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Introduction and objectives Hyperglycaemia in hospitalized patients with type 2 diabetes is preferably managed with insulin. We aimed to analyse the glycaemic efficacy, treatment simplicity, and safety of our hospital's antihyperglycemic regimens (linagliptin-basal insulin versus basal-bolus insulin) in patients with type 2 diabetes admitted for heart failure decompensation. Patients and methods In this real-world study, we included patients with mild-to-moderate hyperglycaemia managed with our antihyperglycemic regimens between 2016 and 2018. To match patients who started one of the regimens, a propensity matching analysis was used. Results After propensity matching, 146 patients were included in each group. There were no differences in mean blood glucose levels (163.6 ± 21.2 vs 159.6 ± 19.2 mg/dl, p = .210). Patients on the linagliptin-basal insulin regimen had a lower total number of hypoglycaemic episodes (36 vs 64, p Conclusions Linagliptin-basal insulin was a safe, simple, and efficacious regimen and could be considered standard of care for these vulnerable, high complex patients to simplify in-hospital management.

Background There is little evidence on the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors in older patients with heart failure. This work analyzed the clinical efficacy and safety of empagliflozin continuation in very old patients with type 2 diabetes hospitalized for acute decompensated heart failure. Methods We conducted a real-world observational study between September 2015 and June 2021. Patients ≥80 years were grouped by antihyperglycemic regimen: (1) continuation of preadmission empagliflozin combined with basal insulin regimen and (2) conventional basal-bolus insulin regimen. A propensity score matching analysis matched patients in both groups in a 1:1 manner. The primary outcome was differences in clinical efficacy measured by the visual analogue scale dyspnea score, NT-proBNP levels, diuretic response, and cumulative urine output. Safety endpoints such as adverse events, worsening heart failure, discontinuation of empagliflozin, length of hospital stay, and in-hospital deaths were also analyzed. Results After propensity score matching, 79 patients were included in each group. At discharge, the N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were lower in the empagliflozin continuation group than in the insulin group (1699 ± 522 vs. 2303 ± 598 pg/ml, p = 0.021). Both the diuretic response and cumulative urine output were greater in patients treated with empagliflozin than in patients with basal-bolus insulin during the hospitalization (at discharge: -0.14 ± -0.06 vs. -0.24 ± -0.10, p = 0.044; and 16,100 ± 1510 vs. 13,900 ± 1220 ml, p = 0.037, respectively). No differences were observed in safety outcomes. Conclusions In very old patients with type 2 diabetes hospitalized for acute heart failure, continuing preadmission empagliflozin reduced NT-proBNP levels and increased diuretic response and urine output compared to a basal-bolus insulin regimen. The empagliflozin regimen also showed a good safety profile.

Background and objectives: The COVID-19 pandemic has forced universities to move the completion of university studies online. Spain's National Conference of Medical School Deans coordinates an objective, structured clinical competency assessment called the Objective Structured Clinical Examination (OSCE), which consists of 20 face-to-face test sections for students in their sixth year of study. As a result of the pandemic, a computer-based case simulation OSCE (CCS-OSCE) has been designed. The objective of this article is to describe the creation, administration, and development of the test. Materials and methods: This work is a descriptive study of the CCS-OSCE from its planning stages in April 2020 to its administration in June 2020. Results: The CCS-OSCE evaluated the competences of anamnesis, exploration, clinical judgment, ethical aspects, interprofessional relations, prevention, and health promotion. No technical or communication skills were evaluated. The CCS-OSCE consisted of ten test sections, each of which had a 12-minutes time limit and ranged from six to 21 questions (mean: 1.1 minutes/question). The CCS-OSCE used the virtual campus platform of each of the 16 participating medical schools, which had a total of 2,829 students in their sixth year of study. It was jointly held on two dates in June 2020. Conclusions: The CCS-OSCE made it possible to bring together the various medical schools and carry out interdisciplinary work. The CCS-OSCE conducted may be similar to Step 3 of the United States Medical Licensing Examination.

The significant and progressive reduction in the number of permanent teachers in medical schools (professor, associate professor and assistant professor) is a reason for concern for the National Conference of Deans. This reduction will intensify in the coming decade (2017-2026). Forty-three percent of the permanent faculty will retire, as will 55% of the faculty linked to clinical areas, 34% of the faculty not linked to clinical areas and 32% of the faculty of basic areas. This deficit is significant now, and, in a few years, the situation will be unsustainable, especially in the clinical areas. This report reveals the pressing need to adopt urgent measures to alleviate the present situation and prevent a greater problem. The training of future physicians, immediately responsible for the health of our society, depends largely on the theoretical and practical training taught in medical schools, with the essential collaboration of healthcare institutions. Paradoxically, while the number of teachers decreases substantially, there is an exponential increase in the number of medical schools and students who are admitted every year without academic or healthcare justification.

