[How to assess health outcomes in chronic non-cancer pain? Qualitative research]. / ¿Cómo evaluar los resultados en salud en el dolor crónico no oncológico? Investigación cualitativa.

INTRODUCTION AND OBJECTIVES: There is a lack of indicators that evaluate the health results of the non-cancer chronic pain (NCCP). The objective of this study was to agree on how to evaluate health outcomes in NCCP in Spain, as well as to propose lines of action to have an optimal evaluation framework not only for patients, but for healthcare professionals and managers as well. MATERIAL AND METHODS: This was a qualitative research study through directed group interviews which followed a script based on structured questions using the PICO methodology. RESULTS: More than the intensity of pain, the main points to be measured are pain-free time, improved rest/sleep, improved mood, recovery of daily activities and adherence to treatment, in addition to -in the scope of management- resource consumption. The therapeutic objective must be defined individually, based on the adjustment of expectations between the healthcare professional and the patients, taking into account their preferences and involving them in the therapeutic process. Patients and caregivers must be informed and trained with special emphasis on the psycho-emotional sphere of pain. CONCLUSIONS: It is necessary to evaluate the health outcomes in NCCP in Spain. Lines of action are proposed that might provide an adequate assessment framework for the patient, the healthcare professionals and the health managers.

Silanized graphene oxide as a reinforcing agent for acrylic bone cements: physicochemical, mechanical and biological characterization.

Recently, different carbon-based nanomaterials have been used as reinforcing agents in acrylic bone cement formulations. Among them, graphene oxide (GO) has attracted the attention of scientific community since it could improve not only the mechanical properties but also the biocompatibility characteristics of these materials. However, using GO presents some drawbacks, such as its poor dispersion and lack of interaction with polymeric matrices, which should be prior resolved to achieve its optimal performance in acrylic bone cement. Thus, in this work, GO was treated with 3-methacryloxy propyl trimethoxy silane at various concentrations (1, 3 and 5 wt.%) to improve the interaction between the nanofiller and the poly (methyl methacrylate) matrix. Modified GO was incorporated at different percentages (0.1, 0.5 and 0.75 wt.%) into acrylic bone cement formulations and some properties were evaluated. The silanization process of the GO was confirmed by FTIR, TGA and EDX. The improvement in the mechanical performance was monitored on the compression properties whereas those related with biological properties were evaluated by osteoblast cell viability and hemocompatibility tests. Results suggest that using a 1 wt.% of the silane coupling agent, during surface treatment of GO, yields the best mechanical performance in this type of materials. It was also found that the presence of neat GO or silanized GO does not compromise the cytocompatibility and hemocompatibility of acrylic bone cement formulations.

Pain Standards for Accredited Healthcare Organizations (ACDON Project): A Mixed Methods Study.

Up to 50% of cancer patients and up to 90% of those in terminal stages experience pain associated with disease progression, poor quality of life, and social impact on caregivers. This study aimed to establish standards for the accreditation of oncological pain management in healthcare organizations. A mixed methods approach was used. First, a pragmatic literature review was conducted. Second, consensus between professionals and patients was reached using the Nominal Group and Delphi technique in a step that involved anesthesiologists, oncologists, family physicians, nurses, psychologists, patient representatives, and caregivers. Third, eight hospitals participated in a pilot assessment of the level of fulfillment of each standard. A total of 37 standards were extracted. The Nominal Group produced additional standards, of which 60 were included in Questionnaire 0 that was used in the Delphi Technique. Two Delphi voting rounds were performed to reach a high level of consensus, and involved 64 and 62 participants with response rates of 90% and 87%, respectively. Finally, 39 standards for the management of cancer pain were agreed upon. In the self-evaluation, the average range of compliance was between 56.4% and 100%. The consensus standards of the ACDON Project might improve the monitoring of cancer pain management. These standards satisfied the demands of professionals and patients and could be used for the accreditation of approaches in cancer pain management.

Determination of serum free light chains as a marker of systemic lupus flare.

