Vasculitis reumatoidea: una manifestación poco habitual. Presentación de tres casos clínicos y revisión de la literatura

La vasculitis reumatoidea es una complicación sistémica y poco frecuente de la Artritis Reumatoidea. Si bien su incidencia ha descendido en los últimos años con el advenimiento de las nuevas terapias inmunosupresoras y biológicas, continua teniendo una alta morbimortalidad. Predomina en el sexo masculino, en pacientes seropositivos y con un largo período de la enfermedad establecida. Requiere de alta presunción diagnostica, siendo el compromiso cutáneo y nervioso periférico el más frecuente. La biopsia de nervio o piel es requerida habitualmente para su diagnóstico. El tratamiento se basa en corticoides e inmunosupresores. Presentamos tres casos clínicos y realizamos una revisión de la literatura.

Rheumatoid vasculitis is a rare systemic complication of rheumatoid arthritis. Although its incidence has decreased in recent years with the advent of new immunosuppressive and biological therapies, it continues to have a high morbidity and mortality. It predominates in males, in seropositive patients and with a long period of established disease. It requires high diagnostic presumption, with skin and peripheral nervous involvement being the most affected. Nerve or skin biopsy is usually required for diagnosis. Treatment is based on corticosteroids and immunosuppressants. We present three clinical cases and carry out a review of the literature.

A vasculite reumatóide é uma complicação sistêmica rara da artrite reumatóide. Embora sua incidência tenha diminuído nos últimos anos com o advento de novas terapias imunossupressoras e biológicas, continua apresentando elevada morbidade e mortalidade. Predomina no sexo masculino, em pacientes soropositivos e com longo período de doença estabelecida. Exige alta presunção diagnóstica, sendo o envolvimento cutâneo e nervoso periférico os mais afetados. A biópsia de nervo ou pele geralmente é necessária para o diagnóstico. O tratamento é baseado em corticosteroides e imunossupressores. Apresentamos três casos clínicos e realizamos uma revisão da literatura.

Effectiveness and safety of neoadjuvant therapy in triple-negative breast cancer in a real-world population.

OBJECTIVE: Triple-negative breast cancer is a subtype of aggressive breast cancer. Our aim is to evaluate the effectiveness and safety of neoadjuvant treatment in early-stage triple-negative breast cancer and to identify predictors of pathological complete response. METHODS: This is a single-center, retrospective study involving 79 patients with triple-negative breast cancer who initiated neoadjuvant treatment between January 2017 and October 2022. Descriptive analyses were performed as appropriate. Statistical analysis utilized bivariate logistic regression to explore the presence of factors related to pathological complete response, and the Kaplan-Meier method was employed for survival analysis. RESULTS: In the overall population, 27 patients (n=78; 34.6%) achieved pathological complete response in the breast and axillary lymph nodes, and 31 (n=73; 42.5%) achieved a grade 5 pathological complete response in the breast, according to the Miller and Payne classification. The addition of platinum to standard therapy improved both breast and axillary lymph node pathological complete response rates. Age less than 40 years was identified as a predictor of pathological complete response in our study population through bivariate analysis, while Ki67 levels lower than 70% were associated with a lower pathological complete response rate. Adverse events were reported in 72 patients (91.1%), with grade 3-5 adverse events observed in 33 (41.8%). There was a particularly notable increase in gastrointestinal and hematological adverse events when platinum was added. CONCLUSIONS: In this population, we observed moderate rates of pathological complete response with acceptable chemotherapy tolerance. Platinum-based chemotherapy appears to enhance the likelihood of achieving pathological complete response, albeit with a less favorable safety profile. Therefore, evaluating the benefit-risk balance is crucial when selecting the optimal chemotherapy regimen for individual patients.

EFFICACY AND SAFETY OF BIOLOGICAL TREATMENT FOR INFLAMMATORY BOWEL DISEASE IN ELDERLY PATIENTS: RESULTS FROM A GETECCU COHORT.

