Un tercio de la población va a morir por accidente cerebrovascular o va a sufrir de demencia, si no se interviene en el diagnóstico, tratamiento y prevención. Este ha sido el punto de partida para la investigación premiada ahora con el Gran Premio BIAL de Medicina, cuyo valor es 200.000 euros.
“El largo fusible: ACV’s silenciosos y la insidiosa enfermedad de Alzheimer" es el título de la obra ganadora centrada en la relación entre los accidentes cerebrovasculares (ACV) y la enfermedad de Alzheimer. El autor, Vladimir Hachinski, sostiene que las enfermedades, aparentemente diferentes, tienen mucho en común y muestra que estas patologías no se suman, sino que se potencian.
Profesor de Neurología en la Universidad de Western Ontario, Canadá, editor de la revista médica “Stroke”, publicación de la American Heart Association, y Vicepresidente del World Federation of Neurology, Vladimir Hachinski es un investigador consagrado. Doctor Honoris Causa en varias Universidades Internacionales, fue galardonado en 2008 con la Order of Canada por su trabajo en investigación en las áreas de demencia y de los ACV.
-Una mirada innovadora a la enfermedad de Alzheimer
El trabajo de investigación premiado ahora abre camino a importantes perspectivas terapéuticas que pueden añadir años de cerebro sano a los años de vida para la mayoría de los pacientes. El autor defiende un plan preventivo, que se basa en un criterio de diagnóstico más riguroso, e indica soluciones que permiten una distinción más precisa entre los déficits cognitivos de la memoria (la mayoría vinculados a la enfermedad de Alzheimer) y los de la función ejecutiva (la mayoría vinculados a los ACVs silenciosos).
En la investigación científica que ha desarrollado, Vladimir Hachinski sostiene que las indicaciones de ligeras pérdidas de la función ejecutiva deben ser vistas como signos de suma importancia, ya que son indicativos de patología inicial capaz de intervención precoz, que pueden cambiar positivamente el curso de la enfermedad.
Cada año 1,4 millones de europeos desarrollan una demencia, lo que significa que cada 24 segundos se diagnostica un nuevo caso. Estos datos revelados por el Proyecto “European Collaboration on Dementia” (Eurocode) y conducido por la Alzheimer Europe, también revelan que el número de ciudadanos europeos con demencia es de alrededor de 7,3 millones. En España se estima que hay cerca de 400.000 personas con demencia. Con el envejecimiento de la población en la mayoría de países europeos, los expertos predicen una duplicación de estos valores en Europa Occidental en 2040, y puede ser tres veces más en el Este de Europa.
-Nuevos usos para los "viejos" medicamentos
Otro trabajo destacado intenta desafiar a la comunidad científica para crear un repositorio de medicamentos para uso clínico, basándose en los éxitos del pasado en lo que respecta el redescubrimiento de los medicamentos.
La mención honorífica "Nuevos usos para los “viejos” medicamentos” ha sido asignada a un proyecto de investigación que ha procurado descubrir los inhibidores de la malaria y de la angiogénesis, útiles bajo el punto de vista clínico, teniendo como origen los fármacos existentes. Los autores crearon y analizaron un repositorio de 2.687 medicamentos, y se identificaron tres nuevas indicaciones clínicamente prometedoras para los medicamentos existentes, en particular para combatir la malaria, la enfermedad que mata más personas cada año en todo el mundo.
El trabajo distinguido ahora ha sido coordinado por Curtis R. Chong, Médico en la Harvard Medical School, Boston, EUA, en colaboración con el profesor Jun Liu, Profesor de Farmacología en la Johns Hopkins University, School of Medicine, Baltimore, EUA y David J. Sullivan Jr., Profesor Asociado de Microbiología Molecular e Inmunología en el Malaria Research Institute, The Johns Hopkins Bloomberg School of Public Health, Baltimore, EUA.
"El genoma humano en acción" es el título de otra obra distinguida con Mención Honorífica. Este estudio describe los principales resultados del grupo de investigación dirigido por la Prof. Carmo Fonseca, Directora Ejecutiva del Instituto de Medicina Molecular, Lisboa, y recientemente galardonada con el Prémio Pessoa, obtenidos en la última década. El tema central de este trabajo se basa en la comprensión y la investigación en torno a la compartimentación nuclear en la función genómica y sus implicaciones para el enfoque terapéutico.
“Estimulación Cerebral Profunda: desde el tratamiento de la enfermedad de Parkinson hacia una nueva visión de la función cerebral" es el título de otro trabajo distinguido con una mención honorífica. La investigación realizada en el tratamiento de la enfermedad de Parkinson con esta técnica permitió acumular conocimientos fundamentales para comprender los mecanismos subyacentes al funcionamiento cerebral. La investigación fue coordinada por el Profesor Rui Vaz, Director del Departamento de Neurocirugía, Hospital S. João, Porto.
