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Spanish to English: Post-stroke depression: Can we predict its appearance from the acute stroke phase?
Source text - Spanish DEPRESIÓN POSTICTUS. ¿PODEMOS PREDECIR SU APARICIÓN DESDE LA FASE AGUDA DEL ICTUS?
Blanca Fuentes, Xochitl Ortiz, Ana Frank, Exuperio Díez Tejedor.
Servicio de Neurología. Hospital Universitario La Paz. Universidad Autónoma de Madrid.
Dirección de correspondencia:
Blanca Fuentes Gimeno,
Unidad de ictus. Servicio de Neurología
Hospital Universitario La Paz
Paseo de la Castellana, 261
28046 Madrid
Tfno: 91 727 7444
Fax. 91 358 1403
e-mail: [email protected]; [email protected]
Resumen:
Introducción:
La depresión postictus es una complicación frecuente tras un infarto cerebral (IC), afectando al 20-40% de los pacientes y relacionada con peor pronóstico funcional. Objetivo: buscar factores predictivos en los momentos iniciales para detectar precozmente los pacientes en riesgo de depresión postictus.
Métodos:
Estudio prospectivo, observacional. Inclusión: Pacientes con IC
Translation - English POST-STROKE DEPRESSION. CAN WE PREDICT ITS APPEARENCE FROM THE ACUTE STROKE PHASE?
Blanca Fuentes, Xochitl Ortiz, Ana Frank, Exuperio Díez Tejedor.
Neurology Service. University Hospital La Paz. Autonomous Univeristy of Madrid.
Address correspondence to:
Blanca Fuentes Gimeno,
Unidad de ictus. Servicio de Neurología
Hospital Universitario La Paz
Paseo de la Castellana, 261
28046 Madrid
Tel: 91 727 7444
Fax. 91 358 1403
e-mail: [email protected]; [email protected]
Abstract:
Introduction:
Post-stroke depression is a common complication after a cerebral infarction (CI), affecting up to 20-40% of stroke patients, and it is related to poor functional outcome. Objective: to identify predictive factors within the first days of stroke onset in order to detect patients early who are at risk of post-stroke depression.
Methods:
Prospective, observational study. Inclusion: CI 2), concurrent serious or fatal illnesses and acute craneoencephalic trauma.
To classify the etiologic stroke subtype, the criteria of the Study Group of Cerebrovascular Illnesses of the Spanish Neurology Society were followed (10). To quantify the severity of the stroke, the Canadian Stroke Scale was used and the functional consequences were evaluated using the modified Rankin Scale and the Barthel Index which were administered by a neurologist at the moment a patient was included in the study and during follow-up visits.
Neuropsychological Evaluation:
Once the patient was established in the Stroke Unit, and before reaching 10 days post-stroke, he or she was informed of the objectives and procedures of the present study. Those patients who agreed to participate were given a functional cognitive evaluation and depressive symptomology by two psychologists from the Neurology Service, alsways at the end of the morning, with the objective of minimizing any possible influence of daily mood variations. After a brief semi-structured interview concerning the physical, cognitive, and psychological status of the patient, specific questions about depressive symptoms were asked, according to the Hamilton Depression Scale. Finally, a structured interview was carried out with a relative of the patient to evaluate the presence of cognitive deterioration before the stroke, using the Jorm Informant Test and the Blessed Dementia scale.
DSM-IV criteria were used to define post-stroke depression using the Hamilton Depression Scale and the Bech melancholy for the quantitative evaluation of the severity of depressive symptoms. This scale has proved to be a reliable instrument in patient studies of post-stroke depression (11-13). The established cutoff points are 0-7 (absence of depression), 8-15 (minor depression), and values higher than 16 (major depression.) For our study we have used the validated version in Castellano Spanish (14). The neurologic and neuropsychologic evaluations were repeated at 3 months.