INTRODUCTION: The aim of this study was to explore the usefulness of the determination of free light chains (FLC) in serum as a biomarker of flare in patients with systemic lupus erythematosus (SLE) and to analyze the differences in their discriminatory capacity with complement C3 and C4. METHODS: This was a prospective cohort study. The definition of flare was based on the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) Flare Index. The discriminatory capacity of FLC and C3 and C4 levels was compared using receiver operating characteristic (ROC) curves and the area under the curve (AUC). RESULTS: Forty-six patients were enrolled. Patients with SLE flare showed significantly lower C3 (p = 0.025) and C4 levels (p = 0.028), as well as a higher concentration of lambda light chains (λ-LC) (p = 0.028) compared with the non-flare group. λ-LC, as opposed to kappa light chains and total light chains, demonstrated a discriminatory capacity for detecting the presence of SLE flare (AUC 0.781), with 100% sensitivity, 65% specificity, and 69.6% of patients correctly classified for a cutoff point of ≥ 19.5 mg/L. Complement C3 and C4 also showed a high discriminatory capacity for SLE flare (AUC 0.804 and 0.837, respectively). Comparing λ-LC, C3, and C4, the last one demonstrates better discriminatory capacity for SLE flare with the highest AUC (0.837; 95% CI 0.663-1.000). CONCLUSIONS: λ-LC have good discriminatory capacity for SLE flare and could be useful as a biomarker of SLE exacerbation.Key Points• The usefulness of free light chains as a biomarker could be compared with complement.• Lambda free light chains have good discriminatory capacity for SLE flare.• Free light chains are a promising marker of SLE activity.

Prevalence of Celiac Disease in a Long-term Study of a Spanish At-genetic-risk Cohort From the General Population.

OBJECTIVES: To perform long-term celiac disease (CD) screening in an HLA-DQ2 (+) cohort from the general population and to assess the influence of risk genotypes on its development. METHODS: In 2004, an HLA-DQ2 (+) cohort was selected. After the first CD screening at age 2 to 3 years, we performed a follow-up screening 8 to 10 years later. Antitransglutaminase 2 antibodies were determined using a rapid test kit. Results were confirmed by serum IgA antitransglutaminase 2 and IgA endomysial antibody determination. CD diagnosis was carried out by intestinal biopsies. Four HLA-DQ2 genotypic groups were used: G1: DQ2.5/DQ2.5 (G1A) or DQ2.5/ DQ2.2 (G1B); G2: DQ2.2/DQ7.5 (DQ2.5 trans); G3: DQ2.5/ X; G4: DQ2.2/X. RESULTS: CD prevalence after 10 years of follow-up was 5.8% (95% confidence interval 3.8-8.7). One of every 3 HLA-DQ2(+) children carried at least 1 haplotype DQ2.2 or DQ7. The homozygous genotype DQ2.5/DQ2.5 and the HLA-DQ2.5 trans genotype increased CD risk 4- and 3-fold, respectively. The homozygous genotype DQ2.5/ DQ2.2 did not increase the CD risk. Children carrying G1 or G2 genotypes were diagnosed with CD earlier and more frequently during the follow-up compare with those carrying G3 or G4 genotypes. Approximately 81% of children with spontaneous antibody negativization after the first screening maintained negative antibodies. CONCLUSIONS: A repeated screening of at-risk children during their follow-up allowed us to diagnose new CD cases. In our cohort, HLA- DQ2.5 trans genotype conferred a higher risk in the development of CD than HLA- DQ2.5/DQ2.2. The majority of children with potential CD and CD autoimmunity at 10 years of age remained healthy.

Recommendations to report and interpret HLA genetic findings in coeliac disease.

Coeliac disease (CD) is a chronic autoimmune enteropathy triggered by gluten and related prolamines in genetically predisposed individuals. Although CD is a polygenic disease, there is a strong association with genes of the human leukocyte antigen (HLA) region. Most patients present the HLA-DQ2 heterodimer, specifically the DQ2.5 isoform, which is present in around 90-96% of patients of European ancestry.

Severe Isotype-Matched Immunosuppression (IMI) as a Potential Risk Factor for Progression of MGUS Patients.

