Factors Influencing the Training Process of Paralympic Women Athletes.

(1) Background: Paralympic women athletes in their training process go through a series of interrelated stages which are parallel to their evolutionary development, during which a wide variety of psychological, social, and biological factors will have an impact. The purpose of this study was to analyze the factors influencing the sports training process of Spanish Paralympic women athletes (social, sporting, psychological, technical-tactical factors, physical condition, as well as barriers and facilitators) who had won at least one medal (gold, silver, or bronze) in the 21st century Paralympic Games (from Sydney 2000 to Tokyo 2020). (2) Methods: The research involved 28 Spanish Paralympic women athletes who had won at least one medal at a Paralympic Games in the 21st century. An interview of 54 questions grouped into 6 dimensions (sport context, social context, psychological, technical-tactical, physical fitness, and barriers and facilitators) was used. (3) Results: Coaches, as well as families, were essential in the sport development of Paralympic athletes. In addition, most women athletes recognized that psychological aspects were of vital importance, as well as working on technical-tactical aspects and physical fitness in an integrated way. Finally, the Paralympic women athletes highlighted that they had to face numerous barriers, mainly financial challenges and issues with visibility in the media. (4) Conclusions: Athletes consider it necessary to work with specialists to control emotions, increase motivation and self-confidence, as well as to reduce stress and anxiety and manage pressure. Finally, the training process and sporting performance of Paralympic women athletes are conditioned by several barriers, including economic, social, architectural, and disability barriers. These considerations can be taken into account by the technical teams working with Paralympic women athletes, as well as by the competent bodies, to improve the sports training process of these athletes.

Post-transplant diabetes mellitus and renal cell cancer after renal transplantation.

BACKGROUND: Diabetes is a risk factor for cancer in the general population. However, few data are available on the association between post-transplant diabetes mellitus (PTDM) and cancer after transplantation. METHODS: We analyzed this issue in a Spanish cohort of patients without diabetes before transplantation. PTDM was diagnosed with consensus criteria at 12 months after transplantation and 12 months before the diagnosis of cancer. The association between PTDM and cancer (overall and specific types) was evaluated with regression analysis. RESULTS: During a follow-up of 12 years (interquartile range 8-14), 85 cases of 603 developed cancer (829/100 000/year) and 164 (27%) PTDM. The most frequent cancers were renal cell cancer (RCC) n = 15, 146/cases/100 000/year), lung (n = 12, 117/cases/100 000/year), colon (n = 9, 88/cases/100 000/year) and prostate (n = 9, 88/cases/100 000/year). In logistic regression, PTDM was not associated with cancer. Eight of the 164 patients with PTDM (4.9%) vs 7 of the 439 without PTDM developed RCC (1.6%) (P = .027). In multivariate analysis, PTDM was independently associated with RCC [odds ratio (OR) 2.92, confidence interval (CI) 1.03-8.27], adjusting for smoking (OR 4.020, 95% CI 1.34-12.02) and other covariates. PTDM was not associated with other types of cancer. CONCLUSIONS: Patients with PTDM must be considered a population at risk for RCC and accordingly, the subject of active surveillance.

Stent en una fístula sistémico-pulmonar de Blalock-Taussig modificada en un adulto paliado con atresia tricúspide con estenosis infundibular pulmonar crítica / Stenting of a modified Blalock-Taussig shunt in an adult with palliated tricuspid atresia and critical pulmonary stenosis

Resumen: Los adultos con cardiopatía congénita compleja, con fisiología univentricular y flujo pulmonar disminuido, constituyen un reto terapéutico. Muchos de ellos reciben tratamiento paliativo con fístula sistémico-pulmonar desde la etapa pediátrica. Dicha fístula puede presentar oclusión o estenosis y ocasionar deterioro de la capacidad funcional y clínica. Colocar una nueva fístula sistémico-pulmonar a través de una cirugía se considera de alto riesgo, por lo que el uso de stents a través de cateterismo cardíaco surge como una opción que ha tenido buenos resultados. Se describe el caso de un adulto con atresia tricúspide con fístula sistémico-pulmonar en la etapa pediátrica, quien acudió al servicio de urgencias por deterioro de su clase funcional y desaturación en aire ambiente de hasta un 64%; en la tomografía cardíaca se evidenció estenosis del tercio distal de la fístula sistémico-pulmonar, por lo que se decidió colocar, mediante cateterismo cardíaco intervencionista, dos stents (Express LD vascular 6 x 37 mm y 6 x 27 mm), luego de lo cual la saturación sistémica fue del 75%, por lo que se consideró exitosa la colocación de los dispositivos. La oclusión de estas fístulas es una complicación habitual, que genera disminución de la perfusión pulmonar con los subsecuentes síntomas respiratorios, disminución de la saturación y la oxigenación, cianosis y acidosis metabólica, y puede generar un evento que amenaza la vida si se presenta de manera aguda. La recanalización transcatéter de una fístula sistémico-pulmonar con stent es una alternativa adecuada para evitar un riesgo quirúrgico y arroja resultados óptimos.

