Validation of the International Classification of Functioning, Disability, and Health (ICF) core set for post-acute musculoskeletal conditions in a primary care physiotherapy setting from the perspective of patients using focus groups.

PURPOSE: To validate the comprehensive ICF core set for post-acute musculoskeletal conditions from the perspective of patients in a primary care physiotherapy setting. MATERIALS AND METHODS: A qualitative study was conducted with patients suffering from musculoskeletal problems. A phenomenological approach based on focus groups was used to identify the most relevant aspects related to physical therapy care in their condition. The data were analyzed using a meaning condensation procedure, identifying relevant themes and concepts. The identified concepts were linked to the ICF and compared to the ICF core set for post-acute musculoskeletal conditions. RESULTS: Forty-three patients were included in eight focus groups. A total of 1281 relevant concepts were extracted and related to 156 ICF second-level entities. Entities in the ICF core set for post-acute musculoskeletal conditions were 95.7% confirmed. Eighty-nine additional second-level ICF entities were identified. CONCLUSIONS: Entities in the ICF core set for post-acute musculoskeletal conditions are relevant to patients seen in primary care physical therapy units. However, there are areas of functioning related to community health care not covered by this ICF-based tool.IMPLICATIONS OF REHABILITATIONAn ICF-based framework is feasible for the assessment of musculoskeletal conditions.Post-acute musculoskeletal ICF core set was confirmed in patient focus groups.Additional ICF categories emerged for a primary care physical therapy setting.Community features of functioning could be addressed by a tailored ICF core set.

Late gadolinium enhancement distribution patterns in non-ischaemic dilated cardiomyopathy: genotype-phenotype correlation.

AIMS: Late gadolinium enhancement (LGE) is frequently found in patients with dilated cardiomyopathy (DCM); there is little information about its frequency and distribution pattern according to the underlying genetic substrate. We sought to describe LGE patterns according to genotypes and to analyse the risk of major ventricular arrhythmias (MVA) according to patterns. METHODS AND RESULTS: Cardiac magnetic resonance findings and LGE distribution according to genetics were performed in a cohort of 600 DCM patients followed at 20 Spanish centres. After exclusion of individuals with multiple causative gene variants or with variants in infrequent DCM-causing genes, 577 patients (34% females, mean age 53.5 years, left ventricular ejection fraction 36.9 ± 13.9%) conformed to the final cohort. A causative genetic variant was identified in 219 (38%) patients, and 147 (25.5%) had LGE. Significant differences were found comparing LGE patterns between genes (P < 0.001). LGE was absent or rare in patients with variants in TNNT2, RBM20, and MYH7 (0, 5, and 20%, respectively). Patients with variants in DMD, DSP, and FLNC showed a predominance of LGE subepicardial patterns (50, 41, and 18%, respectively), whereas patients with variants in TTN, BAG3, LMNA, and MYBPC3 showed unspecific LGE patterns. The genetic yield differed according to LGE patterns. Patients with subepicardial, lineal midwall, transmural, and right ventricular insertion points or with combinations of LGE patterns showed an increased risk of MVA compared with patients without LGE. CONCLUSION: LGE patterns in DCM have a specific distribution according to the affected gene. Certain LGE patterns are associated with an increased risk of MVA and with an increased yield of genetic testing.

Estudio sociodemográfico comparativo de los períodos 2007-2009 y 2015-2019 de la Unidad de Tratamiento de Identidad de Género del Principado de Asturias / Sociodemographic comparative between the periods 2007-2009 and 2015-2019 of the Gender Identity Treatment Unit of Asturias

