Mortalidad asociada al trastorno neurocognitivo y dependencia en personas mayores de 55 años. Revisión sistemática / Mortality associated with neurocognitive disorder and dependence in people over 55 years of age. Systematic review

Introducción El creciente envejecimiento poblacional trae consigo un aumento de la incidencia del trastorno neurocognitivo (TNC) así como diversas situaciones generadoras de dependencia. Objetivo Analizar mediante una revisión sistemática la relación que existe entre TNC y dependencia con el riesgo de mortalidad en personas mayores. Métodos Se realizó una búsqueda bibliográfica de los estudios longitudinales publicados en Pubmed y Scopus abordando la relación entre TNC, dependencia para las actividades básicas de la vida diaria (ABVD) y mortalidad publicados entre los años 1995 y 2021 De los 1040 artículos encontrados, se seleccionaron 10 estudios. Resultados Se observó que las cohortes de personas mayores con TNC presentaron riesgo de mortalidad asociado a la afectación de las ABVD (test de Barthel) y a las puntuaciones de Mini-Mental State Examination siguiendo una tendencia lineal significativa. Otros factores asociados al riesgo de mortalidad fueron: niveles bajos de educación, vivir solo y presentar fragilidad. Es clara la vinculación entre los tres términos utilizados en la búsqueda de este trabajo y, sin embargo, destaca que haya pocos estudios longitudinales que los analicen conjuntamente. Conclusiones Los resultados hallados subrayan la importancia de realizar evaluaciones del estado cognitivo y funcional mediante escalas validadas, ya que ambas áreas se asocian con la mortalidad. La evaluación de la dependencia y de la función cognitiva en adultos mayores debe considerarse tanto en la investigación como en la práctica clínica, ya que aportarían información sobre su posible relación con la mortalidad. (AU)

Introduction The increasing aging of the population brings with it an increase in the incidence of neurocognitive disorder (NCD) as well as various situations that generate dependence. Objective To analyze by means of a systematic review the relationship between NCD and dependence with the risk of mortality in the elderly. Methods A bibliographic search of longitudinal studies published in Pubmed and Scopus addressing the relationship between NCI, dependence for basic activities of daily living (ADL) and mortality published between 1995 and 2021 was performed. Of the 1040 articles found, 10 studies were selected. Results It was observed that cohorts of elderly people with NCI presented mortality risk associated with ABVD impairment (Barthel test) and Mini-Mental State Examination scores following a significant linear trend. Other factors associated with mortality risk were low levels of education, living alone, and frailty. Conclusions The results underline the importance of performing assessments of cognitive and functional status using validated scales, since both areas are associated with mortality. The link between the three terms used in the search for this work is clear, but it is noteworthy that there are few longitudinal studies that analyze them together. The assessment of dependence and cognitive function in older adults should be considered in both research and clinical practice as it would provide information on their possible relationship with mortality. (AU)

Mortalidad asociada al trastorno neurocognitivo y dependencia en personas mayores de 55 años. Revisión sistemática / Mortality associated with neurocognitive disorder and dependence in people over 55 years of age. Systematic review

Introducción El creciente envejecimiento poblacional trae consigo un aumento de la incidencia del trastorno neurocognitivo (TNC) así como diversas situaciones generadoras de dependencia. Objetivo Analizar mediante una revisión sistemática la relación que existe entre TNC y dependencia con el riesgo de mortalidad en personas mayores. Métodos Se realizó una búsqueda bibliográfica de los estudios longitudinales publicados en Pubmed y Scopus abordando la relación entre TNC, dependencia para las actividades básicas de la vida diaria (ABVD) y mortalidad publicados entre los años 1995 y 2021 De los 1040 artículos encontrados, se seleccionaron 10 estudios. Resultados Se observó que las cohortes de personas mayores con TNC presentaron riesgo de mortalidad asociado a la afectación de las ABVD (test de Barthel) y a las puntuaciones de Mini-Mental State Examination siguiendo una tendencia lineal significativa. Otros factores asociados al riesgo de mortalidad fueron: niveles bajos de educación, vivir solo y presentar fragilidad. Es clara la vinculación entre los tres términos utilizados en la búsqueda de este trabajo y, sin embargo, destaca que haya pocos estudios longitudinales que los analicen conjuntamente. Conclusiones Los resultados hallados subrayan la importancia de realizar evaluaciones del estado cognitivo y funcional mediante escalas validadas, ya que ambas áreas se asocian con la mortalidad. La evaluación de la dependencia y de la función cognitiva en adultos mayores debe considerarse tanto en la investigación como en la práctica clínica, ya que aportarían información sobre su posible relación con la mortalidad. (AU)

Introduction The increasing aging of the population brings with it an increase in the incidence of neurocognitive disorder (NCD) as well as various situations that generate dependence. Objective To analyze by means of a systematic review the relationship between NCD and dependence with the risk of mortality in the elderly. Methods A bibliographic search of longitudinal studies published in Pubmed and Scopus addressing the relationship between NCI, dependence for basic activities of daily living (ADL) and mortality published between 1995 and 2021 was performed. Of the 1040 articles found, 10 studies were selected. Results It was observed that cohorts of elderly people with NCI presented mortality risk associated with ABVD impairment (Barthel test) and Mini-Mental State Examination scores following a significant linear trend. Other factors associated with mortality risk were low levels of education, living alone, and frailty. Conclusions The results underline the importance of performing assessments of cognitive and functional status using validated scales, since both areas are associated with mortality. The link between the three terms used in the search for this work is clear, but it is noteworthy that there are few longitudinal studies that analyze them together. The assessment of dependence and cognitive function in older adults should be considered in both research and clinical practice as it would provide information on their possible relationship with mortality. (AU)

[Mortality associated with neurocognitive disorder and dependence in people over 55 years of age. Systematic review]. / Mortalidad asociada al trastorno neurocognitivo y dependencia en personas mayores de 55 años. Revisión sistemática.

