Recurrence After Atrial Fibrillation Ablation and Investigational Biomarkers of Cardiac Remodeling.

BACKGROUND: Recurrence after atrial fibrillation (AF) ablation remains common. We evaluated the association between recurrence and levels of biomarkers of cardiac remodeling, and their ability to improve recurrence prediction when added to a clinical prediction model. METHODS AND RESULTS: Blood samples collected before de novo catheter ablation were analyzed. Levels of bone morphogenetic protein-10, angiopoietin-2, fibroblast growth factor-23, insulin-like growth factor-binding protein-7, myosin-binding protein C3, growth differentiation factor-15, interleukin-6, N-terminal pro-brain natriuretic peptide, and high-sensitivity troponin T were measured. Recurrence was defined as ≥30 seconds of an atrial arrhythmia 3 to 12 months postablation. Multivariable logistic regression was performed using biomarker levels along with clinical covariates: APPLE score (Age >65 years, Persistent AF, imPaired eGFR [<60 ml/min/1.73m2], LA diameter ≥43 mm, EF <50%; which includes age, left atrial diameter, left ventricular ejection fraction, persistent atrial fibrillation, and estimated glomerular filtration rate), preablation rhythm, sex, height, body mass index, presence of an implanted continuous monitor, year of ablation, and additional linear ablation. A total of 1873 participants were included. A multivariable logistic regression showed an association between recurrence and levels of angiopoietin-2 (odds ratio, 1.08 [95% CI, 1.02-1.15], P=0.007) and interleukin-6 (odds ratio, 1.02 [95% CI, 1.003-1.03]; P=0.02). The area under the receiver operating characteristic curve of a model that only contained clinical predictors was 0.711. The addition of any of the 9 studied biomarkers to the predictive model did not result in a statistically significant improvement in the area under the receiver operating characteristic curve. CONCLUSIONS: Higher angiopoietin-2 and interleukin-6 levels were associated with recurrence after atrial fibrillation ablation in multivariable modeling. However, the addition of biomarkers to a clinical prediction model did not significantly improve recurrence prediction.

Durable pulmonary vein isolation with diffuse posterior left atrial ablation using low-flow, median power, short-duration strategy.

INTRODUCTION: To target posterior wall isolation (PWI) in atrial fibrillation (AF) ablation, diffuse ablation theoretically confers a lower risk of conduction recovery compared to box set. We sought to assess the safety and efficacy of diffuse PWI with low-flow, medium-power, and short-duration (LF-MPSD) ablation, and evaluate the durability of pulmonary vein isolation (PVI) and PWI among patients undergoing repeat ablations. METHODS: We retrospectively studied patients undergoing LF-MPSD ablation for AF (PVI + diffuse PWI) between August 2017 and December 2019. Clinical characteristics were collected. Kaplan-Meier survival analysis was performed to study AF/atrial flutter (AFL) recurrence. Ablation data were analyzed in patients who underwent a repeat AF/AFL ablation. RESULTS: Of the 463 patients undergoing LF-MPSD AF ablation (PVI alone, or PVI + diffuse PWI), 137 patients had PVI + diffuse PWI. Acute PWI with complete electrocardiogram elimination was achieved in 134 (97.8%) patients. Among the 126 patients with consistent follow-up, 38 (30.2%) patients had AF/AFL recurrence during a median duration of 14 months. Eighteen patients underwent a repeat AF/AFL ablation after PVI + diffuse PWI, and 16 (88.9%) patients had durable PVI, in contrast to 10 of 45 (23.9%) patients who had redo ablation after LF-MPSD PVI alone. Seven patients (38.9%) had durable PWI, while 11 patients had partial electrical recovery at the posterior wall. The median percentage of area without electrical activity at the posterior wall was 70.7%. Conduction block across the posterior wall was maintained in 16 (88.9%) patients. CONCLUSION: There was a high rate of PVI durability in patients undergoing diffuse PWI and PVI. Partial posterior wall electrical recovery was common but conduction block across the posterior wall was maintained in most patients.