INTRODUCTION: Biological therapies used for the treatment of inflammatory bowel disease (IBD) have shown to be effective and safe, although these results were obtained from studies involving mostly a young population, who are generally included in clinical trials. The aim of our study was to determine the efficacy and safety of the different biological treatments in the elderly population. METHODS: Multicenter study was carried out in the GETECCU group.Patients diagnosed with IBD and aged over 65 years at the time of initiating biological therapy (infliximab, adalimumab, golimumab, ustekinumab or vedolizumab) were retrospectively included. Among the patients included, clinical response was assessed after drug induction (12 weeks of treatment) and at 52 weeks. Patients' colonoscopy data in week 52 were assesment, where available. Regarding complications, development of oncological events during follow-up and infectious processes occurring during biological treatment were collected (excluding bowel infection by cytomegalovirus). RESULTS: A total of 1090 patients were included. After induction, at approximately 12-14 weeks of treatment, 419 patients (39.6%) were in clinical remission, 502 patients (47.4%) had responded without remission and 137 patients (12.9%) had no response. At 52 weeks of treatment 442 patients (57.1%) had achieved clinical remission, 249 patients had responded without remission (32.2%) and 53 patients had no response to the treatment (6.8%). Before 52 weeks, 129 patients (14.8%) had discontinued treatment due to inefficacy, this being significantly higher (p<0.0001) for Golimumab - 9 patients (37.5%) - compared to the other biological treatments analysed. With respect to tumor development, an oncological event was observed in 74 patients (6.9%): 30 patients (8%) on infliximab, 23 (7.14%) on adalimumab, 3 (11.1%) on golimumab, 10 (6.4%) on ustekinumab, and 8 (3.8%) on vedolizumab. The incidence was significantly lower (p = 0.04) for the vedolizumab group compared to other treatments.As regards infections, these occurred in 160 patients during treatment (14.9%), with no differences between the different biologicals used (p = 0.61): 61 patients (19.4%) on infliximab, 39 (12.5%) on adalimumab, 5 (17.8%) on golimumab, 22 (14.1%) on ustekinumab, and 34 (16.5%) on vedolizumab. CONCLUSIONS: Biological drug therapies have response rates in elderly patients similar to those described in the general population, Golimumab was the drug that was discontinued most frequently due to inefficacy.

Effect of stainless-steel wire internal fixation on intracapsular condylar fracture.

OBJECTIVES: The aim of the study was to investigate the clinical effect of stainless-steel wire fixation on the early mouth-opening movement of an intracapsular fracture involving the condylar process. MATERIALS AND METHODS: In this study, patients who underwent mandibular condylar intracapsular fracture surgery in our hospital from 2012 to 2020 were selected as research subjects. A total of 44 patients received steel wire internal fixation treatment, 32 patients received titanium plate-and-nail rigid internal fixation, and 28 patients underwent conservative non-surgical treatment. RESULTS: For the patients in the stainless-steel wire group, the degree of mouth opening reached normal levels of 3.7 cm approximately 10 days after surgery. The recovery time for the patients in the titanium plate-and-nail rigid internal-fixation group was 21 days, while the patients in the conservative treatment group needed 60 days to recover. CONCLUSION: The treatment of fixation with a stainless-steel wire for intracapsular condylar fracture reduced the time taken to perform mouth-opening exercises and improved the recovery rate of patients.

OBJETIVO: Explorar el efecto clínico de la fijación de alambre de acero inoxidable en el movimiento temprano de apertura de la boca en la fractura interna del cóndilo. MÉTODO: Este estudio seleccionó a pacientes que se sometieron a cirugía de fractura intracapsular de cóndilo en nuestro hospital de 2012 a 2020 como sujetos de investigación. Un total de 44 pacientes recibieron tratamiento de fijación interna de alambre de acero, 32 recibieron placa de titanio y fijación interna con clavos, y 28 recibieron tratamiento conservador no quirúrgico. RESULTADOS: En los pacientes del grupo de alambre de acero inoxidable, alrededor de 10 días después de la cirugía el grado de apertura de la boca alcanzó un valor normal de 3.7 cm. El tiempo de recuperación de los pacientes en el grupo de fijación interna con clavos y placa de titanio fue de 21 días, mientras que los pacientes en el grupo de tratamiento conservador tardaron 60 días en recuperarse. CONCLUSIONES: La fijación con alambre de acero inoxidable para el tratamiento de la fractura intracapsular del cóndilo acorta el tiempo hasta la apertura de la boca y mejora la tasa de recuperación de los pacientes.

Superior versus anteroinferior plating for mid-shaft clavicle fractures: a randomized clinical trial.