Abstract: Adults with complex congenital heart disease with univentricular physiology and decreased in the pulmonary flow constitute a therapeutic challenge, many of these patients are palliated with modified Blalock-Taussig shunt (mBTS). The mBTS can develop occlusion or stenosis over time with deterioration of functional class and poor exercise tolerance. Dysfunction of a mBTS is a life-threatening situation requiring urgent therapy. A new surgical palliation is a high-risk procedure, so stenting a mBTS can be an alternative. We report a 29-year-old female with tricuspid atresia and pulmonary infundibular stenosis palliated with mBTS with progressive cyanosis (oxygen saturation of 54%) and dyspnea; computed tomography revealed a stenosed mBTS, and an interventional percutaneous approach was made. The stenting of the mBTS was made with two stents (Express LD vascular 6 x 37 mm and 6 x 27 mm). Oxygen saturation post-procedure increase to 70-75%. Occlusion of these shunts are a common major complication, leading to a decrease in pulmonary perfusion with subsequent respiratory symptoms, low saturation and oxygenation, cyanosis, metabolic acidosis and can generate a life-threatening event if it occurs acutely. Stent implantation into a previous mBTS through cardiac catheterization can be an alternative to shunt operation in patients with cyanotic congenital heart disease having a good long-term results.

The Sport Training Process of Para-Athletes: A Systematic Review.

The aim of this systematic review was to identify the main factors affecting the training process of para-athletes, as well as the barriers they encounter. For this purpose, a systematic review was carried out in accordance with the PRISMA declaration guidelines, in which six databases were analysed (Web of Science, Scopus, SportDiscus, Pubmed, Eric, and PsycInfo). A total of 19 articles were selected for analysis after applying the inclusion criteria. The results show that the figures of the coach and families in the sporting and social contexts, respectively, had a relevant influence on the training process of para-athletes. Furthermore, in terms of psychological aspects, stress reduction, the importance of self-esteem, and motivation were highlighted. On the other hand, there are some barriers hindering the training and performance of athletes, which are related to the lack of financial support, lack of visibility in the media, and dependence on other people. These considerations can be of great help to coaches and competent institutions in the field (Paralympic committees, federations, etc.) in order to improve the training process and performance of para-athletes and to eliminate the barriers encountered by this group, promoting policies which facilitate access to sports for people with disabilities.

[Consensus document of the Mexican Society of Cardiology for post-COVID-19 cardiovascular clinical follow-up]. / Consenso de la Sociedad Mexicana de Cardiología para el seguimiento clínico cardiovascular post-COVID-19.

Background: The cardiovascular sequelae by the SARS-COV-2 infection is prevalent in a significant portion of the recovered patients from the acute presentation of the SARS-COV-2. Actually, the clinic cardiac control of the post-acute COVID syndrome has been working out without a well-established protocol, making the appropriate diagnosis of the cardiac diseases produced by the different damage mechanisms from COVID-19. Objectives: Standardize cardiovascular care and the follow up of COVID-19 survivors in the function on disease severity and identify patients who develop SPC-19A for timely care. Materials and methods: Through an extensive bibliographic review, this article has the purpose of provide the necessary information to make possible the early diagnosis and following of the cardiac complications that has been recorded trough the months after the acute disease from COVID-19.

Antecedentes: Las secuelas cardiovasculares ocasionadas por la enfermedad por coronavirus 2019 (COVID-19) son frecuentes en una importante proporción de los pacientes recuperados del cuadro agudo de la enfermedad. Hasta el día de hoy el seguimiento cardiológico del síndrome agudo post-COVID-19 (SPC-19A) se ha realizado de forma heterogénea y sin directrices que permitan al clínico identificar oportunamente los cambios que preceden a enfermedades cardiológicas derivadas de los distintos mecanismos de daño inducidos por COVID-19. Objetivos: Estandarizar la atención y seguimiento cardiovascular de los supervivientes de COVID-19 en función de la gravedad de la enfermedad e identificar a los pacientes que desarrollen SPC-19A para su atención oportuna. Material y métodos: Mediante una revisión extensa de bibliografía, este documento tiene la intención de unificar y proporcionar la información necesaria para diagnosticar y dar seguimiento a las complicaciones cardiacas que se han documentado en los meses posteriores a la resolución de la COVID-19 aguda.