Reflexiones en torno a la pertinencia de los procesos de formación e investigación en psicología clínica en la contemporaneidad / Reflections on the Relevance of the Training and Research Processes in Clinical Psychology in the Contemporary World

Resumen El cambio cultural asociado a la contemporaneidad ha traído consigo el debilitamiento de las instituciones disciplinares y la caída de los grandes metarrelatos y los valores absolutos como guías orientadoras de los sujetos. Concomitantemente, los marcos referenciales en los que la psicología clínica ha soportado la lectura e intervención de las problemáticas en salud mental son cuestionados en su vigencia y conveniencia para responder a ellas. Objetivo: analizar los procesos de formación e investigación de la psicología clínica para valorar su capacidad de responder a las problemáticas en salud mental en la contemporaneidad. Metodología: investigación de enfoque cualitativo, con perspectiva hermenéutica y técnicas de análisis documental y teoría fundamentada. Resultados: los procesos de formación en psicología clínica en EE. UU., Europa, Iberoamérica y Colombia en la contemporaneidad siguen el modelo de Boulder y sus variantes de Vail y Clinical Science, conservando las premisas ontológicas realistas y su dependencia del método clínico médico. Consecuentemente, los procesos investigativos se centran en la psicopatología y la psicoterapia, dejando rezagadas las reflexiones relativas a la contemporaneidad, las subjetividades y problemáticas emergentes de ella.

Abstract The cultural change associated with contemporaneity has brought with it the weakness of the disciplinary institutions and the decline of the great meta-narratives and absolute values as guides for the subjects. Concomitantly, the reference frameworks in which clinical psychology has supported the reading and intervention of mental health problems are questioned in their validity and convenience to respond to these issues. This situation confronts clinical psychology regarding the relevance of its training and research processes to understand and intervene the mental health problems in the contemporary context. Objective: analyze the training and research processes of clinical psychology to assess its ability to respond to contemporary mental health problems. Methodology: qualitative investigation, hermeneutic perspective and documentary analysis techniques and grounded theory. Results: the processes of training in clinical psychology in the US, Europe, Latin America and Colombia in the contemporary world follow Boulder model of and its variants of Vail and Clinical Science, preserving the realistic ontological premises and their dependence on the clinical medical method. Consequently, the research processes is focused on psychopathology and psychotherapy, leaving behind reflections related to contemporaneity, subjectivities and problems emerging from it. In conclusion, in order to increase its relevance, it is proposed to include reflections on contemporaneity and its emerging subjectivities in training and research processes in clinical psychology.

Conduction Recovery After Cavotricuspid Isthmus Ablation When Performed With or Without Concomitant Atrial Fibrillation Ablation.

OBJECTIVES: This study sought to define the association between conduction recovery across the cavotricuspid isthmus (CTI) and typical atrial flutter (AFL) recurrence when CTI ablation is performed with pulmonary vein isolation (PVI) compared with a stand-alone procedure. BACKGROUND: CTI ablation is commonly performed at the same time as PVI to treat AFL or as an empiric therapy. Conduction recovery is a recognized problem after linear ablation in the left atrium (e.g., mitral isthmus ablation) and is proarrhythmic. Less is known about conduction recovery after CTI ablation and possible differences in outcomes when performed at the time of PVI compared with at the time of a stand-alone procedure. METHODS: Eligible participants who underwent stand-alone CTI ablation were compared with those who underwent a combined (CTI+PVI) procedure. CTI conduction recovery was assessed at the time of a second ablation. Conduction recovery across the CTI (primary outcome) and recurrence of typical AFL (secondary outcome) were studied using multivariable logistic regression. RESULTS: Among 295 eligible participants (median age: 64 years [interquartile range: 55 to 69 years]; 33% women), recovery was assessed in 232 and was more common after combined versus stand-alone CTI ablation (52% [72 of 139] vs. 13% [12 of 93]; p < 0.001). In multivariable analysis, CTI ablation performed as a combined procedure increased odds of CTI conduction recovery 7.8-fold (odds ratio: 7.8; 95% confidence interval: 3.3 to 18.3; p < 0.001) and clinical AFL recurrence 4.1-fold (odds ratio: 4.1; 95% confidence interval: 1.0 to 16.9; p = 0.049). CONCLUSIONS: CTI ablation performed at the time of atrial fibrillation ablation is associated with higher rates of conduction recovery and typical flutter recurrence.