Statistical Analysis:
The description of qualitative data was calculated in absolute frequencies and percentages, and the quantitative data by average, median, and standard deviation. The comparison between qualitative data was done using the Chi-squared test or Fisher's exact test, and the quantitative data using the T-student or non-parametric tests. To study the predictive factors for development of post-stroke depression at 3 months, multivariate stepwise logistic analysis was used, introducing those variables that, having a sufficient number of cases, had in the univariate analysis a statistical significance less than or equal to 0.20. ROC curve analysis was used to identify the cutoff point on the Hamilton Depression Scale on admission with the greatest sensitivity and specificity to predict later development of post-stroke depression at 3 months. The data were analyzed using a PC compatible computer and with the statistical program SPSS for Window. All differences were considered statistically significant at a level of p
Spanish to English: Public Health/Ethics
Source text - Spanish Los principales valores protegidos por el Estado en el ámbito de la Salud Pública son el derecho a la vida y a la salud, derecho al ejercicio de la libertad religiosa e ideológica, el principio de igualdad en la asistencia sanitaria y el principio de autonomía del paciente.
El art. 15 determina que “Todos tienen derecho a la vida y a la integridad física y moral, sin que, en ningún caso, puedan ser sometidos a tortura ni a penas o tratos inhumanos o degradantes. Queda abolida la pena de muerte, salvo lo que puedan disponer las Leyes penales militares para tiempos de guerra”.
Por su parte, el artículo 16 de la Constitución española establece que “se garantiza la libertad ideológica, religiosa y de culto de los individuos y las comunidades sin más limitación, en sus manifestaciones, que la necesaria para el mantenimiento del orden público protegido por la Ley.”
Ambos artículos poseen el mismo rango constitucional de derecho fundamental, pero comúnmente la doctrina jurídica se ha inclinado por la protección del derecho a la vida frente a la protección de la libertad ideológica y religiosa. Así, el Tribunal Constitucional y el Supremo han expresado en repetidas ocasiones la primacía del valor vida humana sobre el resto de valores o bienes jurídicos protegidos por el Derecho.
Así, el derecho a la vida, contemplado en el art. 15, no supone un correlativo derecho a la muerte, por lo que la eutanasia en España no es legal y está penalizada en el Código Penal.
Por otro lado, el art. 43, aunque no está recogido bajo la rúbrica de los derechos fundamentales y libertades públicas y, por tanto, no posee la misma fuerza impositiva que los anteriores reconoce el derecho a la protección de la salud, asignando a los poderes públicos la organización y la tutela de la salud pública“
Finalmente, la Ley General de Sanidad de 25 de abril de 1986 establece, el principio de igualdad en la asistencia sanitaria sin que nadie, pueda ser discriminado por razones de raza, de tipo social, de sexo, moral, económico, ideológico, político y sindical. También establece que debe darse un concentimiento informado por el paciente antes de recibir un tratamiento médico. El derecho de todo paciente a rechazar un tratamiento médico se ve reforzado y ampliado por la Ley de Autonomía del Paciente de 2002.
THE RELEVANT CASES
La relevancia de los casos seleccionados radica en que nos permiten ilustrar diferentes maneras que podemos encontrar en España a la hora de afrontar los problemas surgidos cuando la protección valor fundamental de la vida humana entra en conflicto con el derecho la libertad religiosa o el principio de autonomía del paciente; y cómo en los últimos años se puede apreciar una evolución en las mismas.
En el caso de inmaculada Echevarría, lo que se pone en cuestión es el principio de protección de la vida humana incluso contra la voluntad del propio interesado que la vive con gran sufrimiento.
En el caso del rechazo a las transfusiones sanguíneas de los Testigos de Jehová encontramos una doble demanda por parte de este colectivo. Por un lado, piden que no se les aplique una práctica médica usual, como son las transfusiones de sangre; por otro, demandan del sistema sanitario público un tratamiento alternativo consistente con el respeto a sus creencias religiosas.
Tanto el principio de protección a la vida como el de libertad religiosa están protegidos a nivel constitucional (art. 15 y 16 respectivamente). Por su parte, el principio de autonomía del enfermo y su derecho a dar un consentimiento informado antes de que se le aplique un tratamiento médico ya venía recogido en la ley general de sanidad del año 1986, aunque en caso de rechazo de un tratamiento, el enfermo debía solicitar el alta voluntaria. Con la ley de autonomía del paciente de 2002, el enfermo puede rechazar un tramamiento sin que se le exija ninguna motivación ni justificación para ello, y sin tener que solicitar el alta del hospital en el que se encuentre hospitalizado.