BACKGROUND: Clavicle fractures represent 2.5-4% of all fractures observed in emergency services. 80% occurs in the middle third. Treatment by plating requires a higher level of evidence. OBJECTIVE: To compare the functional outcomes of mid-shaft clavicle fractures managed with superior plating compared to anteroinferior plating. TRIAL DESIGN: A randomized, double-blind, parallel, superiority clinical trial. PATIENTS AND METHODS: Patients with fractures of the clavicles AO15B1 and AO15B2 were studied. Patients were randomized to be treated with either 3.5 mm superior or anteroinferior plating. A rehabilitation program was designed for both groups. The primary outcome measure was the Disability of Arm, Shoulder, and Hand (DASH) score; secondary outcomes included pain, union rate, and complication rates. RESULTS: Twenty-eight patients were studied and were eligible for analysis. Significant differences were found in the function assessed with the DASH score at 30 days for the superior plating compared with anteroinferior (43.74 vs. 29.26, respectively, p = 0.027), 60 days (23.97 vs. 11.18, p = 0.021), and 90 days (9.52 vs. 3.5, p = 0.016). One loosening with superficial infection was found with superior plating. CONCLUSIONS: Using an anteroinferior reconstruction plate in diaphyseal fractures offers better functional results than the upper plate in patients with fractures of the middle third of the clavicle.

ANTECEDENTES: Las fracturas de clavícula comprenden el 2.5-4% de todas las fracturas observadas en los servicios de emergencia. El 80% se presentan en el tercio medio. La posición de la placa como tratamiento requiere mayor nivel de evidencia. OBJETIVO: Comparar los resultados funcionales de las fracturas diafisarias de clavícula manejadas con placa superior versus placa anteroinferior. MÉTODO: Ensayo clínico aleatorizado, doble ciego, paralelo, de superioridad. Se estudiaron pacientes con fractura diafisaria de clavícula AO15B1 y AO15B2. Se manejaron con placa de reconstrucción de 3.5 mm colocada en forma superior o anteroinferior. Se diseñó un programa de rehabilitación para ambos grupos. El resultado primario fue medido con el cuestionario DASH y los resultados secundarios incluyeron dolor, presencia de consolidación y complicaciones. RESULTADOS: Fueron elegibles para análisis 28 pacientes. Se encontraron diferencias significativas de la escala DASH a los 30 días para la maniobra superior comparada con la inferior (43.74 vs. 29.26, respectivamente; p = 0.027), a los 60 días (23.97 vs. 11.18; p = 0.021) y a los 90 días (9.52 vs. 3.5; p = 0.016). CONCLUSIONES: El uso de placa de reconstrucción anteroinferior en las fracturas diafisarias ofrece mejores resultados funcionales en comparación con la placa superior en pacientes con fracturas de tercio medio de clavícula.

Characteristics and type of strabismus associated to macular diplopia. Treatment outcomes.

OBJECTIVE: To study the clinical characteristics of macular diplopia, treatment, and outcome. METHODS: Retrospective descriptive study of cases referred to the ocular motility section of a tertiary hospital with diplopia, diagnosed with macular diplopia between 2022-23. The etiology of the macular pathology and the type of associated strabismus were recorded. The result was considered good if the diplopia improved or was eliminated with the medical or surgical treatment. Follow-up time from the onset of diplopia until data collection was recorded. RESULTS: a total of 19 cases comprised the sample (63.2% women), mean age: 67.16 years. Amblyopia (21.1%), high myopia (47.4%), epirretinal membrane (ERM) (36.8%), neovascular membrane (26.3%), macular hole (10.5%), and lamellar (15.8%), and age macular degeneration (5.3%) were registered. The 47.4% had vertical diplopia, horizontal: 5.3 and 47.4% mixed. The mean horizontal deviation was: 7.3 PD (prism diopters) and vertical: 6.22 PD. Ocular extorsion was observed in 26.3%, and intorsion: 5.3%. Torticollis was present in 15.8%. The treatment consisted of strabismus surgery + Botox (15.8%), strabismus surgery (47.4%), medical treatment with Fresnel prims or Scotch cellophane (36.8%). A 68.4% presented a good result at the end of the study. The mean follow-up was 55.58 months. CONCLUSIONS: Misregistration of macular photoreceptors is the most common cause of binocular diplopia in patients with ERM or other macular pathologies. Most complains of vertical or mixed diplopia. Sensorimotor evaluation of these patients should be thorough. Early diagnosis prevents unnecessary prescription of prism glasses. Surgical and/or medical treatment achieves good results in most cases.