Caracterización de la atención psicoterapéutica en la IPS CES Sabaneta, Colombia, 2014-2015 / Characterization of psychotherapeutic assistance in the IPS CES Sabaneta, Colombia, 2014-2015

Resumen Los cambios en la cosmovisión imperante en los últimos decenios han traído consigo sujetos con nuevas características, intereses y exigencias, que han impactado a la psicología clínica en tanto le exigen nuevas formas de comprender e intervenir las problemáticas demandadas por ellos en contextos institucionales, entre otros. De cara a estas nuevas realidades y con el fin de hacer más pertinentes las intervenciones psicoterapéuticas, se realizó una caracterización de las mismas en la Institución Prestadora de Servicios de Salud -IPS- CES Sabaneta (Colombia) durante los años 2014-201 5, a través de un análisis descriptivo de 9.140 registros de atención y 532 historias clínicas elegidas aleatoriamente. Se estudiaron aspectos sociodemográficos, administrativos y teórico-técnicos de la atención a partir de análisis de frecuencia, medidas de tendencia central, de dispersión y de forma. Se encontró que consultan tres hombres por cada mujer, siendo la población entre los 6 y 18 años la que tiene el mayor peso (59,77%). Los trastornos emocionales y del comportamiento fueron el principal diagnóstico (44,92%), seguido por los trastornos neuróticos secundarios a situaciones estresantes y somatomorfos (18,6%). Llama la atención la baja prevalencia de los trastornos de personalidad (0,56%) y que el 48,9% de los pacientes asistió a un máximo de seis sesiones. Los resultados permiten ajustar los perfiles y estrategias de atención de acuerdo con las problemáticas más prevalentes, así como los procesos administrativos y formativos relacionados con ellas.

Abstract The changes happened in the prevailing worldview in the last decades have brought subjects with new characteristics, interests and requirements, which have had an impact on the clinical psychology, as a consequence, they require from clinical psychology new ways of understanding and controlling the arisen issues that concern the institutional contexts. In order to face these realities, relevant psychotherapeutic interventions were implemented through a characterization of health attendance carried out in IPS CES Saba-neta during 2014-201 5, conducted by a descriptive analysis of 9140 records of assistance and an analysis of 532 clinical records, chosen randomly. Sociodemographic, administrative and theoretical-technical aspects of the care service were studied based on frequency analysis, measures of central tendency and dispersion using the SPSS software. It was found that 3 men in 1 woman attend to medical service, being the population between ages of 6 and 18 the one that present the highest weight (59, 77 %). Emotional and behavioral disorders were the main diagnosis (44.92%), followed by neurotic disorders secondary to stressful and somatomorphic situations (18.6%). It is noticed the low prevalence of personality disorders (0.56%) even though 48.9% of patients attended a maximum of six sessions. The results allow adjusting the profiles and care service strategies according to the most prevalent problems, as well as the administrative and formative processes that involve these issues.

La psicología clínica ante el sujeto de la contemporaneidad / The clinical pychology and the contemporary subject / A psicologia clínica e o sujeito da contemporaneidade

Se presentan algunas tensiones y retos para la psicología clínica derivados de las características y necesidades de los sujetos de la contemporaneidad. Para ello se discute el tipo de sujeto en el que tradicionalmente se ha basado, las diferencias con el sujeto contemporáneo y las consecuencias de dichas diferencias para ella, encontrando cuatro tensiones primordiales: la relativización del telos progreso, el cuestionamiento a la adaptación y a la responsabilidad como premisas normalizadoras, y la emergencia del deseo como criterio ético fundamental. Ellas implican nuevas problemáticas y exigencias para la psicología clínica que la confrontan en sus fundamentos ontológicos, epistemológicos y metodológicos, obligándola a revisar sus supuestos formativos, conceptuales y de intervención. Se concluye la necesidad de una profunda revisión de la psicología clínica que le permita adecuarse en sus procesos formativos, conceptuales y aplicados, con el fin de hacerla pertinente a las características y necesidades de los sujetos en la contemporaneidad.

Clinical psychology faces tensions and challenges derived from the characteristics and needs of the contemporary subjects. Therefore, we discuss the traditional subject that has been the basis of psychology, the differences with the contemporary subject and the consequences of the mentioned differences for her, finding four basic tensions: the progress relativization, the question to adjustment and responsibility as normalizing premises, and desire urgency as basic ethical criterion. These imply new problematic and requirements for the clinical psychology, which is confronted with ontological, epistemological and methodological foundations forcing the revision of formative and conceptual suppositions, in addition to strategies of intervention. In conclusion, there is a need of deep review of the clinical psychology allowing a normalization of the formative, conceptual and applied processes, in order to make it pertinent to the characteristics and needs of the contemporary subjects.