INTRODUCTION: The increasing aging of the population brings with it an increase in the incidence of neurocognitive disorder (NCD) as well as various situations that generate dependence. OBJECTIVE: To analyze by means of a systematic review the relationship between NCD and dependence with the risk of mortality in the elderly. METHODS: A bibliographic search of longitudinal studies published in Pubmed and Scopus addressing the relationship between NCI, dependence for basic activities of daily living (ADL) and mortality published between 1995 and 2021 was performed. Of the 1040 articles found, 10 studies were selected. RESULTS: It was observed that cohorts of elderly people with NCI presented mortality risk associated with ABVD impairment (Barthel test) and Mini-Mental State Examination scores following a significant linear trend. Other factors associated with mortality risk were low levels of education, living alone, and frailty. CONCLUSIONS: The results underline the importance of performing assessments of cognitive and functional status using validated scales, since both areas are associated with mortality. The link between the three terms used in the search for this work is clear, but it is noteworthy that there are few longitudinal studies that analyze them together. The assessment of dependence and cognitive function in older adults should be considered in both research and clinical practice as it would provide information on their possible relationship with mortality.

Calidad de vida en adultos mayores con trastorno neurocognitivo mayor moderado a grave institucionalizados: efecto de la Doll Therapy / Quality of life in institutionalized older adults with moderate to severe major neurocognitive disorder: Effect of Doll therapy

Antecedentes y objetivos El trastorno neurocognitivo mayor se caracteriza por el deterioro cognitivo progresivo, la disminución de la capacidad de la persona para realizar actividades de la vida diaria y la aparición de síntomas psicológicos y conductuales, que suponen un deterioro de la calidad de vida y la progresión hacia la institucionalización. El manejo más frecuente del trastorno neurocognitivo mayor es la terapia farmacológica, que mitiga o lentifica el deterioro progresivo y el control de los síntomas. El objetivo de este estudio fue establecer el efecto de una intervención de enfermería basada en la Doll Therapy comparada con el cuidado convencional sobre la calidad de vida de los adultos mayores con trastorno neurocognitivo mayor moderado a grave, institucionalizados en centros de bienestar para adultos mayores de la ciudad de Medellín (Colombia). Método Estudio piloto experimental pretest post-test con dos grupos. La muestra estuvo conformada por 26 adultos mayores con trastorno neurocognitivo mayor moderado a grave, institucionalizados, asignados aleatoriamente a cada grupo. El grupo experimental recibió la terapia de enfermería basada en la Doll Therapy, mientras que el grupo control continuó recibiendo el protocolo de la institución. Se utilizó el instrumento QUALID, el cual fue evaluado por profesionales externos a los centros de atención. Resultados La comparación de los grupos, antes y después de la intervención, señala que el grupo experimental mostró un efecto positivo sobre la calidad de vida, apoyado en la significación estadística de los datos, con un tamaño del efecto moderado. Conclusiones La Doll Therapy, como una terapia no farmacológica, tiene un efecto positivo en la calidad de vida de los pacientes con trastorno neurocognitivo mayor moderado a grave, lo cual constituye un aporte para fortalecer el conocimiento asociado a los efectos de esta intervención (AU)

Background and objectives Major neurocognitive disorder is characterized by progressive cognitive impairment, a decrease in the person's ability to perform activities of daily living and the appearance of psychological and behavioral symptoms that lead to a deterioration in the quality of life and progression towards institutionalization. The most common management of major neurocognitive disorder is pharmacological therapy that mitigates or slow progressive deterioration and symptom control. The objective of this study was to establish the effect of a nursing intervention based on Doll therapy, compared to conventional care on the quality of life of older adults with moderate to severe major neurocognitive disorder institutionalized in nursing homes in the city of Medellín, Colombia. Methods Pilot experimental study with two groups and pretest post-test measurement. The sample consisted of 26 institutionalized elderly adults with advanced-stage major neurocognitive disorder, randomly assigned to each group. The experimental group received Doll therapy, based nursing therapy, while the comparison group continued to receive conventional therapy according to the institution's protocol. The QUALID instrument was used, which was evaluated by professionals external to the care centers. Results The comparison of the groups, before and after the intervention, indicates that the experimental group showed a positive effect on quality of life, supported by the statistical significance of the data, with a moderate effect. Conclusions The Doll therapy as a non-pharmacological therapy has a positive effect on the quality of life of patients with moderate to severe major neurocognitive disorder, which constitutes a contribution to strengthen the knowledge associated with the effects or this intervention (AU)

[Quality of life in institutionalized older adults with moderate to severe major neurocognitive disorder: Effect of Doll therapy]. / Calidad de vida en adultos mayores con trastorno neurocognitivo mayor moderado a grave institucionalizados: efecto de la Doll Therapy.

BACKGROUND AND OBJECTIVES: Major neurocognitive disorder is characterized by progressive cognitive impairment, a decrease in the person's ability to perform activities of daily living and the appearance of psychological and behavioral symptoms that lead to a deterioration in the quality of life and progression towards institutionalization. The most common management of major neurocognitive disorder is pharmacological therapy that mitigates or slow progressive deterioration and symptom control. The objective of this study was to establish the effect of a nursing intervention based on Doll therapy, compared to conventional care on the quality of life of older adults with moderate to severe major neurocognitive disorder institutionalized in nursing homes in the city of Medellín, Colombia. METHODS: Pilot experimental study with two groups and pretest post-test measurement. The sample consisted of 26 institutionalized elderly adults with advanced-stage major neurocognitive disorder, randomly assigned to each group. The experimental group received Doll therapy, based nursing therapy, while the comparison group continued to receive conventional therapy according to the institution's protocol. The QUALID instrument was used, which was evaluated by professionals external to the care centers. RESULTS: The comparison of the groups, before and after the intervention, indicates that the experimental group showed a positive effect on quality of life, supported by the statistical significance of the data, with a moderate effect. CONCLUSIONS: The Doll therapy as a non-pharmacological therapy has a positive effect on the quality of life of patients with moderate to severe major neurocognitive disorder, which constitutes a contribution to strengthen the knowledge associated with the effects or this intervention.