espanolLa disminucion significativa y progresiva en el numero de profesores permanentes en las facultades de Medicina (catedratico, profesor titular y profesor contratado doctor) es motivo de preocupacion para la Conferencia Nacional de Decanos. Esta disminucion se intensificara en la proxima decada (2017-2026). Se jubilara el 43% del profesorado permanente: un 55% del profesorado vinculado de areas clinicas, un 34% del profesorado no vinculado de areas clinicas y un 32% del profesorado de areas basicas. Este deficit es importante en el momento actual y en pocos anos la situacion sera insostenible, especialmente en areas clinicas. Este informe pone de manifiesto la necesidad inaplazable de adoptar medidas urgentes que palien la situacion actual y que prevengan un mal mayor. La formacion de los futuros medicos, responsables inmediatos de salud de nuestra sociedad, depende en gran parte de la ensenanza teorica y practica que se imparte en las facultades de Medicina, con la colaboracion esencial de las instituciones sanitarias. Paradojicamente, a la vez que disminuye sustancialmente el numero de profesores, aumenta exponencialmente el numero de facultades de Medicina y el numero de alumnos que se admiten cada ano sin justificacion academica ni sanitaria. EnglishThe significant and progressive reduction in the number of permanent teachers in medical schools (professor, associate professor and assistant professor) is a reason for concern for the National Conference of Deans. This reduction will intensify in the coming decade (2017-2026). Forty-three percent of the permanent faculty will retire, as will 55% of the faculty linked to clinical areas, 34% of the faculty not linked to clinical areas and 32% of the faculty of basic areas. This deficit is significant now, and, in a few years, the situation will be unsustainable, especially in the clinical areas. This report reveals the pressing need to adopt urgent measures to alleviate the present situation and prevent a greater problem. The training of future physicians, immediately responsible for the health of our society, depends largely on the theoretical and practical training taught in medical schools, with the essential collaboration of healthcare institutions. Paradoxically, while the number of teachers decreases substantially, there is an exponential increase in the number of medical schools and students who are admitted every year without academic or healthcare justification.

There is little evidence on the use of sodium−glucose cotransporter 2 inhibitors in hospitalised patients. This work aims to analyse the glycaemic and clinical efficacy and safety of empagliflozin continuation in patients with type 2 diabetes hospitalised for acute decompensated heart failure. This real-world observational study includes patients treated using our in-hospital antihyperglycaemic regimens (basal-bolus insulin vs. empagliflozin-basal insulin) between 2017 and 2020. A propensity matching analysis was used to match a patient on one regimen with a patient on the other regimen. Our primary endpoints were the differences in glycaemic control, as measured via mean daily blood glucose levels, and differences in the visual analogue scale dyspnoea score, NT-proBNP levels, diuretic response, and cumulative urine output. Safety endpoints were also analysed. After a propensity matching analysis, 91 patients were included in each group. There were no differences in mean blood glucose levels (152.1 ± 17.8 vs. 155.2 ± 19.7 mg/dL, p = 0.289). At discharge, NT-proBNP levels were lower and cumulative urine output greater in the empagliflozin group versus the basal-bolus insulin group (1652 ± 501 vs. 2101 ± 522 pg/mL, p = 0.032 and 16,100 ± 1510 vs. 13,900 ± 1220 mL, p = 0.037, respectively). Patients who continued empagliflozin had a lower total number of hypoglycaemic episodes (36 vs. 64, p &lt, 0.001). No differences were observed in adverse events, length of hospital stay, or in-hospital deaths. For patients with acute heart failure, an in-hospital antihyperglycaemic regimen that includes continuation of empagliflozin achieved effective glycaemic control, lower NT-proBNP, and greater urine output. It was also safer, as it reduced hypoglycaemic episodes without increasing other safety endpoints.

Older patients managed with intensive antidiabetic therapy are more likely to be harmed. Our study's primary endpoint was to analyze the safety and efficacy of linagliptin in combination with basal insulin versus basal-bolus insulin in patients with 75 years of age or older hospitalized in medicine and surgery departments in real-world clinical practice.We retrospectively enrolled non-critically patients ≥75 years with type 2 diabetes admitted to medicine and non-cardiac surgery departments with admission glycated haemoglobin8%, admission blood glucose240mg/dL, and without at-home injectable therapies managed with our hospital's antihyperglycemic protocol (basal-bolus or linagliptin-basal regimens) between January 2016 and December 2018. To match each patient who started on the basal-bolus regimen with a patient who started on the linagliptin-basal regimen, a propensity matching analysis was used.Post-matching, 198 patients were included in each group. There were no significant differences in mean daily blood glucose levels after admission (p=0.203); patients with mean blood glucose 100-140mg/dL (p=0.134), 140-180mg/dL (p=0.109), or200mg/dL (p=0.299); and number and day of treatment failure (p=0.159 and p=0.175, respectively). The total insulin dose and the number of daily injections were significantly lower in the linagliptin-basal group (both, p0.001). Patients on the basal-bolus insulin regimen had more total hypoglycemic events than patients on the linagliptin-basal insulin regimen (p0.001).The linagliptin-basal insulin regimen was an effective alternative with fewer hypoglycemic events and daily insulin injections than intensive basal-bolus insulin in very old patients with type 2 diabetes with mild-to-moderate hyperglycemia treated at home without injectable therapies.

Resumen Antecedentes y objetivos La pandemia de la COVID-19 ha obligado a completar los estudios universitarios online. La Conferencia Nacional de Decanos de Facultades de Medicina coordina una prueba de evaluacion de competencias clinicas objetiva y estructurada (ECOE) de 20 estaciones presenciales a los estudiantes de sexto del grado. Como consecuencia de la pandemia se ha disenado una ECOE sustitutoria con casos-clinicos computarizados simulados (ECOE-CCS). El objetivo del articulo es describir la elaboracion, la ejecucion y el desarrollo de la prueba. Materiales y metodos Estudio descriptivo de la ECOE-CCS conjunta desde su gestacion en abril 2020 hasta su ejecucion en junio 2020. Resultados La ECOE-CCS evaluo las competencias de anamnesis, exploracion, juicio clinico, aspectos eticos, relaciones interprofesionales, prevencion y promocion de la salud. No se evaluaron habilidades tecnicas ni de comunicacion. La ECOE-CCS consistio en 10 estaciones de 12 minutos de duracion, con un numero de preguntas de seis a 21 (media: 1,1 minutos/pregunta). En la ECOE-CCS se utilizo la plataforma virtual del campus de cada una de las 16 facultades de Medicina que participaron, con un total de 2.829 estudiantes de sexto curso. Se realizo de una forma conjunta en dos fechas de junio del 2020. Conclusiones La experiencia de la ECOE-CCS permitio llevar a cabo una integracion y el trabajo interdisciplinar de las diferentes facultades de Medicina. La ECOE-CCS realizada podria asemejarse al Step 3 CCS de la United States Medical Licensing Examination.