Antecedentes y objetivo: La elevada demanda asistencial sanitaria realizada por las personas trans en los últimos años ha dirigido el foco de la investigación hacia el estudio de sus aspectos clínicos y sociodemográficos. Este trabajo tuvo por objetivo comparar y analizar algunas variables sociodemográficas en personas trans en 2 períodos temporales: el período de inicio de funcionamiento de la unidad y el período más reciente. Materiales y método: Se comparó una muestra de 131 usuarios que asistió a la Unidad de Tratamiento de Identidad de Género del Principado de Asturias (UTIGPA) entre 2015-2019, con una muestra de 33 que acudió entre 2007-2009. Los datos se extrajeron de historias clínicas. Resultados: Respecto al período 2007-2009 entre 2015-2019 la ratio se invierte a favor de los hombres trans (HT). Los usuarios de ambos géneros solicitan consulta a edades más tempranas (especialmente los HT), provienen menos del extranjero, alcanzan una mayor cualificación educativa y laboral, presentan menos paro y solicitan más el cambio registral; y aunque las mujeres trans (MT) continúan siendo las que, mayoritariamente, se dedican a la prostitución y se autohormonan, en este período más reciente lo reportan menos y, además, conviven más acompañadas. Conclusiones: Se observan cambios en las variables sociodemográficas de los usuarios de la UTIGPA entre 2007-2009 y 2015-2019, en dirección a una mayor inclusión. No obstante, las condiciones sociodemográficas de las MT siguen en desventaja en comparación con las de los HT. (AU)

Background and objective: The high demand of assistance made by trans people in recent years has directed the focus of research towards the study of their clinical and sociodemographic aspects. The objective of this work was to compare and analyze some sociodemographic variables in trans people in two periods: the period when the unit began to operate and the most recent period. Materials and method: A sample of 131 users who attended the Gender Identity Treatment Unit of the Principality of Asturias (UTIGPA) between 2015-2019 was compared with a sample of 33 who attended between 2007-2009. Data were extracted from medical records. Results: Regarding 2007-2009, in 2015-2019 the ratio is inverted in favor of Trans Men (TM). Users of both genders request consultation at an earlier age (specially TM), come less from abroad, achieve higher educational and work qualifications, are less unemployed and request more name changes. And, although Trans Women (TW) continue to be those who are mostly engaged in prostitution and self-administration of hormones, in the most recent period they report it less and, furthermore, they live more accompanied tan in the past. Conclusions: Changes are observed in the sociodemographic variables of UTIGPA users between 2007-2009 and 2015-2019, in the direction of a greater inclusion. However, the sociodemographic conditions of the TW are still at a disadvantage in comparison to those of the TM. (AU)

[Sociodemographic comparative between the periods 2007-2009 and 2015-2019 of the Gender Identity Treatment Unit of Asturias]. / Estudio sociodemográfico comparativo de los períodos 2007-2009 y 2015-2019 de la Unidad de Tratamiento de Identidad de Género del Principado de Asturias.

BACKGROUND AND OBJECTIVE: The high demand of assistance made by trans people in recent years has directed the focus of research towards the study of their clinical and sociodemographic aspects. The objective of this work was to compare and analyze some sociodemographic variables in trans people in two periods: the period when the unit began to operate and the most recent period. MATERIALS AND METHOD: A sample of 131 users who attended the Gender Identity Treatment Unit of the Principality of Asturias (UTIGPA) between 2015-2019 was compared with a sample of 33 who attended between 2007-2009. Data were extracted from medical records. RESULTS: Regarding 2007-2009, in 2015-2019 the ratio is inverted in favor of Trans Men (TM). Users of both genders request consultation at an earlier age (specially TM), come less from abroad, achieve higher educational and work qualifications, are less unemployed and request more name changes. And, although Trans Women (TW) continue to be those who are mostly engaged in prostitution and self-administration of hormones, in the most recent period they report it less and, furthermore, they live more accompanied tan in the past. CONCLUSIONS: Changes are observed in the sociodemographic variables of UTIGPA users between 2007-2009 and 2015-2019, in the direction of a greater inclusion. However, the sociodemographic conditions of the TW are still at a disadvantage in comparison to those of the TM.

