El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado. / OBJECTIVE: To assess the relationship between physical performance (PP) and muscle strength (MS) in elderly subjects with and without diabetes in a public hospital of Lima, Peru. SUBJECTS AND METHOD: A cross-sectional analysis of subjects aged 60 years or older with and without diabetes. MS was measured with a handheld dynamometer, and PP with the «timed get-up-and-go» test. Nutritional status was determined using body mass index, body fat percentage measured with a handheld fat loss monitor and protein intake based on the 24-hour recall. Age, sex, and history of hospitalization and supplementation were also recorded. The association was assessed using adjusted prevalence ratios. RESULTS: Overall, 139 patients with diabetes (26.6% with low PP and 13.7% with decreased MS) and 382 subjects without diabetes (36.6% with low PP and 23.0% with decreased MS) were evaluated. No association was found between T2DM and MS (aPR: 0.99; 95% CI: 0.67-1.57) or PP (aPR: 1.13; 95% CI: 0.84-1.52). Protein and supplement consumption was also unrelated (P>.05); however, history of hospitalization, age, sex, nutritional status, and body fat percentage were related (P>.05). CONCLUSIONS: No association was found between T2DM, MS, and PP. However, low PP was associated to female sex and overweight/obesity, and decreased MS was associated to high body fat percentage and underweight. Moreover, MS and PP were related to older age and history of hospitalization. / Revisión por pares

Tomando a América Latina como área de estudio, en el presente trabajo se analizan los patrones de cambio institucional en un entorno institucional débil; es decir, en un contexto en el que las reglas de juego son inestables y/o aplicadas de manera desigual. Tomando como punto de partida el trabajo de Kathleen Thelen y sus colaboradores, sostenemos que el cambio institucional en América Latina rara vez se aproxima a los modelos del llamado equilibrio interrumpido y a los modos de cambio gradual. En su lugar, el cambio usualmente toma la forma de un remplazo o sustitución constante, en el cual las instituciones repetidamente atraviesan una transformación abrupta y total. En la primera parte, el artículo examina las condiciones que conllevan a patrones de remplazo constante; posteriormente, el artículo presta atención a la  relación entre el enforcement y el cambio institucional. Se sostiene que el non- enforcement puede ser una fuente importante de estabilidad institucional, y que el aumento o reducción del enforcement puede, en sí mismo, ser un modo importante de cambio institucional.

Este tesis fue publicado como artículo científico en la Revista Endocrinología y Nutrición (DOI: 10.1016/j.endonu.2015.12.008) / Objetivo: Evaluar la asociación entre la fuerza muscular (FM) y rendimiento físico (RF) en adultos mayores con y sin diabetes de un hospital público de Lima, Perú. Pacientes y método: Estudio transversal en pacientes ≥ 60 años con y sin diabetes. Se midió FM con dinamómetro manual y RF con prueba “Timed get-up-and-go”. Se determinó el estado nutricional con el índice de masa corporal, el porcentaje de grasa corporal con bioimpedanciómetro manual y se evaluó el consumo proteico mediante recordatorio de 24 horas. Además, se registró edad, género, antecedente de hospitalización y suplementación. Se evaluó la asociación con razones de prevalencias ajustadas (RPa). Resultados: Se evaluaron 139 pacientes con diabetes (26,6% con bajo RF y 13,7% con FM disminuida) y 382 sin diabetes (36,6% con bajo RF y 23,0% con FM disminuida). No se halló asociación de DM2 con FM (RPa: 0,99; IC95%: 0,67-1,57) ni RF (RPa: 1,13; IC95%: 0,84-1,52). Tampoco se asoció el consumo proteico ni de suplementos (p> 0,05), pero sí el antecedente de hospitalización, la edad, el género, el estado nutricional y el porcentaje de grasa corporal (p< 0,05). Conclusiones: No se encontró asociación entre DM2, FM y RF. Sin embargo, el bajo RF se asoció con ser mujer y presentar sobrepeso/obesidad; y la FM disminuida con tener alto porcentaje de grasa corporal y bajo peso. Además, ambos se relacionaron con el aumento de edad y tener antecedente de hospitalización. / Objective: To compare the association between physical performance (PP) and muscle strength (MS) in older people with and without diabetes in a public hospital of Lima, Peru. Patients and methods: Cross sectional analysis of 60 years and older patients with and without diabetes. MS was measured with a handheld dynamometer and PP with the “Timed get-up-and-go” Test. The nutritional status was determined using the body mass index, the body fat percentage using a handheld fat loss monitor and the protein intake using the 24 hours Recall. Furthermore, age, gender, history of hospitalization and supplementation were registered. The association was evaluated with adjusted prevalence ratios. Results: 139 patients with diabetes (26.6% had low PP and 13.7% diminished MS) and 382 counterparts without diabetes (36.6% had low PP and 23.0% diminished MS) were evaluated. No association was found between MS and T2D (aPR: 0.99; IC95%: 0.67- 1.57), nor with PP (aPR: 1.13; IC95%: 0.84-1.52). Protein and supplement consumption were not related either (p> 0.05); however, age and history of hospitalization, gender, nutritional status and body fat percentage were linked (p< 0.05). Conclusions: No association was found between T2D, MS and PP. Nevertheless, low PP was associated with female sex and overweight/obesity; and diminished MS was linked to high body fat percentage and underweight. Moreover, MS and PP were related to age and history of hospitalization.

