Structural and functional brain changes in middle-aged type 2 diabetic patients: a cross-sectional study.

BACKGROUND Type 2 diabetes mellitus (T2DM) is an emerging risk factor for cognitive impairment. Whether this impairment is a direct effect of this metabolic disorder on brain function, a consequence of vascular disease, or both, remains unknown. Structural and functional neuroimaging studies in patients with T2DM could help to elucidate this question. OBJECTIVE We designed a cross-sectional study comparing 25 T2DM patients with 25 age- and gender-matched healthy control participants. Clinical information, APOE genotype, lipid and glucose analysis, structural cerebral magnetic resonance imaging including voxel-based morphometry, and F-18 fluorodeoxyglucose positron emission tomography were obtained in all subjects. METHODS Gray matter densities and metabolic differences between groups were analyzed using statistical parametric mapping. In addition to comparing the neuroimaging profiles of both groups, we correlated neuroimaging findings with HbA1c levels, duration of T2DM, and insulin resistance measurement (HOMA-IR) in the diabetic patients group. Results: Patients with T2DM presented reduced gray matter densities and reduced cerebral glucose metabolism in several fronto-temporal brain regions after controlling for various vascular risk factors. Furthermore, within the T2DM group, longer disease duration, and higher HbA1c levels and HOMA-IR were associated with lower gray matter density and reduced cerebral glucose metabolism in fronto-temporal regions. CONCLUSION In agreement with previous reports, our findings indicate that T2DM leads to structural and metabolic abnormalities in fronto-temporal areas. Furthermore, they suggest that these abnormalities are not entirely explained by the role of T2DM as a cardiovascular risk factor.

Prospective registry of symptomatic severe aortic stenosis in octogenarians: a need for intervention.

OBJECTIVE To study the factors associated with choice of therapy and prognosis in octogenarians with severe symptomatic aortic stenosis (AS). STUDY DESIGN Prospective, observational, multicenter registry. Centralized follow-up included survival status and, if possible, mode of death and Katz index. SETTING Transnational registry in Spain. SUBJECTS We included 928 patients aged ≥80 years with severe symptomatic AS. INTERVENTIONS Aortic-valve replacement (AVR), transcatheter aortic-valve implantation (TAVI) or conservative therapy. MAIN OUTCOME MEASURES All-cause death. RESULTS Mean age was 84.2 ± 3.5 years, and only 49.0% were independent (Katz index A). The most frequent planned management was conservative therapy in 423 (46%) patients, followed by TAVI in 261 (28%) and AVR in 244 (26%). The main reason against recommending AVR in 684 patients was high surgical risk [322 (47.1%)], other medical motives [193 (28.2%)], patient refusal [134 (19.6%)] and family refusal in the case of incompetent patients [35 (5.1%)]. The mean time from treatment decision to AVR was 4.8 ± 4.6 months and to TAVI 2.1 ± 3.2 months, P < 0.001. During follow-up (11.2-38.9 months), 357 patients (38.5%) died. Survival rates at 6, 12, 18 and 24 months were 81.8%, 72.6%, 64.1% and 57.3%, respectively. Planned intervention, adjusted for multiple propensity score, was associated with lower mortality when compared with planned conservative treatment: TAVI Hazard ratio (HR) 0.68 (95% confidence interval [CI] 0.49-0.93; P = 0.016) and AVR HR 0.56 (95% CI 0.39-0.8; P = 0.002). CONCLUSION Octogenarians with symptomatic severe AS are frequently managed conservatively. Planned conservative management is associated with a poor prognosis.

El modelo de producción japonesa del videojuego y su plasmación en la industria española: deslocalización y procesos de producción

En este trabajo se analiza la industria del videojuego y el modelo de producción dominante, implantado por la industria japonesa en los años ochenta. Este fenómeno se ejemplifica en el caso de España a través de una progresión histórica del proceso de adaptación, que se elaborará tanto a partir de análisis de contenidos como de entrevistas de miembros prominentes de la industria. El análisis de dichos factores servirá para ilustrar la estructura actual de la industria y de qué manera las empresas más prominentes ejercen sobre su influencia sobre el resto de firmas

Tuberculosis in migrant populations. A systematic review of the qualitative literature.