CASE HISTORY (WITH SPECIAL EMPHASIS ON SPECIFIC JUDICIAL CASES)
Caso de Inmaculada Echevarría
El 20 de noviembre de 2006, Inmaculada Echevarría tras 20 años en la cama por una distrofia muscular solicita que se le desconecte el respirador artificial que le mantenía con vida desde hacía 10 años.
Dos meses después, el Comité Ético de la Junta de Andalucía dictamina que la petición de Inmaculada Echevarría es un rechazo de un tratamiento, un derecho reconocido en la ley española de autonomía del paciente.
El Consejo Consultivo Andaluz a ratifica, en febrero de 2007, el dictamen del Comité Ético de la Junta de Andalucía que su caso era una limitación del esfuerzo terapéutico negativa y adecuada a derecho, por lo que considera que la actuación de los profesionales sanitario que procedieran a la desconexión del aparato de ventilación mecánica no podía considerase "punible". En consecuencia autoriza a la Consejeria de Salud a que se cumplan la petición de la paciente.
La Curia General de la Orden de San Juan de Dios, responsable de la gestión del Hospital Universitario San Rafael, donde se encontraba ingresada Inmaculada Echevarría prohibió expresamente a los miembros de su orden desconectar el respirador. La dirección decide trasladar a la paciente a otro hospital, aunque, a petición de la interesada, el equipo médico que la había tratado durante los últimos 10 años continuará haciéndolo en el nuevo hospital.
El 14 de marzo de 2007, Inmaculada Echevarría muere tras que se le desconectara el respirador artificial que le mantenía con vida
Caso de Marcos, Testigo de Jehová de 13 años de edad
El 9 de septiembre de 1994, los médicos del Hospital Arnau de Lléida detectaron que Marcos, de 13 años de edad, se encontraba en una situación de alto riesgo hemorrágico prescribiendo para neutralizarla una transfusión de 6 cm cúbicos de plaquetas. Los padres de Marcos manifestaron que su religión no permitía la aceptación de una transfusión de sangre y que en consecuencia se oponían a la misma. Siendo informados por los médicos de que no conocían ningún otro tratamiento, los padres de Marcos solicitaron el alta médica de su hijo para llevarle a otro centro donde se le pudiera aplicar un tratamiento alternativo. El centro hospitalario denegó el alta y, considerando que la vida de Marcos corría peligro solicitó del juzgado de guardia autorización para realizar la transfusión. El juzgado de guardia concedió dicha autorización pocas horas después y los padres de Marcos la acataron sin poner ningún impedimento para que se realizara.
Sin embargo, cuando los médicos se dispusieron a realizarla, Marcos la rechazó con auténtico terror, reaccionando agitada y violentamente en un estado de excitación que los médicos estimaron contraproducente, pues podía precipitar una hemorragia cerebral, desistiendo de su realización, sin que consiguieran convencer al menor para que accediera al tratamiento. Los padres de Marcos no intentaron convencer a su hijo y solicitaron el alta voluntaria.
Tres días después, el 12 de septiembre, Marcos y sus padres acudieron al Hospital Vall d’Hebron de Barcelona donde se les informó que Marcos necesitaban una transfusión de manera urgente y que no existían ningún tratamiento alternativo. Lo mismo ocurrió ese mismo día en el Hospital General de Cataluña. En ambos casos, Marcos y sus padres rechazaron que se le practicara una transfusión de sangre, y regresaron a su casa en Huesca. Dos días después, Marcos sufrió una hemorragia cerebral y falleció.
En 2002, el tribunal constitucional anuló la condena a dos años de prisión impuesta por el tribunal Supremo a los padres de Marcos en 1997, por un delito de Homicidio por omisión.
Translation - English The main values protected by the State in the area of Public Health are the right to life and to health, the right to exercise religious liberty and ideology, the principle of equality in health care and the principle of patient autonomy.