Desenvolvimento de Aplicativo Re·Habilita em Reabilitação Neurocognitiva: Estudo de Usabilidade / Development of the Re-Habilita Application for Neurocognitive Rehabilitation: Usability Study

O processo de envelhecimento, em geral, acarreta um conjunto de alterações neurocognitivas que afetam múltiplas habilidades cognitivas da pessoa, e neste protótipo do Re·Habilita, desenvolvemos exercícios virtuais para exercer essas habilidades, como atenção, linguagem, reconhecimento e movimento, por meio de objetos físicos (Almeida, G. et al. 2020). Esta temática é muito relevante para a prática clínica do enfermeiro especialista em enfermagem de reabilitação dado o envelhecimento da população e consequente aumento das doenças neurodegenerativas e neurocognitivas associadas ao mesmo, as estatísticas revelam que Portugal é um dos países com maior número de casos por mil habitantes entre os países da OCDE (World Health Organization, 2015). A presente investigação insere-se na área da Reabilitação Neurocognitiva e aplicação de novas tecnologias para a maior eficiência do plano de reabilitação e para a obtenção de ganhos em saúde. Deste modo tem como objetivos principais: aferir a usabilidade do Protótipo Re·Habilita para pessoas com défice cognitivo, identificar as principais limitações do protótipo e apresentar recomendações para aperfeiçoamento de um futuro protótipo. No presente estudo de investigação utilizou-se uma metodologia mista, tendo os dados sido recolhidos através de dois grupos focais e aplicação do questionário de usabilidade System Usability Scale a 15 Enfermeiros Especialistas em Enfermagem de Reabilitação (EEER) e através de dois grupos focais e aplicação do questionário de usabilidade System Usability Scale a 15 pessoas idosas na comunidade com diagnóstico prévio de défice cognitivo ligeiro, com aplicação da Mini Mental State. No que se refere à metodologia recorreu-se a uma amostra por conveniência com recurso à snowball sampling do tipo exponencial. Com base nas respostas dos participantes à aplicação do questionário de usabilidade System Usability Scale do Grupo Focal de Enfermeiros Especialistas em Enfermagem de Reabilitação, na sua maioria, expressou o desejo de usar o sistema com frequência, achou o sistema fácil de usar, considerou as funções bem integradas e sentiu que o sistema atendeu às suas expectativas. No que se refere ao Grupo Focal da pessoa idosa com défice cognitivo ligeiro, no geral, o estudo de usabilidade recebeu contributos muito positivos, com destaque para a facilidade de uso, integração de funções e confiança dos participantes. No futuro, o Re·Habilita (Almeida, G. et al. 2020) poderá evoluir de forma a integrar novos exercícios e com maior diferenciação na oferta dos conteúdos em aproximação com as necessidades específicas de cada pessoa. Podemos concluir que se trata de um aplicativo inovador e disruptivo na àrea de especialização da enfermagem de reabilitação.

Síndrome opsoclono-mioclono: características clínicas, aspectos terapéuticos y factores pronósticos en una cohorte pediátrica española / Opsoclonus-myoclonus syndrome: clinical characteristics, therapeutic considerations, and prognostic factors in a Spanish paediatric cohort

Introducción: El síndrome opsoclono-mioclono-ataxia es un raro trastorno de inicio pediátrico; de base neuroinflamatoria y origen paraneoplásico, parainfeccioso o idiopático. Actualmente no hay biomarcadores, siendo el diagnóstico clínico. El pronóstico cognitivo parece estar relacionado con el inicio temprano de la terapia inmunomoduladora.MétodoSe describen las características epidemiológicas, clínicas, terapéuticas y pronósticas a largo plazo de una cohorte de 20 pacientes españoles.ResultadosLa edad media de debut fue de 21 meses (2-59 meses). La ataxia y el opsoclonus fueron los síntomas de inicio más frecuentes y predominantes en la evolución. El tiempo medio desde los primeros síntomas hasta el diagnóstico fue de 1,1 mes. Un tumor de extirpe neuroblástica fue detectado en el 45%, realizándose resección quirúrgica en siete y quimioterapia en dos pacientes. En el estudio de líquido cefalorraquídeo se constató pleocitosis en cuatro (25%), con negatividad de anticuerpos antineuronales y bandas oligoclonales en todos los casos estudiados. En el 100% se emplearon fármacos inmunomoduladores. En nueve pacientes el tratamiento combinado inmunomodulador se inició desde el momento del diagnóstico, y en cinco el tiempo medio de implementación fue de 2,2 meses. A largo plazo, seis de 10 pacientes con seguimiento superior a cinco años presentaban secuelas cognitivas leves o moderadas; cuatro pacientes presentaron recaídas, generalmente coincidiendo con el descenso de la corticoterapia.ConclusionesEl inicio precoz de la inmunoterapia, así como de la triple terapia en los casos que lo precisaron, se relacionó con una menor frecuencia de afectación cognitiva a los dos años del debut. (AU)

Introduction: Opsoclonus-myoclonus-ataxia syndrome is a rare neuroinflammatory disorder with onset during childhood; aetiology may be paraneoplastic, para-infectious, or idiopathic. No biomarkers have yet been identified, and diagnosis is clinical. Better cognitive prognosis appears to be related to early onset of immunomodulatory therapy.MethodsWe describe the epidemiological, clinical, therapeutic, and long-term prognostic characteristics of a cohort of 20 Spanish patients.ResultsThe mean age of onset was 21 months (range, 2-59). Ataxia and opsoclonus were the most frequent symptoms both at disease onset and throughout disease progression. The mean time from onset to diagnosis was 1.1 months. Neuroblast lineage tumours were detected in 45% of patients; these were treated with surgical resection in 7 cases and chemotherapy in 2. Cerebrospinal fluid analysis revealed pleocytosis in 4 cases (25%) and neither antineuronal antibodies nor oligoclonal bands were detected in any patient. Immunomodulatory drugs were used in all cases. Nine patients started combined immunomodulatory treatment at the time of diagnosis, and 5 patients after a mean of 2.2 months. In the long term, 6 of the 10 patients followed up for more than 5 years presented mild or moderate cognitive sequelae. Four patients presented relapses, generally coinciding with the decrease of corticosteroid doses.ConclusionsEarly initiation of immunotherapy, as well as triple combination therapy, where needed, was associated with a lower frequency of cognitive impairment 2 years after onset. (AU)

Opsoclonus-myoclonus syndrome: Clinical characteristics, therapeutic considerations, and prognostic factors in a Spanish paediatric cohort.