BACKGROUND The re-emergence of tuberculosis (TB) in low-incidence countries and its disproportionate burden on immigrants is a public health concern posing specific social and ethical challenges. This review explores perceptions, knowledge, attitudes and treatment adherence behaviour relating to TB and their social implications as reported in the qualitative literature. METHODS Systematic review in four electronic databases. Findings from thirty selected studies extracted, tabulated, compared and synthesized. FINDINGS TB was attributed to many non-exclusive causes including air-born transmission of bacteria, genetics, malnutrition, excessive work, irresponsible lifestyles, casual contact with infected persons or objects; and exposure to low temperatures, dirt, stress and witchcraft. Perceived as curable but potentially lethal and highly contagious, there was confusion around a condition surrounded by fears. A range of economic, legislative, cultural, social and health system barriers could delay treatment seeking. Fears of deportation and having contacts traced could prevent individuals from seeking medical assistance. Once on treatment, family support and "the personal touch" of health providers emerged as key factors facilitating adherence. The concept of latent infection was difficult to comprehend and while TB screening was often seen as a socially responsible act, it could be perceived as discriminatory. Immigration and the infectiousness of TB mutually reinforced each another exacerbating stigma. This was further aggravated by indirect costs such as losing a job, being evicted by a landlord or not being able to attend school. CONCLUSIONS Understanding immigrants' views of TB and the obstacles that they face when accessing the health system and adhering to a treatment programme-taking into consideration their previous experiences at countries of origin as well as the social, economic and legislative context in which they live at host countries- has an important role and should be considered in the design, evaluation and adaptation of programmes.

New clinical practice guideline on enteral feeding in very low birth wieght infants; second part

INTRODUCTION: The nutrition of very low birth weight (VLBW) infants is aimed at promoting a similar growth to that occurring in the uterus. However, in practice this is difficult to achieve and extrauterine growth restriction is frequent. The current tendency is to avoid this restriction by means of early parenteral and enteral nutrition. Nonetheless, uncertainty about many of the practices related with nutrition has resulted in a great variation in the way it is undertaken. In 2009 and 2011 in our hospital there was an unexpected increase in necrotizing enterocolitis. To check to see wether our nutrition policy was involved, we underlook a systematic review and drewup clinical practice guidelines (CPG) about enteral feeding in VLBW infants. New considerations about the duration of the fortification and the use of probiotics have led to an update of these CPG. METHODS: A total of 21 clinical questions were designed dealing with the type of milk, starting age, mode of administration, rate and volume of the increments, fortification, use of probiotics and protocol. Afete conducting a systematic search of the available evidence, the information was contrasted and summarized in order to draw up the recommendations. The quality of the evidence and the strength of the recommendations were determined from the SIGN scale. COMMENT: These CPG aim to help physicians in their decision making. The protocolized application of wellproven measurements reduces the variation in clinical practice and improves results.

Aproximación antropológica a los trastornos de la conducta alimentaria

Els trastorns de la conducta alimentària han estat considerats uns dels trastorns psicopatològics més greus de les tres últimes dècades. Això ha comportat que es realitzin multituds d’estudis per determinar les seves causes i poder desenvolupar una teràpia adequada. Amb aquest treball es pretén reflexionar sobre la influència que exerceix la societat i la família en la formació del caràcter de la adolescent, a més de relacionar la simptomatologia de la pacient amb anorèxia amb les “malalties de l’ànima” que descriu Sant Tomàs d’Aquino i els efectes d’algunes d’elles, especialment de la vanitat i la acedia, al descobrir com factor principal un factor moral en el desenvolupament d’aquests trastorns.

Contribution of efflux pumps, porins, and β-lactamases to multidrug resistance in clinical isolates of Acinetobacter baumannii.