El tema de la obesidad también ha sido distinguido en la 14 ª edición del PREMIO BIAL por el trabajo coordinado por la Prof. Isabel do Carmo "La obesidad en la práctica clínica." En comparación con estudios anteriores, realizados entre 1995 - 1998, esta investigación concluye que hubo un aumento del 4% en la población total con sobrepeso. En Portugal, los adultos tuvieron una prevalencia de 39,4% de preobesidad y 14,2% de obesidad, y 45,6% de la población presenta perímetro de la cintura predictivo del riesgo cardiovascular. Las autoras defienden un tratamiento multidisciplinario - médico, nutricional, físico y, si es necesario, la cirugía - para combatir los números crecientes de la obesidad.
En esta edición del PREMIO BIAL son premiados cinco trabajos inéditos que están en la vanguardia de la investigación científica en el área de la salud - el "Gran Premio BIAL de Medicina", contemplando un importe de 200 miles de euros y cuatro menciones honoríficas con un valor de 5000 euros cada una.
--PREMIO BIAL ya ha revisado 518 trabajos candidatos y movilizó a 1.156 investigadores, médicos y científicos
Desde su creación en 1984, el PREMIO BIAL ha analizado 518 obras candidatas y ha involucrado a 1.156 investigadores, médicos y científicos. En sus catorce ediciones, este galardón ha distinguido a 227 autores, ha premiado 87 obras, y se han distribuido gratuitamente entre la clase médica más de 30 obras premiadas, un total de alrededor de 300.000 copias.
Considerado uno de los premios para la investigación científica de mayor prestigio en todo el mundo en el área de la salud, la 14 ª edición del Premio BIAL ha recibido un número récord de 63 candidaturas, de Portugal, Brasil, Canadá, España, EUA, Italia, Perú y Reino Unido.
El jurado del Premio BIAL 2010 tiene como Presidente al Profesor Nuno Sousa y es constituido por representantes de las Escuelas Portuguesas de Medicina, Profesores Agostinho Almeida Santos (Facultad de Medicina, Coimbra) António Sousa Guerreiro (Facultad de Ciencias Médicas, Universidad Nova de Lisboa) Carlos Lopes (Instituto de Ciencias Biomédicas Abel Salazar) Henrique Barros (Facultad de Medicina, Porto) Joana Palha (Escuela de Ciencias de la Salud, Universidad de Minho) José Manuel Calheiros (Facultad de Ciencias de la Salud, Universidad de Beira Interior) Leonor Parreira (Facultad de Medicina, Lisboa)
El valor efectivo del Premio BIAL contempla un total de 320.000 euros, y lo sitúa entre los mayores premios en el área de la salud en Europa. El Premio BIAL es otorgado cada dos años y tiene el alto patrocinio de Su Excelencia el Presidente de la República, del Consejo de Rectores de las Universidades Portuguesas y de la Orden de los Médicos.
17 May 2011
T'ai chi helps prevent falls and improve mental health in the elderly
T'ai chi has particular health benefits for older people, including helping to prevent falls and improving mental wellbeing, reveals a review published ahead of print in the British Journal of Sports Medicine. But the Chinese martial art widely practised for its health benefits does not help improve the symptoms of cancer or rheumatoid arthritis and the evidence is contradictory for many other health conditions and symptoms.
The effectiveness of t'ai chi for a variety of medical conditions and symptoms has been assessed in several studies and reviews, but their findings have been contradictory, so researchers from Korea Institute of Oriental Medicine in South Korea and the University of Exeter in the UK decided to compare the conclusions of these reviews to gain a better understanding of the benefits of t'ai chi.
Thirty five relevant reviews assessing t'ai chi were identified from English, Chinese and Korean databases. They looked at the effectiveness of the technique in a variety of disease areas, including cancer, Parkinson's disease, musculoskeletal pain, osteoarthritis, rheumatoid arthritis, cardiovascular disease, high blood pressure, osteoporosis and type 2 diabetes. Some reviews also assessed the benefits of t'ai chi for psychological health, balance and fall prevention, muscle strength and flexibility and improving aerobic capacity.
For several conditions, the findings of the reviews were contradictory. However, there was relatively clear evidence that t'ai chi is effective for fall prevention and improving psychological health and was associated with general health benefits for older people. On the other hand, t'ai chi seemed to be ineffective for the symptomatic treatment of cancer and rheumatoid arthritis.
The authors conclude: "Our overview showed that t'ai chi, which combines deep breathing and relaxation with slow and gentle movements, may exert exercise-based general benefits for fall prevention and improvement of balance in older people as well as some meditative effects for improving psychological health. We recommend t'ai chi for older people for its various physical and psychological benefits. However, t'ai chi may not effectively treat inflammatory diseases. "
**Source: BMJ-British Medical Journal
The effectiveness of t'ai chi for a variety of medical conditions and symptoms has been assessed in several studies and reviews, but their findings have been contradictory, so researchers from Korea Institute of Oriental Medicine in South Korea and the University of Exeter in the UK decided to compare the conclusions of these reviews to gain a better understanding of the benefits of t'ai chi.