Aim Evidence describing the contribution of cerebral white matter disease and medial temporal atrophy (MTA) to behavioural and psychological symptoms of dementia (BPSD) has been conflicting. The aim of this study was to assess the relationship of white matter hyperintensities (WMH) and MTA observed on magnetic resonance imaging with BPSD among patients with Alzheimer's disease. Methods In a cross-sectional study of a prospective cohort of patients attending a memory clinic, 46 patients with probable Alzheimer's disease (mean age: 72.38 ± 7.05 years) were studied. Sociodemographic, cognitive, and BPSD data were collected. BPSD were assessed using the Neuropsychiatric Inventory. Magnetic resonance imaging, WMH, and MTA were rated using the Scheltens scales for the assessment of signal hyperintensities and atrophy of medial temporal lobes. For multivariate analysis, two binary logistic regression analyses were carried out, with presence or absence of each BPSD as the dependent variable and with WMH or MTA as the predictor variable. Results of the logistic regression were analyzed to see if the significance of the WMH or MTA score was maintained in a model that factored in other possible confounding variables identified in univariate analysis. Results The results of binary logistic regression analysis showed that in models that accounted for confounding variables, increased total MTA was significantly associated with apathy (odds ratio = 1.605, adjusted P = 0.042) and disinhibition (odds ratio = 0.607, adjusted P = 0.042). WMH measures did not significantly predict any BPSD item. Conclusions These findings indicate that MTA potentially contributes to the aetiology of BPSD, and they provide evidence to support the hypothesis that Alzheimer's disease pathology itself can contribute to BPSD.

Resumen Introduccion El proceso docente actual necesita cambios mediante la introduccion de las nuevas tecnologias de la informacion y la comunicacion (TIC) por medio de nuevos sistemas de hardware y software. Tras unos primeros anos de introduccion y adaptacion, hoy en dia, el uso de equipos informaticos fijos, portatiles, moviles y tabletas se ha convertido en un aspecto cotidiano para todos los individuos, permitiendo que nuevas tecnologias se puedan implantar de una manera mas natural. En este sentido, la Facultad de Medicina de Malaga se ha planteado el uso de mandos de respuesta interactivos mediante radiofrecuencias en actividades de grupo reducido ya que se postulan como una herramienta de gran utilidad que podrian mejorar la calidad de la docencia, permitiendo una evaluacion de la misma en tiempo real, superando la realizada por los metodos mas clasicos como el examen escrito u oral. Material y metodos Tras realizar cursos de formacion al personal implicado y dotar las aulas con el hardware preciso, se procedio a entregar a todos los alumnos un mando de respuesta interactiva por radiofrecuencia de forma gratuita para realizar diversas actividades en grupos reducidos un total de 12 asignaturas (6 basicas y 6 clinicas) mediante preguntas tipo test unirrespuesta y posteriormente una encuesta de satisfaccion. Se analizo la estadistica descriptiva y comparativa de los datos obtenidos. Resultados y discusion Los objetivos de nuestro estudio han ido enfocados a comprobar la eficacia de la implantacion de los mandos de respuesta interactiva en las actividades de grupo reducido en el grado en Medicina. Todos los resultados mostraron una distribucion normal. El numero de alumnos que participaron en la experiencia fue de 1.645, divididos en 6 asignaturas basicas y 6 clinicas. En el analisis conjunto el promedio de aciertos en las actividades de evaluacion de la docencia en grupos reducidos mediante test unirrespuesta fue de 73,3 ± 2,7% con un grado de satisfaccion de 4,3 ± 0,2 sobre 5. En el analisis comparativo entre asignaturas basicas y clinicas mediante t de Student, se observo un mayor promedio de aciertos en las asignaturas basicas (79,3 ± 2,9 vs. 67,3 ± 3,1) con un grado de satisfaccion similar (4,3 ± 0,3 vs. 4,2 ± 0,2). El uso de mandos de radiofrecuencia se ha mostrado como una herramienta util como apoyo a la docencia en grupos reducidos, facilitando una buena adquisicion de competencias especificas y un elevado grado de satisfaccion por parte del alumnado.

BACKGROUND Although postoperative cognitive dysfunction is a relevant complication after surgery, assessment for the condition is not routine in clinical practice. OBJECTIVE The aim of this study was to compare the use of screening versus brief domain-specific cognitive tests in assessing long-term cognitive dysfunction after concomitant aortic valve replacement and coronary artery bypass grafting. METHODS In this observational prospective study, we evaluated 70 patients preoperatively and after 1, 6, and 12 months using 2 screening tests (Mini-Mental State Examination and Clock Drawing Test) and 2 brief domain-specific cognitive tests (Trail Making Test to evaluate attention and executive function, and Semantic and Phonological Tests to evaluate verbal fluency). RESULTS The brief domain-specific cognitive tests detected significant postoperative worsening in performances (up to 19% on the Trail Making Test and 15.4% on verbal fluency tests at 6 months). Postoperative mild attention/executive dysfunction or inferior normal performance was detected with the maximums being seen at 6 months (44.6%, P < .001). Performances on screening tests did not significantly change during the study period. CONCLUSIONS A brief domain-specific cognitive evaluation could be routinely implemented in perioperative care practice to detect postoperative cognitive dysfunction.

