Hybrid Cardiac Rehabilitation Program in a Low-Resource Setting: A Randomized Clinical Trial.

Importance: While effective, cardiovascular rehabilitation (CR) as traditionally delivered is not well implemented in lower-resource settings. Objective: To test the noninferiority of hybrid CR compared with traditional CR in terms of cardiovascular events. Design, Setting, and Participants: This pragmatic, multicenter, parallel arm, open-label randomized clinical trial (the Hybrid Cardiac Rehabilitation Trial [HYCARET]) with blinded outcome assessment was conducted at 6 referral centers in Chile. Adults aged 18 years or older who had a cardiovascular event or procedure, no contraindications to exercise, and access to a mobile telephone were eligible and recruited between April 1, 2019, and March 15, 2020, with follow-up until July 29, 2021. Interventions: Participants were randomized 1:1 in permuted blocks to the experimental arm, which received 10 center-based supervised exercise sessions plus counseling in 4 to 6 weeks and then were supported at home via telephone calls and text messages through weeks 8 to 12, or the control arm, which received the standard CR of 18 to 22 sessions with exercises and education in 8 to 12 weeks. Main Outcomes and Measures: The primary outcome was cardiovascular events or mortality. Secondary outcomes were quality of life, return to work, and lifestyle behaviors measured with validated questionnaires; muscle strength and functional capacity, measured through physical tests; and program adherence and exercise-related adverse events, assessed using checklists. Results: A total of 191 participants were included (mean [SD] age, 58.74 [9.80] years; 145 [75.92%] male); 93 were assigned to hybrid CR and 98 to standard CR. At 1 year, events had occurred in 5 unique participants in the hybrid CR group (5.38%) and 9 in the standard CR group (9.18%). In the intention-to-treat analysis, the hybrid CR group had 3.80% (95% CI, -11.13% to 3.52%) fewer cardiovascular events than the standard CR group, and relative risk was 0.59 (95% CI, 0.20-1.68) for the primary outcome. In the per-protocol analysis at different levels of adherence to the intervention, all 95% CIs crossed the noninferiority boundary (eg, 20% adherence: absolute risk difference, -0.35% [95% CI, -7.56% to 6.85%]; 80% adherence: absolute risk difference, 3.30% [95% CI, -3.70% to 10.31%]). No between-group differences were found for secondary outcomes except adherence to supervised CR sessions (79.14% [736 of 930 supervised sessions] in the hybrid CR group vs 61.46% [1201 of 1954 sessions] in the standard CR group). Conclusions and Relevance: The results suggest that a hybrid CR program is noninferior to standard center-based CR in a low-resource setting, primarily in terms of recurrent cardiovascular events and potentially in terms of intermediate outcomes. Hybrid CR may induce superior adherence to supervised exercise. Clinical factors and patient preferences should inform CR model allocation. Trial Registration: ClinicalTrials.gov Identifier: NCT03881150.

Two-Minute Step Test as a Complement to Six-Minute Walk Test in Subjects With Treated Coronary Artery Disease.

The 2-Minute Step Test (2MST) has been presented as an alternative to the 6-Minute Walk Test (6MWT) based on the association between the two tests in older adults; however, some authors propose that it should not be a substitute but rather a complement to the latter in the fitness evaluation. Specifically, in coronary disease, despite the potential and clinical utility of 2MST, the relationship of both tests in this population is unknown. This study aimed to determine the relationship between 6MWT and 2MST and to explore the relationship of biodemographic factors for both tests in subjects with treated coronary artery disease. For this, the 6MWT and the 2MST were applied to patients with coronary artery disease treated in 6 hospitals in Chile between May 2019 and February 2020. Additionally, lower limb strength was assessed by a chair-stand test, grip strength was assessed by a dynamometer, and physical measurements were applied. In total, 163 participants underwent both tests (average age = 58.7 ± 9.8 years; 73.6% men; 64.4% revascularized by angioplasty; 28.2% revascularized by surgery, and 7.4% treated by drugs or thrombolysis). Heart rate was higher at the end of the 6MWT, while the perception of effort was greater at the end of the 2MST. There was a weak positive correlation between the 6MWT and the 2MST in subjects with treated coronary disease (r = 0.28, p = 0.0003). While age (r = -0.27), weight (r = 0.25), height (r = 0.49), and strength of both lower limbs (r = 0.41) and grip strength (r = 0.53) correlated weakly or moderately to the covered distance in 6MWT, the number of steps by the 2MST correlated only weakly to height (r = 0.23), lower limb strength (r = 0.34), and grip strength (r = 0.34). Age, weight, height, lower limb strength, and grip strength would explain better the meters walked in the 6MWT than the steps achieved in the 2MST. With these findings, we can conclude that, in patients with treated coronary artery disease, it does not seem advisable to replace 6MWT with 2MST when it is possible to do so. Additionally, the 2MST may provide additional information in the fitness evaluation. However, the usefulness of 2MST in this population needs to be further studied.