INTRODUCTION: Opsoclonus-myoclonus-ataxia syndrome is a rare neuroinflammatory disorder with onset during childhood; aetiology may be paraneoplastic, para-infectious, or idiopathic. No biomarkers have yet been identified, and diagnosis is clinical. Better cognitive prognosis appears to be related to early onset of immunomodulatory therapy. METHODS: We describe the epidemiological, clinical, therapeutic, and long-term prognostic characteristics of a cohort of 20 Spanish patients. RESULTS: The mean age of onset was 21 months (range, 2-59). Ataxia and opsoclonus were the most frequent symptoms both at disease onset and throughout disease progression. The mean time from onset to diagnosis was 1.1 months. Neuroblast lineage tumours were detected in 45% of patients; these were treated with surgical resection in 7 cases and chemotherapy in 2. Cerebrospinal fluid analysis revealed pleocytosis in 4 cases (25%) and neither antineuronal antibodies nor oligoclonal bands were detected in any patient. Immunomodulatory drugs were used in all cases. Nine patients started combined immunomodulatory treatment at the time of diagnosis, and 5 patients after a mean of 2.2 months. In the long term, 6 of the 10 patients followed up for more than 5 years presented mild or moderate cognitive sequelae. Four patients presented relapses, generally coinciding with the decrease of corticosteroid doses. CONCLUSIONS: Early initiation of immunotherapy, as well as triple combination therapy, where needed, was associated with a lower frequency of cognitive impairment 2 years after onset.

Deterioro cognitivo en ancianos de centros residenciales. Causas y variables sociodemográficas / Cognitive impairment of nursing homes. Causes and sociodemographic variables

Objetivo: Conocer la prevalencia del deterioro cognitivo y la patología con la que se vincula en una muestra de personas mayores que viven en residencias, e identificar la relación del deterioro cognitivo y el diagnóstico asociado con las variables sociodemográficas sexo, edad y nivel de estudios. Metodología: Estudio de naturaleza cuantitativa, observacional, descriptiva, correlacional y de corte transversal, con participación de 8 centros residenciales de atención sociosanitaria en la provincia de Pontevedra. La población de estudio son usuarios de nuevo ingreso (año 2017) que cumplían los siguientes requisitos: tener 60 años o más, tener una valoración cognitiva realizada al ingreso y que la presencia de deterioro cognitivo fuera permanente. Resultados: De 390 usuarios, 312 presentaban deterioro cognitivo (80%). La prevalencia del deterioro cognitivo en las mujeres fue del 86,2%, y en los que no poseen estudios o con estudios primarios, del 87%. Se estima que el deterioro cognitivo se deriva de los trastornos neurocognitivos en el 77,1% de los casos. La depresión está presente en el 27,5% de los usuarios con deterioro cognitivo. Conclusiones: El deterioro cognitivo estuvo presente en 8 de cada 10 ancianos, el trastorno neurocognitivo es el problema más frecuente del que deriva el deterioro cognitivo, seguido por la depresión. Ser mujer, tener más edad y un nivel de estudios bajo se relacionan con una mayor casuística de deterioro cognitivo (AU)

Objective: To know the prevalence of cognitive dysfunction (CD) and the pathology with which it is linked, in a sample of elderly people who live in residences, and to identify the relationship between the CD and the diagnosis associated with sociodemographic variables of sex, age and academic level. Methodology: Study quantitative, observational, descriptive, correlational and cross-sectional. Eight residential centers for socio-health care in the province of Pontevedra, Spain, participated. The study population was the newly elderly people registered (year 2017) who met the following requirements: being 60 years old or older, having a cognitive assessment performed on admission and a permanent CD diagnosis. Results: Out of 390 users, 312 presented CD (80%). The prevalence of CD in women was 86.2%, while in those with no or primary education it was 87%. It was estimated that CD derives from neurocognitive disorders (TNC) in 77.1% of cases. Depression was present in 27.5% of elderly people with CD. Conclusions: CD was present in 8 out of 10 elderly people, TNC is the most frequent illness associated CD, followed by depression. Being a woman and older as well as having a low level of education are related to a greater casuistry of CD (AU)

Variables neuropsicológicas y psicopatológicas moduladoras del insight cognitivo en personas con esquizofrenia / Neuropsychological and psychopathological variables modulating cognitive insightin people with schizophrenia

El insight cognitivo es la capacidad de los pacientes con esqui-zofrenia de evaluar sus experiencias psicóticas y responder a la retroalimen-tación correctiva. Su relación con el funcionamiento neuropsicológico y la modulación que ejercen el estado de ánimo y la ansiedad están aún poco claras. Avanzar y profundizar en su conocimiento tendría un impacto im-portante sobre la comprensión de los mecanismos cognitivos y los progra-mas de intervención. Se seleccionaron dos muestras, muestra clínica, con personas con esquizofrenia (n=43), muestra personas sanas (n=50), a las que se aplicó la Escala de insight cognitivo (EICB), una batería neuropsico-lógica y cuestionarios de depresión y ansiedad. Los resultados sugieren una influencia de la ansiedad y de los déficits de flexibilidad cognitiva en el desarrollo de los mecanismos de la Auto-Reflexión en personas con esqui-zofrenia, con un patrón diferente al encontrado en personas sanas. Se dis-cuten los resultados con respecto a los programas de intervención.(AU)

Cognitive insight is the capacity of patients with schizophrenia to evaluate their psychotic experiences and respond to the corrective feed-back. The relationship with their neuropsychological functions and the modulation exercised by mood and anxiety are still not clear. To make ad-vances and deepen our knowledge would have an important impact on our understanding of the cognitive mechanisms and intervention programmes. Two samples were chosen, one clinical with persons suffering from schiz-ophrenia (n=43) and another with healthy individuals (n=50). The Cog-nitive Insight Scale (BCIS), a neuropsychological battery and questionnaire concerning depression and anxiety, was applied to them. The results sug-gest an influence of anxiety and the deficits in cognitive flexibility on the development of the mechanisms of Self-Reflection in persons with schizo-phrenia, with a different pattern to that found in healthy individuals. The results are discussed with respect to the intervention programmes.(AU)

Neurocognitive Functioning in Adolescents at Risk for Mental Health Problems / Funcionamiento Neurocognitivo en Adolescentes con Riesgo de Trastornos Mentales

Background: The main goal of the study was to assess the neurocognitive performance in adolescents at high psychometric risk for mental healthproblems. Method: A sample of 48 participants at high risk for mentaldisorders and an age-gender matched healthy comparison group of 48adolescents were identified from a community-derived sample of 1,509adolescents. The Strengths and Difficulties Questionnaire problems andthe University of Pennsylvania Computerized Neuropsychological Test Battery for children (included 14 tasks assessing five neurobehavioraldomains: executive functions, episodic memory, complex cognition, socialcognition, and sensorimotor speed) were used. Results: Relative to healthycomparison participants, individuals at high risk showed significant impairments across almost all neurocognitive domains (executive functions, episodic memory, complex cognition, social cognition, and sensorimotorspeed). Conclusions: These findings demonstrate that neurocognitive impairments can be shown in adolescents at high psychometric risk formental health problems before the onset of more severe psychological problems.