Introduction: The use of dipeptidyl peptidase-4 inhibitors in hospitalized patients is an area of active research. We aimed to compare the efficacy and the safety of the basal-bolus insulin regimen versus linagliptin-basal insulin in non-critically ill non-cardiac surgery patients in a real-world setting. Methods: We enrolled patients with type 2 diabetes hospitalized in non-cardiac surgery departments with admission glycated haemoglobin level < 8%, admission blood glucose concentration < 240 mg/dL, and no at-home injectable treatments who were treated with basal-bolus (n = 347) or linagliptin-basal (n = 190) regimens between January 2016 and December 2017. To match patients on the two regimens, a propensity matching analysis was performed. Results: After matching, 120 patients were included in each group. No differences were noted in mean blood glucose concentration after admission (p = .162), number of patients with a mean blood glucose 100–140 mg/dL (p = .163) and > 200 mg/dL (p = .199), and treatment failures (p = .395). Total daily insulin and number of daily insulin injections were lower in the linagliptin-basal group (both p

Resumen Introduccion y objetivos El deterioro cognitivo postoperatorio es una importante complicacion tras la cirugia cardiaca. En este estudio prospectivo se determina su presencia e identifica los factores de riesgo cardiovascular implicados. Metodos Treinta y seis pacientes programados para cirugia coronaria electiva sin circulacion extracorporea fueron evaluados usando una bateria neurocognitiva pre y posquirurgicamente (uno, 6 y 12 meses), estableciendose el deterioro cognitivo como una disminucion significativa del rendimiento respecto a niveles preoperatorios. Las variables implicadas se obtuvieron mediante un analisis de regresion multiple. Resultados Se mostro deterioro cognitivo postoperatorio multidominio (funciones ejecutivas-atencion, p Conclusiones La identificacion del deterioro cognitivo postoperatorio y sus variables asociadas puede ser util para adoptar medidas preventivas y aconsejar a nuestros pacientes preoperatoriamente.

This study was conducted to obtain data regarding the association of caregiver burden (CB) and neuropsychiatric symptoms (NPSs) in patients with Alzheimer’s disease. We conducted a series of multiple linear regressions to determine the relationship between CB and NPSs and whether the caregiver coping strategies mediated this relationship. The NPSs were assessed using the Neuropsychiatric Inventory, and caregivers were evaluated with the Caregiver Burden Interview and the Inventory and the Coping Strategies Inventory. Results show that patients with more frequent and severe NPS were more likely to be cared for by more burdened caregivers, and this was partially mediated by caregiver coping strategies. More disengagement (β = .330, P < .001) and less engagement coping (β = −.347, P < .001) were predictors for NPS after adjusting for patient and caregiver characteristics. These results may be useful with a view to designing treatment interventions that aim to modify the use of caregiver coping strategies and to reduce NPSs.

To determine whether caregiver coping strategies are independently associated with behavioral and psychological symptoms (BPS) in Alzheimer's disease (AD) after accounting for patient characteristics.Cross-sectional data analysis of 80 patients with AD and their primary caregivers. The presence of BPS was recorded using the Neuropsychiatric Inventory (NPI). The relationship between caregiver characteristics and BPS was assessed through one-way analysis of variance, two-tailed student t-tests or correlation coefficients. Multivariate linear regression was used to determine the combined effect of all caregiver factors that were significant on bivariate analysis regarding coping and BPS controlling for patient characteristics.Caregivers were on average 62 years old, 77% female, and most were the children or the spouse of the patient. Over 50% had significant depression or anxiety. Patients were on average 77 years old and 62% were female, and most had moderate to severe dementia. After adjusting for patient characteristics, patients cared for by more depressed, more burdened, or those using more disengagement coping strategies showed higher NPI mean composite scores.Coping strategies are associated with BPS regardeless of patient characteristics. Interventions to reduce BPS should focus on which psychological coping strategies caregivers use. Understanding how coping strategies influence BPS may help tailor specific interventions for caregivers.

New Findings • What is the central question of this study?As the parabrachial complex plays a role in the cardiorespiratory response evoked from the hypothalamic defence area (pressor response and tachycardia) and the A5 region is involved in the responses evoked from the parabrachial complex, a possible interaction between the hypothalamic defence area and A5 is suggested. Accordingly, the present study was carried out to assess this hypothesis in rats. • What is the main finding and its importance?The neuromorphological, neuropharmacological and electrophysiological results of our study demonstrate, for the first time, that the A5 region is an important component of those brainstem pathways known to be involved in mediating the autonomic changes associated with the electrically evoked defence response. In order to assess the possible interactions between the pontine A5 region and the hypothalamic defence area (HDA), we have examined the pattern of double staining for c-Fos protein immunoreactivity (c-Fos-ir) and tyrosine hydroxylase, throughout the rostrocaudal extent of the A5 region in spontaneously breathing anaesthetized male Sprague–Dawley rats during electrical stimulation of the HDA. Activation of the HDA elicited a selective increase in c-Fos-ir with an ipsilateral predominance in catecholaminergic and non-catecholaminergic A5 somata (P < 0.001 in both cases). A second group of experiments was done to examine the importance of the A5 region in modulating the cardiorespiratory response evoked from the HDA. Cardiorespiratory changes were analysed in response to electrical stimulation of the HDA before and after ipsilateral microinjection of muscimol within the A5 region. Stimulation of the HDA evoked an inspiratory facilitatory response, consisting of an increase in respiratory rate (P < 0.001) due to a decrease in expiratory time (P < 0.01). The respiratory response was accompanied by a pressor response (P < 0.001) and tachycardia (P < 0.001). After muscimol microinjection within the A5 region, pressor and heart rate responses to HDA stimulation were reduced (P < 0.01 and P < 0.001, respectively). The respiratory response persisted unchanged. Finally, to confirm functional interactions between the HDA and the A5 region, extracellular recordings of putative A5 neurones were obtained during HDA stimulation. Seventy-five A5 cells were recorded, 35 of which were affected by the HDA (47%). These results indicate that neurones of the A5 region participate in the cardiovascular response evoked from the HDA. The possible mechanisms involved in these interactions are discussed.