Thirty five relevant reviews assessing t'ai chi were identified from English, Chinese and Korean databases. They looked at the effectiveness of the technique in a variety of disease areas, including cancer, Parkinson's disease, musculoskeletal pain, osteoarthritis, rheumatoid arthritis, cardiovascular disease, high blood pressure, osteoporosis and type 2 diabetes. Some reviews also assessed the benefits of t'ai chi for psychological health, balance and fall prevention, muscle strength and flexibility and improving aerobic capacity.
For several conditions, the findings of the reviews were contradictory. However, there was relatively clear evidence that t'ai chi is effective for fall prevention and improving psychological health and was associated with general health benefits for older people. On the other hand, t'ai chi seemed to be ineffective for the symptomatic treatment of cancer and rheumatoid arthritis.
The authors conclude: "Our overview showed that t'ai chi, which combines deep breathing and relaxation with slow and gentle movements, may exert exercise-based general benefits for fall prevention and improvement of balance in older people as well as some meditative effects for improving psychological health. We recommend t'ai chi for older people for its various physical and psychological benefits. However, t'ai chi may not effectively treat inflammatory diseases. "
**Source: BMJ-British Medical Journal
Hormone improves long-term recovery from stroke
Scientists at the Sahlgrenska Academy have discovered an explanation of how stroke patients can achieve better recovery. A hormone that is associated with the growth hormone system has proved to benefit recovery during the later phases of rehabilitation after a stroke. Insulin-like growth factor I, IGF-I, is a hormone that is found in the blood and contributes to, among other things, growth and bone mass. The levels of this hormone are higher in people who exercise regularly and those with good health. Scientists at the Sahlgrenska Academy have shown for the first time that high levels of this hormone are associated with better long-term recovery after a stroke. The study has been presented in an article in the Journal of Clinical Endocrinology and Metabolism.
"This study is interesting for two reasons. The first is that we show that a hormone is associated with improved long-term recovery, and thus there is still the prospect of improvement – even after three months after the stroke. The second is that levels of this hormone are known to be elevated in those who exercise often", says Associate Professor David Åberg at the Sahlgrenska Academy, who has led the study in collaboration with Professor Jörgen Isgaard.
"It is, however, important to add that the levels of IGF-I are controlled also by other factors such as other growth hormones, heredity and nutrition", emphasises David Åberg.
The study is based on 407 patients who are participating in the SAHLSIS study at the Sahlgrenska Academy, in which people aged 18-70 years who are affected by stroke are followed up for two years after the event. SAHLSIS is an acronym for "The Sahlgrenska Academy Study on Ischemic Stroke".
Scientists have measured the levels of IFG-I in these 407 patients and seen that increased levels are associated with better recovery, when the degree of recovery is determined between 3 and 24 months after the stroke. Previous research (Bondanelli et al) has also shown a positive effect of high IGF-I levels in the early phase after a stroke, while the scientists at the Sahlgrenska Academy have now demonstrated that the positive effects on recovery remain long after the stroke event.
"Our results may explain why patients who exercise more actively, with physiotherapy and physical exercise, demonstrate better recovery after a stroke. Unfortunately, we do not know how much our patients exercised after the stroke. This means that we need to carry out further studies in which we measure both the amount of physical activity and the levels of IGF-I, in order to understand the exact relationships better", David Åberg points out.
These results pave the way for further studies on whether drug treatments that raise IGF-I levels can improve long-term recovery after stroke. David Åberg believes that two avenues are open: either to treat with IGF-I, or to treat with the better known growth hormone (GH). This can stimulate the body's own production of IGF-I.
"Of course, these possibilities must be tested in carefully constructed clinical trials, so that we discover any undesired effects that must be considered. This is particularly true during the acute phase of a stroke, while treatment during the recovery phase is probably easier and has greater benefit", says David Åberg.
**Source: University of Gothenburg
"This study is interesting for two reasons. The first is that we show that a hormone is associated with improved long-term recovery, and thus there is still the prospect of improvement – even after three months after the stroke. The second is that levels of this hormone are known to be elevated in those who exercise often", says Associate Professor David Åberg at the Sahlgrenska Academy, who has led the study in collaboration with Professor Jörgen Isgaard.
"It is, however, important to add that the levels of IGF-I are controlled also by other factors such as other growth hormones, heredity and nutrition", emphasises David Åberg.
The study is based on 407 patients who are participating in the SAHLSIS study at the Sahlgrenska Academy, in which people aged 18-70 years who are affected by stroke are followed up for two years after the event. SAHLSIS is an acronym for "The Sahlgrenska Academy Study on Ischemic Stroke".
Scientists have measured the levels of IFG-I in these 407 patients and seen that increased levels are associated with better recovery, when the degree of recovery is determined between 3 and 24 months after the stroke. Previous research (Bondanelli et al) has also shown a positive effect of high IGF-I levels in the early phase after a stroke, while the scientists at the Sahlgrenska Academy have now demonstrated that the positive effects on recovery remain long after the stroke event.
