[Anemia and frailty in older adults from Spain. The FRADEA Study]. / Anemia y fragilidad en ancianos españoles. Estudio FRADEA.

INTRODUCTION: The objective was to examine the prevalence of anemia according to the state of frailty and to analyze the relationship between anemia, hemoglobin concentration and frailty in a cohort of Spanish older adults. MATERIAL AND METHODS: Cross-sectional substudy of the FRADEA (Frailty and Dependency in Albacete) cohort, a population-based concurrent cohort study conducted in people older than 69 years of Albacete (Spain). Of the 993 participants included in the first wave, 790 were selected with valid data on anemia and frailty. Anemia was defined according to the criteria of the World Health Organization (hemoglobin less than 13 g/dL in men and 12 g/dL in women). Frailty was assessed using the Fried's phenotype. The association between anemia, hemoglobin concentration and frailty was determined by binary logistic regression adjusted for age, sex, educational level, institutionalization, comorbidity, cognitive status, body mass index, polypharmacy, creatinine, glucose and total white blood cell count. RESULTS: The mean age was 79 years. The prevalence of anemia was 19.6%. The prevalence of anemia was significantly higher in frail subjects (29.6%) compared to prefrail (16.6%) and robust ones (6%), p<0.001. The average hemoglobin concentrations were significantly lower in frail (12.7 g/dL), compared to the prefrail (13.5 g/dL) and robust participants (14.4 g/dL), p < 0.001. In the fully adjusted regression model, anemia was associated with frailty (OR 1.95; 95% CI: 1.02-3.73, p<0.05), and similarly, the average hemoglobin concentrations showed a significant association with frailty (OR 0.79; 95% CI: 0.66-0.96, p < 0.05). CONCLUSION: Anemia in older adults, defined according to WHO criteria, is independently associated with frailty.

COVID-19 outbreak in long-term care facilities from Spain. Many lessons to learn.

BACKGROUND/OBJECTIVES: To analyze mortality, costs, residents and personnel characteristics, in six long-term care facilities (LTCF) during the outbreak of COVID-19 in Spain. DESIGN: Epidemiological study. SETTING: Six open LTCFs in Albacete (Spain). PARTICIPANTS: 198 residents and 190 workers from LTCF A were included, between 2020 March 6 and April 5. Epidemiological data were also collected from six LTCFs of Albacete for the same period of time, including 1,084 residents. MEASUREMENTS: Baseline demographic, clinical, functional, cognitive and nutritional variables were collected. 1-month and 3-month mortality was determined, excess mortality was calculated, and costs associated with the pandemics were analyzed. RESULTS: The pooled mortality rate for the first month and first three months of the outbreak were 15.3% and 28.0%, and the pooled excess mortality for these periods were 564% and 315% respectively. In facility A, the percentage of probable COVID-19 infected residents were 33.6%. Probable infected patients were older, frail, and with a worse functional situation than those without COVID-19. The most common symptoms were fever, cough and dyspnea. 25 residents were transferred to the emergency department, 21 were hospitalized, and 54 were moved to the facility medical unit. Mortality was higher upon male older residents, with worse functionality, and higher comorbidity. During the first month of the outbreak, 65 (24.6%) workers leaved, mainly with COVID-19 symptoms, and 69 new workers were contracted. The mean number of days of leave was 19.2. Costs associated with the COVID-19 in facility A were estimated at € 276,281/month, mostly caused by resident hospitalizations, leaves of workers, staff replacement, and interventions of healthcare professionals. CONCLUSION: The COVID-19 pandemic posed residents at high mortality risk, mainly in those older, frail and with worse functional status. Personal and economic costs were high.

La anemia aumenta el riesgo de mortalidad debido a fragilidad y discapacidad en mayores: Estudio FRADEA / Anemia increases mortality risk associated with frailty or disability in older adults. The FRADEA Study