Clinical implications of diabetes mellitus in patients with acute coronary syndrome: Prognostic role and use of new P2Y12 receptor inhibitors.

AIMS: We investigated the impact of diabetes mellitus (DM) in acute coronary syndrome (ACS) patients, and the 2-year prognosis based on antiplatelet therapy. METHODS: This is a prospective and multicenter registry including hospitalized ACS patients. Clinical management and antiplatelet therapy at discharge were recorded. Bleeding events, all-cause mortality and major adverse cardiovascular events (MACEs) were recorded during 2-years and compared according to DM and the P2Y12 receptor inhibitor. RESULTS: From 1717 ACS patients, 653 (38%) had DM. Diabetic patients were older, more commonly females, with higher prevalence of comorbidities and more conservative management. After excluding antiplatelet monotherapy or oral anticoagulation, clopidogrel was prescribed in 59.6% of DM patients. Cox regression analysis showed that DM was an independent risk factor for MACE (aHR 1.39, 95% CI 1.05-1.83). The use of clopidogrel instead of ticagrelor/prasugrel was also independently associated with MACE (aHR 1.71, 95% CI 1.11-2.63), and all-cause mortality (aHR 2.47, 95% CI 1.23-4.96) in diabetic patients (log-rank p-values < 0.001). CONCLUSIONS: In ACS patients, DM was associated with higher risk of MACE. In such patients, the use of ticagrelor/prasugrel reduced MACE and mortality compared to clopidogrel. Novel P2Y12 receptor inhibitors might be used as the first therapeutic choice in these high-risk patients.

Effects of Sport Teaching on Students' Enjoyment and Fun: A Systematic Review and Meta-Analysis.

The methodology used in sport teaching influences not only the students' technical and tactical learning, but also psychological and social dimensions such as enjoyment. We aimed to analyze the effects of interventions using conventional and non-conventional sport teaching methodology on students' enjoyment/fun, through a systematic review and meta-analysis. The search was carried out following the PRISMA Statement in the databases of Web of Science, PubMed, Scopus, SportDiscus, Eric and PsycInfo. A total of 1,481 documents were obtained, with the addition of 5 more which were identified in the reference lists of the articles found in the databases. Eleven articles were considered to meet the inclusion criteria. The meta-analysis yielded a moderate effect size of 0.72, and a 95% CI from 0.48 to 0.96 in favor of non-conventional teaching methods, highlighting the model of sports education. Nevertheless, the heterogeneity of the interventions was large and the quality of the evidence, according to GRADE, was very low. In conclusion, the use of non-conventional models in sport teaching with the aim of increasing the enjoyment/fun of boys and girls is advised. These suggestions could be useful for teachers and sport coaches to increase the enjoyment/fun of their trainees during sport practice.

Recommendations for the care of patients with diabetes mellitus with risk factors or established cardiovascular disease and SARS-CoV-2mellitus con factores de riesgo o enfermedad cardiovascular establecida y SARS-CoV-2.

A review is carried out to examine the risk of patients suffering from diabetes mellitus in the context of general morbidity and mortality and related to infection by SARS-CoV-2. Likewise, the general recommendations for food and the prevention of comorbidities that most these patients suffer most frequently are also studied. Finally, a review of the pharmacological recommendations on both oral and parenteral treatment in the outpatient, in hospitalization and in critical states infected with SARS-CoV-2 is made.

Se realiza una revisión sobre el riesgo de los pacientes que padecen diabetes mellitus en el contexto de morbimortalidad general y relacionada a infección por el coronavirus 2 del síndrome respiratorio agudo grave (SARS-CoV-2). Así mismo se repasan las recomendaciones generales, de alimentación y de la prevención de las comorbilidades que más frecuentemente padecen dichos enfermos. Finalmente se hace una revisión de las recomendaciones farmacológicas sobre el tratamiento tanto oral como parenteral en el paciente ambulatorio, en la hospitalización y en estados críticos infectados por el SARS-CoV-2.