Background/Objective: The heterogeneous clinical presentations of individuals with Autism Spectrum Disorders (ASD) pose a significant challenge for sample characterization. Therefore the main goal of DSM-5 must be to identify subgroups of ASD, including comorbidity disorders and severity. The main goal of this study is to explore the psychiatric comorbidities and the severity of symptoms that could be relevant for the phenotype characterization in ASD and also to compare these results according to the different classification criteria between the DSM-IV-TR and the DSM-5. Method: A comparative study of severity and psychiatric comorbidities was carried out between a sample of participants that only met criteria for Pervasive Developmental Disorder (PDD) according to the DSM-IV-TR and a sample of participants that also met ASD criteria according to DSM-5 classification. The recruitment of children was via educational (N=123). The psychiatric symptoms, comorbid disorders and severity of symptoms were assessed through The Nisonger Child Behavior Rating Form, clinical interview and The Inventory of Autism Spectrum Disorder, respectively. The psychiatric comorbidities considered were: anxiety, eating behavioural problems, self-aggressiveness, hetero-aggressiveness, self harm, obsessive compulsive disorder and attention deficit and hyperactivity disorder. Results: Statistically significant differences between both groups were found regarding obsessive compulsive disorder, eating behavioural problems and severity. Conclusions: The results support the hypothesis that patients who meet the DSM-5 criteria have more severe symptoms, not only regarding the core autistic symptoms but also in relation with psychiatric comorbidities. (C) 2016 Asociacion Espanola de Psicologia Conductual. Published by Elsevier Espana, S.L.U.

Background: Caregiving for people with Alzheimer's disease (AD) is highly stressful and has significant negative consequences, such as anxiety and depression. Previous research offers conflicting findings as to whether coping strategies are associated with greater psychological distress or not. We conducted this study with a view to obtaining new data regarding the association of coping strategies and psychological distress in AD caregivers.Methods: Eighty people with AD and their primary caregivers living in the community were recruited from local health services. Purposive recruitment was carried out to ensure that the sample was representative of people living with dementia in terms of dementia severity, gender, and care setting. We used the State-Trait Anxiety Inventory to measure anxiety, the Beck Depression Inventory to measure depression, and the Coping Strategies Inventory to measure coping strategies.Results: Most caregivers reported higher anxiety and depression levels. Use of disengagement coping strategies (Wald = 3.35, p = 0.01) and higher caregiver burden (Wald = 4.83, p = 0.02) predicted anxiety on logistic regression. In turn, use of disengagement coping strategies (Wald = 12.48, p = 0.001) and higher caregiver burden (Wald = 6.91, p = 0.009) predicted depression on logistic regression.Conclusion: These results may be useful for designing treatment interventions that aim to modify the use of coping strategies and thus reduces caregiver anxiety and depression.

Caring for people with Alzheimer's disease can be considered stressful and demand adjustment strategies. While various variables have been associated with caregiver anxiety and depression, a possible mediator role of coping strategies adopted by caregivers between caregiver burden and anxiety and depression is still unclear. We hypothesized that caregivers with clinically significant anxiety and depression were more likely to use disengagement coping strategies that non-anxious and non-depressed caregivers.This study involved 80 Alzheimer disease patients and their primary caregivers. Patients were evaluated using the Mini Mental State Examination, the Bayer Activities of Daily Living Scale, the Global Deterioration Scale and the Neuropsychiatric Inventory. Caregivers were evaluated with the Caregiver Burden Interview, the Beck Depression Inventory, the State-Trait Anxiety Inventory and the Coping Strategies Inventory. We conducted a series of multiple linear regressions to determine the relationship between caregiver burden and caregiver anxiety and depression, and if the coping strategies mediated this relationship.Using more disengagement (β=0.270, p0.001) and less engagement coping (β=-0.310, p0.001) were predictors for anxiety scores. Using more disengagement (β=0.250, p0.001) and less engagement coping (β=-0.261, p0.001) were predictors for depression scores.This study was a cross-sectional design, so the direction of causality should be strengthened by a longitudinal study.Most caregivers reported higher anxiety and depression levels and this was partially mediated by their dysfunctional coping strategies.

The authors performed a cross-sectional study to examine the relationship between specific cognitive domains and behavioral and psychological symptoms in dementia (BPSD) in 125 patients with probable AD. Cognitive deficits were evaluated with the mini mental state examination (MMSE), trail-making test (TMT), Rey auditory verbal learning test (RAVLT), and semantic fluency test (SFT) and phonemic fluency test (PhFT), whereas the neuropsychiatric inventory (NPI) was used to rate BPSD. Patients’ performance in cognitive tests significantly correlated with total NPI scores (p < 0.0001). After controlling for demographic and clinical characteristics, cognitive impairments in memory, executive function, and language (RAVLT, TMT, PhFT, SFT) importantly estimated total NPI scores (p < 0.001, multivariate regression models). These findings suggest that the evaluation of cognitive domains may have a predictive value for the occurrence of BPSD.

The objective of this study is to obtain preliminary normative data on the performance the Pyramids and Palm Trees Test (PPT) for a Spanish-speaking population. The effects of age, gender, and educational level on the PPT test were also analyzed. A total of 234 healthy participants, with a broad range of age (18–80 years) and education (1–20 years) performed the three-picture version of the PPT. The mean performance was 51.1 out of 52 possible points (SD= 1.3). PPT performance did not vary with age or gender. However, subjects with less than 6 years of formal education scored significantly lower than those with more than 6 years of education though this effect was confounded with age because the group with lower education was also older. Given the ceiling effects of the PPT, further investigation is needed to determine if the visual PPT is sensitive to mild semantic memory impairment. (JINS, 2008,14, 148–151.)

