Search

Abstract Background The Eating Disorders Quality of Life instrument (EDQOL) is a disease-specific health related quality of life self-report questionnaire designed for disordered eating patients. Although the EDQOL is one of the most suitable and widely used questionnaires in many countries, no prior research has addressed the psychometric properties of the Spanish adaptation of the EDQOL. Therefore, the aim of this study is to examine the psychometric properties of the Spanish version of the EDQOL among ED patients. Methods 141 female eating disorder patients, with a mean age of 18.06 years (SD = 6.31), completed the EDQL in addition to the Eating Disorder Examination Questionnaire (EDEQ), the Depression, Anxiety and Stress Scales (DASS-21), the Clinical Impairment Assessment (CIA 3.0) and the Health Survey (SF-12). We calculated item/scale characteristics, internal consistencies and bivariate correlations with other measures of quality of life and adjustments. We assessed the goodness-of-fit of the 4-factor model using confirmatory factors analysis and explored the sensitivity of change following skill-based interventions. Results The fit of the 4-factor model was acceptable (Root Mean Square Error of Approximation: 0.07, Standard Root Mean Square Residual: 0.07). Cronbach's alpha was excellent for the total (.91) and acceptable for all subscales (0.78–0.91). The construct validity was found with measures of psychological distress, depression, anxiety, quality of life and clinical impairment. The psychological and physical/cognitive scales and the EDQOL global scale were responsive to change. Conclusion The Spanish EDQOL version is a useful instrument to assess quality of life in eating disorder patients and to evaluate outcomes of skills-based interventions.

The species Senecio nutans Sch. Bip., commonly called “chachacoma”, is widely used as a medicinal plant by the Andean communities of Northern Chile. Ethanolic extracts of S. nutans and the main compound, 4-hydroxy-3-(3-methyl-2-butenyl) acetophenone, have shown interesting biological activity. However, due to the high-altitude areas where this species is found, access to S. nutans is very limited. Due to the latter, in this work, we carried out micropropagation in vitro and ex vitro adaptation techniques as an alternative for the massive multiplication, conservation, and in vitro production of high-value metabolites from this plant. The micropropagation and ex vitro adaptation techniques were successfully employed, and UHPLC-DAD analysis revealed no significant changes in the phenolic profile, with acetophenone 4 being the most abundant metabolite, whose antioxidant and antibacterial activity was studied. Independently of the applied culture condition, the ethanolic extracts of S. nutans presented high activity against both Gram-positive and Gram-negative bacteria, demonstrating their antimicrobial capacity. This successful initiation of in vitro and ex vitro cultures provides a biotechnological approach for the conservation of S. nutans and ensures a reliable and consistent source of acetophenone 4 as a potential raw material for pharmacological applications.

Previously, we designed a subunit vaccine candidate based on three L. intracellularis antigens with promising results in pigs. In this study, antigens were produced individually to achieve an even antigen ratio in the formulation. The emulsion characterization included the drop size and the mechanical and thermal stability. Immune response was evaluated by indirect and sandwich ELISAs, qPCR, and flow cytometry. The vaccine candidate’s safety was assessed by histopathology and monitoring the clinical behavior of animals. The average production yielded for the chimeric antigen as inclusion bodies was around 75 mg/L. The formulation showed mechanical and thermal stability, with a ratio Hu/Ho > 0.85 and a drop size under 0.15 nm. Antigens formulated at a ratio of 1:1:1 induced a significant immune response in inoculated pigs that persisted until the end of the experiment (week 14). The dose of 200 μg significantly activated cellular response measured by transcriptional and translational levels of cytokines. The cell proliferation assay revealed an increment of lymphocytes T CD4+ at the same dose. Animals gained weight constantly and showed proper clinical behavior during immunization assays. This research demonstrated the immunological robustness of the new subunit vaccine candidate against Porcine Proliferative Enteropathy evenly formulated with three chimeric antigens of L. intracellularis.