"Our results may explain why patients who exercise more actively, with physiotherapy and physical exercise, demonstrate better recovery after a stroke. Unfortunately, we do not know how much our patients exercised after the stroke. This means that we need to carry out further studies in which we measure both the amount of physical activity and the levels of IGF-I, in order to understand the exact relationships better", David Åberg points out.
These results pave the way for further studies on whether drug treatments that raise IGF-I levels can improve long-term recovery after stroke. David Åberg believes that two avenues are open: either to treat with IGF-I, or to treat with the better known growth hormone (GH). This can stimulate the body's own production of IGF-I.
"Of course, these possibilities must be tested in carefully constructed clinical trials, so that we discover any undesired effects that must be considered. This is particularly true during the acute phase of a stroke, while treatment during the recovery phase is probably easier and has greater benefit", says David Åberg.
**Source: University of Gothenburg
Hormone improves long-term recovery from stroke
Scientists at the Sahlgrenska Academy have discovered an explanation of how stroke patients can achieve better recovery. A hormone that is associated with the growth hormone system has proved to benefit recovery during the later phases of rehabilitation after a stroke. Insulin-like growth factor I, IGF-I, is a hormone that is found in the blood and contributes to, among other things, growth and bone mass. The levels of this hormone are higher in people who exercise regularly and those with good health. Scientists at the Sahlgrenska Academy have shown for the first time that high levels of this hormone are associated with better long-term recovery after a stroke. The study has been presented in an article in the Journal of Clinical Endocrinology and Metabolism.
"This study is interesting for two reasons. The first is that we show that a hormone is associated with improved long-term recovery, and thus there is still the prospect of improvement – even after three months after the stroke. The second is that levels of this hormone are known to be elevated in those who exercise often", says Associate Professor David Åberg at the Sahlgrenska Academy, who has led the study in collaboration with Professor Jörgen Isgaard.
"It is, however, important to add that the levels of IGF-I are controlled also by other factors such as other growth hormones, heredity and nutrition", emphasises David Åberg.
The study is based on 407 patients who are participating in the SAHLSIS study at the Sahlgrenska Academy, in which people aged 18-70 years who are affected by stroke are followed up for two years after the event. SAHLSIS is an acronym for "The Sahlgrenska Academy Study on Ischemic Stroke".
Scientists have measured the levels of IFG-I in these 407 patients and seen that increased levels are associated with better recovery, when the degree of recovery is determined between 3 and 24 months after the stroke. Previous research (Bondanelli et al) has also shown a positive effect of high IGF-I levels in the early phase after a stroke, while the scientists at the Sahlgrenska Academy have now demonstrated that the positive effects on recovery remain long after the stroke event.
"Our results may explain why patients who exercise more actively, with physiotherapy and physical exercise, demonstrate better recovery after a stroke. Unfortunately, we do not know how much our patients exercised after the stroke. This means that we need to carry out further studies in which we measure both the amount of physical activity and the levels of IGF-I, in order to understand the exact relationships better", David Åberg points out.
These results pave the way for further studies on whether drug treatments that raise IGF-I levels can improve long-term recovery after stroke. David Åberg believes that two avenues are open: either to treat with IGF-I, or to treat with the better known growth hormone (GH). This can stimulate the body's own production of IGF-I.
"Of course, these possibilities must be tested in carefully constructed clinical trials, so that we discover any undesired effects that must be considered. This is particularly true during the acute phase of a stroke, while treatment during the recovery phase is probably easier and has greater benefit", says David Åberg.
**Source: University of Gothenburg
"This study is interesting for two reasons. The first is that we show that a hormone is associated with improved long-term recovery, and thus there is still the prospect of improvement – even after three months after the stroke. The second is that levels of this hormone are known to be elevated in those who exercise often", says Associate Professor David Åberg at the Sahlgrenska Academy, who has led the study in collaboration with Professor Jörgen Isgaard.
"It is, however, important to add that the levels of IGF-I are controlled also by other factors such as other growth hormones, heredity and nutrition", emphasises David Åberg.
The study is based on 407 patients who are participating in the SAHLSIS study at the Sahlgrenska Academy, in which people aged 18-70 years who are affected by stroke are followed up for two years after the event. SAHLSIS is an acronym for "The Sahlgrenska Academy Study on Ischemic Stroke".
Scientists have measured the levels of IFG-I in these 407 patients and seen that increased levels are associated with better recovery, when the degree of recovery is determined between 3 and 24 months after the stroke. Previous research (Bondanelli et al) has also shown a positive effect of high IGF-I levels in the early phase after a stroke, while the scientists at the Sahlgrenska Academy have now demonstrated that the positive effects on recovery remain long after the stroke event.