Ingesta de cuerpos extraños magnéticos en la edad pediátrica. Caso clínico de localización y extracción endoscópica con ayuda de un imán / Ingestion of magnetic foreign bodies during the paediatric age. Case report, location and endoscopic extraction aided by a magnet

La ingesta accidental de más de un imán puede producir complicaciones graves. Los protocolos actuales recomiendan la extracción endoscópica de ser posible. El objetivo de este trabajo es presentar un caso clínico de una ingesta de dos imanes y la técnica endoscópica de extracción. Niño de 11 años que acudió a Urgencias tras la ingesta de dos imanes, asintomático. En la radiografía de abdomen, se identificaron dos cuerpos extraños radiopacos, aparentemente unidos, en la cámara gástrica. Se realizó una endoscopía bajo anestesia general en quirófano. Para facilitar la extracción, se colocó, encima de la pared abdominal, a nivel gástrico, un imán de neodimio. En la endoscopía, se observaron dos pequeños imanes localizados y fijados en la cara anterior del estómago. Una vez localizados, se retiró el imán externo y se procedió a su extracción con cesta

The ingestion of more than one magnet can cause multiple complications. Current protocols recommend endoscopic extraction if possible. We report a patient who swallowed two magnets and the endoscopic extraction technique. An 11-yearold boy presented at the Emergency Room after ingesting two small magnets, being asymptomatic. In the abdominal x-ray two radiopaque bodies were identified at the gastric chamber, apparently together. A gastroscopy was done in the operating room under general anaesthesia. To enable the extraction, a neodymium magnet was placed externally at the abdominal wall. In the endoscopic image, the two magnets were fixed to the anterior gastric wall. Once located, the neodymium magnet was removed and the two magnets were retrieved with an endoscopic basket.

[Ingestion of magnetic foreign bodies during the paediatric age. Case report, location and endoscopic extraction aided by a magnet]. / Ingesta de cuerpos extraños magnéticos en la edad pediátrica. Caso clínico de localización y extracción endoscópica con ayuda de un imán.

The ingestion of more than one magnet can cause multiple complications. Current protocols recommend endoscopic extraction if possible. We report a patient who swallowed two magnets and the endoscopic extraction technique. An 11-yearold boy presented at the Emergency Room after ingesting two small magnets, being asymptomatic. In the abdominal x-ray two radiopaque bodies were identified at the gastric chamber, apparently together. A gastroscopy was done in the operating room under general anaesthesia. To enable the extraction, a neodymium magnet was placed externally at the abdominal wall. In the endoscopic image, the two magnets were fixed to the anterior gastric wall. Once located, the neodymium magnet was removed and the two magnets were retrieved with an endoscopic basket.

La ingesta accidental de más de un imán puede producir complicaciones graves. Los protocolos actuales recomiendan la extracción endoscópica de ser posible. El objetivo de este trabajo es presentar un caso clínico de una ingesta de dos imanes y la técnica endoscópica de extracción. Niño de 11 años que acudió a Urgencias tras la ingesta de dos imanes, asintomático. En la radiografía de abdomen, se identificaron dos cuerpos extraños radiopacos, aparentemente unidos, en la cámara gástrica. Se realizó una endoscopía bajo anestesia general en quirófano. Para facilitar la extracción, se colocó, encima de la pared abdominal, a nivel gástrico, un imán de neodimio. En la endoscopía, se observaron dos pequeños imanes localizados y fijados en la cara anterior del estómago. Una vez localizados, se retiró el imán externo y se procedió a su extracción con cesta.

Clinical Spectrum and Long-term Outcome of 183 Cases of Ebstein's Anomaly, Experience of Mexican Population.

BACKGROUND: Ebstein's anomaly (EA) is a myopathy of the right ventricle that causes a variable spectrum of tricuspid valve delamination failure with diverse clinical and anatomical presentation. We reviewed our data of EA to establish an association between clinical and echocardiographic findings with mortality. METHODS: We divided patients in infants, Children/adolescents (Ch/A), and adults, according to age of presentation. Clinical and echocardiographic parameters were compared among groups. Multivariate analysis was performed for mortality. Survival analysis was plotted using Kaplan Meier curves. RESULTS: Cyanosis, severe forms of AE and heart failure were more frequent among infants, arrhythmias in Ch/A and stroke among adults. Surgery was performed in 71 patients; infants had higher mortality and early complications. We found that the predicted mortality at 40 years of age in the three groups was significantly different (log rank test, p <0.0001): Infants: 38%, Ch/A 16 and 4% in adults. Multivariate model in surgical group showed that progressive drop of right ventricular fractional shortening (RVFS) predicts a higher mortality risk. In the non-surgical group, low RVFS and cyanosis were significantly associated with mortality. CONCLUSION: EA in infants is linked to higher morbidity and mortality, while arrhythmias predominate in Ch/A and stroke in adults. In general, stroke is frequent in patients with EA, some prevention alternative must be implemented. Right ventricular dysfunction is very important in EA and is associated with high mortality. It must be subject of discussion the planning of the type of surgery or even in the decision of to preclude surgical treatment.