Veterans' 12-month PTSD and depression outcomes following 2- and 3-week intensive cognitive processing therapy-based treatment.

Background: Growing evidence indicates that daily delivery of evidence-based PTSD treatments (e.g. Cognitive Processing Therapy (CPT)), as part of intensive PTSD treatment programmes (ITPs), is feasible and effective. Research has demonstrated that a 2-week CPT-based ITP can produce equivalent outcomes to a 3-week ITP, suggesting shorter treatment can also be highly effective. However, the extent to which ITP length and composition impact longer-term outcomes needs further study.Objective: We examined whether PTSD and depression symptoms 3-, 6-, and 12-months following completion of a 2-week ITP could be considered non-inferior, or equivalent, to those of a 3-week ITP.Method: Data from 638 veterans who participated in a 2-week CPT-based ITP were evaluated against 496 veterans who participated in a 3-week CPT-based ITP. A Bayes factor approach was used to examine whether PTSD and depression severity outcomes of the 2-week ITP could be considered equivalent to the 3-week ITP.Results: Participants across both ITPs reported large PTSD (d = 0.98) and moderate to large depression symptom reductions (d = 0.69) from baseline to 12-month follow-up. The PTSD and depression symptom reductions seen in the 2-week ITP were determined to be equivalent to those of the 3-week ITP.Conclusions: Low follow-up completion was a limitation. Future research might replicate the present findings using samples with greater follow-up rates and explore whether adjunctive services impact other relevant constructs, such as quality of life and functioning.

This study demonstrated that intensive PTSD treatment programmes for veterans can produce large and lasting PTSD and depression symptoms reductions.A 2-week intensive PTSD treatment programme that offered 37 fewer clinical hours was just as effective as a 3-week programme for veterans, with lasting symptom improvement up to 12 months after treatment.The 2-week programme focused primarily on individual Cognitive Processing Therapy delivered twice per day whereas the 3-week programme combined individual and group CPT and had a much larger number of adjunctive services.

Withdrawal of drug therapy in responders to cardiac resynchronization therapy: rationale and design of the REMOVE trial.

INTRODUCTION AND OBJECTIVES: Cardiac resynchronization therapy (CRT) is an effective treatment for patients with nonischemic dilated cardiomyopathy associated with left bundle branch block (LBBB). In these patients, the device can normalize left ventricular ejection fraction (LVEF). Nevertheless, it remains unclear whether CRT responders still require neurohormonal blockers. The aim of this study is to determine the long-term safety of withdrawing drug therapy in these patients. METHODS: The REMOVE trial is a prospective, multicenter, open-label and randomized 1:1 study designed to assess the effect of withdrawing neurohormonal blockers in patients with nonischemic dilated cardiomyopathy associated with left bundle branch block who recovered LVEF after CRT. The study will include a 12-month follow-up with the option to continue into the follow-up extension phase for up to 24 months. The primary endpoint is the recurrence of cardiomyopathy defined as any of the following criteria: a) a reduction in LVEF >10% (provided the LVEF is <50%); b) a reduction in LVEF >10% accompanied by an increase >15% in the indexed end-systolic volume relative to the previous value and in a range higher than the normal values, or c) decompensated heart failure requiring intravenous diuretic administration. In patients meeting the primary endpoint, drug therapy will be restarted. CONCLUSIONS: The results of this study will help to enhance our understanding of CRT superresponders, a specific group of patients. Registred at ClinicalTrials.gov (Identifier: NCT05151861).

Update on the treatment of tuberculosis. / Actualización sobre el tratamiento de la tuberculosis.

Tuberculosis (TB) affects more than 10 million people each year. We have contested this burden with a paradoxically slow development of treatments, as compared to other infectious diseases. This review aims to update health care professionals on the last developments for the management of TB. The combination of drugs established more than 40years ago is still adequate to cure most people affected by TB. However, with the generalisation of regimens based on rifampicin and isoniazid for (only) 6months, resistance emerged. Resistant cases needed long treatments based on injectable drugs. Now, after an exciting decade of research, we can treat resistant TB with oral regimens based on bedaquiline, nitroimidazoles, and linezolid for (only) 6months, and we may soon break the 6-month barrier for treatment duration. However, these improvements are not enough to end TB without an engagement of people affected and their communities to achieve adherence to treatment, transmission control, and improve socioeconomic determinants of health.