Apresenta-se um pouco de tensões e desafios para a psicologia clínica derivadas das características e necessidades dos sujeitos da contemporaneidade. Para isto, discute-se o tipo de sujeito no que tradicionalmente foi baseado, as diferenças com o sujeito contemporâneo e as consequências de ditas diferenças para ela, achando quatro tensões primordiais: a relativização do progresso, o questionamento à adaptação e a responsabilidade como premissas normalizadoras e a emergência do desejo como critério ético fundamental. Elas envolvem novas problemáticas e exigências para a psicologia clínica que a confrontam em seus fundamentos ontológicos, epistemológicos e metodológicos, forçando a revisar seus supostos formativos, conceituais e de intervenção. Conclui-se a necessidade de uma profunda revisão da psicologia clínica, permitindo-se adequação em seus processos formativos, conceituais e aplicados, com o fim de fazê-la pertinente às características e às necessidades dos sujeitos na contemporaneidade.

Cardiac sympathectomy for the management of ventricular arrhythmias refractory to catheter ablation.

BACKGROUND: Catheter ablation is now a mainstay of therapy for ventricular arrhythmias (VAs). However, there are scenarios where either physiological or anatomical factors make ablation less likely to be successful. OBJECTIVE: The purpose of this study was to demonstrate that cardiac sympathetic denervation (CSD) may be an alternate therapy for patients with difficult-to-ablate VAs. METHODS: We identified all patients referred for CSD at a single center for indications other than long QT syndrome and catecholaminergic polymorphic ventricular tachycardia who had failed catheter ablation. Medical records were reviewed for medical history, procedural details, and follow-up. RESULTS: Seven cases of CSD were identified in patients who had failed prior catheter ablation or had disease not amenable to ablation. All patients had VAs refractory to antiarrhythmic drugs, with a median arrhythmia burden of 1 episode of sustained VA per month. There were no acute complications of sympathectomy. One of 7 patients (14%) underwent heart transplant. No patient had sustained VA after sympathectomy at a median follow-up of 7 months. CONCLUSION: Because of anatomical and physiological constraints, many VAs remain refractory to catheter ablation and remain a significant challenge for the electrophysiologist. While CSD has been described as a therapy for long QT syndrome and catecholaminergic polymorphic ventricular tachycardia, data regarding its use in other cardiac conditions are sparse. This series illustrates that CSD may be a viable treatment option for patients with a variety of etiologies of VAs.

From the Structured Subject to the Proteiform Subject in the Contemporaneity: Demands, Tensions and Challenges for the Clinical Psychology / Del sujeto estructura al sujeto proteiforme en la contemporaneidad: demandas, tensiones y desafios para la psicología clínica

Resumen Los últimos decenios han traído consigo grandes cambios en la cosmovisión y formas de vida de las personas, caracterizados por una velocidad, profundidad e intensidad sin parangón en la historia de la humanidad. Podrían mencionarse la globalización, la economía neoliberal, la aparición de gigantescas multinacionales y la relativización de los Estados como garantes del orden mundial. Ligados a la aparición de las computadoras y la World Wide Web, han emergido nuevas formas de utilizar el lenguaje, el conocimiento y las relaciones, hechos que han transformado las formas de concebir y ser en el mundo confrontando al establishment. La escuela, la familia, el trabajo, las instituciones religiosas y científicas, se enfrentan con esta "nueva época", obligando a que los sujetos, hasta ahora orientados por lógicas adaptativas en pos del progreso y asumidos como monadas naturales, individuales e intrapsíquicos (sujetos estructura), deban vérselas con la relativización de referentes universales, el cambio, la incertidumbre y la plurivocalidad (sujetos proteiformes). Lo anterior ha cuestionado a la psicología clínica reclamándole profundas transformaciones en las condiciones de la atención, la adecuación a los sistemas de seguridad social, la respuesta a nuevas problemáticas y la revisión de los supuestos ontológicos, gnoseológicos y antropológicos en los que se ha soportado. Se propone una revisión de las exigencias, tensiones y desafíos para la psicología clínica derivados del paso del sujeto estructura al sujeto proteiforme en la contemporaneidad como una contribución al análisis de la respuesta que ella puede ofrecer a las profundas transformaciones acaecidas en los últimos decenios.