One-year efficacy and safety of prasugrel and ticagrelor in patients with acute coronary syndromes: Results from a prospective and multicentre ACHILLES registry.

BACKGROUND: Prasugrel and ticagrelor have demonstrated higher efficacy than clopidogrel in their main clinical trials for patients with acute coronary syndrome (ACS). However, the long-term prognosis and different clinical characteristics related to the type of antiplatelet prescription in current clinical practice ACS patients have not been analysed in depth. The objective of this study was to analyse the clinical profile of ACS and the efficacy and safety of novel oral P2Y12 inhibitors in current clinical practice patients discharged afterACS. METHODS: We collected data from the ACHILLES registry, and an observational, prospective and multicentre registry of patients discharged after ACS. We analysed baseline characteristics, clinical profile and therapy during ACS admission and compared with the different treatments at discharge. After 1 year of follow-up, ischaemic and major bleeding events were analysed. Multivariate Cox regression analysis and Kaplan Meier curves were also plotted. RESULTS: Of 1717 consecutive patients, 1294 (75.4%) were discharged with a P2Y12 inhibitor without oral anticoagulation. Novel oral P2Y12 inhibitors were indicated in 47%. Patients treated with clopidogrel were elderly (69.1 ± 13.4 vs 60.4 ± 11.5 years; P < .001) and had a higher prevalence of cardiovascular risk factors. GRACE and CRUSADE scores were higher in the clopidogrel than in novel oral P2Y12 inhibitors group (P < .001). After 1 year of follow-up, 64(5.0%/year) patients had a new myocardial infarction, 127(10.0%/year) had a major adverse cardiovascular event (MACE) and 78(6.1%/year) died. Patients treated with clopidogrel had a significantly higher annual rate of cardiovascular mortality, MACE and all-cause mortality (allP < .001) without differences in major bleeding (P = .587) compared with novel oral P2Y12 inhibitors. After multivariate adjustment for the main clinical variables related to adverse prognosis in ACS patients, the discharge with novel oral P2Y12 inhibitors therapy was independently associated with lower risk of all-cause mortality (HR0.49, 95% CI [0.24-0.98], P = .044) and lower risk of MACE (HR0.64, 95% CI [0.41-0.98], P = .044). CONCLUSIONS: In this prospective, observational and current clinical practice ACS registry, the use of novel oral P2Y12 inhibitors was associated with a reduction in adverse events compared with clopidogrel in patients with ACS. Novel oral P2Y12 inhibitors prescription at discharge was independently associated with lower all-cause mortality and MACE without differences in bleeding events. However, clopidogrel remained the most common P2Y12 inhibitor employed for ACS, especially in older and high-risk patients.

Influence of lifestyle factors and staple foods from the Mediterranean diet on non-alcoholic fatty liver disease among older individuals with metabolic syndrome features.

OBJECTIVE: Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver morbidity. This condition often is accompanied by obesity, diabetes, and metabolic syndrome (MetS). The aim of this study was to evaluate the connection between lifestyle factors and NAFLD in individuals with MetS. METHODS: A cross-sectional study with 328 participants (55-75 y of age) diagnosed with MetS participating in the PREDIMED-Plus trial was conducted. NAFLD status was evaluated using the non-invasive hepatic steatosis index (HSI). Sociodemographic, clinical, and dietary data were collected. Adherence to the Mediterranean diet (mainly assessed by the consumption of olive oil, nuts, legumes, whole grain foods, fish, vegetables, fruits, and red wine) and physical activity were assessed using validated questionnaires. RESULTS: Linear regression analyses revealed that HSI values tended to be lower with increasing physical activity tertiles (T2, ß = -1.47; 95% confidence interval [CI], -2.73 to -0.20; T3, ß = -1.93; 95% CI, -3.22 to -0.65 versus T1, Ptrend = 0.001) and adherence to the Mediterranean diet was inversely associated with HSI values: (moderate adherence ß = -0.70; 95% CI, -1.92 to 0.53; high adherence ß = -1.57; 95% CI, -3.01 to -0.13 versus lower, Ptrend = 0.041). Higher tertiles of legume consumption were inversely associated with the highest tertile of HSI (T2, relative risk ratio [RRR], 0.45; 95% CI, 0.22-0.92; P = 0.028; T3, RRR, 0.48; 95% CI, 0.24-0.97; P = 0.041 versus T1). CONCLUSION: Physical activity, adherence to the Mediterranean diet, and consumption of legumes were inversely associated with a non-invasive marker of NAFLD in individuals with MetS. This data can be useful in implementing precision strategies aimed at the prevention, monitoring, and management of NAFLD.