La disforia de género en menores trans: nicho ecológico / Gender dysphoria in trans minors: Ecological niche

Antecedentes y objetivo: El objetivo del presente estudio es investigar las características contextuales de la aparición de la disforia de género (DG) en menores trans.Materiales y método: Participaron todos los menores de edad que solicitaron consulta en la Unidad de Tratamiento de Identidad de Género desde marzo de 2007 hasta junio de 2019. Se procedió a la revisión de historias clínicas para la obtención de los datos. Se garantizó la confidencialidad.Resultados: Demandaron atención 64 menores, el 39,1% eran mujeres trans (MT) y el 60,9% hombres trans (HT). El rango de edad estuvo comprendido entre los 6 y los 17 años, con una media de 14,98. El 75% de los menores trans ubicaron el inicio de la DG en la infancia y el 25% en la adolescencia. La reacción de los progenitores fue de sospecha en un 55,6% de los casos y de sorpresa en un 36,5%. El 55,6% presentaron malestar psicológico importante previamente a acudir a la unidad.El apoyo familiar estuvo presente en el 57,1%. El papel de las redes sociales e Internet fue relevante para el 39,7% de la muestra. Tenían pertenencia o contacto con grupos de pares o asociaciones LGTBIQ el 44,4% de los menores. Se analizaron los resultados en función del género sentido.Conclusiones: Los menores continúan demandando atención en las unidades, sobre todo las MT. Aunque la DG aparece en ambos grupos fundamentalmente en la infancia, en la adolescencia es más frecuente en los HT. Los menores trans nacen, se desarrollan y construyen su identidad en un contexto determinado que está en interacción. (AU)

Background and objective: The objective of the present study is to investigate the contextual characteristics of the onset of gender dysphoria (GD) in trans minors.Materials and method: All minors who requested consultation in the Gender Identity Treatment Unit from March 2007 to June 2019 participated. Clinical histories were reviewed to obtain the information. Confidentiality was guaranteed.Results: Sixty-four minors required care, 39.1% were trans women (TW) and 60.9% trans men (TM). The age range was between 6-17 years, with a mean of 14.98. Seventy-five percent of the trans minors located the onset of DG in childhood and 25% in adolescence. Parental reaction was suspicious in 55.6% of cases and surprise in 36.5%; 55.6% presented significant psychological distress before going to the unit.Family support was present in 57.1%. The role of social networks and the Internet was relevant for 39.7% of the sample. Of the minors, 44.4% had membership or contact with peer groups or LGTBIQ associations. Results were analysed according to sense of gender.Conclusions: Minors continue to require care in the units, especially TW. Although GD onset in both groups is mainly in childhood, in adolescence it is more frequent in TM. Trans minors are born, develop and build their identity in a specific context, which is in interaction. (AU)

[Gender dysphoria in trans minors: Ecological niche]. / La disforia de género en menores trans: nicho ecológico.

BACKGROUND AND OBJECTIVE: The objective of the present study is to investigate the contextual characteristics of the onset of gender dysphoria (GD) in trans minors. MATERIALS AND METHOD: All minors who requested consultation in the Gender Identity Treatment Unit from March 2007 to June 2019 participated. Clinical histories were reviewed to obtain the information. Confidentiality was guaranteed. RESULTS: Sixty-four minors required care, 39.1% were trans women (TW) and 60.9% trans men (TM). The age range was between 6-17 years, with a mean of 14.98. Seventy-five percent of the trans minors located the onset of DG in childhood and 25% in adolescence. Parental reaction was suspicious in 55.6% of cases and surprise in 36.5%; 55.6% presented significant psychological distress before going to the unit. Family support was present in 57.1%. The role of social networks and the Internet was relevant for 39.7% of the sample. Of the minors, 44.4% had membership or contact with peer groups or LGTBIQ associations. Results were analysed according to sense of gender. CONCLUSIONS: Minors continue to require care in the units, especially TW. Although GD onset in both groups is mainly in childhood, in adolescence it is more frequent in TM. Trans minors are born, develop and build their identity in a specific context, which is in interaction.