We investigated the mechanisms of resistance to carbapenems, aminoglycosides, glycylcyclines, tetracyclines, and quinolones in 90 multiresistant clinical strains of Acinetobacter baumannii isolated from two genetically unrelated A. baumannii clones: clone PFGE-ROC-1 (53 strains producing the OXA-58 β-lactamase enzyme and 18 strains with the OXA-24 β-lactamase) and clone PFGE-HUI-1 (19 strains susceptible to carbapenems). We used real-time reverse transcriptase PCR to correlate antimicrobial resistance (MICs) with expression of genes encoding chromosomal β-lactamases (AmpC and OXA-51), porins (OmpA, CarO, Omp33, Dcap-like, OprB, Omp25, OprC, OprD, and OmpW), and proteins integral to six efflux systems (AdeABC, AdeIJK, AdeFGH, CraA, AbeM, and AmvA). Overexpression of the AdeABC system (level of expression relative to that by A. baumannii ATCC 17978, 30- to 45-fold) was significantly associated with resistance to tigecycline, minocycline, and gentamicin and other biological functions. However, hyperexpression of the AdeIJK efflux pump (level of expression relative to that by A. baumannii ATCC 17978, 8- to 10-fold) was significantly associated only with resistance to tigecycline and minocycline (to which the TetB efflux system also contributed). TetB and TetA(39) efflux pumps were detected in clinical strains and were associated with resistance to tetracyclines and doxycycline. The absence of the AdeABC system and the lack of expression of other mechanisms suggest that tigecycline-resistant strains of the PFGE-HUI-1 clone may be associated with a novel resistance-nodulation-cell efflux pump (decreased MICs in the presence of the inhibitor Phe-Arg β-naphthylamide dihydrochloride) and the TetA(39) system.

Perifollicular erythema as a trichoscopy sign of progression in frontal fibrosing alopecia.

INTRODUCTION Frontal fibrosing alopecia (FFA) in an entity characterized by the recession of the frontotemporal hairline (FTHL) with alopecic scarring change. In recent years there are numerous articles discussing the usefulness of dermoscopy for the clinical diagnosis of different types of scarring alopecia. MATERIALS AND METHODS We value 79 patients diagnosed with FFA, evaluating some trichoscopical findings described as typical for FFA: Absence of follicular opening, follicular hyperkeratosis, follicular plugs and erythema. RESULTS In a population of 79 women, 100% showed no follicular opening, 72.1% follicular hyperkeratosis, 66.3% perifollicular erythema and 44.8% follicular plugs. Thus, 100% of patients had at least one of the dermoscopic elements described as suggestive of FFA, 53% two of them, 45% three and 27%, all those elements. Perifollicular erythema was present in 95% of cases in which the disease was active. CONCLUSIONS We consider that the presence of perifollicular erythema will be a direct marker of FFA activity.

New clinical practice guideline on enteral feeding in very low birth weight infants; first part.

The nutrition of very low birth weight (VLBW) infants is aimed at promoting a similar growth to that occurring in the uterus. However, in practice this is difficult to achieve and extrauterine growth restriction is frequent. The current tendency is to avoid this restriction by means of early parenteral and enteral nutrition. Nonetheless, uncertainty about many of the practices related with nutrition has resulted in a great variation in the way it is undertaken. In 2009 and 2011 in our hospital there was an unexpected increase in necrotizing enterocolitis. To check to see whether our nutrition policy was involved, we undertook a systematic review and drew up clinical practice guidelines (CPG) about enteral feeding in VLBW infants. New considerations about the duration of the fortification and the use of probiotics have led to an update of these CPG. METHODS: A total of 21 clinical questions were designed dealing with the type of milk, starting age, mode of administration, rate and volume of the increments, fortification, use of probiotics and protocol. After conducting a systematic search of the available evidence, the information was contrasted and summarized in order to draw up the recommendations. The quality of the evidence and the strength of the recommendations were determined from the SIGN scale. COMMENT: These CPG aim to help physicians in their decision making. The protocolized application of well-proven measurements reduces the variation in clinical practice and improves results.

Pandemic 2009 A(H1N1) infection requiring hospitalization of elderly Spanish adults.