Abstract The last decades have brought different changes in the cosmovision and forms in people´s life characterized by a speed, depth and intensity never seen in any other historical moment. It could be mentioned globalization, the emergency of neoliberal economy, the appearance of gigantic multinationals and the relativization of the States as guarantors of the world order. Linked to the appearance of the computers and the Web World Wide, it has emerged new ways of using the language, knowledge, and the relationships; all of them are facts that have transformed the ways of conceiving and being in a world, confronting the establishment. The school, the family, the work, the religious and scientific institutions, are facing among them this "new age ", forcing the subjects, until a few decades ago orientated by adaptive logic, in pursuit of progress, and being assumed as natural monads, individual and intrapsychic (subjects/structure), that have to do with the relativization of universal laws, the change and the uncertainty (proteiform subjects). The previous things have questioned the clinical psychology, claiming for deep transformations in the conditions of the attention, the adequacy to the social security systems, the response to new problematic and the review of the ontological, gnoseological and anthropological suppositions, which have been used for long as a support. Finally, it is proposed a review of the requirements, tensions and challenges for the clinical psychology derived from the transition of the structured subject to the proteiform subject in the contemporaneity as a contribution to the analysis of the response that this discipline can provide to the deep transformations arisen in the last decades.

Non-pulmonary vein mediated atrial fibrillation: A novel sub-phenotype.

BACKGROUND: Atrial fibrillation (AF) is a mechanistically heterogeneous disorder, and the ability to identify sub-phenotypes ("endophenotypes") of AF would assist in the delivery of personalized medicine. We used the clinical response to pulmonary vein isolation (PVI) to identify a sub-group of patients with non-PV mediated AF and sought to define the clinical associations. METHODS: Subjects enrolled in the Vanderbilt AF Ablation Registry who underwent a repeat AF ablation due to arrhythmia recurrence were analyzed on the basis of PV reconnection. Subjects who had no PV reconnection were defined as "non-PV mediated AF". A comparison group of subjects were identified who had AF that was treated with PVI-only and experienced no arrhythmia recurrence >12 months. They were considered a group enriched for "PV-mediated AF". Univariate and multivariable binary logistic regression analysis was performed to investigate clinical associations between the PV and non-PV mediated AF groups. RESULTS: Two hundred and twenty nine subjects underwent repeat AF ablation and thirty three (14%) had no PV reconnection. They were compared with 91 subjects identified as having PV-mediated AF. Subjects with non-PV mediated AF were older (64 years [IQR 60,71] vs. 60 [52,67], P = 0.01), more likely to have non-paroxysmal AF (82% [N = 27] vs. 35% [N = 32], P<0.001), and had a larger left atrium (LA) (4.2cm [3.6,4.8] vs. 4.0 [3.3,4.4], P = 0.04). In univariate analysis, age (per decade: OR 1.56 [95% CI: 1.04 to 2.33], P = 0.03), LA size (per cm: OR 1.8 [1.06 to 3.21], P = 0.03) and non-paroxysmal AF (OR 8.3 [3.10 to 22.19], P<0.001) were all significantly associated with non-PV mediated AF. However, in multivariable analysis only non-paroxysmal AF was independently associated with non-PV mediated AF (OR 7.47 [95% CI 2.62 to 21.29], P<0.001), when adjusted for age (per decade: OR 1.25 [0.81 to 1.94], P = 0.31), male gender (OR 0.48 [0.18 to 1.28], P = 0.14), and LA size (per 1cm: 1.24 [0.65 to 2.33], P = 0.52). CONCLUSIONS: Non-paroxysmal AF was the only clinical variable found to be independently associated with non-PV mediated AF. We demonstrated that analysis of AF ablation outcomes data can serve as a tool to successfully identify a sub-phenotype of subjects who have non-PV mediated AF. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov ID # NCT02404415.