A hybrid exercise-based cardiac rehabilitation program is an effective strategy to improve muscle strength and functional exercise capacity in adults and older people with coronary artery disease.

Coronary heart disease is the most common cause of death worldwide. Standard cardiac rehabilitation (face-to-face sessions) has shown benefits in increasing muscle strength and functional exercise capacity in adults and older people. However, it is unknown whether hybrid cardiac rehabilitation (a first face-to-face phase + a second remote monitoring phase) will have similar benefits in adults versus older subjects. The aim of this study was to compare the effects of a hybrid exercise-based cardiac rehabilitation program on muscle strength and functional exercise capacity in "adult" versus "older" people with coronary artery disease. We hypothesized that a hybrid exercise-based cardiac rehabilitation program would improve muscle strength and functional exercise capacity, but the impact would be smaller in the older group than the adult individuals. This study is part of a larger project (The Hybrid Cardiac Rehabilitation Trial-HYCARET). We subjected 22 adult (<60 y) females and males (ADULT; n = 5/17 (f/m); 52 ± 5 y; 28.9 ± 3.4 kg·m-2) and 20 older (≥60 y) females and males (OLDER; n = 6/14 (f/m); 66 ± 4 y; 27.4 ± 3.9 kg·m-2) with coronary artery disease to 12 weeks of hybrid exercise-based cardiac rehabilitation program. Prior to and after 12 weeks of a hybrid exercise-based cardiac rehabilitation program, grip strength (handgrip), leg strength (chair stand test), and functional exercise capacity (6-minute walk test, 6MWT) were assessed. The hybrid exercise-based cardiac rehabilitation program resulted in a 9.4 ± 14.6% and a 6.2 ± 12.1% grip strength increase, a 14.4 ± 39.4% and a 28.9 ± 48.1% legs strength increase, and a 14.6 ± 26.4% and a 6.8 ± 14.0% functional exercise capacity improvement in ADULT and OLDER, respectively (p < 0.05) with no differences between groups. In conclusion, a hybrid exercise-based cardiac rehabilitation program could increase muscle strength and improve functional exercise capacity in adults and older people with coronary artery disease. More future studies comparing effectiveness among these age groups are needed to strengthen this conclusion.

Photosensitizing activity of advanced glycation endproducts on tryptophan, glucose 6-phosphate dehydrogenase, human serum albumin and ascorbic acid evaluated at low oxygen pressure.