Recomendaciones para la atención de pacientes con diabetes mellitus con factores de riesgo o enfermedad cardiovascular establecida y SARS-CoV-2 / Recommendations for the care of patients with diabetes mellitus with risk factors or established cardiovascular disease and SARS-CoV-2

Resumen Se realiza una revisión sobre el riesgo de los pacientes que padecen diabetes mellitus en el contexto de morbimortalidad general y relacionada a infección por el coronavirus 2 del síndrome respiratorio agudo grave (SARS-CoV-2). Así mismo se repasan las recomendaciones generales, de alimentación y de la prevención de las comorbilidades que más frecuentemente padecen dichos enfermos. Finalmente se hace una revisión de las recomendaciones farmacológicas sobre el tratamiento tanto oral como parenteral en el paciente ambulatorio, en la hospitalización y en estados críticos infectados por el SARS-CoV-2.

Abstract A review is carried out to examine the risk of patients suffering from diabetes mellitus in the context of general morbidity and mortality and related to infection by SARS-CoV-2. Likewise, the general recommendations for food and the prevention of comorbidities that most these patients suffer most frequently are also studied. Finally, a review of the pharmacological recommendations on both oral and parenteral treatment in the outpatient, in hospitalization and in critical states infected with SARS-CoV-2 is made.

Prediabetes is a risk factor for cardiovascular disease following renal transplantation.

Prediabetes and post-transplant diabetes mellitus affect about 20-30% of renal transplant patients. The latter is a risk factor for cardiovascular disease. However, no clear evidence linking prediabetes and cardiovascular disease is available. To study this we analyzed the impact of prediabetes on cardiovascular disease in 603 renal transplant patients followed with repeated oral glucose tests for up to five years and a long term survival evaluation. Prediabetes and post-transplant diabetes mellitus were defined at 12 months after transplantation to avoid their high reversibility rate before this period. 73 cardiovascular events were observed. The incidence of events was significantly higher in patients with either prediabetes, (17%; 0.023 person/year) or post-transplant diabetes mellitus (20%; 0.028 person/year) than in normal individuals, (7%; 0.0095 person/year). The incidence of events was comparable between prediabetes and post-transplant diabetes mellitus. Prediabetes at 12 months was a risk factor for cardiovascular events in univariate and multivariate Cox survival analyses (hazard ratio 2.24, 95% confidence interval 1.11-4.52). Prediabetes at three months and hemoglobin A1c at 12 months were not significantly associated with cardiovascular disease. Thus, prediabetes is a risk factor for cardiovascular disease in renal transplantation, a population at high risk for cardiovascular events. Since prediabetes is potentially a reversible condition, there is an opportunity to prevent cardiovascular disease in this population.

Situación de la circuncisión por motivos religiosos en España / Situation of religious circumcision in Spain

Introducción: la realización de la circuncisión por motivos culturales o religiosos es una práctica cuya indicación no está bien definida dentro de nuestra práctica médica. El objetivo de nuestro trabajo es mostrar la diversidad de su práctica en España a fin de establecer un protocolo de actuación general con respecto a este tema. Material y métodos: se ha realizado una encuesta nacional en 49 centros públicos con disponibilidad de servicio de cirugía pediátrica, en la que se recogen datos epidemiológicos, descriptivos y de opinión tanto colectiva como del personal médico sobre las derivaciones recibidas para hacer circuncisión. Resultados: se enviaron 200 encuestas, de las que se obtuvieron un total de 142 respuestas, el 76,6% de los facultativos no realizan circuncisiones por motivo religioso en el ámbito público. El 89% de los pacientes vistos en consulta son derivados por su pediatra. Hasta el 65% de los médicos afirman que han tenido algún conflicto con la familia del paciente cuando rechazan la indicación de la circuncisión por esta razón. De los profesionales que aceptan la intervención, el 39% lo hace para evitar la cirugía en peores condiciones fuera del hospital. El 57% de los cirujanos desconoce si esta indicación está incluida en la cartera de servicios del Sistema Nacional de Salud. Conclusiones: en base a nuestra encuesta, la mayoría de los profesionales desconoce si esta indicación está dentro de la cartera de servicios y coinciden en la necesidad de tener un consenso de actuación. Es importante tener una actitud conjunta, conocer todas las opiniones, y crear un protocolo de manejo de esta situación

