déficits y realizamos una revisión en relación a los efectos de la rehabilitación cognitiva en el rendimiento cognitivo y social de las personas con esquizofrenia. (AU)
Subject(s)
Humans , Schizophrenia/physiopathology , Cognition Disorders/physiopathology , Cognitive Behavioral Therapy/methods , Neuropsychology/methods , Neuropsychological Tests , Cognition Disorders/therapy , Cognition Disorders/rehabilitationABSTRACT
Desde ya hace algunas décadas existe una polémica creciente respecto al hecho de si la depresión melancólica en edades geriátricas debería constituir una entidad nosológica distinta a la del resto de depresiones. Varios estudios han constatado que existen factores biológicos, psicológicos y sociales diferenciales entre ellas que podrían justificar tal distinción. Además, recientemente, encontramos numerosos estudios que apoyan la hipótesis de que la depresión geriátrica constituye un factor de riesgo para el desarrollo de una demencia. Y aunque de sobras es conocida la diversidad de diagnósticos posibles de trastornos afectivos y también la heterogeneidad en su presentación clínica, en este artículo se revisaran algunas de las últimas investigaciones sobre el papel de la depresión involutiva en el desarrollo de una futura demencia y el papel de otros factores dentro de esta asociación. Finalmente, se expondrán también las hipótesis etiológicas para esta asociación más defendidas en la actualidad (AU)