Article 15 determines that “All have the right to life and to physical and moral integrity, without, in any case, being able to be subjected to torture nor punishment nor inhuman or degrading treatment. The death sentence remains abolished, except as stipulated by Military Criminal Law during wartime.” For its part, Article 16 of the Spanish Constitution establishes that “ideological, religious, and worship liberty of individuals and communities is guaranteed without limitation greater than, in their demonstrations, that needed for maintenance of public order protected by law.
Both articles possess the same constitutional range of fundamental constitutional rights, but commonly, legal doctrine has leaned towards the protection of the right to life when confronted with protection of religious and ideological liberty. In fact, the Constitutional and Supreme Courts have expressed on repeated occasions the primacy of the value of human life above the rest of the values or legal goods protected by the Right.
In fact, the right to life, considered in article 15, does not suppose a correlation with a right to death; therefore euthanasia in Spain is not legal and is punished in the Penal Code.
On the other hand, article 43, although not recognized as under the rubric of the fundamental rights and public liberties, and, therefore, does not possess the same impositive strength as the previous, recognizes the right to the protection of health, assigning to the public powers the organization and guidance of public health.
Finally, the General Law of Health of April 25, 1986 establishes the principle of equality in health care in that no one can be discriminated against for reasons of race, social status, sex, morals, economics, ideology, political affiliation or labour union.
THE RELEVANT CASES
The relevance of the selected cases lies in that they allow us to illustrate various ways we can approach problems in Spain when the protection of the fundamental value of human life conflicts with the right to religious liberty or the principle of patient autonomy; and in recent years an evolution in these approaches can be seen.
In the case of the Inmaculada Echevarría, what is called into question is the principle of the protection of human life even against the will of the person himself who lives in great suffering.
In the case of the rejection of blood transfusions by Jehovah’s Witnesses, we find a double demand on the part of this collective. On the one hand, they ask that a usual medical practice not be applied to them, which is blood transfusions; on the other hand, they demand that the public health system provide an alternative treatment that is consistent with their religious beliefs.
The principles of the protection of life as well as religious liberty are protected at the constitutional level (art. 15 and 16 respectively). For its part, the principle of autonomy of a patient and his right to give informed consent before applying a medical treatment was already covered in the general law of health of the year 1986, although in case of treatment rejection, the patient must apply for voluntary discharge. With the patient autonomy law of 2002, the patient can refuse a treatment without being required to provide any motivation or justification, and without having to apply for discharge from the hospital in which he finds himself hospitalized.
CASE HISTORY (WITH SPECIAL EMPHASIS ON SPECIFIC JUDICIAL CASES)
The Case of Inmaculada Echevarría
On the 20th of November of 2006, Inmaculada Echevarría, after 20 years in bed for muscular distrophy, requests the disconnection of the artificial respirator that has kept her alive for the previous10 years.
Two months later, the Ethics Committee of the Regional Government of Andalucia judges that the petition of Inmaculada Echevarría was a rejection of treatment, a right recognized in the Spanish patient autonomy law.
The Andalusian Consulting Council ratifies the ruling of the Ethics Committee of the Regional Government of Andalusia, arguing that the case was a negative and adequate limitation of therapeutic strength according to the law, by which the intervention of the health professionals that proceeded in disconnecting the mechanical ventilator could not be considered “punishable”.
The General Clergy of the Order of San Juan de Dios, responsible for the management of the University Hospital San Rafael, where Inmaculada Echevarría was admitted, expressly prohibited its members from disconnecting the respirator. The management decided to transfer the patient to another hospital, although, upon petition by the claimant, the medical team that had treated her for the last 10 years would continue to do so at the new hospital.
On March 14, 2007, Inmaculada Echevarría died after the artificial respirator that kept her alive was disconnected.