Introduction: the performance circumcision for cultural or religious reasons is a practice whose indication is not well defined within the scope of medical practice in Spain. The objective of this study was to illustrate the variability in its practice in Spain with the purpose of eventually establishing a general protocol on the subject. Material and methods: we conducted a nationwide survey of public hospitals with a paediatric surgery department to collect epidemiological and descriptive data and opinions, both general and from individual medical providers, on the referrals received for performance of circumcision. Results: we submitted 200 questionnaires and received 142 responses, and 76.6% of the responding physicians reported not performing circumcisions for religious reasons in their practice in the public health system. Of all patients seen for a consultation, 89% had been referred by their paediatricians. Up to 65% of doctors reported having conflict with families when they refused to perform circumcision for this indication. Of the professionals who agreed on religious reasons as an indication, 39% performed the surgery to prevent its being performed under poorer conditions outside a hospital. Of all paediatric surgeons, 57% did not know whether this indication is included among the services covered by the National Health System. Conclusions: based on our survey, most professionals do not know whether this indication is included in the services covered by the public health system and agree on the need of establishing a consensus guideline. We believe that it is important to have a homogeneous approach, to explore the opinions of the professional collective as a whole and to develop a general protocol for approaching this situation

Switching of Oral P2Y12 Inhibitor Treatment in Patients with Acute Coronary Syndrome: Prevalence, Predictors, and Prognosis.

BACKGROUND AND OBJECTIVE: Dual antiplatelet therapy is one of the main treatments in acute coronary syndrome (ACS). Switching antiplatelet agents may be necessary in some patients to improve efficacy or safety. The objective of this study was to determine the prevalence, predictors, and implications of clinical switching in patients during hospital admission and 1-year follow-up at discharge. METHODS: Observational, prospective, multicenter registry study in patients discharged following an admission for ACS and followed up for 1 year. We analyzed ischemic and bleeding events as well as treatment changes. RESULTS: We recruited 1717 patients; in-hospital switching occurred in 425 (24.8%): 15.1% to clopidogrel and 84.9% to newer antiplatelet drugs (prasugrel or ticagrelor). Those switched to newer antiplatelets were younger, with lower scores on the GRACE and CRUSADE scales, admitted more frequently for ST-elevation myocardial infarction and underwent more invasive management and percutaneous revascularization. The clinical cardiologist was responsible for most in-hospital switching to newer antiplatelets (79.6%). The loading dose of the second antiplatelet did not affect incidence of bleeding events. Post-discharge switching was infrequent (2%) and depended mainly on clinical indications; only 30% was related to a new ACS. CONCLUSIONS: In a contemporary registry with ACS, in-hospital switching of antiplatelet drugs was frequent. Those switched to newer antiplatelets were younger and admitted more frequently for ST-elevation myocardial infarction. Post-discharge switching was infrequent.

Conservatively managed patients with non-ST-segment elevation acute coronary syndrome are undertreated with indicated medicines.

INTRODUCTION AND AIMS: Patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) are often managed conservatively. Clinical practice guidelines recommend treating these patients with the same pharmacological drugs as those who receive invasive treatment. We analyze the use of new antiplatelet drugs (NADs) and other recommended treatments in people discharged following an NSTE-ACS according to the treatment strategy used, comparing the medium-term prognosis between groups. METHODS: Prospective observational multicenter registry study in 1717 patients discharged from hospital following an ACS; 1143 patients had experienced an NSTE-ACS. We analyzed groups receiving the following treatment: No cardiac catheterization (NO CATH): n = 134; 11.7%; Cardiac catheterization without revascularization (CATH-NO REVASC): n = 256; 22.4%; percutaneous coronary intervention (PCI): n = 629; 55.0%; and coronary artery bypass graft (CABG): n = 124; 10.8%. We assessed major adverse cardiovascular events (MACE), all-cause mortality, and hemorrhagic complications at one year. RESULTS: NO CATH was the oldest, had the most comorbidities, and was at the highest risk for ischemic and hemorrhagic events. Few patients who were not revascularized with PCI received NADs (NO CATH: 3.7%; CATH-NO REVASC: 10.6%; PCI: 43.2%; CABG: 3.2%; p<0.001). Non-revascularized patients also received fewer beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), and statins (p<0.001). At one year, MACE incidence in NO CATH group was three times that of the other groups (30.1%, p<0.001), and all-cause mortality was also much higher (26.3%, p<0.001). There were no significant differences in hemorrhagic events. Belonging to NO CATH group was an independent predictor for MACE at one year in the multivariate analysis (HR 2.72, 95% CI 1.29-5.73; p = 0.008). CONCLUSIONS: Despite current invasive management of NSTE-ACS, patients not receiving catheterization are at very high risk for under treatment with recommended drugs, including NADs. Their medium-term prognosis is poor, with high mortality. Patients treated with PCI receive better pharmacological management, with high use of NADs.