"Our results may explain why patients who exercise more actively, with physiotherapy and physical exercise, demonstrate better recovery after a stroke. Unfortunately, we do not know how much our patients exercised after the stroke. This means that we need to carry out further studies in which we measure both the amount of physical activity and the levels of IGF-I, in order to understand the exact relationships better", David Åberg points out.
These results pave the way for further studies on whether drug treatments that raise IGF-I levels can improve long-term recovery after stroke. David Åberg believes that two avenues are open: either to treat with IGF-I, or to treat with the better known growth hormone (GH). This can stimulate the body's own production of IGF-I.
"Of course, these possibilities must be tested in carefully constructed clinical trials, so that we discover any undesired effects that must be considered. This is particularly true during the acute phase of a stroke, while treatment during the recovery phase is probably easier and has greater benefit", says David Åberg.
**Source: University of Gothenburg
Objective evidence of skin infestation lacking in patients with diagnosis of delusional infestation
Among patients with a diagnosis of delusional skin infestation, neither biopsies nor patient-provided specimens provided objective evidence of skin infestation, according to a report posted online today that will be published in the September issue of Archives of Dermatology, one of the JAMA/Archives journals. Delusional infestation is a condition in which patients steadfastly yet mistakenly believe that pathogens are infesting their skin. Sometimes, patients believe their skin is literally crawling with bugs, worms, or germs, which is also known as "delusions of parasitosis." In other cases, patients perceive that inanimate objects such as wood chips, fibers, or little tubes are involved. While case reports and small case series of these reports exist, there has not been much formal study of the validity of the specimens, whether derived from biopsies or provided by the patients themselves.
Sara A. Hylwa, B.S., and colleagues from the Mayo Medical School and Mayo Clinic in Rochester , Minn. conducted a retrospective review of delusional infestation cases seen at the Mayo Clinic between 2001 and 2007. Of the 108 patients included in this study, 80 received biopsies, 80 provided self-procured specimens, and 52 had both. Among the materials reported to be infesting the skin were bugs (79%), worms, eggs, fibers, "specks," "triangles," and gravel or grainlike material.
None of the biopsies showed evidence of infestation, the authors report. Sixty-one percent did reveal dermatitis and nearly half (48%) exhibited excoriation, ulceration or erosion of the skin. Of the patient-provided specimens, one-fourth of which were examined by a pathologist, only one contained an infesting parasite—a pubic louse that was determined not to be responsible for the symptoms reported.
The authors write that the results suggest that in cases of delusional infestation, biopsies may not overturn the diagnosis: "This study is important for patients. Patients frequently believe that physicians are dismissive of their concerns and are not examining their skin closely enough, and therefore patients request that more testing be performed." In conclusion, the authors note, "The majority of skin biopsy results did show dermatitis, raising the possibility that skin inflammation and its attendant tactile discomfort might be the trigger provoking delusional symptoms in susceptible individuals."
**Source: JAMA and Archives Journals
Sara A. Hylwa, B.S., and colleagues from the Mayo Medical School and Mayo Clinic in Rochester , Minn. conducted a retrospective review of delusional infestation cases seen at the Mayo Clinic between 2001 and 2007. Of the 108 patients included in this study, 80 received biopsies, 80 provided self-procured specimens, and 52 had both. Among the materials reported to be infesting the skin were bugs (79%), worms, eggs, fibers, "specks," "triangles," and gravel or grainlike material.
None of the biopsies showed evidence of infestation, the authors report. Sixty-one percent did reveal dermatitis and nearly half (48%) exhibited excoriation, ulceration or erosion of the skin. Of the patient-provided specimens, one-fourth of which were examined by a pathologist, only one contained an infesting parasite—a pubic louse that was determined not to be responsible for the symptoms reported.
The authors write that the results suggest that in cases of delusional infestation, biopsies may not overturn the diagnosis: "This study is important for patients. Patients frequently believe that physicians are dismissive of their concerns and are not examining their skin closely enough, and therefore patients request that more testing be performed." In conclusion, the authors note, "The majority of skin biopsy results did show dermatitis, raising the possibility that skin inflammation and its attendant tactile discomfort might be the trigger provoking delusional symptoms in susceptible individuals."
**Source: JAMA and Archives Journals
Decision aid helps families, clinicians communicate about care decisions
Surrogate decision-makers faced with the difficult task of overseeing loved ones' medical care may find help thanks to a new decision aid aimed at patients with prolonged mechanical ventilation. According to a study conducted by researchers in North Carolina, Pennsylvania and Washington who developed and tested the aid, surrogates reported the aid significantly improved the often daunting decision-making process. The study results will be presented at the ATS 2011 International Conference in Denver.
The decision aid was developed specifically for surrogate decision makers of patients who require mechanical ventilation for extended periods, a condition known as prolonged mechanical ventilation (PMV). Each year, about 300,000 U.S. patients are placed on prolonged mechanical ventilation. About 50 percent of those patients die within a year, typically after spending 75 percent of their final days in health care facilities. These patients have healthcare costs exceeding $20 billion each year in the United States.