The Case of Marcos, 13-year old Jehovah’s Witness
On September 9, 1994, doctors at the Arnau Hospital in Lléida determined that Marcos, 13 years of age, was in a situation of high risk of haemorrhage, thus prescribing a transfusion of 6 cubic cm of platelets to neutralize it. The parents of Marcos protested that their religion did not permit the acceptance of a blood transfusion and as a consequence they were opposed to it. Once informed that the doctors did not know any other treatment, the parents requested their son’s discharge so they could take him to another centre where they could apply an alternative treatment. The hospital centre denied the discharge and, considering that the life of Marcus was in danger, requested authorization from the attending judge to perform the transfusion. The attending judge gave the authorization a few hours later and the Marcos’s parents complied without imposing any impediment on the process.
However, when the doctors prepared to perform it, Marcos rejected it with authentic terror, acting agitated and in such a violent state of excitement that the doctors decided it was counterproductive, as it could precipitate a cerebral haemorrhage, desisted in their efforts, without convincing the young person to allow the treatment. Marcos’s parents did not try to convince their son and requested voluntary discharge.
Three days later, on the 12th of September, Marcos and his parents went to Vall d’Hebron Hospital where they were informed that Marcos urgently needed a transfusion and there wasn’t any available alternative treatment. The same happened that same day at the General Hospital of Cataluña. In both cases, Marcos and his parents rejected the blood transfusion, and returned to their home in Huesca. Two days later, Marcos suffered a cerebral haemorrhage and died.
In 2002, the Constitutional Court annulled the penalty of two years in prison imposed on Marcos’s parents by the Supreme Court for the crime of Homicide by Omission.
Spanish to English: Philosophy: Debate over Islamic Veil Detailed field: Philosophy
Source text - Spanish Caso 4
Velo islámico en las aulas de colegios públicos.
País: España. (Febrero de 2002, El País)
Sujetos (quién): Familia marroquí con una niña menor que profesa la religión musulmana.
Objeto (qué): Los padres de la niña se oponen a que la niña vaya al colegio si en el Instituto al que le correspondería acudir (Colegio Público Juan Herrera de San Lorenzo de El Escorial) no le permiten asistir a las clases con el velo cubriéndole la cabeza.
Value basis of the law questioned: La normativa del colegio que prohíbe la entrada de la niña en clase con el velo se apoya en la valoración del velo islámico como signo discriminatorio contra la mujer.
Content of the claim: La familia solicita que se le deje asistir a su hija a clase con el velo. Los padres añaden que es una decisión que la niña ha tomado voluntariamente a la edad de 13 años. Si no se le permite entrar a clase con el velo los padres se niegan a escolarizarla a modo de protesta.
Value basis of the claim: Se ponen en conflicto dos tipos de derechos: derecho a la educación de la menor y derecho a la libertad religiosa. La demanda de los padres se fundamenta en el derecho a la libertad religiosa y piden que su hija no sea discriminada por portar un signo religioso en un centro de enseñanza pública aconfesional.
Tipo de acción: Desobediencia civil.
Resultado legal; respuesta de las instituciones: El consejero de Educación de la Comunidad de Madrid ordena que la niña marroquí acuda al colegio con el velo islámico. Se ordena así la escolarización de la menor sin condicionamientos y se exige al instituto que permita a la niña la entrada a las clases con el velo, retirando la prohibición.
Value basis of the legal response: La Constitución española reconoce el derecho a la educación, universal y de calidad. Este derecho es prioritario sobre la decisión o normativa particular que pueda tomar un centro de educación pública sobre la vestimenta de los alumnos.
Impacto social y político: Debate público entorno al uso de signos religiosos en espacios públicos, como los colegios, hospitales, puestos de trabajo. Asimismo se pone en cuestionamiento la tolerancia ante el pluralismo cultural y religioso que se vive en España con el aumento de población inmigrante. Enfrentamiento entre partidos políticos, hay quienes se muestran a favor y otros en contra del uso de signos religiosos en espacios públicos, apoyándose bien en argumentos como la libertad religiosa o en argumentos que cuestionan la validez y legitimidad de ciertos signos que se valoran como discriminatorios.
El debate social, así como el impacto en los medios de comunicación se amplía a raíz de casos similares sucedidos en otros países europeos, donde la respuesta legal ha sido distinta a la española, llegando incluso a proclamarse leyes que regulan la situación al respecto.