OBJETIVO: Analizar si la presencia de anemia incrementa el riesgo de mortalidad a largo plazo asociado al estado de fragilidad y discapacidad en adultos mayores. DISEÑO: Subestudio de la cohorte concurrente de base poblacional FRADEA (Fragilidad y Dependencia en Albacete), con 10 años de seguimiento (2007-2017), en mayores de 69 años. EMPLAZAMIENTO: Albacete capital, España. PARTICIPANTES: De los 993 participantes incluidos en la primera oleada se seleccionaron 790 sujetos con datos válidos de función (fragilidad y discapacidad), anemia y estado vital a los 10 años. MEDICIONES PRINCIPALES: La anemia se definió según los criterios de la Organización Mundial de la Salud (hemoglobina < 13 g/dl en hombres y < 12 g/dl en mujeres). Se creó la variable «clasificación funcional» incluyendo fragilidad y discapacidad, e identificando cuatro niveles progresivos: robusto, prefrágil, frágil y con discapacidad en actividades básicas de la vida diaria, empleando el fenotipo de fragilidad e índice de Barthel, respectivamente. Se construyó una nueva variable de ocho categorías combinando las cuatro funcionales con la presencia o ausencia de anemia. La asociación con mortalidad se determinó mediante Kaplan-Meier y análisis de riesgos proporcionales de Cox ajustado por edad, sexo, comorbilidad, polifarmacia, institucionalización y creatinina. RESULTADOS: Edad media 79 años, siendo el 59,6% mujeres. Un total de 393 participantes (49,7%) fallecieron durante el periodo de seguimiento. La mediana de supervivencia fue de 98,4 meses (rango intercuartil 61). El riesgo de mortalidad aumentó desde los niveles con mejor clasificación funcional hasta aquellos con peor, y para cada subgrupo fue mayor en los participantes con anemia. Prefrágiles sin anemia hazard ratio (HR): 1,59, I C95%: 1,07-2,36, y con anemia HR: 2,37, IC 95%: 1,38-4,05. Frágiles sin anemia HR: 3,18, IC 95%: 1,68-6,02, y con anemia HR: 4,42, IC 95%: 1,99-9,84. Discapacitados sin anemia HR: 3,81, IC 95%: 2,45-5,84, y con anemia HR: 5,48, IC 95%: 3,43-8,76. CONCLUSIÓN: La anemia incrementa el riesgo de mortalidad asociado a la fragilidad y discapacidad en adultos mayores

OBJECTIVE: To analyze if anemia increases 10-year mortality risk associated to frailty and disability in older adults. DESIGN: Substudy of the FRADEA population-based concurrent cohort study (Frailty and dependence in Albacete), with a 10-year follow-up (2007-2017) in people older than 69 years. SETTING: Albacete city, Spain. PARTICIPANTS: Of the 993 participants included in the first wave, 790 were selected with valid data on function (frailty and disability), anemia and vital status at 10 years. MAIN MEASUREMENTS: Anemia was defined according to the criteria of the World Health Organization (hemoglobin < 13 g/dL in men and < 12 g/dL in women). A functional classification variable was created, including frailty and disability, identifying four progressive functional levels: robust, prefrail, frail and disabled in basic activities of daily life, using frailty phenotype and Barthel index respectively. A new eight categories variable was constructed combining the four functional groups with the presence or absence of anemia. The association with mortality was determined by Kaplan-Meier and Cox proportional hazards analysis adjusted for age, sex, comorbidity, polypharmacy, institutionalization and creatinine. RESULTS: Mean age was 79years and 59.6% were women. 393 participants (49.7%) died during the follow-up period. The median survival was 98.4months (interquartile range 61). The risk of mortality increased from the levels with better functionality to those with worse functionality, and for each subgroup it was higher in the participants with anemia. Prefrail without anemia HR [hazard ratio] 1.59 (95% CI 1.07-2.36) and with anemia HR 2.37 (95% CI 1.38-4.05). Frail without anemia HR 3.18 (95% CI 1.68-6.02) and with anemia HR 4.42 (95% CI 1.99-9.84). Disabled without anemia HR 3.81 (95%CI 2.45-5.84) and with anemia HR 5.48 (95% CI 3.43-8.76). CONCLUSION: Anemia increases the risk of mortality associated with frailty and disability in older adults

[Anemia increases mortality risk associated with frailty or disability in older adults. The FRADEA Study]. / La anemia aumenta el riesgo de mortalidad debido a fragilidad y discapacidad en mayores: Estudio FRADEA.