Implementación de la Escala de Alvarado en apendicitis aguda. Validación de prueba / Validaton of Alvarado Score for the Diagnosis of Acute Appendicits

Introducción: La Escala de Alvarado se basa en síntomas, signos clínicos y hallazgos de laboratorio que se encuentran comúnmente en la apendicitis aguda; su principal valor radica en aplicar en forma ordenada y sistematizada un adecuado interrogatorio, exploración física e interpretación de los estudios básicos de laboratorio disponibles en la mayoría de las unidades de salud que atienden urgencias. Objetivo: Determinar la sensibilidad y especificidad de la escala de Alvarado en el diagnóstico de apendicitis aguda en el Hospital Roosevelt. Metodología: Validación de prueba diagnóstica en pacientes con diagnóstico de apendicitis aguda de la Emergencia de Cirugía de Adultos del Hospital Roosevelt en el período de enero a octubre 2014. Resultados: En el presente estudio, se incluyó un total de 105 pacientes, de los cuales 55 (52%) correspondió al sexo femenino y 50 (48%) al sexo masculino. A la totalidad de pacientes sometidos a cirugía se les realizó estudio anatomopatológico de la pieza quirúrgica pudiendo evidenciar que según Escala de Alvarado, los pacientes que obtuvieron un valor igual o mayor a 7 puntos con indicación clara de cirugía fueron 75, de los cuales 68 tuvieron diagnóstico de apendicitis aguda confirmada, mientras que únicamente 7 tuvieron diagnóstico negativo, resultando un valor predictivo positivo de 90%. Por otra parte los pacientes que obtuvieron un valor igual o menor a los seis puntos fueron 30, y solo 3 tuvieron diagnóstico confirmado de apendicitis aguda, mientras que 27 tuvieron diagnóstico negativo, dando un valor predictivo negativo del 90%. En este estudio se obtuvo una sensibilidad (95%) y especificidad de (79%) Conclusiones: La Escala de Alvarado es útil como herramienta diagnóstica para apendicitis aguda, con alta sensibilidad, buena especificidad y un valor predictivo adecuado,

Background: Alvarado Score is based on symptoms, clinical signs and laboratory fndings that are commonly found in acute appendicits; its main value lies in applying systematc and orderly appropriate history, physical examinaton and interpretaton of basic laboratory studies available in most health units that serve the emergency room. Objectve: Determine the sensitvity and specifcity of the Alvarado score in the diagnosis of acute appendicits at Roosevelt Hospital. Methodology: Validaton of a diagnostc test in patents diagnosed with acute appendicits in the surgical emergency room of Roosevelt Hospital in the period from January to October 2014. Results: In this study, we included a total of 105 patents, of whom 55 (52%) corresponded to the female sex and 50 (48%) were male. All patents undergoing surgery, underwent pathological examinaton of the surgical specimen and may show that according to Alvarado score, patents who obtained a value equal to or greater than 7 points, clear indicaton of surgery was 75, of whom 68 had confrmed diagnosis of acute appendicits, while only 7 had negatve diagnosis, resultng in a positve predictve value of 90%. Moreover patents who obtained a value equal to or less than six points were 30, and only 3 had confrmed diagnosis of acute appendicits, while 27 had negatve diagnosis, giving a negatve predictve value of 90%. In this study sensitvity (95%) and specifcity (79%) was obtained. Conclusions: Alvarado Score is useful as a diagnostc tool for acute appendicits with high sensitvity, good specifcity and adequate predictve value

Crisis intervention strategy for attempted suicide in children and adolescents: interactionist perspective / Estrategia de intervención en crisis para el intento de suicidio en niños y adolescentes: perspectiva interaccionista

An intervention strategy is presented for suicide attempt in children and adolescents during the crisis period, based on the approach of symbolic interactionism. Using a qualitative approach and hermeneutic methodology, 18 in-depth interviews were analyzed of children and adolescents with at least one suicide attempt and of psychiatrists, psychologists and general practitioners who have treated this type of cases. Two types of drive to suicide surged, each with two subtypes: The anomic type with "ambivalent" and "desperate" subtypes. The exalted type with subtypes: "matchstick" and "matchstick in gasoline." For each type were defined specific intervention strategies. It is necessary to discriminate the various types and subtypes of drive to suicide as an essential aspect to make appropriate interventions adapted to the needs of each case.