Resumen: La dirección de un Colegio Público prohíbe a una niña marroquí que asista a clase portando el velo islámico. Ante esta prohibición sus padres se niegan a que asista al colegio en esas condiciones y argumentan que la decisión de portar el velo ha sido tomada por la niña. El hecho llega a las administraciones públicas, pues en España la escolarización es obligatoria hasta los 16 años, y se cuestiona que se esté discriminando a la niña por razones religiosas. Finalmente las autoridades competentes ordenan que la niña sea escolarizada y se le permita ir al colegio con el velo, pues no existe ningún indicio en la Constitución española que lo condene. Por otro lado, prima el derecho a la educación y la obligación de escolarizar a la menor sobre la decisión del Colegio basada en la valoración del velo como un signo religioso discriminatorio contra la mujer.
Translation - English
Case 4
Islamic Veil in public school classrooms.
Country: Spain (February 2002, El Pais)
Subjects (who): Moroccan family with a girl, a minor, who profess Islam.
Object (what): The girl’s parents are opposed to letting her go to school if, in the institute she is designated to (in this case, Public School Juan Herrera de San Lorenzo de El Escorial), she is not permitted to attend classes wearing a veil covering the head.
Value basis of the law questioned: The school’s regulation that prohibits the girl’s entrance into class while wearing a veil is based on the determination that the Islamic veil represents a visible symbol of discrimination against women.
Content of the claim: The family requests that she be allowed to attend class wearing the veil. The parents add that this is a decision that the girl took voluntarily at the age of 13. If she is not allowed to enter class wearing the veil the parents will, as a form of protest, refuse to send her to school.
Value basis of the claim: There are two types of rights in conflict here: the right to an education for the minor and the right to religious freedom. The parents’ demand is based on the right to religious freedom and they request that their daughter not be discriminated against for carrying a religious symbol in a public non-denominational centre of learning.
Type of action: Civil disobedience
Legal outcome; the institutions’ response: The councillor for Education for the Community of Madrid orders that the Moroccan girl be able to attend school with the Islamic veil. The schooling of the minor without conditions is thus ordered and the school is required to allow the girl entrance into the classrooms with veil, thus removing the prohibition.
Value basis of the legal response: The Spanish Constitution recognizes the right to a universal and quality education. This right overrides the particular decisions or rules that a public centre of education can make concerning the clothing of its students.
Social and political impact: Public debate concerning the use of religious symbols in public spaces, such as schools, hospitals, and the workplace. This also brings into question the tolerance of cultural and religious pluralism that is experienced in Spain with the increase in the immigrant population. Confrontations between political parties, there are those in favour of and those opposed to the use of religious symbols in public spaces, based heavily on arguments such as religious liberty or on arguments that question the validity and legitimacy of certain symbols which are deemed discriminatory. The social debate, as well as the impact in the media, widens due to similar cases that occur in other European countries where the legal response has been different from the Spanish one, including reaching the point of passing laws that regulate the situation at hand.
Summary: The headship of a public school prohibits a Moroccan girl from attending class wearing an Islamic veil. Faced with this prohibition, her parents refuse to allow her to attend school under these conditions and argue that the decision to wear the veil was taken by the girl. The case reaches the public administrators, since in Spain schooling is obligatory until the age of 16, and the question of whether the girl is being discriminated against for religious reasons is analyzed. Finally the competent authorities order that the girl be sent to school and that she be permitted to go school wearing the veil since there is no evidence that the Spanish Constitution prohibits it. Furthermore, the right to an education and the obligation to school a minor takes priority over the decision of the school that is based on a valuation of the veil as a religious symbol that is discriminatory against women.
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I am a medical translator and editor, Spanish to English, living in The Netherlands. I work as a TEP team with my husband, Roland Combes. I am currently a medical translator and editor for the PPD, a division of Thermo Fischer Scientific (Global), for The Language Doctors, Inc. (Global), and for Morote Traducciones and the University of Santiago de Compostela, in Spain. I also write news briefs on rare diseases for Rare Disease Advisor in New York City, USA.
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