BACKGROUND: Monoclonal gammopathy of undetermined significance (MGUS) precedes multiple myeloma in virtually every case. However, only a small percentage will progress and at very different rates. In addition, recent data have suggested that MGUS is associated with other comorbidities including infections, suggesting impaired immune function in some MGUS patients. Therefore, we aimed at assessing the value of isotype-matched immunosuppression (IMI; e.g., suppression of an IgAκ in an IgAλ patient), a type of immunosuppression more specific than classical immunoparesis (IP; e.g., IgG and/or IgM suppression in an IgA patient), as a prognostic marker for MGUS progression. METHODS: The Hevylite assay was used to assess IMI and immunoglobulin ratios in 307 serum samples from a cohort of 248 MGUS patients. Follow-up clinical records were available for 154 individuals. RESULTS: A greater incidence of IMI (51%) over classical IP (37%) was observed, although both show a progressive increase with higher risk groups. Survival analysis of 154 patients showed that severe IMI (>50% suppression) differentiates 2 groups with significantly different time to progression (P = 0.024) while severe IP does not (P = 0.48). Also, a combination of severe IMI and involved monoclonal immunoglobulin >1.5g/dL by Hevylite (both variables found to be independent prognostic markers in multivariate analysis) identified a group of patients with a median time to progression 6-fold shorter than the remaining group (P < 0.0001). CONCLUSIONS: These findings indicate a possible role for IMI in the malignant transformation of MGUS patients and a potential utility as a new risk factor.

Prevalence and Natural History of Celiac Disease in a Cohort of At-risk Children.

OBJECTIVES: To assess the prevalence and clinical presentation of celiac disease (CD) in a cohort of children with HLA-DQ2 positive and evaluate the risk factors in the development of CD. METHODS: Between July 2004 and July 2005, parents of all healthy full-term newborns in our hospital were invited to participate. HLA-DQ2 was tested in blood sample of the umbilical cord. A point of contact serological test was performed on children between 2 and 3 years of age. Positive results were confirmed by serum anti-transglutaminase 2 and endomysial antibodies. Children with high autoantibody titers underwent an intestinal biopsy. Children of the cohort diagnosed with CD before the screening study were included. Sex, mode of delivery, breast-feeding duration, and age of gluten introduction were studied. RESULTS: Of 1291 children, 362 were HLA-DQ2 positive and 262 participated in the study. CD was diagnosed in 4.1% (95% confidence interval (CI) 1.9-6.3). In the whole cohort, 60% had gastrointestinal symptoms, 7% poor weight gain, and 33% were asymptomatic. Five children with potential CD and 6 with CD autoimmunity became negative (42.3%) and are still negative after 5 to 7 years. Female sex was at-risk factor odds ratio 5.7 (95% CI 1.5-20.9), whereas breast-feeding during gluten introduction had a protective effect odds ratio 0.1 (95% CI 0.01-0.8). CONCLUSIONS: Prevalence of CD in this cohort was 4%, half of whom had digestive symptoms. Because a high proportion of children showed a spontaneous disappearance of antibodies, prevalence studies of CD in young children should be based on intestinal damage so as not to overestimate results.

Relación entre el índice de masa corporal, la actividad física y los tiempos de comida en adolescentes mexicanos / Relationship between body mass index, physical activity and meal times in Mexican adolescents

Objetivos: los objetivos de este estudio son: 1) describir la distribución del IMC, los niveles de actividad física y la frecuencia de los tiempos de comida, y 2) examinar la relación de estas variables con el IMC en una muestra de adolescentes mexicanos estudiantes de preparatoria. Métodos: participaron 1.028 adolescentes (58,9% mujeres y 41,1% hombres) de 15 a 19 años de edad (M= 16,12; DE= 0,9). Se calculó el IMC y se utilizó la referencia del CDC-2000. Los tiempos de comida se midieron con uno de los factores del cuestionario Factores de Riesgo Asociados a Trastornos Alimentarios para Púberes (FRATAP). La actividad física se evaluó mediante el International Physical Activity Questionnaire (IPAQ) en su versión corta. Se realizaron correlaciones de Pearson para ver la relación entre las variables. Resultados: la prevalencia combinada de sobrepeso y obesidad alcanzó el 29,2% para mujeres y el 29,3% en hombres. En el factor tiempos de comida, los sujetos con desnutrición y bajo peso fueron quienes siempre obtuvieron los valores más altos en la opción de respuesta. El 31,9% del total de la muestra reportó un nivel de actividad física bajo. Los tiempos de comida mostraron asociaciones significativas con el IMC (r= -0,142, p < 0,01) y los niveles de actividad física (r= 0,125, p < 0,01). Discusión: en la muestra se identificaron problemas importantes de malnutrición, frecuencia de comidas e inactividad física. De estos hallazgos surge la necesidad de diseñar e implantar programas para promover estilos de vida saludables en adolescentes (AU)