To describe the clinical presentation and prognosis of elderly adults hospitalized with pandemic 2009 A(H1N1) influenza infection and to compare these data with those of younger patients. DESIGN: Prospective, observational, multicenter study. SETTING: Thirteen hospitals in Spain. PARTICIPANTS: Adults admitted to the hospital with confirmed pandemic 2009 A(H1N1) influenza infection. MEASUREMENTS: Demographic, clinical, laboratory, radiological, and outcome variables. RESULTS: Between June 12 and November 10, 2009, 585 adults with confirmed 2009 A(H1N1) influenza were hospitalized, of whom 50 (8.5%) were aged 65 and older (median age 72, range 65-87). Older adults (≥ 65) were more likely to have associated comorbidities (88.0% vs 51.2%; P < .001), primarily chronic pulmonary diseases (46.0% vs 27.3%; P < .001). Lower respiratory tract symptoms and signs such as dyspnea (60.0% vs 45.6%) and wheezing (46.0% vs 27.8%; P = .007) were also more common in these elderly adults, although pulmonary infiltrates were present in just 14 (28.0%) of the older adults, compared with 221 (41.3%) of the younger adults (P = .06). Multilobar involvement was less frequent in elderly adults with pulmonary infiltrates than younger adults with pulmonary infiltrates (21.4% vs 60.0%; P = .05). Rhinorrhea (4.0% vs 21.9%; P = .003), myalgias (42.0% vs 59.1%; P = .01), and sore throat (14.0% vs 29.2%; P = .02) were more frequent in younger adults. Early antiviral therapy (<48 hours) was similar in the two groups (34.0% vs 37.9%; P = .58). Two older adults (4.0%) died during hospitalization, compared with 11 (2.1%) younger adults (P = .30). CONCLUSION: Elderly adults with 2009 A(H1N1) influenza had fewer viral-like upper respiratory symptoms than did younger adults. Pneumonia was more frequent in younger adults. No significant differences were observed in hospital mortality.

Prospective registry of symptomatic severe aortic stenosis in octogenarians: a need for intervention.

OBJECTIVE To study the factors associated with choice of therapy and prognosis in octogenarians with severe symptomatic aortic stenosis (AS). STUDY DESIGN Prospective, observational, multicenter registry. Centralized follow-up included survival status and, if possible, mode of death and Katz index. SETTING Transnational registry in Spain. SUBJECTS We included 928 patients aged ≥80 years with severe symptomatic AS. INTERVENTIONS Aortic-valve replacement (AVR), transcatheter aortic-valve implantation (TAVI) or conservative therapy. MAIN OUTCOME MEASURES All-cause death. RESULTS Mean age was 84.2 ± 3.5 years, and only 49.0% were independent (Katz index A). The most frequent planned management was conservative therapy in 423 (46%) patients, followed by TAVI in 261 (28%) and AVR in 244 (26%). The main reason against recommending AVR in 684 patients was high surgical risk [322 (47.1%)], other medical motives [193 (28.2%)], patient refusal [134 (19.6%)] and family refusal in the case of incompetent patients [35 (5.1%)]. The mean time from treatment decision to AVR was 4.8 ± 4.6 months and to TAVI 2.1 ± 3.2 months, P < 0.001. During follow-up (11.2-38.9 months), 357 patients (38.5%) died. Survival rates at 6, 12, 18 and 24 months were 81.8%, 72.6%, 64.1% and 57.3%, respectively. Planned intervention, adjusted for multiple propensity score, was associated with lower mortality when compared with planned conservative treatment: TAVI Hazard ratio (HR) 0.68 (95% confidence interval [CI] 0.49-0.93; P = 0.016) and AVR HR 0.56 (95% CI 0.39-0.8; P = 0.002). CONCLUSION Octogenarians with symptomatic severe AS are frequently managed conservatively. Planned conservative management is associated with a poor prognosis.

Entre la irrelevancia internacional y el aprendizaje institucional: La Presidencia Española de la Unión Europea (2010)

El presente volumen es una nueva contribución del Observatorio de Política Exterior Europea (Obs) al análisis de la interacción entre la política exterior española y la acción exterior de la Unión Europea. En esta ocasión, el lector se encuentra frente a un ejercicio de balance de la Presidencia española de la Unión Europea del primer semestre de 2010, una presidencia única, que sus mismos protagonistas han definido como presidencia de transición. Una transición entre el viejo y el nuevo modelo, impuesto por el Tratado de Lisboa, que entró en vigor poco antes del inicio de la presidencia rotatoria de España. El volumen se compone de más de 20 capítulos, que abordan de manera sistematizada y sucinta los temas fundamentales para entender cuál ha sido el cometido de España a la hora de gestionar el papel de Europa en el mundo. El Obs ya ha realizado este tipo de ejercicio en tres ocasiones desde 2002. De ahí que este “Entre la irrelevancia internacional y el aprendizaje institucional: La presidencia española de la Unión Europea (2010)” deba ser entendido como un balance de la presidencia española al frente de la agenda exterior de la UE, pero también como un referente para los estudiosos de la política europea de España, por un lado, o de la acción exterior de la UE, por el otro, que se suma a la línea de análisis seguida por el Obs a lo largo de casi una década de trabajo.