Se presenta una estrategia de intervención para el intento de suicidio en niños y adolescentes durante el periodo de la crisis, fundamentada en el interaccionismo simbólico. Con enfoque cualitativo y metodología hermenéutica, se analizaron 18 entrevistas en profundidad a niños y adolescentes con al menos un intento de suicidio y a psiquiatras, psicólogos y médicos generales que han atendido casos de intento. Emergieron dos tipos de empuje al suicidio, con dos subtipos cada uno: El tipo anómico, con subtipos "ambivalente" y "desesperado". El tipo exaltado, con subtipos: "fosforito" y "fosforito en gasolina". Para cada uno de ellos se definieron estrategias de intervención específicas y claramente definidas. Es necesario discriminar los diversos tipos y subtipos de empuje al suicidio como aspecto imprescindible para realizar intervenciones pertinentes y ajustadas a las necesidades de cada caso.

Normality and Mental Health: analysis of a multivalent relationship / Normalidad y Salud Mental: análisis de una relación multivalente

The categories "Normality" and "Mental health" are closely related. What is considered "mentally healthy" is linked with what is estimated as "normal" in every historical and cultural context. There are at least four ways to comprehend "normality" which determinate the forms of conceptualization and intervention in mental health: adjustment/ maladjustment understood as the subject’s adaptation to the social expectation; health/illness determined by biological factors under the medical model; statistics normality/ statistics abnormality defined from statistics criteria of population distribution and wellbeing/ discomfort related with the assessment that subjects make about their own life experiences. This paper shows discussion about the relationship between the categories "normality2 and "mental health" from the perspective of these four antithetical pairs and the analysis of the theoretical and practical implications of each one of these perspectives.

Las categorías de "Normalidad" y "Salud Mental" se encuentran estrechamente relacionadas; aquello que se considera "mentalmente sano", está ligado a una idea de lo que se estima como "normal" en cada contexto histórico y cultural. Existen al menos cuatro formas de entender la "normalidad", que determinan las formas de conceptualización e intervención en salud mental: adaptación/inadaptación, entendida como el ajuste del sujeto a las expectativas sociales; salud/enfermedad, determinada por factores biológicos, bajo la lógica del modelo médico; normalidad estadística/anormalidad estadística, definida a partir de criterios estadísticos de distribución poblacional, y bienestar/malestar, relacionada con la valoración que los propios sujetos hacen sobre sus experiencias vitales. En el presente artículo se discute la relación entre las categorías de normalidad y salud mental a partir de estos cuatro pares antitéticos, señalando algunas implicaciones teóricas y prácticas derivadas de cada uno de ellos.

Aproximaciones a una clínica psicológica y su método, fundamentada en la epistemología compleja y adecuada a contextos postmodernos / Approaches to psychological clinical and its method grounded in complex epistemology and adapted postmodern contexts

El propósito de este artículo es presentar una propuesta de clínica psicológica y su método adecuada a los contextos postmodernos y fundamentada en la epistemología compleja. Para el efecto, se realiza un recorrido por el concepto "clínica", con especial énfasis en lo clínico en psicología, y una ilustración de los cambios acaecidos con el paso de la modernidad a la postmodernidad. Se desarrollan los fundamentos de la clínica psicológica enclavados en la catastroficidad, caoticidad, borrosidad y fractalidad. Finalmente, se describe el método clínico psicológico. El método así propuesto se convierte en una alternativa para adecuar lo clínico en psicología a los retos y exigencias propios la época postmoderna, haciéndola más pertinente y contextualizada.

The aim of this article is to present a proposal of clinical psychology and its method adapted to postmodernity and based in complex epistemology. Initially, a historical approximation of the concept "clinic" is developed with special emphasis on "clinic in psychology". Then, modernity and postmodernity are compared showing their differences during the transition from one to another and using this comparison as the frame to present the basis of a clinical psychology based on fuzzy sets, catastrophe theory, fractal theory and chaos theory as their principles. Finally, it is described the Psychological clinical method. Thus, the proposed method becomes an alternative to adequate clinical psychology at the proper challenges and demands of postmodern era, more relevant and contextualized.

Variation in the 4q25 chromosomal locus predicts atrial fibrillation after coronary artery bypass graft surgery.