Pig is one of the most consumed meats worldwide. One of the main conditions for pig production is Porcine Enteropathy caused by Lawsonia intracellularis. Among the effects of this disease is chronic mild diarrhea, which affects the weight gain of pigs, generating economic losses. Vaccines available to prevent this condition do not have the desired effect, but this limitation can be overcome using adjuvants. Pro-inflammatory cytokines, such as interleukin 18 (IL-18), can improve an immune response, reducing the immune window of protection. In this study, recombinant porcine IL-18 was produced and expressed in Escherichia coli and Pichia pastoris. The protein’s biological activity was assessed in vitro and in vivo, and we determined that the P. pastoris protein had better immunostimulatory activity. A vaccine candidate against L. intracellularis, formulated with and without IL-18, was used to determine the pigs’ cellular and humoral immune responses. Animals injected with the candidate vaccine co-formulated with IL-18 showed a significant increase of Th1 immune response markers and an earlier increase of antibodies than those vaccinated without the cytokine. This suggests that IL-18 acts as an immunostimulant and vaccine adjuvant to boost the immune response against the antigens, reducing the therapeutic window of recombinant protein-based vaccines.

Review of: Hulme, Peter. The Dinner at Gonfarone’s. Salomón de la Selva and His Pan-American Project in Nueva York, 1915-1919. American Tropics. Liverpool: Liverpool University Press, 2019, 416 pp., il. ISBN: 978-1-78694-200-5.

El periodo entre la posguerra y el final de la década de los sesenta (1947 a 1970), que incluye las etapas centrales de la guerra fría cultural latinoamericana, fue particularmente fructífero en el desarrollo del periodismo cultural en México. Aunado a este proceso, hubo un auge de traducciones de poesía concentrado en la década de 1960. Desde un análisis cuantitativo, este artículo ofrece un primer panorama general de ese crecimiento, ligado a varias coyunturas editoriales. En un segundo momento se estudian las “políticas de traducciones” y “geografías culturales”, según lo estipula Beatriz Sarlo (1992), de tres revistas y suplementos cruciales para el periodo (Revista de la Universidad de México, La Cultura en México y El Corno Emplumado). Nos enfocamos en ciertas facetas biográficas interculturales de los poetas-traductores y otros intermediarios, como lo aconseja Anthony Pym, para reconstruir un ínfimo episodio de la historia de la traducción en México.

In a recent work, we reported a methodology for imaging the different stages of amyloid aggregation in quantitative multiparametric dual-color fluorescence lifetime imaging (FLIM) and superresolution microscopy by using a pair of dyes capable of binding aggregates and undergoing subsequent intra-aggregate energy transfer (FRET) (RuizArias et al. Sensors Actuat. B, 2022, 350:130882). In this microarticle we present the optimization process for choosing the best pair of dyes through a screening of different naphthalimides and quinolimides and other known amyloid-binding dyes.

Introduction: One of the major problems with inpatient treatment of adolescent girls with an eating disorder (ED) is that the strategies learned during their hospital stay are not easily applied or maintained in their daily lives, and this has been related to high rates of relapse and readmission. The ECHOMANTRA programme was developed to optimize outcomes during and following inpatient or day-patient treatment. ECHOMANTRA is based on interventions for carers (Experienced Carers Helping Others, ECHO) and patients (Maudsley Model of Anorexia Nervosa Treatment for Adults, MANTRA) and is developed from the cognitive interpersonal model of anorexia (Schmidt and Treasure, 2006; Treasure and Schmidt, 2013). This study aims to describe the study protocol of a randomized controlled trial (RCT) for evaluating the efficacy of an adaptation of a novel intervention for patients and carers (ECHOMANTRA) to be implemented as an add-on to treatment-as-usual (TAU).Method: In a multi−center pilot RCT, 80 female adolescent patients with a DSM-5 diagnosis of an ED and their carers will be invited to participate in the study. They will then be randomized to receive either the ECHOMANTRA intervention as an add-on to TAU or TAU alone. A repeated measures design will be conducted across four time points. Primary outcomes will be patient psychological well-being and eating disorder symptoms, and secondary outcomes will include body mass index, obsessive-compulsive symptoms, perfectionism, motivation to change and psychosocial adjustment. For carers, outcome variables will include psychological well-being, expressed emotion, accommodation and enabling behaviors, burden, and care skills.Discussion: The results from this trial will establish the effectiveness of ECHOMANTRA and may reveal whether and to what extent this novel intervention can optimize outcomes during and following inpatient treatment. This study will also provide the adaptation of the ECHOMANTRA in the Spanish context for inpatient/day-care treatment.