A comparative study of the photosensitizing activity of advanced glycation endproducts (AGEs) prepared by incubating glucose (Glc), threose (Threo) and ascorbate (AH-) in the presence of lysine (Lys) was performed. Photochemical activity was evaluated under low oxygen pressure with the aim to simulate the conditions of the eye lens. AGE-sensitized tryptophan and AH- photodecomposition and glucose 6-phosphate dehydrogenase inactivation were studied. In all systems, glucose-derived AGEs showed the highest photosensitizing efficiency, followed by ascorbate and threose. The presence of different sensitizers in glycation products mixtures was investigated. For this purpose, Trp decomposition quantum yields were determined at 344 and 367 nm. The values obtained at 344 nm are between three and six times higher than those observed at 367 nm, confirming the presence of at least two compounds with different photosensitizing activities in the mixtures. The chemiluminescence associated with the AGE-mediated oxidation of free Trp and Trp residues in human serum albumin was also studied, and a good correlation between the emission of light and the extent of Trp decomposition was found. In conclusion, it is demonstrated that glucose derived AGEs, which can be formed in vivo in the eye lens of diabetic patients and are accumulated in elderly lenses, have a higher photosensitizing efficiency, at low oxygen pressure, than those arising from ascorbate and threose. This high efficiency is especially significant when proteins are employed as photochemical targets, indicating that protein-sensitizer interaction and the local environment around the sensitizers play an important role.

Protocolo de categorización de la demanda kinesiológica (CDK) del Complejo Hospitalario San José: Desde una perspectiva funcional / Kinesiology demand categorization protocol (CDK) of the San José Hospital: From a functional perspective

Existe un gran número de eventos deletéreos que impactan y deterioran la funcionalidad de los usuarios hospitalizados. Asimismo, Hay escasa información disponible en la literatura sobre la categorización funcional de usuarios atendidos por unidades de kinesiología en servicios hospitalarios que favorezca la gestión eficiente de los recursos y la recuperacion funcional de los usuarios. Esta conjunción genera importantes brechas de acceso, oportunidad y calidad en la intervención kinesiológica. El presente artículo tiene como objetivo presentar y describir el protocolo de "Categorización de la demanda Kinesiológica (CDK)" adaptado y desarrollado por la Unidad de Kinesiología del Complejo Hospitalario San José, el cual busca implementar un modelo de gestión basado en el perfil funcional del usuario.

There is a large number of deleterious events that impact and impair the functionality of hospitalized users. Likewise, there is little information available in the literature regarding functional categorization of users attended by kinesiology units in hospital services that benefits efficient management of resources and functional recovery of users. This conjunction generates important breaches in access, opportunity and quality of kinesiology intervention. The objective of this article is to present and describe the "Categorización de la demanda Kinesiológica (CDK)" protocol adapted and developed by the kinesiology unit from Complejo Hospitalario San José, which seeks to implement a management model based on the functional profile of the user.

Recrimination in the analytic situation. A hypothesis about its influence on psychoanalytical groups.

This paper deals with certain distortions in communication generated by mutual recrimination that is the result of disturbances in the ideal agencies of both parties. Although the ideal ego, superego and ego ideal participate equally in reproach, it is the latter which is the most decisive. In clinical experience, recrimination may easily colour the analytic dialogue. In such cases, interpretation loses its sense of clarification and another type of dialogue replaces it. There, words are used to take possession of the other, for its autonomy is a threat to the static character of the pathology of mourning. The problem of recrimination has also tainted the development of psychoanalysis, to the point of disrupting the process of discovery itself. This paper deals with repercussions in the psychoanalytic movement and also in the elements that constitute its structure. Finally, different variations and disturbances in the psychoanalytic ideal are considered, as well as the involvement of the psychoanalytic institution in preserving or transforming the ideal. Here the importance of institutions and institutional ideals is emphasised. Finally, we suggest that ideals either encourage or hinder the working through of individual and collective mourning.

Comentario al trabajo de la Dra. Puget: "Coartada social y psicoanálisis" / Commentary of Dr. Manuel J. Galvez on the work of Dr. Janine Puget

La autora del trabajo comentado dice: ômiramos para otro lado cuando intentamos entender la constitución del sentimiento de pertenencia social y la subjetividad que de ello deriva, à como extrapolación del mundo interno àõ. En otro sentido complementario a éste el ômirar con un ojo ciegoõ del analista se muestra a partir de un error del paciente durante la sesión. Al no ser escuchado este error como un posible acceso a lo inconsciente, dado el énfasis que se pone en la realidad social, se crearía una coartada a la percepción de la realidad psíquica