Liberalismo, libertarismo y anarquismo: análisis comparado

Un dels corrents polítics que ha estat sotmès a un contrast més polèmic i aspre amb l'esdevenir dels fets, ha estat el liberalisme. A diferència d'altres tendències polítiques encara contemporànies, el liberalisme gaudeix d'una esplèndida salut 300 anys després, encara que els seus inicis puguin rastrejar-se en ple Segle d'Or espanyol. Són poques les filosofies polítiques que han superat amb alts i baixos, amb canvis, amb avanços i retrocessos gairebé tres segles d'existència. Pot avui detectar-se en el liberalisme polític el pensament de filòsofs espanyols, anglesos i escocesos que van conformar amb la seva reflexió i els seus escrits un cos doctrinal que conforma i enriqueix, encara avui, la vida política de les societats plurals modernes i més avançades del planeta. Quan algunes filosofies i/o religions polítiques han pràcticament desaparegut de l'horitzó en progrés dels homes del segle XXI, el liberalisme de Locke, Juan de Mariana, Tomás de Mercado, Hume, Ferguson, Hutcheson, Smith i tants altres, mostra inequívocs signes de vitalitat. La preocupació per l'individu lliure, responsable i ètic i el seu esforç titànic per desprendre's de l'opressió i l'asfíxia governativa i burocràtica, encoratgen la resposta de major abast que ens és possible encara contemplar en les dues primeres dècades del segle XXI. Homes i dones lliures, autònoms, independents, amb capacitat creativa, amb voluntat i disposats a enfrontar problemes, dificultats i traves per defensar la seva llibertat. Aquesta és avui una herència de primer ordre del pensament humanista que arrenca al món hel•lènic i dura fins als nostres dies. La concepció de la funció de l'Estat i la seva extensió, l’acceptació major o menor de la seva grandària, el paper de la burocràcia, els mecanismes de submissió, control i opressió, són avui una assignatura encara pendent per a milions de ciutadans a tot el món que intueixen encara, a palpentes, que la llibertat és el valor més preuat de la humanitat, la seva pedra angular. Liberals, anarquistes i llibertaris discrepen en moltes qüestions i en el treball present, donem complerta compte d'algunes de les diferències més significatives, però coincideixen en l'anhel infrangible de l'home lliure. No tots els camins condueixen a la llibertat, no totes les solucions garanteixen la llibertat, però l'esperit que anima a aquests tres corrents polítics nascuts del pensament dels filòsofs, historiadors i polítics més lliures i compromesos, justifica que abordem les seves dimensions –acords i diferències- amb la seguretat que hi ha moltes coses que aprendre de la seva història i tantes altres que preservar de la seva memòria.

Desempenho organizacional e suas relações com competências gerenciais, suporte organizacional e treinamento

Na pesquisa aqui relatada, objetivou-se verificar a existência de relações preditivas entre as competências expressas por gerentes de agências bancárias, a percepção deles sobre o suporte organizacional, o número de horas dedicadas por eles a treinamentos e o desempenho das agências em que atuam. Valeu-se de questionários estruturados para coleta de dados primários, sendo a amostra constituída por 186 gerentes de agências e 77 superintendentes regionais do Banco do Brasil. Utilizaram-se, também, dados secundários sobre o desempenho das agências em seis dimensões: resultado econômico, estratégia e operações, sociedade, clientes, processos e comportamento organizacional. Foram realizadas análises de regressão padrão para teste do modelo de investigação. As competências relativas à gestão estratégica e à gestão financeira revelaram-se preditoras de diferentes dimensões do desempenho das agências. Outras competências (gestão de processos e gestão socioambiental), o número de horas dedicadas a treinamentos e a percepção dos gestores acerca das práticas de gestão de desempenho da empresa (uma dimensão do suporte organizacional) apresentaram efeitos menos abrangentes. Depois de isolados os efeitos de variáveis de controle, as variâncias explicadas pelos referidos preditores situaram-se entre 2,2% e 6,8%. Recaiu sobre o desempenho da agência na perspectiva clientes o menor percentual de explicação e sobre o desempenho nas perspectivas resultado econômico e estratégia e operações a maior variância explicada. Ao final, são discutidas implicações dos resultados e apresentadas recomendações práticas.