This paper explains the inclusion process done with a student with a severe visual impairment in Physical Activity and Sports Sciences Degree. This inclusion process required a close collaboration with professionals and social workers such as the family, the Spanish National Organization for Blind People (ONCE), the university Service for students with disabilities, faculty managers, professors and the student's peers. The student did the admission exam (theory and practical) in similar conditions to his classmates and specific adaptations were arranged. This case study paper is organized following the next group of actions: a) theory subjects, b) practical and sport subjects, c) adapted physical activity and the double inclusion paradigm, d) evaluations, and e) professional training. The inclusion of this student has been experienced as a great value for his classmates education and to date he is the only student with a severe visual impairment that has finished this studies in Spain. [ABSTRACT FROM AUTHOR]

Due to its relatively lower thermal conductivity, the suitability of wood is called into question when selecting the flooring material best suited to radiant heating systems. The European standard EN 1264 considers floorings with a thermal resistance over 0.15 m2 K/W to be out of scope. This belief was partially disproved in a previous article that studied wooden floors for Madrid’s climate. However, the effect of climate still needs to be addressed. The present study extends the previous research to worldwide climates and aimed to answer the following questions: (1) Do the lowest thermal conductivity woods present good thermal performance when used in radiant floors? (2) Should the flooring have a maximum thermal resistance value? (3) Is the standard thermal resistance limit of 0.15 m2 K/W objectively justified? And (4) Do the answers of the preceding questions depend on the climate and the construction characteristics? To answer these questions, 28 cities were selected according to the Köppen–Geiger climate classification. In each city, 216 different dwellings were simulated with 60 wood floorings and one of low thermal resistance as a reference, comprising a total of 368,928 cases. Thermal performance was evaluated in terms of three parameters: energy demand, thermal comfort, and start-up lag time. Consequently, the answers to the previous questions were: (1) The lowest thermal conductivity woods can be used efficiently worldwide in radiant floor heating systems with start-up lag times close to that of the reference flooring; (2) There is no limit value for thermal resistance for floorings that can be applied to all dwellings and climates; (3) No objective justification was found for establishing a thermal resistance limit for flooring of 0.15 m2 K/W; and (4) Climate and construction characteristics can play an important role in the correct selection of flooring properties, especially in severe winters and dwellings with the greatest outdoor-exposed envelope and the worst insulation.

Radiant floor heating is becoming increasingly popular in cold climates because it delivers higher comfort levels more efficiently than conventional systems. Wood is one of the surface coverings most frequently used in radiant flooring, despite the widely held belief that in terms of thermal performance it is no match for higher conductivity materials if a high energy performance is intended. Given that the highest admissible thermal resistance for flooring finishes or coverings is generally accepted to be 0.15 m2K/W, wood would appear to be a scantly appropriate choice. Nonetheless, the evaluation of the thermal performance of wooden radiant floor heating systems in conjunction with the building in terms of energy demand, thermal comfort, and start-up period, has been insufficiently explored in research. This has led to the present knowledge gap around its potential to deliver lower energy consumption and higher thermal comfort than high-thermal-conductivity materials, depending on building characteristics. This article studies the thermal performance of wood radiant floors in terms of three parameters: energy demand, thermal comfort, and start-up lag time, analysing the effect of wood properties in conjunction with building construction on each. An experimentally validated radiant floor model was coupled to a simplified building thermal model to simulate the performance of 60 wood coverings and one reference granite covering in 216 urban dwellings differing in construction features. The average energy demand was observed to be lower in the wood than in the granite coverings in 25% of the dwellings simulated. Similarly, on average, wood lagged behind granite in thermal comfort by less than 1 h/day in 50% of the dwellings. The energy demand was minimised in a significant 18% and thermal comfort maximised in 14% of the simulations at the lowest thermal conductivity value. The vast majority of the wooden floors lengthened the start-up lag time relative to granite in only 30 min or less in all the dwellings. Wood flooring with the highest thermal resistance (even over the 0.15 m2K/W cited in standard EN 1264-2) did not significantly affect the energy demand or thermal comfort. On average, wood flooring lowered energy demand by 6.4% and daily hours of thermal comfort by a mere 1.6% relative to granite coverings. The findings showed that wood-finished flooring may deliver comparable or, in some cases, higher thermal performance than high-conductivity material coverings, even when their thermal resistance is over 0.15 m2K/W. The suggestion is that the aforementioned value, presently deemed the maximum admissible thermal resistance, may need to be revised.