The author says ôwe turn a blind eye when we try to understand the constitution of feelings of social appartenance and its derived social subjectivity ààas an extrapolation of the inner worldàõ. In another, complementary sense, the analystÆs ôturning of an eyeõ could be illustrated through an error committed by the patient during the session. If this is not considered as a way to reach the unconscious, because the main emphasis of the analyst is on the social reality, an alibi to the perception of the psychic reality is created. Key words: Alibi. Social subject. Overlapping world. Every day life

Un point de vue complémentaire de lÆauteur: lÆauteur dit ôon ne fait que regarder côte si lÆon tache de comprendre la constitution du sentiment dÆappartenance sociale et la subjectivité qui sÆen détache àcomme lÆextra-polation du monde interneàõ Un autre sens, complémentaire du précédent: ôregarder avec un yeux aveugleõ se fait évident lorsque le patient commis une erreur dans la session. Si cet erreur ne se prend pas comme une possible voie dÆaccès a lÆinconscient, se métamorphose en ôalibiõ de la perception de la réalité psychique

La supervisión didáctica / Training supervision

El análisis didáctico debería pasar a ser un análisis ´común y corriente´ no solo desde el punto de vista del proceso analítico sino, sobre todo, para proteger a paciente y analista de los excesos de poder que surgen inevitablemente del marco institucional, tanto externo y real como internalizado, propenso a la idealización, escisión y desmentida. Dada por supuesta la necesidad del análisis del candidato para llegar a ser analista, es posible imaginar una transmisión institucional del psicoanálisis centrada en la supervisión. ¿Cómo podría organizarse la supervisión didáctica si pasara a ser el centro de la formación, evaluación y promoción? Se tratan en estas notas puntos vinculados a los aspectos institucionales y a algunos temas del proceso de supervisión. Entre los primeros figuran: relaciones entre analistas supervisores y didactas, evaluación del proceso, promoción, supervisiones colectivas etc. Entre los segundos: El lugar de la TR y contratransferencia. La oposición ambigua entre ´enseñar´ y ´tratar´. Función de la imaginación y la sorpresa. La supervisión como área transicional entre la subjetividad y la objetividad. Evaluación-calificación-promoción

El papel de las teorías en la transmisión del psicoanálisis / The rol of theories in the transmision of psychoanalyisis

¿Es beneficioso, en la formación analítica, que los candidatos tengan contacto con varias concepciones teóricas? ¿Es mejor que se relacionen en mayor profundidad sólo con una de ellas? ¿Hasta qué punto es conveniente el énfasis en la formación teórica por sobre otros aspectos? ¿Cuál es el valor de la teoría en la formación de un analista?. Contar con diversas teorías podría acarrear algunas ventajas: a) encontrar puentes entre ideas divergentes; b) hallar similares referentes entre ideas aparentemente disímiles; c) confrontar diversos modelos, haciendo evidente lo no contemplado por otra teoría; d) ´golpear´ una teoría con otra poniendo de manifiesto sus puntos de inconsistencia; e) leer una teoría desde otra, lo que podría arrojar una nueva luz sobre ambas. Sin embargo, es posible que la diversidad de teorías aumente la confusión, desfavorezca la profundización de cada situación e interfieran con la escucha de la singularidad de cada caso. Las teorías pierden su función cuando lo que ellas propician deja de ser considerado como una construcción, y adquiere cualidad ontológica. Jerarquizamos la importancia de la relación entre la descripción teórica y su correlato clínico; la enseñanza del psicoanálisis adquiere un carácter de vacío cuando se pretende enseñar materias teóricas apartadas de la experiencia clínica de la cual partieron. Sugerimos que en la enseñanza del psicoanálisis se debería tender a estimular la función teorizante en nuestros candidatos antes que su adhesión a determinadas teorías. Las teorías sexuales infantiles son construcciones teóricas creadas entre otros motivos para anular lo perturbador de la ´realidad´ presumida u observada. Por ello, persisten sin ser abandonadas aun cuando no coincidan con los hechos. Las teorías psicoanalíticas deberían, en cambio, ser destituidas si evidencian un carácter encubridor. De todos modos, lo infantil se infiltra entre los diversos elementos que constituyen el factor pasional generando en el aprendizaje diversas perturbaciones y toda teoría, por completa y acabada que se presuma, tiene, además de un carácter develador, otro encubridor