Objectives: 1) to describe the distribution of the body mass index (BMI), physical activity levels and meal times’ frequency and; 2) to assess its relationships in a sample of high school Mexican adolescents. Methods: a total of 1028 adolescents (41.1% males and 58.9% females) aged 15-19 years (M= 16.12; SD= 0.9) were included in the final analysis. BMI was calculated using the CDC-2000 as reference. Meal times were evaluated by one factor of the RFAEDP questionnaire (Risk Factors Associated to Eating Disorders in Pubescents). Physical activity was measured trough short version of the International Physical Activity Questionnaire (IPAQ). Pearson’s correlations were used to determine relationship between the variables. Results: overweight and obesity prevalence together reached, 29.2% for females and 29.3% in males. In meal times’ factor, undernourished and low weight subjects achieved the highest values in the answer option always. In total sample, according to the physical activity, 31.9% reported low level. Meal times showed significant association with BMI (r= -0.142, p < 0.01) and physical activity level (r= 0.125, p < 0.01). Discussion: important problems of malnutrition, meal times’ frequency and inactivity were identified in the sample. From these findings, the need to design and implement programs with the aim of promoting healthy lifestyles among adolescent arises (AU)

[RELATIONSHIP BETWEEN BODY MASS INDEX, PHYSICAL ACTIVITY AND MEAL TIMES IN MEXICAN ADOLESCENTS]. / RELACIÓN ENTRE EL ÍNDICE DE MASA CORPORAL, LA ACTIVIDAD FÍSICA Y LOS TIEMPOS DE COMIDA EN ADOLESCENTES MEXICANOS.

OBJECTIVES: 1) to describe the distribution of the body mass index (BMI), physical activity levels and meal times' frequency and; 2) to assess its relationships in a sample of high school Mexican adolescents. METHODS: a total of 1028 adolescents (41.1% males and 58.9% females) aged 15-19 years (M= 16.12; SD= 0.9) were included in the final analysis. BMI was calculated using the CDC-2000 as reference. Meal times were evaluated by one factor of the RFAEDP questionnaire (Risk Factors Associated to Eating Disorders in Pubescents). Physical activity was measured trough short version of the International Physical Activity Questionnaire (IPAQ). Pearson's correlations were used to determine relationship between the variables. RESULTS: overweight and obesity prevalence together reached, 29.2% for females and 29.3% in males. In meal times' factor, undernourished and low weight subjects achieved the highest values in the answer option always. In total sample, according to the physical activity, 31.9% reported low level. Meal times showed significant association with BMI (r= -0.142, p < 0.01) and physical activity level (r= 0.125, p < 0.01). DISCUSSION: important problems of malnutrition, meal times' frequency and inactivity were identified in the sample. From these findings, the need to design and implement programs with the aim of promoting healthy lifestyles among adolescent arises.

Objetivos: los objetivos de este estudio son: 1) describir la distribución del IMC, los niveles de actividad física y la frecuencia de los tiempos de comida, y 2) examinar la relación de estas variables con el IMC en una muestra de adolescentes mexicanos estudiantes de preparatoria. Métodos: participaron 1.028 adolescentes (58,9% mujeres y 41,1% hombres) de 15 a 19 años de edad (M= 16,12; DE= 0,9). Se calculó el IMC y se utilizó la referencia del CDC-2000. Los tiempos de comida se midieron con uno de los factores del cuestionario Factores de Riesgo Asociados a Trastornos Alimentarios para Púberes (FRATAP). La actividad física se evaluó mediante el International Physical Activity Questionnaire (IPAQ) en su versión corta. Se realizaron correlaciones de Pearson para ver la relación entre las variables. Resultados: la prevalencia combinada de sobrepeso y obesidad alcanzó el 29,2% para mujeres y el 29,3% en hombres. En el factor tiempos de comida, los sujetos con desnutrición y bajo peso fueron quienes siempre obtuvieron los valores más altos en la opción de respuesta. El 31,9% del total de la muestra reportó un nivel de actividad física bajo. Los tiempos de comida mostraron asociaciones significativas con el IMC (r= -0,142, p < 0,01) y los niveles de actividad física (r= 0,125, p < 0,01). Discusión: en la muestra se identificaron problemas importantes de malnutrición, frecuencia de comidas e inactividad física. De estos hallazgos surge la necesidad de diseñar e implantar programas para promover estilos de vida saludables en adolescentes.

Glomerulonephritis and cryoglobulinemia: first manifestation of visceral leishmaniasis.