Introduccion. El trastorno por deficit de atencion/hiperactividad (TDAH) afecta aproximadamente al 5% de los ninos y adolescentes, y los problemas del sueno son comunes en estos pacientes. Sin embargo, la asociacion entre los trastornos del sueno y el TDAH es multifacetica y compleja. Objetivo. Explorar la relacion entre los trastornos del sueno y el TDAH. Desarrollo. Los problemas del sueno en ninos con TDAH incluyen alteraciones del sueno y trastornos especificos per se o debidos a trastornos psiquiatricos comorbidos o a los farmacos estimulantes para el TDAH. Actualmente se recomienda la evaluacion de las condiciones del sueno en ninos con TDAH antes de la iniciacion del tratamiento farmacologico. La primera linea de actuacion para el manejo de los problemas de sueno es la higiene del sueno y la psicoterapia cognitivo-conductual. Otra opcion es considerar la modificacion de la posologia y formulacion de los farmacos estimulantes. La atomoxetina y la melatonina son alternativas terapeuticas para los ninos con TDAH y problemas del sueno mas graves. Para los trastornos respiratorios y del movimiento en el sueno existen tratamientos especificos. Conclusiones. Es importante evaluar el sueno en los ninos que presentan sintomas sugestivos de TDAH, ya que los problemas en el sueno pueden desempenar un papel causal o exacerbar la clinica del TDAH. Una correcta evaluacion y tratamiento de los trastornos del sueno aumentan la calidad de vida de la familia y del nino y pueden disminuir la gravedad de los sintomas del TDAH

Sleep disturbances (SDs) in Alzheimer's disease (AD) may significantly affect the behavioral, functional, and cognitive capacities of patients to the point of becoming a major determinant of caregiver burden. We conducted a cross-sectional study in 125 patients with probable AD to assess the association of SDs with neuropsychiatric symptoms, cognitive and functional status of patients, and severity and duration of dementia and to ascertain the role of antidementia drugs in the treatment of SD. SDs were assessed using the questionnaire on sleep disorders in the Neuropsychiatric Inventory. The prevalence of SDs in this sample was 36%. SDs in patients with AD are significantly associated with depression (Wald's test, 3.983; p < 0.05), disinhibition (Wald's test, 5.522; p < 0.05), and aberrant motor behavior (Wald's test, 7.430; p < 0.01). The patients treated with memantine presented lower mean SDs scores (t = 2.76; p < 0.001). These results highlight the need for a standardized and validated approach to the assessment of SDs in AD.

1. In order to assess the importance of the parabrachial nuclei in modulating cardiorespiratory activity, electric current or microinjections of glutamate were used to stimulate discrete regions of the parabrachial nuclei in anaesthetized rats. 2. Stimulation of cell bodies in the medial region of the parabrachial nuclei and in the Kölliker-Fuse nuclei, caused an expiratory facilitatory response. This consisted mainly of a decrease in respiratory rate as measured by observing phrenic nerve activity. 3. Stimulation of cell bodies in the lateral region of the parabrachial nuclei caused an inspiratory facilitatory response. This consisted mainly of an increase in respiratory rate. 4. At the majority of sites (16 out of 20) where changes in respiratory rate were elicited by glutamate injection or electrical stimulation an increase in blood pressure was observed. The coexistence of increases in blood pressure and heart rate indicates the presence of inhibition of the heart rate component of the baroreflex and/or an increase in cardiac sympathetic drive. 5. The expiratory facilitatory response was not evoked reflexly by the rise in blood pressure since it was still present after administration of guanethidine, which abolished the rise in blood pressure. 6. The interactions between the parabrachial nuclei and the medullary respiratory complex in eliciting these changes are discussed.

In spontaneously breathing, decerebrate cats, extracellular recordings in the intermediate region of the ambiguus complex have been used to characterize the activity of inspiratory laryngeal motoneurones (ILMNs) during mechanical stimulation of tracheal irritant receptors. Laryngeal resistance was measured using an isolated larynx in situ. The effect of tracheal stimulation was analysed successfully in twenty-seven neurones. Eleven were ILMNs and sixteen inspiration-related neurones. Inspiration-related neurones increased their phasic discharge frequency during tracheal stimulation while ILMNs fired tonically, during both the inspiratory and the expiratory efforts of the cough. The tonic discharge of ILMNs coincided with a decrease of laryngeal resistance.

La extraccion de los trombos pulmonares en el tromboembolismo pulmonar masivo antes de 1953 (operacion de Trendelenburg) cosecho fracaso tras fracaso. Desde el advenimiento de la circulacion extracorporea (CEC) el porcentaje de exito de esta operacion mejoro notablemente, no habiendo dejado de aumentar hasta la actualidad, existiendo series que reflejan porcentajes de hasta el 94% de supervivencia inmediata, con 86 y 83% de supervivencia actuarial a 1 y 3 anos. Presentamos un caso de paciente varon de 35 anos sin enfermedad previa ni antecedentes familiares de enfermedad tromboembolica. Consulta por insuficiencia respiratoria, siendo diagnosticado por tomografia computarizada de tromboembolismo en AP izquierda, la cual ocluye. El ECO-Doppler de MMII descarta trombosis venosa profunda (TVP). Una nueva tomografia computarizada informa de persistencia de la obstruccion de AP izquierda y sus ramas, que parece haber aumentado. En ecocardiografia transtoracica (ETT) dilatacion de cavidades derechas con funcion de ventriculo derecho (VD) normal y presion sistolica de la arteria pulmonar (PSAP) de 70 mmHg. Los estudios para investigar trombofilia fueron negativos. Tras unos dias empeora su situacion, produciendose dos paradas cardiorrespiratorias, de las que es reanimado y tratado inmediatamente con TNK. La tomografia computarizada muestra la existencia de nuevo episodio de tromboembolismo pulmonar que afecta a la AP derecha gravemente. Es intervenido quirurgicamente bajo CEC sin parada circulatoria, extrayendose molde trombotico de tronco y ambas ramas de la AP. La evolucion postoperatoria fue favorable. En tomografia computarizada de control se observan limpios el tronco y las ramas de la AP, con cierto compromiso en ramas subsegmentarias de la AP izquierda. Se muestran imagenes de la intervencion y tomografia computarizada pre y posquirurgicas.