Abstract Background Porcine circovirus type 2 (PCV2) is a very small, non-enveloped and icosahedral virus, with circular single stranded DNA genome. This virus is the most ubiquitous and persistent pathogen currently affecting the swine industry worldwide. PCV2 has been implicated as the major causative agent of postweaning multisystemic wasting syndrome (PMWS), a disease which is characterized by severe immunosuppressive effects in the porcine host. Worldwide PCV2 isolates have been classified into four different genotypes, PCV2a, PCV2b, PCV2c and PCVd. The goal of this work was to conduct the first phylogenetic analysis of PCV2 in Chile. Methods PCV2 partial ORF2 sequences (462 nt) obtained from 29 clinical cases of PMWS in 22 Chilean intensive swine farms, covering over the 90% of the local pork-production, were analyzed. Results 14% and 52% of sequences belonged to the genotypes PCV2a and PCV2b, respectively. Surprisingly, 34% of sequences were PCV2a/PCV2d recombinant viruses. Conclusions Our findings suggested that a novel cluster of Chilean sequences emerged resulting from intergenotypic recombination between PCV2a and PCV2d.

Bimetallic nanoparticles are of special interest for their potential applications for fuel cells, mainly for portable power applications. Among the bimetallic systems, Pt-Pd bimetallic nanoparticles have received great interest as they can be widely used as effective catalysts for various electrochemical reactions. In this work, Pt-Pd alloy bimetallic nanoparticles were synthesized through a chemical reduction method. The nanoparticles were characterized using aberration-corrected scanning/transmission electron microscopy (STEM). Also, parallel beam X-Ray diffraction analysis was carried out to evaluate the crystallographic structure. High-angle annular dark field (HAADF)-STEM images of the Pt-Pd bimetallic nanoparticles were obtained. The contrast of the images shows that the nanoparticles have an alloy structure with an average size of 7.15 nm. To understand the properties of the bimetallic nanoparticles, it is necessary to know the distribution of the elements in the nanostructure. We have used a semi-quantitative method to analyze the HAADF-STEM images, which allowed us to measure the total intensity of the scattered electrons for each atomic column. HAADF-STEM images of the Pt-Pd bimetallic nanoparticles were compared directly with image simulations, good agreement between simulation and experimental images was found. Cyclic voltammetry studies were carried out to analyze the electrochemical behavior of the bimetallic nanoparticles.

This essay describes two 20th Century exceptional writers: Paz and Revueltas. Both writers share ideas and trust in the world of books, art and culture that the Mexican Revolution created. They tried to change the world, but each one of them, at the right time, was changed by history. I see similarities as well as strong differences among those two 20th Century minds. They both believed in the Revolution and above all, in the power of words to change men, but they were hit by fascism, the Spanish Civil War, the soviet socialism turned into dystopia and the Holocaust. Only writing could save them from the tragic era or from failure.

Buildings are known to be responsible for about a third of energy consumption in developed countries. This situation, together with the fact that the existing building stock is being renovated at a very slow pace, makes it crucial to focus on the energy retrofitting of buildings as the only way to reduce their contribution to these energy consumptions and the consequences derived from them in terms of pollution and climate change. The same level of insulation and the same type of windows is usually proposed for all dwellings in a building block. This article shows that since the improvements required by each dwelling in the same block are different, the proposed solution must also be different. The methodology is proposed for a practical case consisting of an apartment block in Cádiz, a demonstration building of the European RECO2ST project. To achieve the optimum solution for each case, a multi-objective optimization problem is solved: to minimize the annual heating demand of the building and the standard deviation of the annual demand of the different dwellings. Thanks to the use of the proposed methodology, it is possible to bring the building to a Nearly Zero Energy Building (NZEB) level, while avoiding excessive insulation that causes overheating in summer.