OBJECTIVE: To analyze if anemia increases 10-year mortality risk associated to frailty and disability in older adults. DESIGN: Substudy of the FRADEA population-based concurrent cohort study (Frailty and dependence in Albacete), with a 10-year follow-up (2007-2017) in people older than 69years. SETTING: Albacete city, Spain. PARTICIPANTS: Of the 993 participants included in the first wave, 790 were selected with valid data on function (frailty and disability), anemia and vital status at 10years. MAIN MEASUREMENTS: Anemia was defined according to the criteria of the World Health Organization (hemoglobin <13g/dL in men and <12g/dL in women). A functional classification variable was created, including frailty and disability, identifying four progressive functional levels: robust, prefrail, frail and disabled in basic activities of daily life, using frailty phenotype and Barthel index respectively. A new eight categories variable was constructed combining the four functional groups with the presence or absence of anemia. The association with mortality was determined by Kaplan-Meier and Cox proportional hazards analysis adjusted for age, sex, comorbidity, polypharmacy, institutionalization and creatinine. RESULTS: Mean age was 79years and 59.6% were women. 393 participants (49.7%) died during the follow-up period. The median survival was 98.4months (interquartile range 61). The risk of mortality increased from the levels with better functionality to those with worse functionality, and for each subgroup it was higher in the participants with anemia. Prefrail without anemia HR [hazard ratio] 1.59 (95%CI 1.07-2.36) and with anemia HR 2.37 (95%CI 1.38-4.05). Frail without anemia HR 3.18 (95%CI 1.68-6.02) and with anemia HR 4.42 (95%CI 1.99-9.84). Disabled without anemia HR 3.81 (95%CI 2.45-5.84) and with anemia HR 5.48 (95%CI 3.43-8.76). CONCLUSION: Anemia increases the risk of mortality associated with frailty and disability in older adults.

Recuentos de células T reguladoras en sangre periférica como biomarcador predictivo del resultado del trasplante renal: revisión sistemática / Peripheral blood regulatory T cell counts as a predictive biomarker for the outcome of kidney transplant: A systematic review

Fundamento y objetivo: Las células T reguladoras circulantes podrían convertirse en un adecuado biomarcador para los trasplantados renales. El objetivo de este estudio es evaluar el efecto de los inhibidores de la mammalian target of rapamycin (I-mTOR, «diana de rapamicina en células de mamífero») en las células reguladoras, y el interés clínico de este efecto. Material y métodos: Revisión sistemática de trabajos publicados y no publicados. Bases de datos y repositorios del mundo entero. Se buscaron ensayos controlados aleatorizados y estudios de cohortes que compararon recuentos de células reguladoras y episodios de rechazo entre trasplantados tratados con y sin I-mTOR. Los trabajos podían medir la correlación células reguladoras-filtrado glomerular. Se evaluó la codependencia células reguladoras-eficacia de los I-mTOR. Resultados: Se incluyeron 5 ensayos y 9 estudios. Las diferencias clínicas no permitieron una estimación cuantitativa del efecto de la inmunosupresión en el número de células reguladoras. Sin embargo, observamos que hay más células reguladoras con sirolimus o everolimus. El número de episodios de rechazo fue similar con anticalcineurínicos que con I-mTOR, a pesar de las diferencias en el número de células reguladoras. La correlación combinada células reguladoras-filtrado glomerular fue prospectivamente de 0,114, con un intervalo de confianza al 95% (IC 95%) de 0,062-0,406, y retrospectivamente, de 0,13 (IC 95% 0,0-0,361). Existen pruebas directas, aunque de bajo nivel (aleatorización estratificada por el biomarcador), respecto a la codependencia células reguladoras-eficacia de los I-mTOR. Conclusión: El número de células reguladoras puede asociarse a buenos resultados o desenlaces en los tratados con I-mTOR (eficacia antirrechazo), considerando la relación entre estas células y la función del injerto. Registro: PROSPERO (CRD42016046285) (AU)