To analyze the role of parabrachial complex (PBc) in the modulation of cardiorespiratory response evoked from the hypothalamic defense area (HDA), cardiorespiratory changes were analyzed in spontaneously breathing anesthetised rats in response to electrical stimulation of the HDA (1 ms pulses, 30-50 microA, 100 Hz for 5 s) before and after the microinjection of muscimol (50 nl, 0.25 nmol, 5 s) within the PBc. HDA stimulation evoked an inspiratory facilitatory response, consisting of an increase in respiratory rate (p0.001) due to a decrease in expiratory time (p0.01). The respiratory response was accompanied by a pressor (p0.001) and a tachycardic (p0.001) response. Muscimol microinjection within the lateral parabrachial region (lPB) abolished the respiratory response to HDA stimulation (p0.01) and decreased the pressor response (p0.05). Muscimol within the medial parabrachial region and Kölliker-Fuse (mPB-KF) decreased the magnitude of the pressor (p0.01) and tachycardic (p0.05) responses to HDA stimulation. The respiratory response persisted unchanged. Finally, extracellular recording of putative neurons from these regions were obtained during HDA stimulation to confirm functional interaction between HDA and parabrachial regions. 105 pontine cells were recorded during HDA stimulation, 57 from the lPB and 48 from the mPB-KF. In mPB-KF 34/48 (71%) and in lPB 38/57 (67%) cells were influenced from HDA. The results indicate that neurons from different regions of the PBc have an important function in mediating the cardiorespiratory response evoked from the HDA. The possible mechanisms involved in these interactions are discussed.

Introduccion. Aunque la privacion de sueno se ha utilizado durante anos en electroencefalografia (EEG) como metodo de activacion de descargas epileptiformes intercriticas (DEI) en pacientes con alta sospecha de epilepsia, su sensibilidad y especificidad estan aun en discusion. Pacientes y metodos. Estudio descriptivo y retrospectivo de pacientes pediatricos derivados a neurofisiologia clinica para valoracion de epilepsia. Se han comparado los resultados de los EEG de privacion de sueno (EEG-PS) con los EEG de vigilia (EEG-V) en cada paciente para describir su rendimiento como mecanismo activador de DEI. Resultados. Se han analizado 500 pacientes (830 EEG-PS y 1.018 EEG-V). En los EEG-V se detectaron DEI en el 44%. El EEG-PS aumento en un 35% la capacidad del test para detectar las DEI. En los EEG-PS en los que se alcanzo sueno espontaneo se observaron DEI (no detectadas en el EEG-V) en un 25,1%. En el grupo de epilepsias focales se constato que el EEG-V detecto DEI en el 60,1% frente al 79,12% demostradas con el EEG-PS. En las epilepsias generalizadas esta diferencia fue mas marcada (27,2% y 77,2%, respectivamente). En los pacientes en los que tras un EEG-PS no se detectaron DEI (23,7%) y la sospecha clinica de epilepsia seguia siendo alta, se realizo polisomnografia nocturna y se llego a objetivar actividad epileptiforme intercritica en un 13,6%. Conclusiones. El EEG-PS aumenta la posibilidad de recoger DEI en un 35% con respecto al EEG-V. La privacion de sueno es un metodo activador de paroxismos epileptiformes, independientemente de si hay sueno o no durante la realizacion del EEG, aunque este efecto es mas marcado en los pacientes que alcanzan sueno.

To assess cognitive impairment after off-pump coronary-artery bypass grafting, with a particular emphasis on long-term follow-up and related risk factors.Prospective study.Virgen de la Victoria University Hospital, Málaga, Spain.Participants were 36 patients undergoing off-pump coronary-artery bypass grafting.Changes in the neuropsychological test battery administered from before to after surgery (1, 6, and 12 months). Postoperative cognitive impairment was defined by a significant decrease.A significantly multidomain (attention-executive functions, P.01; immediate and delayed memory, P.001; and verbal fluency, P.05) postoperative cognitive impairment was shown, being maximum at 6 months (more than 50% of patients) and still presented at 12 months (more than 30% of patients), but partially recovered. Related risk factors as smoking (P.01), diabetes mellitus (P.01), peripheral arteriopathy (P.01), obesity (P.05), lower hematocrit (P.01), and hemoglobin (P.05) levels and diastolic blood pressure (P.05) were identified as predictors of cognitive impairment. Better New York Heart Association class (P.01) and less severity of angina (P.01) were associated with partial postoperative recovering.A multidomain long-term postoperative cognitive impairment and a partial neurocognitive recovering were detected after off-pump coronary-artery bypass grafting and were associated with several nonspecific surgery factors. These findings may be useful when counseling patients before surgery and suggest the importance of long-term neurocognitive evaluation.