Association of Genetic Variants With Outcomes in Patients With Nonischemic Dilated Cardiomyopathy.

BACKGROUND: The clinical relevance of genetic variants in nonischemic dilated cardiomyopathy (DCM) is unsettled. OBJECTIVES: The study sought to assess the prognostic impact of disease-causing genetic variants in DCM. METHODS: Baseline and longitudinal clinical data from 1,005 genotyped DCM probands were retrospectively collected at 20 centers. A total of 372 (37%) patients had pathogenic or likely pathogenic variants (genotype positive) and 633 (63%) were genotype negative. The primary endpoint was a composite of major adverse cardiovascular events. Secondary endpoints were end-stage heart failure (ESHF), malignant ventricular arrhythmia (MVA), and left ventricular reverse remodeling (LVRR). RESULTS: After a median follow-up of 4.04 years (interquartile range: 1.70-7.50 years), the primary endpoint had occurred in 118 (31.7%) patients in the genotype-positive group and in 125 (19.8%) patients in the genotype-negative group (hazard ratio [HR]: 1.51; 95% confidence interval [CI]: 1.17-1.94; P = 0.001). ESHF occurred in 60 (16.1%) genotype-positive patients and in 55 (8.7%) genotype-negative patients (HR: 1.67; 95% CI: 1.16-2.41; P = 0.006). MVA occurred in 73 (19.6%) genotype-positive patients and in 77 (12.2%) genotype-negative patients (HR: 1.50; 95% CI: 1.09-2.07; P = 0.013). LVRR occurred in 39.6% in the genotype-positive group and in 46.2% in the genotype-negative group (P = 0.047). Among individuals with baseline left ventricular ejection fraction ≤35%, genotype-positive patients exhibited more major adverse cardiovascular events, ESHF, and MVA than their genotype-negative peers (all P < 0.02). LVRR and clinical outcomes varied depending on the underlying affected gene. CONCLUSIONS: In this study, DCM patients with pathogenic or likely pathogenic variants had worse prognosis than genotype-negative individuals. Clinical course differed depending on the underlying affected gene.

Founder mutation in myosin-binding protein C with an early onset and a high penetrance in males.

OBJECTIVE: One of the challenges in hypertrophic cardiomyopathy (HCM) is to determine the pathogenicity of genetic variants and to establish genotype/phenotype correlations. This study aimed to: (1) demonstrate that MYBPC3 c.2149-1G>A is a founder pathogenic variant, (2) describe the phenotype and clinical characteristics of mutation carriers and (3) compare these patients with those with the most frequent pathogenic HCM variants: MYBPC3 p.Arg502Trp/Gln. METHODS: We reviewed genetic tests performed in HCM probands at our institution. We carried out transcript analyses to demonstrate the splicing effect, and haplotype analyses to support the founder effect of MYBPC3 c.2149-1G>A. Carriers with this mutation were compared with those from MYBPC3 p.Arg502Trp/Gln in terms of presentation features, imaging and outcomes. RESULTS: MYBPC3 c.2149-1G>A was identified in 8 of 570 probands and 25 relatives. Penetrance was age and sex dependent, 50.0% of the carriers over age 36 years and 75.0% of the carriers over 40 years showing HCM. Penetrance was significantly higher in males: in carriers older than 30 years old, 100.0% of males vs 50.0% of females had a HCM phenotype (p=0.01). Males were also younger at diagnosis (32±13 vs 53±10 years old, p<0.001). MYBPC3 c.2149-1G>A resulted in an abnormal transcript that led to haploinsufficiency and was segregated in two haplotypes. However, both came from one founder haplotype. Affected carriers showed a better functional class and higher left ventricular ejection fraction (LVEF) than patients with MYBPC3 p.Arg502Trp/Gln (p<0.05 for both). Nevertheless, the rate of major adverse outcomes was similar between the two groups. CONCLUSIONS: MYBPC3 c.2149-1G>A splicing variant is a founder mutation. Affected males show an early onset of HCM and with higher penetrance than women. Carriers show better functional class and higher LVEF than MYBPC3 p.Arg502Trp/Gln carriers, but a similar rate of major adverse outcomes.