Background and objective: Circulating regulatory T cells could become a suitable biomarker for kidney recipients. The objective of this study was to evaluate the effect of mammalian target of rapamycin (mTOR) inhibitors on regulatory T cell numbers, and the clinical interest of this effect. Material and methods: Systematic review of published and unpublished studies. Worldwide databases or repositories. Randomised controlled trials and cohort studies comparing regulatory T cell counts and rejection episodes between patients with and without mTOR inhibitors were searched. Correlation of regulatory T cells-glomerular filtration rate might be supplied. Co-dependency regulatory T cells-mTOR inhibitors efficacy was evaluated. Results: Five trials and 9 studies were included. Clinical differences made it difficult to obtain quantitative estimates of the effect of immunosuppression on regulatory T cell numbers. Nevertheless, we found that there are higher regulatory T cell numbers under treatment with sirolimus or everolimus. Rejection episodes were similar under calcineurin inhibitors and mTOR inhibitors despite different regulatory T cell numbers. Pooled correlation regulatory T cells-glomerular filtration rate was, prospectively 0.114 (95% confidence interval [95% CI] 0.062-0.406), and retrospectively 0.13 (95% CI 0.0-0.361). There is direct evidence although of low level (biomarker-stratified randomisation) on the co-dependency regulatory T cells-mTOR inhibitors efficacy. Conclusions: Regulatory T cells counts may be associated with better outcomes under treatment with mTOR inhibitors (anti-rejection efficacy), considering that there is a relationship between these cells and kidney graft function Registration: PROSPERO (CRD42016046285) (AU)

Peripheral blood regulatory T cell counts as a predictive biomarker for the outcome of kidney transplant: A systematic review. / Recuentos de células T reguladoras en sangre periférica como biomarcador predictivo del resultado del trasplante renal: revisión sistemática.

BACKGROUND AND OBJECTIVE: Circulating regulatory T cells could become a suitable biomarker for kidney recipients. The objective of this study was to evaluate the effect of mammalian target of rapamycin (mTOR) inhibitors on regulatory T cell numbers, and the clinical interest of this effect. MATERIAL AND METHODS: Systematic review of published and unpublished studies. Worldwide databases or repositories. Randomised controlled trials and cohort studies comparing regulatory T cell counts and rejection episodes between patients with and without mTOR inhibitors were searched. Correlation of regulatory T cells-glomerular filtration rate might be supplied. Co-dependency regulatory T cells-mTOR inhibitors efficacy was evaluated. RESULTS: Five trials and 9 studies were included. Clinical differences made it difficult to obtain quantitative estimates of the effect of immunosuppression on regulatory T cell numbers. Nevertheless, we found that there are higher regulatory T cell numbers under treatment with sirolimus or everolimus. Rejection episodes were similar under calcineurin inhibitors and mTOR inhibitors despite different regulatory T cell numbers. Pooled correlation regulatory T cells-glomerular filtration rate was, prospectively 0.114 (95% confidence interval [95% CI] 0.062-0.406), and retrospectively 0.13 (95% CI 0.0-0.361). There is direct evidence although of low level (biomarker-stratified randomisation) on the co-dependency regulatory T cells-mTOR inhibitors efficacy. CONCLUSIONS: Regulatory T cells counts may be associated with better outcomes under treatment with mTOR inhibitors (anti-rejection efficacy), considering that there is a relationship between these cells and kidney graft function. REGISTRATION: PROSPERO (CRD42016046285).

Intervención en la discapacidad intelectual y trastorno mental asociado en el adulto: de la intervención sistémica, el equipo interdisciplinar y la coherencia de las intervenciones / Intervention in intellectual disabilities and mental disorder in adults associated: systemic intervention, the interdisciplinary team and consistency of assistance

Toda reflexión en la línea de mejorar el abordaje en la Discapacidad Intelectual (DI) desde la visión ecológica y biopsicosocial, debe incluir el estudio de las relaciones significativas del individuo, tanto las familiares como las del contexto, como forma de entender las capacidades que aún estando conservadas, la disfunción relacional las aminora. En el abordaje sistémico se lee la patología desde la relación de los sistemas con los que la persona está en contacto, formulando hipótesis que pueden confirmarse o refutarse durante el proceso terapéutico. El trabajo compartido con el grupo familiar permite organizar los recuerdos como un puzzle que de sentido a la propia historia. Se describe el programa de intervención en Discapacidad intelectual y trastornos de conducta en Asprona de Albacete, las estrategias de intervención basadas en trabajo interdisciplinar, análisis funcional de la conducta, evaluación familiar e importancia del profesional de referencia como vínculo privilegiado. Se destaca la importancia de la figura nutricia o vínculo familiar privilegiado, patrones de relación redundantes como triangulaciones manipuladoras, sobreindulgencia y parentificación sobre los que intervenir con la familia y en el contexto (AU)