The assessment of visual perception and cognition forms an important part of any general cognitive evaluation. We have studied the possible influence of age, sex, and education on a normal elderly Spanish population (90 healthy subjects) in performance in visual perception tasks. To evaluate visual perception and cognition, we have used the subjects performance with The Visual Object and Space Perception Battery (VOSP). The test consists of 8 subtests: 4 measure visual object perception (Incomplete Letters, Silhouettes, Object Decision, and Progressive Silhouettes) while the other 4 measure visual space perception (Dot Counting, Position Discrimination, Number Location, and Cube Analysis). The statistical procedures employed were either simple or multiple linear regression analyses (subtests with normal distribution) and Mann-Whitney tests, followed by ANOVA with Scheffe correction (subtests without normal distribution). Age and sex were found to be significant modifying factors in the Silhouettes, Object Decision, Progressive Silhouettes, Position Discrimination, and Cube Analysis subtests. Educational level was found to be a significant predictor of function for the Silhouettes and Object Decision subtests. The results of the sample were adjusted in line with the differences observed. Our study also offers preliminary normative data for the administration of the VOSP to an elderly Spanish population. The results are discussed and compared with similar studies performed in different cultural backgrounds.

We have examined the importance of the A5 region modulating cardiorespiratory responses evoked from the parabrachial complex (PB) in spontaneously breathing rats. Cardiorespiratory changes were analyzed in response to electrical stimulation and glutamate microinjections into the PB (10-20 nl, 1-2 nmol) before and after ipsilateral microinjection of muscimol (50 nl, 0.25 nmol) or lidocaine (50 nl, 0.5 nmol) within the A5 region. Stimulation of medial parabrachial and Kölliker-Fuse nuclei (mPB-KF) evoked a decrease in respiratory rate (P0.001) with a rise in blood pressure (P0.001) and heart rate (P0.05). After muscimol or lidocaine microinjections within the A5 region, the pressor and heart rate responses to mPB-KF stimulation were reduced (P0.05, both cases). Muscimol within the A5 region altered the respiratory response to glutamate stimulation of mPB-KF, evoking an increase in respiratory rate (P0.05). Lidocaine abolished the respiratory response to mPB-KF stimulation. Stimulation of the lateral parabrachial nuclei (lPB) caused an increase in respiratory rate (P0.001) with a rise in blood pressure (P0.001) and heart rate (P0.05). Muscimol or lidocaine microinjections within A5 region decreased heart rate (P0.05) and pressor responses (P0.05) evoked from lPB. The increase of respiratory rate persisted unchanged. To confirm functional interactions between A5 and PB, extracellular recordings of putative A5 neurones were obtained during PB stimulation. Eighty-three A5 cells were recorded, 35 were activated from the mPB-KF (42%). The results indicate that neurones of the A5 region participate in the cardiorespiratory response evoked from the different regions of the PB complex. The possible mechanisms involved in these interactions are discussed.

In order to study the importance of two pontine regions modulating laryngeal resistance, electrical current or microinjections of glutamate (10-30 nl, 1-3 nmol) were made into the pontine parabrachial complex and the A5 region in spontaneously breathing anaesthetized rats. Two distinct patterns of laryngeal and respiratory responses were elicited. An increase of subglottal pressure was accompanied with an expiratory facilitatory response consisted of a decrease in both respiratory rate and phrenic nerve activity. A decrease of subglottal pressure was accompanied with an inspiratory facilitatory response consisted of an increase in both respiratory rate and phrenic nerve activity. The modification of laryngeal calibre occurred during both respiratory phases in most cases. The concomitant cardiovascular changes of these responses were also analyzed. Controls using guanethidine to block autonomic responses which might interact with respiratory control were also made. Histological analysis of stimulation sites showed a topographical organization of these responses: laryngeal constriction was evoked from Kolliker-Fuse, medial parabrachial nuclei and A5 region, whilst the laryngeal dilation was evoked from the lateral parabrachial nucleus.

To assess the importance of the pontine A5 region in modulating respiratory activity, electric current or microinjections of glutamate (10-30 nl, 1-3 nmol) were used to stimulate discrete zones within this region in the spontaneously breathing, anaesthetised rat. These stimuli evoked an expiratory facilitatory response, consisting of a decrease in respiratory rate ( P

Presentamos un caso de paciente mujer de 38 anos con antecedentes de coartacion aortica tipica leve, que consulta por clinica de disfagia lusoria, objetivandose masa pulsatil en la fosa supraclavicular izquierda en la exploracion fisica. Se practica angiotomografia computarizada que muestra aneurisma sacular localizado en arco aortico, cuyo origen se encuentra entre los origenes de las arterias carotida y subclavia izquierdas y se extiende hasta la zona coartada, con diametro maximo de 8 cm. La arteria carotida izquierda es hipoplasica y la subclavia derecha es aberrante, naciendo de la aorta descendente y cruzando la linea media hasta alcanzar MSD. Es intervenida quirurgicamente a traves de esternotomia media y toracotomia anterolateral izquierda. Tras establecer bypass femorofemoral izquierdo se clampa arco aortico entre el origen de ambas carotidas y distalmente a la coartacion, resecando el aneurisma que incluye los origenes de ambas arterias subclavias, interponiendo a continuacion injerto vascular tubular de dacron de 20 mm de diametro, reinsertando en el mismo la arteria subclavia izquierda. No se reimplanto la arteria subclavia derecha. El control de la presion arterial se establecio mediante sendas canulas en aorta ascendente y arteria femoral derecha. En el postoperatorio se produjo trombosis venosa del eje subclavio izquierdo secundario verosimilmente a la seccion iatrogena del tronco venoso innominado y que se resolvio satisfactoriamente con tratamiento convencional. Se muestran las imagenes de la tecnica quirurgica y la idoneidad de la correccion quirurgica con la angiotomografia computarizada postoperatorio.