Antecedentes: el objetivo principal del estudiofue evaluar el funcionamiento neurocognitivo en adolescentes con altoriesgo psicométrico de presentar problemas de salud mental. Método: seseleccionó una muestra de 48 participantes con alto riesgo de trastornos mentales y un grupo de comparación de 48 adolescentes emparejados por edad y género a partir de la muestra total de 1.509 adolescentes. Se administró el Cuestionario de Capacidades y Dificultades y la Batería Neurocognitiva Computerizada de la Universidad de Pensilvania para población infantil y adolescente (incluidas 14 tareas que evalúan cinco dominios neurocognitivos: funciones ejecutivas, memoria episódica, cognición compleja, cognición social y velocidad sensoriomotora).Resultados: en relación con el grupo de comparación, los participantes dealto riesgo mostraron diferencias significativas en casi todos los dominiosneurocognitivos. Conclusiones: estos hallazgos demuestran que diferentesalteraciones neurocognitivas pueden manifestarse en adolescentes con altoriesgo psicométrico de presentar problemas de salud mental antes de laaparición de dificultades psicológicas más graves.

Sintomatología depresiva y trastornos neurocognitivos en pacientes con VIH adherentes y no adherentes a TARAA: estudio transversal analítico / Depressive symptomatology and neurocognitive disorders in haart-adherent and non-adherent hiv patients: a cross-sectional analytical study

Introducción: Las personas portadoras del virus de inmunodeficiencia humana (VIH) presentan mayor comorbilidad de trastornos neurocognitivos y del ánimo que la población general. La introducción de los antirretrovirales ha disminuido significativamente la demencia asociada a VIH, relacionado a la adherencia a la terapia antirretroviral altamente activa (TARAA). Diversos estudios han demostrado la coexistencia de otros factores para explicar dicho trastorno cognitivo, tales como enfermedad neurológica previa, enfermedad psiquiátrica, consumo de drogas, nivel educativo, reserva cognitiva, entre otras. Objetivo: Determinar el grado de sintomatología depresiva, deterioro cognitivo y su relación con la adherencia a TARAA y otros factores de curso clínico en pacientes portadores de VIH en control ambulatorio. Métodos: Estudio transversal. Se incluyeron pacientes que viven con VIH adscritos al programa de infectología del Hospital Dr. Gustavo Fricke, Viña del mar, Chile. Se utilizaron datos sociodemográficos, clínicos y se aplicaron las escalas Depression in the Medicaly III Questionary, Montreal Cognitive Assesment y Morysky Green Levin Test. Resultados: Se incluyeron 29 participantes, en su mayoría hombres (86,2%) y con escolaridad técnica o profesional (86.2%). No hubo diferencias entre variables biodemográficas, depresivas ni subdimensiones cognitivos. Entre pacientes adherentes y no adherentes se encontró diferencias significativas respecto a la presencia de algún deterioro cognitivo. Conclusiones: Los resultados deben ser interpretados con cautela, dado su alcance limitado. Futuros estudios traslacionales debieran incorporar mediciones más certeras del nivel de adherencia al TARAA.

Introduction: Human immunodeficiency virus (HIV) carriers present more neurocognitive and mood disorders than the general population. The introduction of antiretrovirals has significantly lowered the incidence of HIV associated dementia, and this is related to adherence to highly active antiretroviral therapy (HAART). Several studies have shown the coexistence of other factors that could explain the cognitive disorder, such as a pre-existing neurological disease, psychiatric disease, drug consumption, level of education, cognitive reserve, and others. Objective: To determine the degree of depressive symptomatology and cognitive impairment and their relation to adherence to HAART and other factors of the clinical course of HIV carriers in outpatient supervision. Methods: Cross-sectional study. We included HIV patients in the infectious diseases program, Dr Gustavo Fricke Hospital, Viña del Mar, Chile. We used sociodemographic and clinical data and we applied the Depression in the Medically Ill questionnaire, Montreal Cognitive Assessment, and the Morysky Green Levin Test. Results: 29 patients participated, mainly men (86.2%) with technical or professional education (86.2%). There were no significant differences in sociodemographic, depressive, or cognitive subdomain variables. There were significant differences in cognitive impairment between adherents and non-adherents. Conclusions: Care should be taken with interpreting the results, given their limited scope. Future cross-sectional studies should incorporate more accurate measurements of HAART adherence.

Análisis de desempeños cognitivos y polimorfismos en SORL, PVRL2, CR1, TOMM40, APOE, PICALM, GWAS_14q, CLU y BIN1 en pacientes con trastorno neurocognitivo leve y en sujetos cognitivamente sanos / Analysis of cognitive performance and polymorphisms of SORL1, PVRL2, CR1, TOMM40, APOE, PICALM, GWAS_14q, CLU, and BIN1 in patients with mild cognitive impairment and cognitively healthy controls

Introducción: Los polimorfismos de riesgo para el desarrollo de enfermedad de Alzheimer (se han estudiado en pacientes con demencia, pero aún no se han explorado en trastorno neurocognitivo leve (TNL) en nuestra población, ni se han considerado en relación con variables cognitivas, las cuales pueden ser biomarcadores predictivos de enfermedad.ObjetivoEvaluar los desempeños cognitivos y los polimorfismos en los genes SORL1(rs11218304), PVRL2(rs6859), CR1(rs6656401), TOMM40(rs2075650), APOE(isoformas ɛ2, ɛ3, ɛ4), PICALM(rs3851179), GWAS_14q(rs11622883), BIN(rs744373), CLU (rs227959 y rs11136000) en pacientes con TNL y en sujetos sanos.MetodologíaEstudio descriptivo, exploratorio y transversal, en una cohorte prospectiva de participantes seleccionados mediante muestreo no probabilístico, evaluados por neurología, neuropsicología y genética, y clasificados como cognitivamente sanos y pacientes con TNL, según criterios. La cognición se evaluó por medio de la batería Neuronorma y se analizó en relación con las variantes polimórficas por medio de medidas de tendencia, intervalos de confianza y estadísticos no paramétricos.ResultadosSe identificaron diferencias en los desempeños en tareas de lenguaje y memoria en relación con las variantes de BIN1, CLU y CR1, junto con tendencias en las variantes de PICALM, GWArs, SORL y PVRL2, mientras que en APOE y TOMM40 no se encontraron tendencias.DiscusiónLas tendencias en los desempeños cognitivos en relación con variantes polimórficas podrían indicar que, en ausencia de demencia, los mecanismos que regulan estos genes podrían tener un efecto sobre la cognición; sin embargo, esta aproximación tiene un carácter exploratorio y sus resultados permiten generar hipótesis que requieren ser exploradas en muestras de mayor tamaño. (AU)