BACKGROUND: Atrial fibrillation (AF) is the most common adverse event following coronary artery bypass graft surgery. A recent study identified chromosome 4q25 variants associated with AF in ambulatory populations. However, their role in postoperative AF is unknown. We hypothesized that genetic variants in the 4q25 chromosomal region are independently associated with postoperative AF after coronary artery bypass graft surgery. METHODS AND RESULTS: Two prospectively collected cohorts of patients undergoing coronary artery bypass graft surgery, with or without concurrent valve surgery, at 3 US centers. From a discovery cohort of 959 patients, clinical and genomic multivariate predictors of postoperative AF were identified by genotyping 45 single-nucleotide polymorphisms (SNPs) encompassing the 4q25 locus. Three SNPs were then assessed in a separately collected validation cohort of 494 patients. After adjustment for clinical predictors of postoperative AF and multiple comparisons, rs2200733, rs13143308, and 5 other linked SNPs independently predicted postoperative AF in the discovery cohort. Additive odds ratios for the 7 associated 4q25 SNPs ranged between 1.57 and 2.17 (P=8.0x10(-4) to 3.4x10(-6)). Association with postoperative AF were measured and replicated for rs2200733 and rs13143308 in the validation cohort. CONCLUSIONS: In 2 independently collected cardiac surgery cohorts, noncoding SNPs within the chromosome 4q25 region are independently associated with postoperative AF after coronary artery bypass graft surgery after adjusting for clinical covariates and multiple comparisons.

Clinical use of and future perspectives on antiarrhythmic drugs.

Cardiac arrhythmias are associated with significant morbidity and mortality. Antiarrhythmic drug therapy was traditionally the mainstay of arrhythmia treatment; however, the limited efficacy and proarrhythmic potential of conventional antiarrhythmic drugs has generated interest in new approaches to the treatment of arrhythmias. Over the last decade, there has been improved characterization of the molecular pathways that culminate in arrhythmias. By analyzing mechanisms that increase susceptibility to arrhythmias in individuals with genetic syndromes, it might be possible to not only improve current therapies but also to develop novel approaches to treat and prevent common arrhythmias.

Factores pronosticos en el sindrome de respuesta inflamatoria sistemica (SRIS): Desarrollo de un indice de severidad / Prognosis factors in SIRS

Objetivo: desarrollar un índice de severidad para el síndrome de respuesta inflamatoria sistémica (SRIS) de etiología infecciosa comprobada o probable, que determine la probabilidad de muerte desde el momento de la admisión en urgencias. Diseño: estudio observacional analítico en una cohorte concurrente. Lugar de estudio: servicios de urgencias del Hospital Universitario San Vicente de Paúl y el Hospital General de Medellín Luz Castro de Gutiérrez. Pacientes: admitidos por urgencias con SRIS de etiología no traumática entre agosto de 1998 y marzo de 1999, de edad igual o superior a 14 años y con cambios en la temperatura o en el recuento de blancos como uno de los criterios necesarios para la definición del síndrome. Intervenciones: reclutamiento de la población de estudio y recolección de la información pertinente, de manera directa, en los servicios de urgencias de las dos instituciones. Mediciones: variables predictivas: edad, enfermedad sistémica inmunosupresora (ESI: cáncer, SIDA, uso de esferoides o quimioterapia), enfermedad sistémica general (ESG: insuficiencia cardíaca, insuficiencia renal, diabetes, enfermedad pulmonar obstructiva crónica o cirrosis), índice de choque, temperatura, frecuencia respiratoria, escala de Glasgow, recuento de leucocitos, recuento de plaquetas y valor de creatinina. Variable de desenlace: mortalidad intrahospitalaria dentro de los primeros 30 días de la admisión por urgencias. Análisis bivariado exploratorio y análisis de regresión logística paso a paso, asignación de puntaje de acuerdo con los coeficientes de regresión de las variables admitidas, evaluación de la capacidad discriminativa por medio del índice C y de la capacidad predictiva por medio del estadístico de Hosmer-Lemeshow. Resultados: fueron admitidos 533 pacientes, 45 por ciento mujeres, con un promedio de edad de 48 años y una estancia hospitalaria media de 11 días. El 14 por ciento requirió manejo en cuidado intensivo. Los principales diagnósticos de admisión fueron neumonía (36.3 por ciento), infección de piel y tejidos blandos (17 por ciento) y bacteremia o sepsis (13 por ciento...