New developments in infective endocarditis.

Infective endocarditis is a continually evolving disease. Present-day patients differ significantly from those treated a few decades ago: they tend to be older and have more comorbidities and health care-related episodes, while new groups of patients have emerged with new types of endocarditis, such as those affecting patients with percutaneous valve prostheses. There have also been changes in diagnostic techniques. Although transthoracic and transesophageal echocardiography are still the most commonly used imaging modalities, other techniques, such as 3-dimensional transesophageal ultrasound, cardiac computed tomography, and nuclear medicine tests (PET/CT and SPECT/CT), are increasingly used for diagnosing both the disease and its complications. In recent years, there have also been significant developments in antibiotic therapy. Currently, several treatment strategies are available to shorten the hospital phase of the disease in selected patients, which can reduce the complications associated with hospitalization, improve the quality of life of patients and their families, and reduce the health care costs of the disease. This review discusses the main recent epidemiological, diagnostic and therapeutic developments in infective endocarditis.

First Mexican Consensus on Crohn's disease.

INTRODUCTION: Crohn's disease (CD) is a subtype of chronic and incurable inflammatory bowel disease. It can affect the entire gastrointestinal tract and its etiology is unknown. OBJECTIVE: The aim of this consensus was to establish the most relevant aspects related to definitions, diagnosis, follow-up, medical treatment, and surgical treatment of Crohn's disease in Mexico. MATERIAL AND METHODS: Mexican specialists in the areas of gastroenterology and inflammatory bowel disease were summoned. The consensus was divided into five modules, with 69 statements. Applying the Delphi panel method, the pre-meeting questions were sent to the participants, to be edited and weighted. At the face-to-face meeting, all the selected articles were shown, underlining their level of clinical evidence; all the statements were discussed, and a final vote was carried out, determining the percentage of agreement for each statement. RESULTS: The first Mexican consensus on Crohn's disease was produced, in which recommendations for definitions, classifications, diagnostic aspects, follow-up, medical treatment, and surgical treatment were established. CONCLUSIONS: Updated recommendations are provided that focus on definitions, classifications, diagnostic criteria, follow-up, and guidelines for conventional medical treatment, biologic therapy, and small molecule treatment, as well as surgical management.

Diagnosis and treatment of deep vein thrombosis of the lower and upper limbs. 2024 recommendations of the venous thromboembolism group of the Spanish Society of Internal Medicine.

Deep vein thrombosis (DVT) of the limbs is a common disease and causes significant morbidity and mortality. It is frequently the prelude to pulmonary embolism (PE), it can recur in 30% of patients and in 25-40% of cases they can develop post-thrombotic syndrome (PTS), with a significant impact in functional status and quality of life. This document contains the recommendations on the diagnosis and treatment of acute DVT from the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI). PE and thrombosis of unusual venous territories (cerebral, renal, mesenteric, superficial, etc.) are outside its scope, as well as thrombosis associated with catheter and thrombosis associated with cancer, which due to their peculiarities will be the subject of other positioning documents of the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI).

Strategies for prevention and treatment of SARS-COV-2 infection in patients with chronic kidney disease: Literature review.

COVID-19 has proven to be particularly aggressive in patients with chronic kidney disease (CKD). The lower immune response rate and the greater susceptibility to progress to severe forms of the disease have contributed to this phenomenon, which has persisted in the post-vaccination era of the pandemic. Paradoxically, CKD has been excluded from most clinical trials of the main therapeutic tools developed against SARS-CoV-2. However, experience in the use of these drugs has been accumulating in different stages of CKD, supporting their use with guarantees of efficacy and safety. The objective of this review is to gather all treatment indications for COVID-19 in the different phases of the disease, tailored to CKD in its various stages, including renal replacement therapy.

Analysis of antiretroviral therapy interruption in people living with HIV during the 2010-2021 Period. / [Artículo traducido] Análisis de la interrupción de la terapia antirretroviral en personas que viven con VIH/sida durante el periodo 2010­2021.