Introduction: In elderly seniors (>80 years), respiratory function may be compromised when, in addition to the presence of comorbidity and loss of mobility, there is also reduced respiratory muscle (RM) strength. The literature has shown that RM training could be an effective method to improve RM function and prevent clinical deterioration, particularly in population with RM weakness.The main purpose of this paper was to assess the effectiveness of RM training on the respiratory muscle strength and endurance of institutionalized elderly women with functional impairment. Method: Fifty-four residents (mean=85 years, SD=6.7) were randomly assigned to either a control (n=27) or training (n=27) group. A supervised training program was developed with Threshold®IMT, five times per week for 6-weeks. The main variables of the intervention were: maximum inspiratory pressure (PImax), maximum expiratory pressure (PEmax) and maximal voluntary ventilation (MVV), all of which were measured at weeks 0, 4, 7 and 10. Results: Statistical analysis revealed no significant differences in PImax (F3,114=1.04, p=0.368, R2=0.027), PEmax (F3,114=1.86, p=0.14, R2=0.047) and MVV (F3,114=1.74, p=0.162, R2=0.044) between the two groups after the intervention. However, the workload significantly improved with the training sessions (F5,100=72.031, p<0.001, R2=0.791). Conclusion: In a 6-week interval-based training program, the threshold loading device does not significantly improve parameters related to RM strength and endurance of the study population.

Introduction: In elderly seniors (>80 years), respiratory function may be compromised when, in addition to the presence of comorbidity and loss of mobility, there is also reduced respiratory muscle (RM) strength. The literature has shown that RM training could be an effective method to improve RM function and prevent clinical deterioration, particularly in population with RM weakness.The main purpose of this paper was to assess the effectiveness of RM training on the respiratory muscle strength and endurance of institutionalized elderly women with functional impairment. Method: Fifty-four residents (mean=85 years, SD=6.7) were randomly assigned to either a control (n=27) or training (n=27) group. A supervised training program was developed with Threshold®IMT, five times per week for 6-weeks. The main variables of the intervention were: maximum inspiratory pressure (PImax), maximum expiratory pressure (PEmax) and maximal voluntary ventilation (MVV), all of which were measured at weeks 0, 4, 7 and 10. Results: Statistical analysis revealed no significant differences in PImax (F3,114=1.04, p=0.368, R2=0.027), PEmax (F3,114=1.86, p=0.14, R2=0.047) and MVV (F3,114=1.74, p=0.162, R2=0.044) between the two groups after the intervention. However, the workload significantly improved with the training sessions (F5,100=72.031, p<0.001, R2=0.791). Conclusion: In a 6-week interval-based training program, the threshold loading device does not significantly improve parameters related to RM strength and endurance of the study population.

This article analyzes the judicial behavior and the importance of judges in policy making in Peru regarding the case of the magistrates of the Constitutional Tribunal and its decisions regarding the morning after pill. We will focus our research on the shift in orientation of two veredicts issued by this judicial institution; one in favor of its state sponsored distribution (2006) and one against it (2009). In order to analyze the circumstances that led to this two different outcomes, we state that the morning after pill, a case of consciousness, made the judges decide based on their strategic alliances inside the tribunal or their own personal trajectories. In order to solve these dilemmas, the analysis of the kind of judges in the tribunal was crucial to understand the relationship between the elected judges and the interests of political parties in parliament. We believe that the shift in orientation of the veredicts lies in the fact that, for cases of consciousness, the Tribunal uses its sitting judges. / Este artículo analiza el comportamiento judicial y la creciente importancia de los jueces en la hechura de las políticas públicas en el Perú a partir del caso de los magistrados del Tribunal Constitucional y sus decisiones frente a la píldora del día siguiente. Nos enfocaremos en el cambio de orientación de dos sentencias emitidas por la máxima institución judicial ante la misma política; por un lado, a favor de su distribución desde el Estado (2006) y, por el otro, en contra (2009). Para analizar los factores que llevaron a este resultado sostenemos que la píldora del día siguiente, al ser un caso de conciencia, les planteó a los jueces la disyuntiva de decidir a partir de un comportamiento estratégico, de acuerdo con las tendencias dominantes al interior del tribunal o haciendo prevalecer sus trayectorias personales. Para resolver estos dilemas, el tipo de jueces que componía el tribunal resultó crucial por lo que exploraremos cómo se configuraron estas composiciones a partir de las bancadas parlamentarias y qué tipo de jueces resultaron electos (de trayectorias públicas u opacas). Sostenemos que el cambio se explicaría porque, para los casos de conciencia, el Tribunal Constitucional utiliza a sus jueces de turno y las reglas así lo permiten.