Endoscopic ultrasound cytologic brushing vs endoscopic ultrasound - fine needle aspiration for cytological diagnosis of cystic pancreatic lesions. A multicenter, randomized open-label trial

Introduction: the incidence of cystic pancreatic lesions (CPL) in the asymptomatic population is increasing. Achieving a preoperative diagnosis of CPL still remains a challenge. Objectives: to evaluate the diagnostic accuracy of the cytological diagnosis of CPL from samples obtained by cytology brush versus standard endoscopic ultrasound fine needle aspiration (EUS-FNA). Methods: a multicenter, randomized, open-label trial was performed of EUS-cytology brush (EUS-EB) versus EUS-FNA for the cytological diagnosis of CPL. Patients that underwent EUS-FNA with a CPL > 15 mm were included and randomized into two groups: group I, EUS-EB; group II, EUS-FNA. The final diagnosis was based on the histological evaluation of surgical specimens and clinical parameters, imaging and a five year follow-up in non-operated patients. The main outcome was the diagnostic accuracy of both methods. Secondary outcomes were the diagnostic adequacy of specimens and the rate of adverse events. Data were compared using the Chi-squared test. An intention to treat (ITT) and per-protocol (PP) analysis were performed. Results: sixty-five patients were included in the study, 31 in group I and 34 in group II. Three patients initially randomized to group I were changed to group II as it was impossible to obtain a sample using the brush. The mean size of the CPL was 28.2 mm (range 16-60 mm). The diagnostic accuracy of EUS-EB was not superior to EUS-FNA, neither in the ITT nor the PP analysis (44.8% vs 41.1%, p = 0.77 and 38.4% vs 45.9%, p = 0.55). Conclusions: EUS-EB does not improve the diagnostic accuracy of CPL in comparison with EUS-FNA

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Endoscopic ultrasound cytologic brushing vs endoscopic ultrasound - fine needle aspiration for cytological diagnosis of cystic pancreatic lesions. A multicenter, randomized open-label trial.

INTRODUCTION: the incidence of cystic pancreatic lesions (CPL) in the asymptomatic population is increasing. Achieving a preoperative diagnosis of CPL still remains a challenge. OBJECTIVES: to evaluate the diagnostic accuracy of the cytological diagnosis of CPL from samples obtained by cytology brush versus standard endoscopic ultrasound fine needle aspiration (EUS-FNA). METHODS: a multicenter, randomized, open-label trial was performed of EUS-cytology brush (EUS-EB) versus EUS-FNA for the cytological diagnosis of CPL. Patients that underwent EUS-FNA with a CPL > 15 mm were included and randomized into two groups: group I, EUS-EB; group II, EUS-FNA. The final diagnosis was based on the histological evaluation of surgical specimens and clinical parameters, imaging and a five year follow-up in non-operated patients. The main outcome was the diagnostic accuracy of both methods. Secondary outcomes were the diagnostic adequacy of specimens and the rate of adverse events. Data were compared using the Chi-squared test. An intention to treat (ITT) and per-protocol (PP) analysis were performed. RESULTS: sixty-five patients were included in the study, 31 in group I and 34 in group II. Three patients initially randomized to group I were changed to group II as it was impossible to obtain a sample using the brush. The mean size of the CPL was 28.2 mm (range 16-60 mm). The diagnostic accuracy of EUS-EB was not superior to EUS-FNA, neither in the ITT nor the PP analysis (44.8% vs 41.1%, p = 0.77 and 38.4% vs 45.9%, p = 0.55). CONCLUSIONS: EUS-EB does not improve the diagnostic accuracy of CPL in comparison with EUS-FNA.