OBJECTIVE: In the context of the advancement of antiretroviral therapy and, as the characteristics of people living with HIV progress toward an aging population, understanding the causes of treatment interruption becomes crucial. The aim of the study was to determine the change in reasons for antiretroviral treatment discontinuation for 12 years. Secondarily, compare annual antiretroviral regimen discontinuation rate and factors associated. METHODS: We conducted an analysis using data from people living with HIV who were receiving antiretroviral therapy and discontinued it for any reason. The study included people with HIV infection who visited an outpatient hospital pharmacy clinic from January 2010 to December 2021. Two periods were differentiated for the analysis: 2010-2015 and 2016-2021. The reasons for antiretroviral treatment discontinuation followed classification described by Swiss cohort. In the context of this study, it is pertinent to note that the term 'interruption' will be consistently used in this article to refer to the act of switching or stopping antiretroviral treatment. To examine factors associated with antiretroviral therapy discontinuation, we utilized Kaplan-Meier methods and Cox proportional models. RESULTS: We included 789 people living with HIV, predominantly male (81,5%). The main reason for discontinuation was clinical decision (50.2%) followed by adverse effects (37.9%). Focusing on clinical decision, we observed a trend change that went from antiretroviral treatment simplification regimen (56.1%) in the first part of the period analyzed to the therapeutic optimization (53.6%) in the second half. Furthermore, factors that were statistically significantly associated with antiretroviral treatment discontinuation were people with HIV ≥50 years (HR 1.60; 95%CI 1.25-2.04), post-discontinuation single-tablet regimen (HR 1.49; 95%CI 1.06-2.11) and antiretroviral drug classes. CONCLUSIONS: Over the 12 years there has been a change in the main cause of antiretroviral treatment discontinuation, currently therapeutic optimization being the main reason. Integrase inhibitors-based regimens and singletablet regimen strategies were less likely to be discontinued than others antiretroviral drug classes, allowing for better clinical management due to the efficacy profile, especially in people living with HIV ≥50 years with comorbidities.

Influence of sex on the timing of coronary angiography and the prescription of antiplatelet therapy in patients with nonST-segment elevation myocardial infarction. / Impacto del sexo en los tiempos de cateterismo y en el uso de pretratamiento antiagregante plaquetario en pacientes con síndrome coronario agudo sin elevación del segmento ST (SCASEST).

OBJECTIVES: To assess differences in the clinical management of nonST-segment elevation myocardial infarction (NSTEMI), including in-hospital events, according to biological sex. MATERIAL AND METHODS: Prospective observational multicenter study of patients diagnosed with NSTEMI and atherosclerosis who underwent coronary angiography. RESULTS: We enrolled 1020 patients in April and May 2022; 240 (23.5%) were women. Women were older than men on average (72.6 vs 66.5 years, P .001), and more women were frail (17.1% vs 5.6%, P .001). No difference was observed in pretreatment with any P2Y12 inhibitor (prescribed in 68.8% of women vs 70.2% of men, P = .67); however, more women than men were prescribed clopidogrel (56% vs 44%, P = .009). Women prescribed clopidogrel were more often under the age of 75 years and not frail. Coronary angiography was performed within 24 hours less corooften in women (29.8% vs 36.9%, P = .03) even when high risk was recognized. Frailty was independently associated with deferring coronary angiography in the adjusted analysis; biological sex by itself was not related. The frequency and type of revascularization were the same in both sexes, and there were no differences in in-hospital cardiovascular events. CONCLUSION: Women were more often prescribed less potent antithrombotic therapy than men. Frailty, but not sex, correlated independently with deferral of coronary angiography. However, we detected no differences in the frequency of coronary revascularization or in-hospital events according to sex.