Introduction: Alzheimer disease risk polymorphisms have been studied in patients with dementia, but have not yet been explored in mild cognitive impairment (MCI) in our population; nor have they been addressed in relation to cognitive variables, which can be predictive biomarkers of disease.ObjectiveTo evaluate cognitive performance and presence of polymorphisms of the genes SORL1(rs11218304), PVRL2(rs6859), CR1(rs6656401), TOMM40(rs2075650), APOE (isoforms ɛ2, ɛ3, ɛ4), PICALM(rs3851179), GWAS_14q(rs11622883), BIN1(rs744373), and CLU (rs227959 and rs11136000) in patients with MCI and healthy individuals.MethodologyWe performed a cross-sectional, exploratory, descriptive study of a prospective cohort of participants selected by non-probabilistic sampling, evaluated with neurological, neuropsychological, and genetic testing, and classified as cognitively healthy individuals and patients with MCI. Cognition was evaluated with the Neuronorma battery and analysed in relation to the polymorphic variants by means of measures of central tendency, confidence intervals, and nonparametric statistics.ResultsWe found differences in performance in language and memory tasks between carriers and non-carriers of BIN1, CLU, and CR1 variants and a trend toward poor cognitive performance for PICALM, GWAS_14q, SORL1, and PVRL2 variants; the APOE and TOMM40 variants were not associated with poor cognitive performance.DiscussionDifferences in cognitive performance associated with these polymorphic variants may suggest that the mechanisms regulating these genes could have an effect on cognition in the absence of dementia; however, this study was exploratory and hypotheses based on these results must be explored in larger samples. (AU)

Fazer a Diferença 3 - um programa de estimulação cognitiva individual para pessoas idosas: Aceitabilidade e aplicabilidade / Making a Difference 3 - an individual cognitive stimulation program for older people: Appropriateness and feasibility / Fazer a Diferença 3 - un programa de estimulación cognitiva individual para personas mayores: Aceptabilidad y aplicabilidad

Resumo Enquadramento: A estimulação cognitiva individual desenvolvida em contexto domiciliar por um cuidador é uma intervenção inovadora. O programa de estimulação cognitiva Fazer a Diferença 3 (FD3) é um exemplo deste tipo de intervenção. Objetivo: Explorar a aceitabilidade e a aplicabilidade do programa FD3 para a população portuguesa. Metodologia: Estudo desenvolvido em duas fases: na Fase 1 realizaram-se entrevistas exploratórias a académicos, profissionais de saúde e cuidadores, com o intuito de se conhecer a recetividade a este tipo de intervenção; na Fase 2 conduziu-se um painel de peritos e grupos focais, com cuidadores, para explorar a suas perceções sobre o programa FD3, versão portuguesa. Resultados: A Fase 1 foi impulsionadora do estudo. As partes interessadas analisaram este tipo de intervenção como muito útil e versátil. A Fase 2 permitiu perceber as potencialidades em termos de aceitabilidade e de aplicabilidade da intervenção, traduzida e adaptada, para a população portuguesa. Conclusão: O programa FD3 poderá ser uma excelente ferramenta no cuidado à pessoa idosa com deterioração cognitiva a residir em contexto domiciliar.

Abstract Background: The delivery of individual cognitive stimulation by caregivers in a home-based setting is an innovative intervention. An example of this type of intervention is the Making a Difference 3 (MD3) cognitive stimulation program. Objective: To explore the appropriateness and feasibility of the MD3 program for the Portuguese population. Methodology: This study was developed in two phases. In Phase 1, exploratory interviews were conducted with academics, healthcare professionals, and caregivers to identify the receptivity to this type of intervention. In Phase 2, a panel of experts and focus groups with caregivers were conducted to explore their perceptions about the Portuguese version of the MD3 program. Results: Phase 1 was the driving force behind the study. Participants considered this type of intervention very useful and versatile. Phase 2 allowed identifying the level of appropriateness and feasibility of the intervention that was translated and adapted to the Portuguese population. Conclusion: The MD3 program can be an excellent tool in caring for older adults with cognitive impairment living at home.

Resumen Marco contextual: La estimulación cognitiva individual, desarrollada en casa, por un cuidador, es una intervención innovadora. El programa de estimulación cognitiva Marcando la diferencia 3 (MD3) es un ejemplo de este tipo de intervención. Objetivo: explorar la aceptabilidad y aplicabilidad del programa MD3 para la población portuguesa. Metodología: se desarrollaron dos fases. En la Fase 1, se realizaron entrevistas exploratorias con académicos, profesionales y cuidadores, con el fin de conocer la receptividad a este tipo de intervenciones; La Fase 2, se desarrolló un panel de expertos y grupos focales para explorar sus percepciones sobre el programa, versión portuguesa. Resultados: La Fase 1 fue la fuerza impulsora detrás del estudio. Los grupos de interés consideraron este tipo de intervención como muy útil y versátil. La Fase 2 permitió percibir las potencialidades en términos de aceptabilidad y aplicabilidad de la intervención, traducida y adaptada, para la población. Conclusión: El programa MD3 puede ser una excelente herramienta para el cuidado de las personas mayores con deterioro cognitivo que viven en el hogar.

Analysis of cognitive performance and polymorphisms of SORL1, PVRL2, CR1, TOMM40, APOE, PICALM, GWAS_14q, CLU, and BIN1 in patients with mild cognitive impairment and cognitively healthy controls.