Any reflection on the line to improve the approach to the Intelectual Disability (ID) from the ecological and biopsychosocial view, should include consideration of the significant relation-ships of the individual, the family as much context as a way to understand the capabilities while still conserved, the relational dysfunction makes it smaller. In the systemic approach pathology is read from the ratio of the systems with which the person is contacted by formulating hypotheses that can be confirmed or refuted during the therapeutic process. The share in the household work to organize the memories like a puzzle that sense of history itself. Intervention program in intellectual disability and behavioral disorders in Asprona AB , intervention strategies based on interdisciplinary work, functional behavior analysis, family assessment and importance of professional reference and special link is described. The importance of nurturing figure or privileged family ties, redundant patterns of relationship as manipulative triangulations, overindulgence and parentification on to intervene with the family and the context is emphasized (AU)

Successful therapy of progressive rhino-orbital mucormycosis caused by Rhizopus arrhizus with combined and sequential antifungal therapy, surgery and hyperbaric therapy.

We present a case of rhino-orbitary mucormycosis which progressed despite liposomal amphotericin and early surgical debridement. Combined echinocandin and high dose liposomal amphotericin, repeated debridement, prolonged therapy with hyperbaric oxygen and continued therapy with posaconazole, along with strict diabetic control, allowed cure without disfigurement.

Validation of the Spanish version of the Short-Form Late-Life Function and Disability Instrument.

OBJECTIVES: To validate the Short-Form Late-Life Function and Disability Instrument (SF-LLFDI), a valid measure of functional limitations and disability in older adults, in Spanish-speaking populations and to analyze its psychometric properties. DESIGN: Validation study. SETTING: Complejo Hospitalario Universitario de Albacete, Spain. PARTICIPANTS: Sample population of 876 participants aged 70 and older from Albacete, Spain. MEASUREMENTS: Forward and back translation of the SF-LLFDI; concurrent validity was determined according to the Barthel Index and the Lawton Scale for disability and according to grip strength, gait speed, the Timed Up and Go Test, and the Short Physical Performance Battery (SPPB) for function. Construct validity, internal consistency, and floor and ceiling effect were determined. The area under the receiver operating characteristic curve (AUC) was calculated to identify function and disability. Intraclass correlation coefficients (ICCs) were used to analyze reliability in a subsample of 50 participants. RESULTS: The SF-LLFDI was significantly correlated with the Barthel Index (correlation coefficient (r)=0.827), the Lawton Scale (r=0.693), gait speed (r=0.661), and the SPPB (r=0.650). Internal consistency (Cronbach α=0.974), interobserver reliability (ICC=0.989; 95% confidence interval (CI)=0.984-0.993), and intraobserver reliability (ICC=0.982, 95% CI=0.967-0.990) were all excellent. The SF-LLFDI demonstrated excellent discriminant validity, as evidenced by an AUC for a Barthel Index less than 65 points of 0.991 (95% CI=0.986-0.996), with a better cutoff of less than 65 points (sensitivity, 94%; specificity, 94%), and for a Lawton Scale score of less than 4 of 0.976 (95% CI% 0.967-0.985), with a better cutoff of less than 72 (sensitivity, 91%; specificity, 91%). No participant had a maximum score; 36 (4.1%) obtained the minimum. CONCLUSION: The Spanish SF-LLDFI is a valid instrument for detecting disability and functional limitation.

Fragilidad y dependencia en Albacete (estudio FRADEA): razonamiento, diseño y metodología / Frailty and dependence in Albacete (FRADEA study): reasoning, design and methodology