"For patients at risk for PMV, challenging decisions must be made about whether to continue a course of aggressive treatment or whether to emphasize comfort at the possible expense of survival," said study author Christopher Cox, MD, an assistant professor of medicine and co-director of the medical ICU at Duke University Medical Center. "The burden of life support decision-making rests on family members and other surrogate decision-makers because of patients' severe illnesses. However the quality of this decision-making process is severely deficient."
Dr. Cox said the communication deficit between clinicians and surrogates in the decision-making process has several causes, including difficulty explaining a complicated critical illness and its management options to surrogates, particularly in a multi-provider, shift-work environment.
"This poor communication quality leads to a dramatic degree of discordance between surrogates and clinicians for expected patient outcomes," Dr. Cox noted. "These deficiencies also may lead to decisions that are inconsistent with a patient's values, prolonged life support that is extraordinarily costly and ineffective, and psychological distress among surrogates."
Initially designed in a written format, the decision aid integrates clinical data, treatment goals and individualized prognostic estimates.
"The decision aid we developed was designed specifically for the surrogates of patients at risk of PMV to assist them in this complicated process," said Cox.
For their study, the researchers enrolled 30 surrogates of patients at risk for PMV who were being treated in medical and surgical ICUs at three North Carolina medical centers, and divided them into two groups: 20 surrogates who used the decision aid and 10 control surrogates who relied on usual care.
According to their results, surrogates who used the decision aid experienced greater improvements in the agreement between surrogates and both physicians and nurses about expected patient survival , decisional conflict, and both quality of communication and medical comprehension score, compared to controls. Those who used the decision aid also reported a 31 percent decrease in uncertainty about preferred treatment goals and were 44 percent more likely than controls to report that they engaged physicians in discussing long-term patient outcomes. Additionally, decision-aid patients had shorter hospital lengths of stay yet similar mortality to control patients.
"These data provide initial evidence that the PMV decision aid could help to improve surrogate-clinician decision-making quality and may reduce health care utilization," Dr. Cox said.
The results could have an important impact in ICUs around the world, he added.
"We hope that the decision aid can be used to complement, not replace, the physician-family interaction - and in this age of digital information, empower surrogates by providing them with useful information to make better decisions," he said.
Since the initial study involved a small sample of patients and was confined to two medical centers, Dr. Cox said future studies will need to involve larger patient populations and more medical centers to confirm the results.
Additional studies are under way to test both web-based and iPad-based versions of the decision aid, he said.
"We hope these digital versions will allow the decision aid to be widely disseminated to other providers worldwide," Dr. Cox said. "The potential target audience is both large and deserving."
Source: American Thoracic Society
The decision aid was developed specifically for surrogate decision makers of patients who require mechanical ventilation for extended periods, a condition known as prolonged mechanical ventilation (PMV). Each year, about 300,000 U.S. patients are placed on prolonged mechanical ventilation. About 50 percent of those patients die within a year, typically after spending 75 percent of their final days in health care facilities. These patients have healthcare costs exceeding $20 billion each year in the United States.
"For patients at risk for PMV, challenging decisions must be made about whether to continue a course of aggressive treatment or whether to emphasize comfort at the possible expense of survival," said study author Christopher Cox, MD, an assistant professor of medicine and co-director of the medical ICU at Duke University Medical Center. "The burden of life support decision-making rests on family members and other surrogate decision-makers because of patients' severe illnesses. However the quality of this decision-making process is severely deficient."
Dr. Cox said the communication deficit between clinicians and surrogates in the decision-making process has several causes, including difficulty explaining a complicated critical illness and its management options to surrogates, particularly in a multi-provider, shift-work environment.
"This poor communication quality leads to a dramatic degree of discordance between surrogates and clinicians for expected patient outcomes," Dr. Cox noted. "These deficiencies also may lead to decisions that are inconsistent with a patient's values, prolonged life support that is extraordinarily costly and ineffective, and psychological distress among surrogates."
Initially designed in a written format, the decision aid integrates clinical data, treatment goals and individualized prognostic estimates.
"The decision aid we developed was designed specifically for the surrogates of patients at risk of PMV to assist them in this complicated process," said Cox.
For their study, the researchers enrolled 30 surrogates of patients at risk for PMV who were being treated in medical and surgical ICUs at three North Carolina medical centers, and divided them into two groups: 20 surrogates who used the decision aid and 10 control surrogates who relied on usual care.
According to their results, surrogates who used the decision aid experienced greater improvements in the agreement between surrogates and both physicians and nurses about expected patient survival , decisional conflict, and both quality of communication and medical comprehension score, compared to controls. Those who used the decision aid also reported a 31 percent decrease in uncertainty about preferred treatment goals and were 44 percent more likely than controls to report that they engaged physicians in discussing long-term patient outcomes. Additionally, decision-aid patients had shorter hospital lengths of stay yet similar mortality to control patients.