Meta-Analysis of Reversal Agents for Severe Bleeding Associated With Direct Oral Anticoagulants.

BACKGROUND: Direct oral anticoagulants (DOACs) have shown a positive benefit-risk balance in both clinical trials and real-world data, but approximately 2% to 3.5% of patients experience major bleeding annually. Many of these patients require hospitalization, and the administration of reversal agents may be required to control bleeding. OBJECTIVES: The aim of this study was to investigate clinical outcomes associated with the use of 4-factor prothrombin complex concentrates, idarucizumab, or andexanet for reversal of severe DOAC-associated bleeding. METHODS: The investigators systematically searched for studies of reversal agents for the treatment of severe bleeding associated with DOAC. Mortality rates, thromboembolic events, and hemostatic efficacy were meta-analyzed using a random effects model. RESULTS: The investigators evaluated 60 studies in 4,735 patients with severe DOAC-related bleeding who were treated with 4-factor prothrombin complex concentrates (n = 2,688), idarucizumab (n = 1,111), or andexanet (n = 936). The mortality rate was 17.7% (95% confidence interval [CI]: 15.1% to 20.4%), and it was higher in patients with intracranial bleedings (20.2%) than in patients with extracranial hemorrhages (15.4%). The thromboembolism rate was 4.6% (95% CI: 3.3% to 6.0%), being particularly high with andexanet (10.7%; 95% CI: 6.5% to 15.7%). The effective hemostasis rate was 78.5% (95% CI: 75.1% to 81.8%) and was similar regardless of the reversal agent considered. The rebleeding rate was 13.2% (95% CI: 5.5% to 23.1%) and 78% of rebleeds occurred after resumption of anticoagulation. The risk of death was markedly and significantly associated with failure to achieve effective hemostasis (relative risk: 3.63; 95% CI: 2.56 to 5.16). The results were robust regardless of the type of study or the hemostatic scale used. CONCLUSIONS: The risk of death after severe DOAC-related bleeding remains significant despite a high rate of effective hemostasis with reversal agents. Failure to achieve effective hemostasis strongly correlated with a fatal outcome. Thromboembolism rates are particularly high with andexanet. Comparative clinical trials are needed.

[Sex/gender ratio of adolescents with gender dysphoria of the Gender Identity Treatment Unit of Asturias]. / Ratio sexo/género de los adolescentes con disforia de género de la Unidad de Tratamiento de Identidad de Género de Asturias.

BACKGROUND AND OBJECTIVE: Demand from minors with complaints of gender dysphoria has increased in recent years. This increase has been more pronounced in adolescent trans men in some international research studies. The first objective of this research study was to determine the sex/gender ratio of minors requesting a consultation in the Gender Identity Treatment Unit of the Principality of Asturias (UTIGPA) and presenting complaints of gender dysphoria. The second objective was to analyse the relationship of the sex/gender ratio with the age variable at which they requested the first consultation and the year in which they requested it. MATERIALS AND METHOD: The sample consisted of 42 children under 18, attended between January 2016 and January 2019. The medical records were then reviewed to obtain information. Descriptive statistics were analysed with the collected data. RESULTS: The sex / gender ratio over the period was 2/1 in favour of trans men. The average age at the request for consultation was 15.02 years (SD=1.84), with a range of 6 to 17 years. A higher percentage of applications was recorded (35.7%) in 2018, mostly made by trans men (93.3%). CONCLUSIONS: There was an inversion of the sex/gender ratio, a favour of trans men, over the last 3years, and an increase in the number of applications by adolescent trans men, coinciding with several international investigations.