Objetivo. Obtener una cohorte de sujetos con edad igual o mayor a 70 años, representativa de una población urbana española, para estimar la prevalencia de fragilidad y seguirla en el tiempo para analizar factores asociados. Material y métodos. Estudio de cohortes concurrente de base poblacional. Sobre un universo de 18.137 ancianos, se realizó un muestreo aleatorio estratificado para obtener una muestra representativa de 1.172. Aceptaron participar 993 personas (84,7%). Se recogieron variables sociodemográficas, de comorbilidad, funcionales (n=825), cognitivas, afectivas y de calidad de vida. A los sujetos que aceptaron se les determinó la composición corporal por bioimpedanciometría (n=557), el gasto energético basal por calorimetría indirecta (n=450) y se obtuvo muestra de sangre para la determinación de biomarcadores (n=859). La fragilidad se definió por la presencia de 3 o más de los criterios Fried: pérdida de peso no intencionada, baja fuerza, cansancio, lentitud al caminar y baja actividad física. La cohorte será seguida en el tiempo hasta el fallecimiento de los sujetos. Resultados. Edad media±desviación estándar 79,4±6,4 años, con 601 (60,5%) mujeres. Institucionalizados el 21,3%. Fueron frágiles el 16,9%, prefrágiles 48,5%, no frágiles 21,8%, y no se dispuso de 3 criterios para poder determinar su estado en el 12,8%, de los cuales el 9,5% tenía una discapacidad moderada-severa, por lo que la prevalencia de fragilidad podría aumentar hasta el 26,4%. Conclusiones. Se ha construido la cohorte FRADEA, representativa de los mayores de una población urbana de España. La prevalencia de fragilidad en la cohorte fue del 16,9%(AU)

Objective. To obtain a cohort of subjects of equal to or greater than 70 years, representative of a Spanish urban population, to estimate the prevalence of frailty and follow it up over time to analyse associated factors. Material and methods. A prospective, population-based cohort study. From a population of 18,137 elderly persons, a representative sample of 1172 was randomly stratified, of which 993 (84.7%) agreed to take part. The variables collected were; sociodemographic, comorbidity, functional (n=825), cognitive, affective and quality of life. On the patients who agreed, body composition was determined by bioimpedance analysis (n=557), basal metabolic rate by indirect calorimetry (n=450) and a blood sample was obtained for biomarkers (n=859). Frailty was defined by the presence of 3 or more Fried criteria: unintentional weight loss, low energy, exhaustion, slow walking, and low physical activity. The cohort will be followed up over time until the death of the subjects. Results. Mean age 79.4 (SD 6.4) years, with 601 (60.5%) women. A total of 21.3% were institutionalised; 16.9% were frail, 48.5% pre-frail, 21.3% non-frail, and 12.8% did not have the 3 criteria to be able to determine their state, of which 9.5% had moderate-severe incapacity, which would increase the prevalence of frailty to 26.4%. Conclusions. A FRADEA cohort has been constructed, representative of an urban population in Spain. The prevalence of frailty in the cohort was 16.9%(AU)

[Frailty and dependence in Albacete (FRADEA study): reasoning, design and methodology]. / Fragilidad y dependencia en Albacete (estudio FRADEA): razonamiento, diseño y metodología.

OBJECTIVE: To obtain a cohort of subjects of equal to or greater than 70 years, representative of a Spanish urban population, to estimate the prevalence of frailty and follow it up over time to analyse associated factors. MATERIAL AND METHODS: A prospective, population-based cohort study. From a population of 18,137 elderly persons, a representative sample of 1172 was randomly stratified, of which 993 (84.7%) agreed to take part. The variables collected were; sociodemographic, comorbidity, functional (n=825), cognitive, affective and quality of life. On the patients who agreed, body composition was determined by bioimpedance analysis (n=557), basal metabolic rate by indirect calorimetry (n=450) and a blood sample was obtained for biomarkers (n=859). Frailty was defined by the presence of 3 or more Fried criteria: unintentional weight loss, low energy, exhaustion, slow walking, and low physical activity. The cohort will be followed up over time until the death of the subjects. RESULTS: Mean age 79.4 (SD 6.4) years, with 601 (60.5%) women. A total of 21.3% were institutionalised; 16.9% were frail, 48.5% pre-frail, 21.3% non-frail, and 12.8% did not have the 3 criteria to be able to determine their state, of which 9.5% had moderate-severe incapacity, which would increase the prevalence of frailty to 26.4%. CONCLUSIONS: A FRADEA cohort has been constructed, representative of an urban population in Spain. The prevalence of frailty in the cohort was 16.9%.

Mujer y comedores populares / Woman and peoples's restaurants

Contiene: Asistencia alimentaria en el Perú; Eficiencia de los comedores y nutrición; El programa de asistencia directa; FOVIDA y la alimentación popular; Aspectos organizativos; Economía y organización en los comedores; Los comedores y la promoción de la mujer; Estrategias de promoción y comedores; Parando la olla juntas, el caso de El Agustino; Impacto de los comedores en las mujeres; Conclusiones