Visceral leishmaniasis due to Leishmania Infantum is an endemic parasitic infection in the Mediterranean area. Since 2009, Europe's largest outbreak of Leishmaniasis has been reported in the region of Madrid (Spain). Renal involvement is an unusual complication. Different forms of renal disease have been described: interstitial, glomerular, and vascular damage. Direct invasion of renal parenchyma by the parasite has been described as a mechanism of kidney damage, especially in the immunocompromised. Immune complex deposition and T cells adhesion molecules activation have demonstrated that a pathogenic role in glomerulonephritis related to visceral leishmaniasis. The association between mixed cryoglobulinemia and visceral leishmaniasis has been previously reported in six patients. Renal involvement is only described in one of them. From July 2009 to October 2012, 4 patients with membranoproliferative glomerulonephritis and mixed cryoglobulinemia with negative serology for hepatitis B and C were diagnosed in our hospital. Serology of Leishmania in serum bank samples was performed; it was positive in 3 patients. Leishmania parasite was confirmed by other tests. We present 3 patients with mixed cryoglobulinemia and membranoproliferative glomerulonephritis as first clinical manifestation of visceral leishmaniasis.

Conocimiento de las técnicas de diagnóstico prenatal por parte de los médicos de atención primaria / Awareness of prenatal diagnosis methods among primary care physicians

En el año 2000, la Consejería de Salud de la Junta de Andalucía pone en marcha los procesos asistenciales integrados (PAI). El PAI correspondiente al embarazo, el parto y el puerperio, que implica tanto al médico de atención primaria como al obstetra, fue uno de los primeros en implantarse. Los avances en genética han propiciado una mejora en el diagnóstico precoz de anomalías genéticas, por ello es importante el conocimiento y la formación del médico de atención primaria en las técnicas de cribado. Objetivo: Valorar los conocimientos teóricos de los médicos de atención primaria sobre las técnicas de diagnóstico prenatal y si se consideran capacitados para ofrecer asesoramiento genético. Diseño: Estudio descriptivo transversal. Ámbito: Distritos sanitarios Valle del Guadalhorce (Málaga) y Condado-Campiña (Huelva). Población: Médicos de atención primaria de la zona que aceptaron participar, con exclusión de pediatras, médicos de urgencias y dispositivos de apoyo. Intervenciones: Mediante un cuestionario se evaluaron los conocimientos de los médicos de atención primaria y su percepción consciente en cuanto a su falta de conocimiento en el tema. Participaron 108 médicos, y se obtuvieron 100 cuestionarios válidos. Los datos se analizaron con el paquete estadístico SPSS 13.0 Windows. Conclusiones: Existe un alto índice de desconocimiento sobre las técnicas de diagnóstico prenatal por parte de los médico de atención primaria...

Cystatin C as a predictor of mortality and cardiovascular events in a population with chronic kidney disease.

Background. We examine whether cystatin C, a surrogate marker of renal function, could identify patients with chronic kidney disease (CKD) with an increased risk of renal disease progression, death, or cardiovascular events. Methods. Data were obtained for 180 patients, with a diagnosis of chronic renal failure based on serum creatinine estimated glomerular filtration rate (eGFRcreat) <90 mL/min/1.73 m(2). This population was grouped in tertiles according to cystatin C and creatinine values at baseline. Cardiovascular events and overall mortality were estimated for each tertile. Predictors of overall mortality and for the development of renal disease progression were analyzed. Results. The median age was 75 years (interquartile range 69-82) and the median eGFRcreat 38 mL/min m(2) (interquartile range 33-49). Overall mortality was lower on the first and on the second tertiles of cystatin C than on the third one (HR = 0.060; 95% CI: 0.008-0.447 and HR = 0.094; 95% CI: 0.022-0.406, resp.). Deaths related to the creatinine tertiles followed the same pattern, but differences were not as large. Cardiovascular mortality was lower on the second than on the third cystatin C tertile (HR = 0.198; 95% CI: 0.040-0.987), but it did not show differences on the first and the second creatinine tertiles compared with the third one (HR = 0.126; 95% CI: 0.013-1.265 and HR = 0.403; 95% CI: 0.093-1.740). The only independent predictors of mortality during followup were baseline cystatin C (OR = 0.100; 95% CI: 0.021-0.463) and baseline uric acid (OR = 1.377; 95% CI: 1.070-1.773). Conclusion. Cystatin C may be an alternative to creatinine for detecting a high risk of death and cardiovascular events in a population with CKD.