"These data provide initial evidence that the PMV decision aid could help to improve surrogate-clinician decision-making quality and may reduce health care utilization," Dr. Cox said.
The results could have an important impact in ICUs around the world, he added.
"We hope that the decision aid can be used to complement, not replace, the physician-family interaction - and in this age of digital information, empower surrogates by providing them with useful information to make better decisions," he said.
Since the initial study involved a small sample of patients and was confined to two medical centers, Dr. Cox said future studies will need to involve larger patient populations and more medical centers to confirm the results.
Additional studies are under way to test both web-based and iPad-based versions of the decision aid, he said.
"We hope these digital versions will allow the decision aid to be widely disseminated to other providers worldwide," Dr. Cox said. "The potential target audience is both large and deserving."
Source: American Thoracic Society
La reconstrucción del suelo pélvico no tiene edad
A sus 88 años, Matilde Bardón ha recuperado "la comodidad". Ella -"una señora de León"- no habla de útero, recto o vejiga, pero dice gráficamente que "tenía todo caído lo de abajo". "Me costaba caminar, estaba muy incómoda, he pasado así 10 años". Se refiere Bardón a lo que médicamente se llama desprendimiento del suelo pélvico, un proceso que consiste en que los músculos que sujetan la parte más baja del paquete abdominal se debilitan, y el aparato urinario, el genital y el final del digestivo se descuelgan.
En España no hay un registro de operaciones, pero "seguramente Matilde sea una de las pacientes de más edad, si no la mayor, que se somete a esta operación", dice el urólogo Juan Ruiz de Burgos, de la clínica USP San Camilo, que intervino a la mujer el pasado 12 de marzo. No es la única octogenaria que ha pasado por la consulta de este médico. "También hemos operado a otra de 82 años, una monjita que no podía ni bajar a la capilla", dice.
Aunque no hay registros sobre afectadas, el médico recuerda que solo en lo que respecta a la pérdida de orina (una de las manifestaciones más frecuentes de este problema), aproximadamente entre el 15% y el 30% de las mujeres mayores lo sufren, un porcentaje que aumenta al 50% entre las que están en residencias.
La intervención consiste en sujetar los órganos internos de la región pélvica (vejiga, útero, recto) mediante unas mallas biocompatibles "parecidas a las que se usan para las hernias" que se fijan a los ligamentos. "Es como si se tensaran los vientos de una tienda de campaña", explica gráficamente el médico. "Las de la parte delantera recolocan la vejiga urinaria, y las de la parte posterior el recto. En medio queda la vagina", añade.
Puede hacer falta el proceso completo, o solo una parte. En el caso de Bardón el prolapso (la caída) era completo. Pero al menos ella, por cómo había quedado colocada la vejiga, no tenía pérdidas de orina. "Como la tenía caída el problema era el contrario: acumulaba la orina y le costaba expulsarla. Tenía lo que se denomina un cuadro obstructivo. El resultado era que iba con un bulto entre las piernas que menguaba mucho su calidad de vida. Tanto que lo que nos decía era que estaba tan incómoda que se quería morir", cuenta el médico.
Y no son solo molestias. "Las mujeres sufren por su imagen, las relaciones sexuales se resienten", afirma.
"Lo que queremos con estas técnicas es llamar la atención para que las mujeres sepan que hay alternativas que cada vez son más seguras y menos incómodas", afirma el urólogo. Eso no quiere decir, aclara, que haya que operar a la primera. "Hay otras opciones, empezando por los ejercicios para reforzar el suelo pélvico, pero en el momento en que los tratamientos más conservadores no dan resultado, lo mejor es operar", sostiene.
El avance en las cirugías mínimamente invasivas -con lo que implican de menos tiempo en quirófano y de una recuperación mejor- es lo que ha permitido que esta técnica se extienda a cada vez más mujeres. "Se utiliza anestesia epidural, y en un día las mujeres pueden estar en su casa", afirma. En el caso de Matilde el postoperatorio fue un poco más largo. "Pasé cuatro días en el hospital, pero me fui a casa como nueva", dice la paciente.
"En verdad, si descontamos que ingresó un día antes para el preoperatorio, y que se fue al mediodía, estuvo poco más de 48 horas ingresada después de la operación", matiza el médico. "Hay que tener en cuenta además que con su edad tuvimos especial cuidado", añade. Como prueba de que la intervención no es complicada, da un dato: "La mañana que operamos a Matilde hicimos seis operaciones. Claro que no estaba solo. Colaboró con nosotros el ginecólogo Francesc Pla i Claver, del hospital Vall d'Hebron de Barcelona. Solo en esta clínica realizamos unas cien intervenciones al año", dice.
En lo que médico y paciente están de acuerdo es en la causa del prolapso. "Me casé muy jovencita, y tuve mi primer hijo con 20 años. Como entonces el parto era con comadrona, tardé dos días con sus dos noches en dar a luz", cuenta la mujer. "Mi siguiente hijo nació al año siguiente, y ya no pude tener más porque no me quedé bien", cuenta.