INTRODUCTION: Alzheimer disease risk polymorphisms have been studied in patients with dementia, but have not yet been explored in mild cognitive impairment (MCI) in our population; nor have they been addressed in relation to cognitive variables, which can be predictive biomarkers of disease. OBJECTIVE: To evaluate cognitive performance and presence of polymorphisms of the genes SORL1(rs11218304), PVRL2(rs6859), CR1(rs6656401), TOMM40(rs2075650), APOE (isoforms ε2, ε3, ε4), PICALM(rs3851179), GWAS_14q(rs11622883), BIN1(rs744373), and CLU(rs227959 and rs11136000) in patients with MCI and healthy individuals. METHODOLOGY: We performed a cross-sectional, exploratory, descriptive study of a prospective cohort of participants selected by non-probabilistic sampling, evaluated with neurological, neuropsychological, and genetic testing, and classified as cognitively healthy individuals and patients with MCI. Cognition was evaluated with the Neuronorma battery and analysed in relation to the polymorphic variants by means of measures of central tendency, confidence intervals, and nonparametric statistics. RESULTS: We found differences in performance in language and memory tasks between carriers and non-carriers of BIN1, CLU, and CR1 variants and a trend towards poor cognitive performance for PICALM, GWAS_14q, SORL1, and PVRL2 variants; the APOE and TOMM40 variants were not associated with poor cognitive performance. DISCUSSION: Differences in cognitive performance associated with these polymorphic variants may suggest that the mechanisms regulating these genes could have an effect on cognition in the absence of dementia; however, this study was exploratory and hypotheses based on these results must be explored in larger samples.

Five-Word Test, Screening of Mixed Dementia in Older Adults. Validation Study.

INTRODUCTION AND OBJECTIVES: The prevalence of mixed dementia (MixD), defined as the coexistence of Alzheimer's disease (AD) and vascular dementia (VaD), is likely to increase as the population ages. The five-word test (5WT) is a neuropsychological test that differentiates between major and mild neurocognitive disorder (NCD). The objective of the study is to validate 5WT for the detection of MixD. METHODS: 230 participants were evaluated: cognitively healthy (CH) (n=70), mild NCD (n=70), and major NCD (n=90): AD (n=30), VaD (n=30), and MixD (n=30). The Spearman's coefficient, d Sommer and ROC curves were used to determine the construct validity of the 5WT. The linear regression model was performed to determine the association between age and education with 5WT performance. RESULTS: The mean age was 79 ±7.7 years (P≤.001), 58% were female (P=.252), and the mean education was 9 ±5.3 years (P≤.001). Construct validity when comparing 5WT and MMSE was: Spearman's correlation ρ=.830 (P<.001) and d Sommer=.41 (P<.001). The area under the curve in the total weighted score (TWS) for MixD was .985, with 98% sensitivity (95%CI, 0.96-1.00) and 99% specificity (95%CI, 0.94-1.00), PPV of 88% (95%CI, 0.82-0.89), NPV of 100% (95%CI, 0.96-1.00), and cut-off point ≤16/20 (P<.001). CONCLUSIONS: 5WT is a rapid test with neuropsychological validation for the exploration of cognitive characteristics in major NCD type MixD, regardless of age and education.

Cannabinoids for major neurocognitive disorder: case report and literature review.

INTRODUCTION: Major neurocognitive disorder (MNCD) affects millions of people worldwide. However, the pharmacological options for its management are limited, ineffective and frequently associated with severe adverse reactions. CASE REPORT: An 85-year-old man with history of multiple chronic brain injuries (alcohol-use disorder, haemorrhagic stroke, brain trauma, chronic use of benzodiazepines) developed an MNCD, reaching 7 points on the Reisberg Global Deterioration Scale. He had minimal response to antidepressants, antipsychotics and anticholinergic medications. After the use of mother tincture of Indian hemp (cannabis), a significant improvement was found in his cognitive function, ability to carry out activities of daily living and independence. DISCUSSION: The endocannabinoid system seems to be implicated in age-related cognitive decline. In addition, the evidence derived from in-vitro and animal models suggest that this system could play an important role in the management of MNCD of different causes. CONCLUSIONS: Cannabinoid treatment for MNCD emerges as a promising therapeutic approach that may benefit a growing number of patients who do not have other treatment options. It is therefore necessary to encourage more research efforts that will help to remove political and scientific barriers to its clinical use.

Quality of life of children and adults following cardiac surgery for congenital heart disease: A Mexican cohort.

Objective: The real burden of (congenital heart defects [CHD]) and the improvement after surgical correction or palliation is both reflected in the quality of life (QoL). There are few studies in Latin-America that evaluate QoL in the CHD population. The purpose of this study was to measure the QoL after corrective or palliative surgery for CHD. Materials and methods: An observational, cross-sectional, and comparative study was carried out at the Miguel Hidalgo Centennial Hospital. Patients from 8 to 18 years old who underwent surgery for CHD were included during a period of 8 months. A total of 40 patients were included, together with a group of 80 healthy controls. From all participants, a KIDSCREEN-52 questionnaire was taken. A comparative analysis of the results was performed. Results: Overall, patients with cardiac surgery had better QoL indexes than healthy controls (p < 0.0001). The difference was greatest in moods and emotions, autonomy, and parent relations. Conclusions: Self-perception of QoL in post-operative patients for congenital heart disease is similar and in certain dimensions higher than the healthy population, possibly due to socioeconomic differences, parental care, and styles of coping with their disease. Higher complexity studies that include psychosocial variables and parental perception are required, and a better understanding of the QoL determinants will improve the attention provided to the patient and their families. Objetivo: Los efectos de las cardiopatías congénitas en los pacientes, así como la mejoría después de la paliación o la corrección quirúrgica, se reflejan en la calidad de vida (CV). Hay pocos estudios en Latinoamérica que evalúen la CV en esta población. El objetivo de este artículo es notificar la CV posterior a la operación paliativa o correctiva para defectos cardíacos congénitos. Material y métodos: Se llevó a cabo un estudio observacional, transversal y comparativo en el Centenario Hospital Miguel Hidalgo. Durante un período de ocho meses se incluyó a pacientes de 8 a 18 años sometidos a una intervención para cardiopatías congénitas. Se reunió a dos grupos de 40 pacientes y 80 controles sanos, pareados por edad y sexo. A cada participante se le aplicó el cuestionario KIDSCREEN-52 y se realizó un análisis comparativo de los resultados. Resultados: Los pacientes sometidos a operación cardíaca tuvieron mejores índices de CV que los controles sanos (p < 0.0001). La mayor diferencia se obtuvo en los aspectos de estado de ánimo y emociones, autonomía y relación con los padres. Conclusiones: La autopercepción de la CV después de una intervención para cardiopatías congénitas es similar y, en ciertas dimensiones, mejor que la de la población sana, tal vez por diferencias socioeconómicas, atención de los padres y modelos de adaptación a la enfermedad. Se requieren estudios más extensos que incluyan variables psicosociales y percepción parental. Una mayor comprensión de los determinantes de la CV podría mejorar la atención ofrecida al paciente y su familia.