Notas sobre aspectos atuais da transmissão da psicanálise / Some notes on current aspects of the transmission of Psychoanalysis

A primeira parte deste trabalho refere-se à transmissão da psicanálise em seus aspectos de idealização, identificação, infantilização, ideologização e ilusão, seguindo as idéias de Luiz Meyer quanto à formação analítica em seu conjunto, e destacando a questão do fetichismo. A segunda parte trata da supervisão de formação (didática). Alguns aspectos da bibliografia corrente dos últimos anos sobre o assunto são revistos. De acordo com tendências de analistas da comunidade internacional, o autor propõe que a supervisão se constitua como o centro da transmissão da psicanálise, o que implica que a análise do analista passe a ser separada da transmissão institucional, modalidade que comporta diversas possibilidades. A terceira parte, intitulada "os tempos atuais", trata do desafio da "construção da análise" em situações de análise que em outros tempos não eram considerados e que constitui a maior parte de nossos pacientes de hoje. A opção entre "fabricar" uma análise e "construi-la" acarreta problemas de regulamentos quanto à supervisão. Ressalta-se a necessidade de reconhecer "pedidos latentes" de análise

Búsqueda de Dirofilaria immitis en perros en la provincia Ciudad de La Habana / Searching of Dirofilaria immitis in dogs at Habana city province

Se informa que se estudiaron 2 281 perros en busca de infestación por Dirofilaria immitis. Se indica que se encontraron adultos en 10 de ellos (0,52%) y el 40% (265 perros) tenía microfilaremia. No se observó relación entre la densidad de microfilarias y el número de adultos. Se plantea que la microfilaremia fue mayor en los perros de raza indetinida y se encontraron adultos en la raza pastor alemán

Criptosporidiosis: reporte de un caso / Cryptosporidiosis: report of a case

Se consigna por segunda vez en Cuba la presencia de Cryptosporidium sp (Apicomplexa: Sporozoae) en las heces de una niña de 3 meses de edad. El diagnóstico se realizó mediante las técnicas de Carbol-Fushina y Zeil-Neelsen modificada. En la actualidad el Cryptosporidium, pequeño protozoo intestinal, se considera como causa importante de diarrea en algunas especies animales, entre ellas: terneros, ovejas y en el hombre

Guía para la producción artesanal y uso de la soya en la alimentación humana / Guide for the artisan production and use of soy in human nutrition

La soya es un cultivo muy antiguo, cuyo grano se consume hace siglos en la China y otros países asiáticos. Es un alimento básico de los pueblos orientales, de gran importancia porque tiene un poder alimenticio similar a la carne, con mayor contenido de proteínas, a un menor precio y se puede preparar en innumerables formas. Además de su gran valor nutritivo en la alimentación humana, este grano produce aceite comestible, tiene muchos usos industriales y se emplea en la producción de alimentos concentrados para aves y otros animales. La producción de soya en países tropicales se ha desarrollado debido a que existen variedades adaptadas a las condiciones de clima caliente y lluvioso, como las de Panamá. La soya se cultiva hace mucho tiempo en países tropicales del Asia, como Filipinas, Indonesia, Sri Lanka, que tienen clima similar a Panamá y la utilizan en la alimentación humana. El uso de la soya como alimento para la población humana ha generado mucho interés, debido a que se puede producir en huertos familiares, se comprende su valor alimenticio y se está divulgando como prepararla con los alimentos típicos del panameño. Esta publicación es una guía para la producción y consumo de la soya a nivel familiar. Contiene información sobre su valor nutritivo, algunas recetas simples para la preparación de platos sencillos, e instrucciones para producir este grano en huertos caseros. Este manual está dirigido a personal de extensión agrícloa y agentes de desarrollo agrícola