Recombinant vaccines have low-cost manufacturing, regulatory requirements, and reduced side effects compared to attenuated or inactivated vaccines. In the porcine industry, post-weaning multisystemic disease syndrome generates economic losses, characterized by progressive weight loss and weakness in piglets, and it is caused by porcine circovirus type 2 (PCV2). We designed a chimeric antigen (Qm1) to assemble the main exposed epitopes of the Cap-PCV2 protein on the capsid protein of the tobacco necrosis virus (TNV). This design was based on the Cap-N-terminal of an isolated PCV2 virus obtained in Chile. The virus was characterized, and the sequence was clustered within the PCV2 genotype b clade. This chimeric protein was expressed as inclusion bodies in both monomeric and multimeric forms, suggesting a high-molecular-weight aggregate formation. Pigs immunized with Qm1 elicited a strong and specific antibody response, which reduced the viral loads after the PCV2 challenge. In conclusion, the implemented design allowed for the generation of an effective vaccine candidate. Our proposal could be used to express the domains or fragments of antigenic proteins, whose structural complexity does not allow for low-cost production in Escherichia coli. Hence, other antigen domains could be integrated into the TNV backbone for suitable antigenicity and immunogenicity. This work represents new biotechnological strategies, with a reduction in the costs associated with vaccine development.

In this research, the adsorption capacity of Ag nanoparticles on natural zeolite from Oaxaca is presented. In order to describe the adsorption mechanism of silver nanoparticles on zeolite, experimental adsorption models for Ag ions and Ag nanoparticles were carried out. These experimental data obtained by the atomic absorption spectrophotometry technique were compared with theoretical models such as Lagergren first-order, pseudo-second-order, Elovich, and intraparticle diffusion. Correlation factors R2 of the order of 0.99 were observed. Analysis by transmission electron microscopy describes the distribution of the silver nanoparticles on the zeolite outer surface. Additionally, a chemical characterization of the material was carried out through a dilution process with lithium metaborate. An average value of 9.3 in the Si/Al ratio was observed. Factors such as the adsorption behavior of the silver ions and the Si/Al ratio of the zeolite are very important to support the theoretical models and establish the adsorption mechanism of Ag nanoparticles on natural zeolite.

Assessing the performance or energy efficiency of a single construction element by itself is often a futile exercise. That is not the case, however, when an element is designed, among others, to improve building energy performance by harnessing renewable energy in a process that requires a source of external energy. Harnessing renewable energy is acquiring growing interest in Mediterranean climates as a strategy for reducing the energy consumed by buildings. When such reduction is oriented to lowering demand, the strategy consists in reducing the building’s energy needs with the use of construction elements able to passively absorb, dissipate, or accumulate energy. When reduction is pursued through M&E services, renewable energy enhances building performance. The efficiency of construction systems that use renewable energy but require a supplementary power supply to operate can be assessed by likening these systems to regenerative heat exchangers built into the building. The indicators needed for this purpose are particularly useful for designers, for they can be used to compare the efficiency or performance to deliver an optimal design for each building. This article proposes a series of indicators developed to that end and describes their application to façades bearing phase change materials (PCMs).

Objetivo: Evaluar si las funciones de riesgo de Framingham y PROCAM son aplicables a la población colombiana. Métodos: Se desarrolló un estudio de validación externa dentro de una cohorte histórica, en la que se incluyeron pacientes de la clínica de prevención primaria del Hospital Militar Central de Bogotá (Colombia). Se evaluaron 1.013 pacientes entre 30 y 74 años, libres de eventos cardiovasculares al ingreso a la cohorte (1984 a 1996) que recibieron seguimiento durante diez años en busca de eventos cardiovasculares (muerte coronaria, infarto del miocardio o angina de pecho). Se comparó el número de eventos cardiovasculares predichos y observados en esos diez años (calibración). Finalmente, se estimó la capacidad de las funciones de riesgo para separar los sujetos de alto y bajo riesgo (discriminación). Resultados: En pacientes de riesgo bajo e intermedio, el número de eventos cardiovasculares predichos por la función de riesgo de Framingham sobrestimó los observados (relación entre eventos esperados y observados de 1,31), con baja capacidad para separar los pacientes de bajo riesgo de los de alto riesgo (AUC 0,65). La función de riesgo de PROCAM ajustada por sexo tuvo mejor capacidad de discriminación (AUC 0,74) con buena calibración (relación entre eventos esperados y observados de 1,07). No se contó con suficientes pacientes de alto riesgo para generalizar los resultados a esta población. Conclusiones: La función de riesgo de Framingham debería usarse con precaución en población colombiana de riesgo bajo e intermedio sin historia previa de eventos cardiovasculares dado que sobrestima el riesgo y tiene baja capacidad de discriminación. La función de riesgo de PROCAM ajustada por sexo es una mejor opción para estimar el riesgo de enfermedad cardiovascular dura.