Analysis of porcine IGF2 gene expression in adipose tissue and its effect on fatty acid composition.

IGF2:g.3072G>A polymorphism has been described as the causal mutation of a maternally imprinted QTL for muscle growth and fat deposition in pigs. The objective of the current work was to study the association between the IGF2:g.3072G>A polymorphism and the IGF2 gene expression and its effect on fatty acid composition in adipose tissue in different pig genetic backgrounds. A cis-eQTL region associated with the IGF2 mRNA expression in adipose tissue was identified in an eGWAS with 355 animals. The IGF2 gene was located in this genomic interval and IGF2g.3072G>A was the most significant SNP, explaining a 25% of the gene expression variance. Significant associations between IGF2:g.3072G>A polymorphism and oleic (C18:1(n-9); p-value = 4.18x10-07), hexadecanoic (C16:1(n-9); p-value = 4.04x10-07), linoleic (C18:2(n-6); p-value = 6.44x10-09), α-linoleic (C18:3(n-3); p-value = 3.30x10-06), arachidonic (C20:4(n-6); p-value = 9.82x10-08) FAs and the MUFA/PUFA ratio (p-value = 2.51x10-9) measured in backfat were identified. Animals carrying the A allele showed an increase in IGF2 gene expression and higher PUFA and lower MUFA content. However, in additional studies was observed that there could be other proximal genetic variants affecting FA composition in adipose tissue. Finally, no differences in the IGF2 gene expression in adipose tissue were found between heterozygous animals classified according to the IGF2:g.3072G>A allele inherited from the father (APGM or AMGP). However, pyrosequencing analysis revealed that there is imprinting of the IGF2 gene in muscle and adipose tissues, with stronger differences among the paternally and maternally inherited alleles in muscle. Our results suggested that IGF2:g.3072G>A polymorphism plays an important role in the regulation of IGF2 gene expression and can be involved in the fatty acid composition in adipose tissue. In both cases, further studies are still needed to deepen the mechanism of regulation of IGF2 gene expression in adipose tissue and the IGF2 role in FA composition.

Causes of Death in Patients with Venous Thromboembolism Anticoagulated with Direct Oral Anticoagulants: A Systematic Review and Meta-Analysis.

Death is more frequent than nonfatal recurrent venous thromboembolism (VTE) and major bleeding after acute VTE. The analysis of the causes of death is fundamental to explore new strategies to reduce mortality rates in these patients. The authors performed a meta-analysis to analyze mortality and independently adjudicated causes of death in anticoagulated patients due to VTE, and to evaluate potential differences between different anticoagulant schemes. They searched MEDLINE and CENTRAL, from January 1, 2000, to January 31, 2017, and performed additional searches in Web sites of regulatory agencies, clinical trial registers, and conference proceedings. Two investigators independently selected studies and extracted the data. Study quality was assessed with the Cochrane Collaboration's tool for assessing the risk of bias in randomized studies. Seven prospective randomized trials in 29,844 patients (22,025 patient-year follow-up) were included, comparing dabigatran, rivaroxaban, apixaban, and edoxaban with the standard anticoagulant treatment of VTE. A total of 718 patients died during the follow-up (3.4% per year; 95% confidence interval [CI]: 2.3-4.8). The most frequent causes of death were cancer (42%), followed by VTE (20%), infections (13%), hemorrhage (6%), heart disease (4%), and stroke (2%). There were no differences in the overall survival and causes of death according to the anticoagulant type. Concomitant active cancer during the study was significantly associated with death (odds ratio: 15.2; 95% CI: 9.2-25.1). Cancer is the leading cause of death in contemporary VTE trials. Interventions beyond anticoagulation, particularly in patients with active cancer, are needed.