OBJETIVO: Evaluar las diferencias en el manejo clínico y eventos intrahospitalarios en una cohorte de pacientes con síndrome coronario agudo sin elevación del segmento ST (SCASEST) en función del sexo. METODO: Estudio observacional, prospectivo y multicéntrico que incluyó pacientes consecutivos con diagnóstico de SCASEST sometidos a coronariografía con enfermedad ateroesclerótica responsable. RESULTADOS: Entre abril y mayo de 2022 se incluyeron 1.020 pacientes; de ellos, 240 eran mujeres (23,5%). En comparación con los hombres, las mujeres fueron mayores (72,6 años vs 66,5 años; p 0,001) y más frágiles (17,1% vs 5,6%; p 0,001). No hubo diferencias en el pretratamiento con un inhibidor del receptor P2Y12 (68,8% vs 70,2%, p = 0,67), aunque las mujeres recibieron más pretratamiento con clopidogrel (56% vs 44%, p = 0,009), principalmente aquellas de edad 75 años y sin fragilidad. En las mujeres se realizaron menos coronariografías precoces (# 24 h) (29,8% vs 36,9%; p = 0,03) a pesar de presentar la misma indicación (criterios de alto riesgo). En el análisis ajustado, la fragilidad, pero no el sexo, se asoció de forma independiente con la realización de una coronariografía diferida. La tasa y el tipo de revascularización fue igual en ambos sexos, y no hubo diferencias en los eventos cardiovasculares intrahospitalarios. CONCLUSIONES: Las mujeres recibieron con mayor frecuencia un tratamiento antitrombótico menos potente. La fragilidad y no el sexo se asoció con la realización de coronariografía diferida. Sin embargo, no hubo diferencias en la tasa de revascularización coronaria ni en los eventos intrahospitalarios en función del sexo.

The effects of an intensive outpatient treatment for PTSD.

Introduction: Research has shown that combining different evidence-based PTSD treatments for patients with PTSD in an intensive inpatient format seems to be a promising approach to enhance efficiency and reduce generally high dropout rates.Objective: To assess the effectiveness of an intensive six-day outpatient trauma-focused treatment for patients with PTSD.Method: Data from 146 patients (89.7% female, mean age = 36.79, SD = 11.31) with PTSD due to multiple traumatization were included in the analyses. The treatment programme consisted of six days of treatment within two weeks, with two daily individual 90-minute trauma-focused sessions (prolonged exposure and eye movement desensitization and reprocessing), one hour of exercise, and one hour of psychoeducation. All participants experienced multiple traumas, and 85.6% reported one or more comorbid psychiatric disorders. PTSD symptoms and diagnoses were assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), and self-reported symptoms were assessed with the PTSD Checklist for DSM-5 (PCL-5).Results: A significant decline in PTSD symptoms (CAPS-5 and PCL-5) from pretreatment to one-month follow-up (Cohen's d = 1.13 and 1.59) was observed and retained at six-month follow-up (Cohen's d = 1.47 and 1.63). After one month, 52.4% of the patients no longer met the diagnostic criteria for PTSD (CAPS-5). The Reliable Change Index (RCI) shows that 73.9% of patients showed improvement on the CAPS-5 and 77.61% on the PCL-5. Additionally, 21.77% (CAPS-5) and 20.0% (PCL-5) showed no change, while 4.84% (CAPS-5) and 2.96% (PCL-5) showed symptom worsening.Discussion: The results show that an intensive outpatient trauma treatment programme, including two evidence-based trauma-focused treatments, exercise, and psychoeducation, is effective for patients suffering from PTSD as a result of multiple traumatization. Subsequent research should focus on more controlled studies comparing the treatment programme with other intensive trauma treatments and less frequent routine treatment.

Intensive outpatient trauma treatment is effective in treating PTSD.Six days of combining prolonged exposure, EMDR, exercise and psycho-education seems feasible and effective in treating PTSD.73.9% of the patients show improvement on the CAPS-5 and 77.61% show improvement on the PCL-5, symptom worsening was there in 4,84, respectively 2.96%.

Cognitive-behavioural conjoint therapy versus prolonged exposure for PTSD in military service members and veterans: results and lessons from a randomized controlled trial.