Introduction: Glaucoma is a progressive and chronic optic neuropathy being the second cause of irreversible blindness worldwide. Several approaches are used to try to avoid this course, being the Trabeculectomy the surgical choice in the adult patient. Objetive: To analyze a cohort of patients that had trabeculectomy between 2005 and 2011 in San Ignacio’s University Hospital. Conclusion: Although is a small cohort of patients it enables us to confirm that this surgery is a good choice in the control of the intraocular pressure in order to avoid further damage to the optic nerve.

El objetivo de este artículo es revisar la importancia del síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) en la población que va a ser llevada a cirugía y cómo detectar en el preoperatorio a pacientes con riesgo elevado de complicaciones en el perioperatorio mediante el cuestionario STOP-BANG. Para lo anterior, se realizó una búsqueda en las bases Pubmed, Science y SciELO. El SAHOS es un problema médico importante con prevalencia variable (hasta el 26 % en la población general dependiendo del centro donde se evalúe). Es una enfermedad de inicio insidioso y progresivo, en la que hay episodios recurrentes de apneas o hipopneas causadas por obstrucción de la vía aérea superior durante el sueño que produce un deterioro significativo de la calidad de vida. Se quiere evaluar si el cuestionario STOP-BANG es útil para identificar, en el preoperatorio, a pacientes que tengan complicaciones perioperatorias, probablemente porque identifica pacientes con SAHOS no diagnosticado.

El déficit de atención e hiperactividad (TDAH) es uno de los trastornos del comportamiento más frecuentes en pediatría, que genera conductas maladaptativas inconsistentes con la edad y el desarrollo del niño. Recientemente ha despertado gran interés la alta coexistencia de este con trastornos de sueño, al igual que una posible causa bidireccional entre las alteraciones de la arquitectura del sueño y los síntomas principales del TDAH. El objetivo de esta revisión es encontrar la asociación entre el TDAH y los trastornos del sueño en la población pediátrica, evaluando a profundidad los documentos, con el fin de encontrar nivel de evidencia, para ampliar a futuro la intervención sobre el TDAH y optimizar la calidad de vida de estos pacientes, a corto y largo plazos. Se realizó la búsqueda en Pubmed, Cochrane y Fabumed, escogiendo estudios en niños, con menos de 10 años de publicación, en inglés o español, con acceso completo. Se escogieron 52 estudios basándose en su calidad y nivel de evidencia.

The emergence of novelties and their rise and fall in popularity is an ubiquitous phenomenon in human activities. The coexistence of popular evergreens with novel and sometimes ephemeral trends pervades technological, scientific and artistic production. Though this phenomenon is very intuitively captured by our common sense, a comprehensive explanation of how waves of novelties are not hampered by well established old-comers is still lacking. Here we first quantify this phenomenology by empirically looking at different systems that display innovation at very different levels: the creation of hashtags in Twitter, the evolution of online code repositories, the creation of texts and the listening of songs on online platforms. In all these systems surprisingly similar patterns emerge as the non-trivial outcome of two contrasting forces: the tendency of retracing already explored avenues (exploit) and the inclination to explore new possibilities. These findings are naturally explained in the framework of the expansion of the adjacent possible, a recently introduced theoretical framework that postulates the restructuring of the space of possibilities conditional to the occurrence of innovations. The predictions of our theoretical framework are borne out in all the phenomenologies investigated, paving the way to a better understanding and control of innovation processes.

En este trabajo analizamos las variables de deseo y de poder que están presentes en todos los discursos y, en particular, que atraviesan al discurso de la Medicina Basada en la Evidencia en su aplicación dentro del ámbito de la salud mental, por lo que la introducción nos servirá de marco definitorio de dichas variables. Seguidamente partiremos de las dificultades que la adopción del enfoque de la Medicina Basada en la Evidencia encuentra dentro de la práctica clínica de la salud mental y que nos hacen dudar de su condición del nuevo paradigma científico. Con el fin de comprender cómo la Medicina Basada en la Evidencia se convierte en un discurso atravesado por el deseo y el poder, examinaremos los elementos retóricos que ayudan a establecer en ciencia la verdad de una proposición para, posteriormente, dilucidar de qué forma se adquieren y actúan en el discurso el deseo y el poder. Para finalizar analizaremos brevemente las implicaciones éticas y las consecuencias epistemológicas que conllevan el conocimiento del deseo y el poder en el discurso de la Medicina Basada en la Evidencia.