Caso clínico: embarazo ectópico cervical, presentación de un caso clínico / Clinical case: cervical ectopic pregnancy, presentation of a clinical case

RESUMEN Antecedentes: El embarazo cervical es una forma rara del embarazo ectópico y representa < 1% de todos los embarazos ectópicos. Objetivo: Se presenta el caso de un embarazo ectópico cervical. Se realiza una revisión literaria sobre las diferentes opciones de manejo y tratamiento. Caso clínico: Mujer de 32 años en la semana 7+4 de embarazo en la que se objetiva un saco gestacional ístmico vascularizado, que ofrece dudas diagnósticas. Se establece el diagnóstico de embarazo ectópico cervical y se realiza un cerclaje por metrorragia. Conclusión: El embarazo ectópico cervical sigue siendo un reto importante en el campo del embarazo. El éxito del tratamiento conservador depende principalmente del diagnóstico precoz, lo que puede reducir las posibilidades de hemorragia grave y de histerectomía.

ABSTRACT Background: Cervical pregnancy is a rare type of ectopic pregnancy and it represents <1% of all ectopic pregnancies. Objetive: The case of a cervical ectopic pregnancy is presented. A literary review is carried out on the different management and treatment options. Case report: A 32-year-old woman in week 7 + 4 of pregnancy in which is objetived a vascularized isthmic gestational sac, which ofeers diagnostic doubt. The diagnosis of ectopic cervical pregnancy is established and cercaclage is performed by metrorrhagia. Conclusion: Cervical ectopic pregnancy remains a major challenge in the field of early pregnancy. The success of conservative treatment depends primarily on early diagnosis, which may reduce the chances of severe bleeding and require a hysterectomy.

Importancia de una profilaxis dietética en una intervención quirúrgica / No disponible

No disponible

La edad del donante en la evolución de la creatinina plasmática en receptores renales / No disponible

No disponible

Causes of Death in Anticoagulated Patients With Atrial Fibrillation.

BACKGROUND: Oral anticoagulation reduces the risk of mortality in atrial fibrillation (AF), but examination of the causes of death is essential to design new strategies to further reduce the high mortality rates observed in this population. OBJECTIVES: The authors sought to analyze and compare causes of death in patients receiving direct oral anticoagulants (DOAC) or warfarin for prevention of stroke and systemic embolism (SE) in AF. METHODS: The authors systematically searched for randomized trials of DOAC versus warfarin for prevention of stroke/SE in AF. The main outcome was mortality and independently adjudicated specific causes of death. The authors used the random effects model of meta-analysis to combine the studies. RESULTS: 71,683 patients from 4 trials were included (134,046 patient-years of follow-up). A total of 6,206 patients (9%) died during follow-up. Adjusted mortality rate was 4.72%/year (95% confidence interval [CI]: 4.19 to 5.28). Cardiac deaths accounted for 46% of all deaths, whereas nonhemorrhagic stroke/SE and hemorrhage-related deaths represented 5.7% and 5.6% of the total mortality, respectively. Compared with patients who were alive, those who died had more frequent history of heart failure (odds ratio [OR]: 1.75; 95% CI: 1.25 to 2.44), permanent/persistent AF (OR: 1.38; 95% CI: 1.25 to 1.52) and diabetes (OR: 1.37; 95% CI: 1.11 to 1.68); were more frequently male (OR: 1.24; 95% CI: 1.13 to 1.37) and older (mean difference 3.2 years; 95% CI: 1.6 to 4.8); and had a lower creatinine clearance (-9.9 ml/min; 95% CI: -11.3 to -8.4). There was a small, but significant, reduction in all-cause mortality with the DOAC versus warfarin (difference -0.42%/year; 95% CI: -0.66 to -0.18), mainly driven by a reduction in fatal bleedings. CONCLUSIONS: In contemporary AF trials, most deaths were cardiac-related, whereas stroke and bleeding represented only a small subset of deaths. Interventions beyond anticoagulation are needed to further reduce mortality in AF.