Military personnel and veterans are at heightened risk for exposure to traumatic events and posttraumatic stress disorder (PTSD), as well as intimate relationship problems associated with PTSD.The purpose of this study was to evaluate the relative efficacy of CBCT and PE in improving intimate relationship functioning in active duty military personnel or veterans and their intimate partners; both conditions were hypothesized to significantly improve PTSD. Method: In this study, 32 military service members or veterans with PTSD and their intimate partners were randomized to receive either Cognitive-Behavioral Conjoint Therapy for PTSD (n = 15; CBCT; [Monson, C. M., & Fredman, S. J. (2012). Cognitive-behavioral conjoint therapy for posttraumatic stress disorder: Harnessing the healing power of relationships. Guilford]), a trauma-focused couple therapy, or Prolonged Exposure (n = 17; PE; [Foa, E. B., Hembree, E. A., Dancu, C. V., Peterson, A. L., Cigrang, J. A., & Riggs, D. S. (2008). Prolonged exposure treatment for combat-related stress disorders - provider's treatment manual [unpublished]. Department of Psychiatry, University of Pennsylvania]), a front-line evidence-based individual treatment for PTSD.There were significant challenges with recruitment and a significant difference in dropout from treatment for the two therapies (65% for PE; 27% for CBCT). Treatment dropout was differentially related to pre-treatment relationship functioning; those with below average relationship functioning had higher dropout in PE compared with CBCT, whereas those with above average relationship functioning did not show differential dropout. In general, CBCT led to relational improvements, but this was not consistently found in PE. Clinician- and self-reported PTSD symptoms improved with both treatments.This study is the first to test a couple or family therapy against a well-established, front-line recommended treatment for PTSD, with expected superiority of CBCT over PE on relationship outcomes. Lessons learned in trial design, including considerations of equipoise, and the effects of differential dropout on trial analyses are discussed. This trial provides further support for the efficacy of CBCT in the treatment of PTSD and enhancement of intimate relationships.

Differential dropout from trial of couple versus individual therapy for PTSD.General pattern of improvements in relationship outcomes in couple therapy for PTSD.PTSD symptoms improved in the individual and couple therapy for PTSD.Lessons learned in trial design, including considerations of equipoise, and the effects of differential dropout by condition on trial analyses are discussed.

Effect of PTSD treatment on cardiovascular reactivity during trauma memory recall and correspondence with symptom improvement.

ABSTRACTBackground: Prior research has shown PTSD treatment leads to reductions in cardiovascular reactivity during trauma recall, but the extent to which such reductions are associated with changes in PTSD symptoms is less clear. Moreover, such relationships have not been investigated in a cognitively focused PTSD treatment.Objective: To examine changes in cardiovascular reactivity to the trauma memory in patients receiving cognitive processing therapy (CPT), CPT with a written trauma account, and a written account only condition. We also examined the association of such changes with symptom improvement.Method: 118 women with PTSD secondary to interpersonal violence completed pre- and post-treatment assessments of PTSD symptoms and cardiovascular reactivity during a script-driven imagery task.Results: Results indicated a significant but modest reduction in cardiovascular reactivity in CPT conditions. Changes in cardiovascular reactivity and reexperiencing symptoms were significantly associated among the whole sample. Among individuals with the greatest reactivity to the trauma memory at pretreatment, associations were also seen with changes in total PTSD, numbing, and trauma-related guilt.Conclusions: Results indicate that previous findings on the effect of PTSD treatment on cardiovascular reactivity during trauma recall extend to cognitively oriented treatment. Baseline cardiovascular reactivity may influence the extent to which reductions in PTSD symptoms and reactivity during trauma recall are related.

Cognitive Processing Therapy leads to reduced heart rate reactivity when recalling a trauma memory.Decreases in heart rate reactivity are associated with reduced reexperiencing symptoms.Changes in heart rate reactivity and PTSD symptoms are more closely related among patients with greater pretreatment reactivity.

Good clinical practice recommendations for the diagnosis and treatment of gastroesophageal reflux disease. An expert review from the Asociación Mexicana de Gastroenterología.

INTRODUCTION: Gastroesophageal reflux disease (GERD) is very prevalent in the general population, with a broad spectrum of clinical manifestations, requiring accurate diagnosis and treatment. AIM: The aim of this expert review is to establish good clinical practice recommendations for the diagnosis and personalized treatment of GERD. METHODS: The good clinical practice recommendations were produced by a group of experts in GERD, members of the Asociación Mexicana de Gastroenterología (AMG), after carrying out an extensive review of the published literature and discussing each recommendation at a face-to-face meeting. This document does not aim to be a clinical practice guideline with the methodology such a document requires. RESULTS: Fifteen experts on GERD formulated 27 good clinical practice recommendations for recognizing the symptoms and complications of GERD, the rational use of diagnostic tests and medical treatment, the identification and management of refractory GERD, the overlap with functional disorders, endoscopic and surgical treatment, and GERD in the pregnant woman, older adult, and the obese patient. CONCLUSIONS: An accurate diagnosis of GERD is currently possible, enabling the prescription of a personalized treatment in patients with this condition. The goal of the good clinical practice recommendations by the group of experts from the AMG presented in this document is to aid both the general practitioner and specialist in the process of accurate diagnosis and treatment, in the patient with GERD.