Antecedentes: en el último consenso de la AHA/ACC se recomiendan puntajes clínicos para mejorar la sensibilidad (68%) y la especificidad (77%) de la prueba de esfuerzo, método diagnóstico de primera línea en el tratamiento de la enfermedad coronaria (una de las principales causas de morbimortalidad en Colombia y el mundo). Sin embargo, son pocas las instituciones del país que los utilizan y son difíciles de aplicar en poblaciones diferentes a aquellas para las cuales fueron desarrollados, haciéndose necesario realizar un estudio que valore su desempeño en nuestro medio. Materiales y métodos: se escogieron las escalas de Morise y Duke para evaluar por qué han sido validadas en varias poblaciones y fueron citadas en el consenso de la AHA/ACC. Los puntajes de Morise y Duke clasificaron a los pacientes en probabilidad baja, intermedia o alta para enfermedad coronaria. Objetivos primarios: validar las escalas de predicción para enfermedad coronaria y determinar el mejor punto de corte para cada escala en un tiempo de seguimiento de un año. Objetivos secundarios: determinar un desenlace compuesto por infarto agudo del miocardio, muerte cardiaca, angina que requiere hospitalización, obstrucción coronaria mayor a 50% y/o angioplastia e implante de stent. Determinar el mejor punto de corte mediante curvas de ROC. Criterios de inclusión: pacientes mayores de 18 años de edad, con sospecha de enfermedad coronaria. Criterios de exclusión: pacientes embarazadas, con enfermedad coronaria documentada, electrocardiograma no interpretable, incapacidad o contraindicación para realizar prueba de esfuerzo por cualquier motivo, depresión del segmento ST menor a 1 mm en el electrocardiograma de base, imposibilidad de realizar seguimiento, y datos incompletos que impidieran el cálculo de las escalas. Análisis estadístico: la muestra se calculó utilizando error alfa menor de 0,05, error beta menor de 0,20 (poder de 80%), probabilidad de clasificación correcta 0,4, nivel de kappa para la hipótesis nula 0,85 y nivel de kappa para la hipótesis alterna 0,7. Se utilizó el programa Tamaño de la Muestra (TaMaMu), versión 1,0, se requirieron 101 pacientes. Resultados: se reclutaron 127 pacientes y se excluyeron 9; 2 por pruebas de esfuerzo submáximas y 7 por no ser posible el seguimiento, y se analizaron 118. El seguimiento promedio fue de 343 días (1-564. Edad media: 59 años (29-83). Mujeres: 53% (63) y hombres: 47% (55). Edad media de 59 y de 57 años, respectivamente. Otras características: tabaquismo: 47% (55), dislipidemia: 68% (80), índice de masa corporal mayor a 27,5: 18% (45) y diabetes mellitus: 16% (19). La escala de Morise clasificó 36% (43) en bajo riesgo, 52% (61) en riesgo intermedio y 12% (14) en riesgo alto. Según Duke los resultados fueron 53% (63), 41% (48) y 6% (7) respectivamente. Al interpretar la prueba de esfuerzo aislada, los cardiólogos clasificaron a los pacientes así: 81% (95) negativas, 8% (10) sugestivas y 11% (14) positivas. El punto o desenlace final compuesto se presentó en 11% (14 pacientes). Al comparar a los pacientes con desenlace y sin éste, los primeros se clasificaban con más frecuencia como de alta probabilidad que aquellos que no, con diferencias estadísticamente significativas (Morise: p=0,0002 y Duke: 0,0005). En la escala de Morise con punto de corte de 48, se logró sensibilidad de 92% y especificidad de 68%. En Duke, con punto de corte de 38, fue de 100% y 31%. Discusión: la concordancia para Morise es mejor que para los demás métodos evaluados. Adicionar los puntajes clínicos a la interpretación de la prueba de esfuerzo mejora las características operativas de la misma sin aumentar los costos, y se logra un ahorro de 10% a 18%. Conclusiones: los puntajes clínicos aumentan la sensibilidad y la especificidad, por lo cual se deberían utilizar de manera rutinaria para el informe de una prueba de esfuerzo convencional. Sin embargo, se hace necesario buscar soluciones que mejoren aún más dicho desempeño.Background: in the last AHA/ACC expert consensus document, clinical scores to improve sensitivity (68%) and specificity (77% of the exercise testing, diagnostic method considered a first line diagnostic method for coronary heart disease treatment (one of the main causes of mortality in Colombia and worldwide), are