High prevalence of HIV-associated neurocognitive disorders (HAND) in São Paulo City, Brazil / Alta prevalência de desordem neurocognitiva associada ao HIV (HAND) na Cidade de São Paulo, Brazil

INTRODUCTION: HIV-associated neurocognitive disorders (HAND) are the subject of many studies, some of them reporting a prevalence of up to 50 percent. OBJECTIVES: To determine the prevalence and factors associated with HIV neurocognitive disorders (HAND) in a cohort of HIV-1-infected patients in São Paulo city, Brazil. METHODOLOGY: Descriptive cross-sectional study including 106 HIV-1-infected patients, employing direct interview and neuropsychological tests, applied by trained neuro-psychologists with expertise in the tests. Other, similar assessment tools we used were Brief Neurocognitive Questionnaire, International HIV Dementia Scale, Lawton Instrumental Activities of Daily Living, Hospital Anxiety and Depression Scale, Social Support Scale for People with HIV/Aids, Assessment of Adherence to Antiretroviral Therapy Questionnaire, and a complex neuropsychological assessment. RESULTS: We included 106 patients from May 2015 to April 2018. We found a high prevalence of HAND in our patients (45%), with 27.5% presenting asymptomatic neurological impairment (ANI) and 17.5% mild neurological dysfunction (MND); only one patient presented HIV-associated dementia (HAD) (0.9%). Women were more likely to have MND (52.9%) and the only case of HAD was also female. The high prevalence of neurocognitive disorders was independent of the immunological status, use of efavirenz, or virological control. CONCLUSIONS: This study may mirror the national and international scenarios, showing a high prevalence of HAND (45%) and the prevalence of some risk factors, in special among women

INTRODUÇÃO: As doenças neurocognitivas associadas ao HIV (HAND), são o assunto de muitos estudos, alguns deles relatando uma prevalência de até 50 por cento. OBJETIVOS: Determinar a prevalência e os fatores associados aos distúrbios neurocognitivos do HIV (HAND) em uma coorte de pacientes infectados pelo HIV-1 na cidade de São Paulo, Brasil. METODOLOGIA: Estudo transversal descritivo incluindo 106 pacientes infectados pelo HIV-1, utilizando entrevista direta e testes neuropsicológicos, aplicados por neuropsicólogos treinados com experiência nos testes. Foram utilizados também: Questionário Neurocognitivo Breve, Escala Internacional de Demência do HIV, Atividades Instrumentais de Vida Diária de Lawton, Escala Hospitalar de Ansiedade e Depressão, Escala de Apoio Social para Pessoas com HIV / Aids, Avaliação da Adesão à Terapia Antiretroviral Questionário e uma bateria de avaliação neuropsicológica complexa. RESULTADOS: Foram avalaidos 106 pacientes de maio de 2015 a abril de 2018. Foi observado uma alta prevalência de HAND em nossos pacientes (45%), com 27,5% apresentando comprometimento neurológico assintomático (ANI) e 17,5% comprometimento cognitive leve (MND); apenas um paciente apresentou demência associada ao HIV (DAH) (0,9%). As mulheres eram mais propensas a ter MND (52,9%) e o único caso de HAD também era do sexo feminino. A alta prevalência de distúrbios neurocognitivos foi independente do estado imunológico, uso de efavirenz ou controle virológico. CONCLUSÕES: Este estudo pode espelhar o cenário nacional e internacional, mostrando uma alta prevalência de HAND (45%) e a prevalência de alguns fatores de risco, em especial entre as mulheres

Cannabinoids for major neurocognitive disorder: case report and literature review / Uso de cannabinoides en trastorno neurocognitivo mayor: reporte de un caso y revisión de la literatura

ABSTRACT Introduction: Major neurocognitive disorder (MNCD) affects millions of people worldwide. However, the pharmacological options for its management are limited, ineffective and frequently associated with severe adverse reactions. Case report: An 85-year-old man with history of multiple chronic brain injuries (alcohol-use disorder, haemorrhagic stroke, brain trauma, chronic use of benzodiazepines) developed an MNCD, reaching 7 points on the Reisberg Global Deterioration Scale. He had minimal response to antidepressants, antipsychotics and anticholinergic medications. After the use of mother tincture of Indian hemp (cannabis), a significant improvement was found in his cognitive function, ability to carry out activities of daily living and independence. Discussion: The endocannabinoid system seems to be implicated in age-related cognitive decline. In addition, the evidence derived from in-vitro and animal models suggest that this system could play an important role in the management of MNCD of different causes. Conclusions: Cannabinoid treatment for MNCD emerges as a promising therapeutic approach that may benefit a growing number of patients who do not have other treatment options. It is therefore necessary to encourage more research efforts that will help to remove political and scientific barriers to its clinical use.

RESUMEN Introducción: El trastorno neurocognitivo mayor (TNM) afecta a millones de personas a nivel mundial. Sin embargo, las opciones farmacológicas para su manejo son limitadas, poco efectivas y se asocian a importantes reacciones adversas. Caso clínico: Se presenta el caso clínico de un hombre de 85 años, con antecedente de múltiples lesiones cerebrales crónicas (abuso de alcohol, enfermedad cerebrovascular, traumatismo cerebral, uso crónico de benzodiacepinas), quien desarrolló un TNM clasificado con 7 puntos en la Reisberg Global Deterioration Scale. Tuvo poca respuesta al manejo con antidepresivos, antipsicóticos y anticolinérgicos. Tras el uso de tintura madre de cáüamo índico (cannabis), se evidenció una mejoría en la función cognitiva, la capacidad de cuidado para las actividades de la vida diaria y la independencia. Discusión: El sistema endocanabinoide parece estar relacionado con los procesos de deterioro cognitivo asociados con la edad. Además, la evidencia derivada de modelos in vitro y animales sugiere que podría tener un papel importante en el manejo del TNM de diferentes etiologías. Conclusiones: El uso de cannabinoides en el TNM se presenta como una pista terapéutica prometedora. Por lo tanto, es necesario promover procesos de investigación que contribuyan a eliminar las barreras políticas y científicas para su uso clínico, beneficiando a un número creciente de pacientes que no poseen opciones terapéuticas eficaces.