"Esta es una causa típica de este proceso", confirma el médico: "Mujeres que tienen partos vaginales traumáticos y con niños muy grandes". Además, son un factor de riesgo "los oficios ocupacionales, los trabajos en los que hay que estar mucho tiempo de pie o agachada, como el de la huerta de la monja que comenté antes", dice. El médico comenta otra de las ventajas de la operación. "La mujer no necesita ni someterse a revisiones. Como el material es biocompatible se integra en el organismo". Ella no puede ocultar su satisfacción. "Si hubiera quien me quitara la artrosis igual que me han quitado lo otro, no podría pedir más".
En España no hay un registro de operaciones, pero "seguramente Matilde sea una de las pacientes de más edad, si no la mayor, que se somete a esta operación", dice el urólogo Juan Ruiz de Burgos, de la clínica USP San Camilo, que intervino a la mujer el pasado 12 de marzo. No es la única octogenaria que ha pasado por la consulta de este médico. "También hemos operado a otra de 82 años, una monjita que no podía ni bajar a la capilla", dice.
Aunque no hay registros sobre afectadas, el médico recuerda que solo en lo que respecta a la pérdida de orina (una de las manifestaciones más frecuentes de este problema), aproximadamente entre el 15% y el 30% de las mujeres mayores lo sufren, un porcentaje que aumenta al 50% entre las que están en residencias.
La intervención consiste en sujetar los órganos internos de la región pélvica (vejiga, útero, recto) mediante unas mallas biocompatibles "parecidas a las que se usan para las hernias" que se fijan a los ligamentos. "Es como si se tensaran los vientos de una tienda de campaña", explica gráficamente el médico. "Las de la parte delantera recolocan la vejiga urinaria, y las de la parte posterior el recto. En medio queda la vagina", añade.
Puede hacer falta el proceso completo, o solo una parte. En el caso de Bardón el prolapso (la caída) era completo. Pero al menos ella, por cómo había quedado colocada la vejiga, no tenía pérdidas de orina. "Como la tenía caída el problema era el contrario: acumulaba la orina y le costaba expulsarla. Tenía lo que se denomina un cuadro obstructivo. El resultado era que iba con un bulto entre las piernas que menguaba mucho su calidad de vida. Tanto que lo que nos decía era que estaba tan incómoda que se quería morir", cuenta el médico.
Y no son solo molestias. "Las mujeres sufren por su imagen, las relaciones sexuales se resienten", afirma.
"Lo que queremos con estas técnicas es llamar la atención para que las mujeres sepan que hay alternativas que cada vez son más seguras y menos incómodas", afirma el urólogo. Eso no quiere decir, aclara, que haya que operar a la primera. "Hay otras opciones, empezando por los ejercicios para reforzar el suelo pélvico, pero en el momento en que los tratamientos más conservadores no dan resultado, lo mejor es operar", sostiene.
El avance en las cirugías mínimamente invasivas -con lo que implican de menos tiempo en quirófano y de una recuperación mejor- es lo que ha permitido que esta técnica se extienda a cada vez más mujeres. "Se utiliza anestesia epidural, y en un día las mujeres pueden estar en su casa", afirma. En el caso de Matilde el postoperatorio fue un poco más largo. "Pasé cuatro días en el hospital, pero me fui a casa como nueva", dice la paciente.
"En verdad, si descontamos que ingresó un día antes para el preoperatorio, y que se fue al mediodía, estuvo poco más de 48 horas ingresada después de la operación", matiza el médico. "Hay que tener en cuenta además que con su edad tuvimos especial cuidado", añade. Como prueba de que la intervención no es complicada, da un dato: "La mañana que operamos a Matilde hicimos seis operaciones. Claro que no estaba solo. Colaboró con nosotros el ginecólogo Francesc Pla i Claver, del hospital Vall d'Hebron de Barcelona. Solo en esta clínica realizamos unas cien intervenciones al año", dice.
En lo que médico y paciente están de acuerdo es en la causa del prolapso. "Me casé muy jovencita, y tuve mi primer hijo con 20 años. Como entonces el parto era con comadrona, tardé dos días con sus dos noches en dar a luz", cuenta la mujer. "Mi siguiente hijo nació al año siguiente, y ya no pude tener más porque no me quedé bien", cuenta.
"Esta es una causa típica de este proceso", confirma el médico: "Mujeres que tienen partos vaginales traumáticos y con niños muy grandes". Además, son un factor de riesgo "los oficios ocupacionales, los trabajos en los que hay que estar mucho tiempo de pie o agachada, como el de la huerta de la monja que comenté antes", dice. El médico comenta otra de las ventajas de la operación. "La mujer no necesita ni someterse a revisiones. Como el material es biocompatible se integra en el organismo". Ella no puede ocultar su satisfacción. "Si hubiera quien me quitara la artrosis igual que me han quitado lo otro, no podría pedir más".
**Publicado en "EL PAIS"
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