Rotura uterina completa en el intento de parto vaginal en gestantes con cesárea anterior / Complete uterine rupture in trial of labour after caesarean delivery

Objetivo: revisión de los casos de rotura uterina completa y su relación con el intento de parto vaginal en la cesárea anterior en el Hospital Universitario Marqués de Valdecilla. Sujetos y métodos: durante el periodo de estudio (2007-2013), se atendieron 27.008 partos, de los cuales 2.644 fueron en mujeres con cesárea anterior. Se produjeron un total de 5 roturas uterinas completas, todas ellas en las 2.198 mujeres con cesárea anterior que intentaron el parto vaginal. Resultados: la incidencia total de rotura uterina fue del 0,019%. Entre las gestantes con cesárea anterior fue del 0,19% y en el subgrupo que intentó el parto vaginal fue de 0,23%. Conclusión: todas las roturas uterinas se produjeron en las gestantes con cesárea anterior que intentaron el parto vaginal. En todos los casos se emplearon uterotónicos y en cuatro de ellos se observó un patrón cardiotocográfico característico (deceleraciones variables seguidas de bradicardia y ritmo silente o bradicardia mantenida) (AU)

Objective: To review of cases of complete uterine rupture and its association with trial of labour after caesarean delivery at the Marqués de Valdecilla University Hospital. Subjects and methods: During the study period (2007-2013), 27.008 births were attended, of which 2.644 were in women with a previous caesarean section. There were 5 complete uterine ruptures, all in the 2.198 women with a previous caesarean section who attempted vaginal birth. Results: The overall incidence of uterine rupture was 0.019%. The incidence was 0.19% in pregnant women with a previous caesarean and was 0.23% in the subgroup who attempted vaginal delivery. Conclusions: All uterine ruptures occurred in pregnant women with a trial of labour after caesarean delivery. Uterotonics were employed in all patients, with observation of a characteristic cardiotographic pattern (variable decelerations followed by bradycardia and silent rhythm or sustained bradycardia) in four of them (AU)

Direct oral anticoagulants for stroke prevention in patients with atrial fibrillation: meta-analysis by geographic region with a focus on European patients.

AIMS: To analyse clinical outcomes with direct oral anticoagulants in patients with atrial fibrillation according to geographic region. METHODS: We systematically searched MEDLINE, CENTRAL, websites of regulatory agencies, clinical trials registers and conference proceedings for randomized controlled trials of direct oral anticoagulants (DOAC: dabigatran, rivaroxaban, apixaban or edoxaban) against warfarin for prophylaxis of stroke and systemic embolic events (SEE) in patients with atrial fibrillation (AF). Two investigators independently extracted data. Relative risks of stroke and SEE as well as major bleeding depending on geographic region were estimated using a random effect meta-analysis. RESULTS: Five trials in 72 963 patients were analysed; 32 089 (44%) patients were recruited in Europe (Western Europe: 13 676; Eastern Europe: 18 413). We found significant subgroup differences for stroke/SEE depending on the geographic region (interaction P = 0.003; I(2) 88.5%), with a neutral effect of the DOAC vs. warfarin in Europe [relative risk (RR) 0.97, 95% confidence interval (CI) 0.85-1.11, I(2) 0%] and a significant reduction of stroke/SEE in other regions including North America, Latin America and Asia-Pacific/other (RR 0.72, 95% CI 0.63-0.83, I(2) 33%). There was a similar reduction in risk of major bleeding in Europe (RR 0.82, 95% CI 0.73-0.92, I(2) 0%) and in other regions (RR 0.86, 95% CI 0.72-1.02, I(2) 78%). CONCLUSION: The DOAC did not provide additional benefit in reducing the risk of stroke/SEE compared with warfarin in European patients with AF, but were generally associated with a lower bleeding tendency than warfarin regardless of geographic region.

Aplicación de terapia VAC por dehiscencia de herida quirúrgica en paciente intervenido de cistectomía / No disponible

No disponible

El mejor abrazo de bienvenida al paciente / No disponible

No disponible