recommended. Nevertheless, few institutions in our country use them and they are difficult to apply in populations different to the ones for which they were developed. For this reason, a study to assess its performance in our environment, is needed. Materials and Methods: Morise and Duke treadmill scores were chosen to assess the reason for its validation in several populations, and were mentioned in the AHA/ACC consensus. The Morise and Duke scores classified patients in at low, middle and high risk for coronary heart disease. Primary objectives: validate the prediction scales for coronary heart disease and determine the best cutoff value for each score in a one year follow-up. Secondary objectives: determine the composite endpoint for acute myocardial infarction, cardiac death, angina requiring hospitalization, coronary obstruction >50% and/or angioplasty and stent implantation. Determine the best cutoff point through the ROC curves. Inclusion Criteria: patients >18 years old with suspected coronary heart disease. Exclusion Criteria: pregnant women with documented coronary heart disease, uninterpretable EKG, incapacity or contraindication for performing exercise stress test for any reason, ST depression < 1 mm in basal EKG, follow-up impossibility and incomplete data that might hinder the score calculation. Statistical analysis: the sample was calculated using alpha error < 0.05, beta error < 0.20 (power 80%), correct classification probability 0.4, kappa level for null hypothesis 0.85 and kappa level for alternate hypothesis 0,7. The Sample Size Program version 1.0 was used. 101 patients were required. Results: 127 patients were enrolled and 9 were excluded: 2 because of submaximal exercise testings and 7 because the follow-up was impossible. 118 patients were analyzed. Mean follow-up was 343 days (1 - 564). Mean age was 59 years (29 - 83). Women: 53% (63) and men: 47% (55). Mean age 59 and 57 years respectively. Other characteristics: cigarette smoking: 47% (55), dyslipidemia: 68% (80), body mass index > 27,5: 18% (45) and diabetes mellitus: 16% (19). Morise score classified 36% (43) patients at low risk, 52% (61) at intermediate risk and 12% (14) at high risk. According to Duke the results were 53% (63), 41% (48) and 6% (7) respectively. When interpreting an isolated exercise testing, cardiologists classified patients: 81% (95) negative, 8% (10) suggestive and 11% (14) positive. The composite endpoint appeared in 11% (14 patients). When comparing patients with and without outcomes, the first ones classified more frequently as having higher probability than those that had not, with statistically significant differences (Morise: p = 0,0002 and Duke: 0,0005). In the Morise score with cutoff value 48, 92% sensitivity and 68% specificity was achieved. In Duke, with cutoff value 38, it was 100% and 31% respectively. Discussion: concordance for Morise is better than for the other evaluated methods. The addition of clinical scores to the exercise testing interpretation improves its operative characteristics without any cost increment, achieving savings of 10% to 18%. Conclusions: clinical scores increase sensitivity and specificity, and for this reason they should be used as routine in the conventional exercise testing report. Nevertheless, it is necessary to look for solutions to improve its performance even further.

El derecho a morir con dignidad es un concepto vago y que recibe múltiples interpretaciones, muchas de ellas inapropiadas. Se propone la necesidad de que sea el médico quien se haga responsable de proteger los derechos del paciente, de garantizar el uso racional de los recursos y de velar porque las decisiones sean apropiadas y proporcionadas a la situación del paciente, a su pronóstico, expectativas y deseos, pero también, a la utilidad esperada y a la relación costo-beneficio. Se enfatiza que la dignidad puede ser entendida de muchas maneras y que, a veces, en su nombre se somete al paciente, o lo hace él mismo, a sufrimientos, dolor y complicaciones que podrían haberse evitado, no necesariamente en busca de prolongar la vida. Se hace énfasis en que, cuando no hay probabilidades razonables de supervivencia o cuando no puede ya buscarse mejorar la calidad de vida, deben enfocarse los esfuerzos en procurar calidad de muerte.