Nukbone® promotes proliferation and osteoblastic differentiation of mesenchymal stem cells from human amniotic membrane.

Bovine bone matrix Nukbone® (NKB) is an osseous tissue-engineering biomaterial that retains its mineral and organic phases and its natural bone topography and has been used as a xenoimplant for bone regeneration in clinics. There are not studies regarding its influence of the NKB in the behavior of cells during the repairing processes. The aim of this research is to demonstrate that NKB has an osteoinductive effect in human mesenchymal stem cells from amniotic membrane (AM-hMSCs). Results indicated that NKB favors the AM-hMSCs adhesion and proliferation up to 7 days in culture as shown by the scanning electron microscopy and proliferation measures using an alamarBlue assay. Furthermore, as demonstrated by reverse transcriptase polymerase chain reaction, it was detected that two gene expression markers of osteoblastic differentiation: the core binding factor and osteocalcin were higher for AM-hMSCs co-cultured with NKB in comparison with cultivated cells in absence of the biomaterial. As the results indicate, NKB possess the capability for inducing successfully the osteoblastic differentiation of AM-hMSC, so that, NKB is an excellent xenoimplant option for repairing bone tissue defects.

High levels of cerebrospinal fluid free kappa chains predict conversion to multiple sclerosis.

BACKGROUND: A clinically isolated syndrome (CIS) may be the initial presentation of multiple sclerosis (MS). However, some CIS never develop MS. The identification of patients at risk of MS conversion is crucial as early treatment may improve their outcome. Free kappa chains (FKC) are increased in cerebrospinal fluid (CSF) of MS patients. We studied the accuracy of CSF FKC level measurement, using a new nephelometric test, to predict conversion of CIS patients to MS. METHODS: We calculated linearity and inter-assay variability of the FKC test for CSF values and quantified this protein in CSF from 25 patients with non-inflammatory neurological diseases (NIND) and 78 consecutive CIS patients. We assessed whether high CSF FKC levels associate with CIS conversion to clinically definite MS, defined as the onset of new relapses during follow-up. RESULTS: Between 0.1 and 5mg/l the FKC test showed linearity of 0.98 and inter-assay correlation coefficient of =0.99. A cut-off value of 0.53 mg/l (mean+2SD of NIND group CSF FKC values) was calculated. CIS patients with CSF FKC above this value showed earlier conversion to MS in univariate and multivariate Cox analysis (HR=6.41; 95% CI=1.88-21.78, p=0.003). CONCLUSION: High CSF FKC levels accurately predict CIS patient conversion to MS.

Large Evaluation of Anti-Cardiolipin and anti-Beta2Glycoprotein I Assays: Results from the AutoimmunityWorkshop of the Spanish Society of Immunology

Despite their clinical utility and the importance that laboratory testshave in APS diagnosis, probably the most important drawback of suchtests is the elevated intra- and inter-laboratory variation. The aim of thepresent work was to assess the multilaboratory performance of aCL (..) (AU)

A pesar de la indudable utilidad clínica y de la importancia de laspruebas de laboratorio en el diagnóstico del síndrome antifosfolípido(APS), probablemente el mayor defecto de dichas pruebas es su elevadavariabilidad intra- e inter-laboratorio. El objetivo del presente trabajo fueevaluar el comportamiento de los ensayos (..) (AU)

Relación entre comprensión del lenguaje figurado y rendimiento escolar en estudiantes de enseñanza básica / The relationship between figurative language comprehension and academic achievement in primary school students

El propósito del presente trabajo es conocer la relación que existe entre la comprensión del lenguaje figurado y el desempeño escolar en niños de 4º, 6º y 8º año de educación general básica. Para ello, se sometió a los niños a tareas de compresión de modismo y refranes. Es decir, expresiones de significado no literal. Los resultados indican que existen diferencias de rendimiento por curso, tanto en modismo como en refranes evidenciando que a medida que se avanza en escolaridad mejora el enfrentamiento con este tipo de tarea metalingüística. Se establece además, que en los tres cursos considerados en esta investigación existe relación entre el rendimiento en tareas de comprensión de lenguaje figurado y el rendimiento escolar en diversas asignaturas. Se discute en relación a estos resultados y su implicación para el trabajo escolar.