La Enfermedad Pulmonar Obstructiva Crónica (EPOC), presenta signos y síntomas sistémicos que se han venido explorando desde hace algún tiempo. La presente Tesis Doctoral estudia la disfunción que presentan los músculos respiratorios y periféricos, específicamente el cuádriceps de los pacientes con EPOC. Esta disfunción muscular afecta las actividades de la vida diaria, la tolerancia al ejercicio, limita la calidad de vida y disminuye la expectativa de vida de estos pacientes. Una de las posibles causas de disfunción muscular en los pacientes con EPOC puede ser la pérdida de masa muscular; por eso nos dedicamos a evaluar, los datos antropométricos de los pacientes con EPOC que asistieron durante 2 años a nuestro Laboratorio de Función Respiratoria del Hospital del Mar de Barcelona. La prevalencia de bajo peso en pacientes con EPOC en un hospital con predominante población mediterránea con, índice de masa corporal (IMC) por debajo de 20 Kg/m2, fue de tan sólo 6,6%, cifra que se reducía al 3,1% si el dintel escogido era de 18 Kg/m2. Estas cifras van claramente en oposición a la prevalencia referida en el mundo anglosajón y del norte-centro europeo, que muestra una prevalencia de bajo peso en pacientes con EPOC que oscila entre el 25 y el 35%. Teniendo en cuentas estos datos de baja prevalencia de bajo peso en nuestros pacientes con EPOC, no se explica la alta prevalencia de disfunción muscular en ellos. Por ello evaluamos variables de función muscular en pacientes con EPOC grave, específicamente del músculo cuádriceps y encontramos que los pacientes con EPOC tenían una disminución tanto de la fuerza muscular (43%), como de la resistencia muscular (77%), al compararlos con controles del mismo grupo etáreo.Tratando de profundizar en la causa de la disfunción muscular periférica en los pacientes con EPOC, hicimos a continuación otro estudio donde evaluamos el daño sarcoplásmico y sarcomérico mediante inmunohistoquímica y microscopía electrónica. Este trabajo demostró por primera vez que los pacientes con EPOC presentan mayor daño a nivel del músculo cuádriceps que los controles sanos.Debido a que en la EPOC los músculos periféricos, específicamente los de las extremidades inferiores, pudieran estar afectados por el sedentarismo, decidimos estudiar otras causas de disfunción muscular en un grupo de músculos en que este factor se hallara ausente, como son los músculos respiratorios. Estos mantienen su nivel de actividad normal o incluso aumentada. Para ello tomamos un músculo como el intercostal externo, que es fácilmente accesible a la biopsia, siguiendo un modelo mínimamente invasivo descrito por nuestro grupo. Como en trabajos precedentes ya habíamos valorado el daño sarcomérico, el estrés oxidativo o la actividad enzimática, en esta ocasión el trabajo se centró en la evaluación de la actividad inflamatoria. En él se ha demostrado que las citocinas proinflamatorias TNF-&#945; e IL-6 se encuentran aumentadas en los músculos intercostales externos de los pacientes con EPOC al compararlo con los controles sanos. / Chronic Obstructive Pulmonary Disease (COPD), shows systemic sign and symptoms that have been studied for some time. The present Doctoral Thesis studies the dysfunction shown by the respiratory and peripheral muscles, specifically the quadriceps muscle of patients with COPD. This muscle dysfunction affects the activities of daily living, tolerance to exercise, limits quality of life and diminishes life expectancy of these patients. One of the possible causes of muscle dysfunction in the patients with COPD could be the loss of muscle mass; for that reason we evaluated, the anthropometrics data of the patients with COPD that attended during 2 years our Respiratory Function Laboratory, Hospital del Mar of Barcelona. The prevalence of low weight in patients with COPD in a hospital with a predominantly Mediterranean population with an Body Mass Index (BMI) below 20 Kg/m2, was only 6.6%, a figure that was reduced to 3.1% if the chosen threshold was 18 Kg/m2. These numbers starkly contrast to the prevalence in Northern Europe, with a low weight in patients with COPD raging from 25 to 35%. Considering these data of low prevalence of low weight in our patients with COPD, the high prevalence of muscle dysfunction is not explained. We evaluated variables of muscle function in patients with severe COPD, specifically the quadriceps muscle and we found that the patients with COPD had a decreased muscle strength (43%), and muscle endurance (77%), when comparing with healthy age matched. To study the cause of the peripheral muscle dysfunction in patients with COPD, we began another study where we assessed sarcoplasmic and sarcomeric damage by immunohystochemical methods and electronic microscopy. This work demonstrated for the first time that patients with COPD show greater muscle injury at the quadriceps muscle level that healthy age matched controls.Because in COPD, peripheral muscles, specifically those of the lower limbs, could be affected by sedentarism, we decided to study other causes of muscle dysfunction in a muscle group in which this factor was absent, as they are the respiratory muscles. These maintain their level of normal activity or activity is even increased. For this we chose a respiratory muscle like the external intercostal muscle, that is easily accessible by biopsy, following a minumum invasive model described by our group. As in preceding works of our group we evaluated the sarcomeric damage, oxidative stress or the enzymatic activity, the present work was focused in the inflammatory activity evaluation. We demonstrated that proinflammatory cytokines such as TNF-&#945; and IL-6 are increased in the external intercostal muscles of patients with COPD when comparing with healthy age matched controls.