Sex-Specific Disparities in Risk Factors for Coronary Heart Disease

Burden of ischemic heart disease in Spain: incidence, hospital mortality and costs of hospital care

BACKGROUND

Ischemic heart disease (IHD) is the leading global cause of death and is assumed to entail a significant social and economic burden globally. This study aimed to evaluate incidence and mortality trends of IHD in Spain and to estimate direct medical costs.

METHODS

Admission files corresponding to patients with IHD registered between 2011 and 2019 were obtained from a Spanish hospital discharge database and analyzed in a retrospective study.

RESULTS

Admission data corresponding to 814,740 patients with IHD was analyzed. The majority of patients were males, and about half of the hospitalizations were due to an acute myocardial infarction. Incidence decreased significantly in most age groups over time, while hospital mortality rate remained stable (4.4%). Additionally, mortality rate was significantly higher among females (6.6%). Median admission cost was €5175; the higher costs per admission were found in patients with an acute myocardial infarction and in admissions with an ICU stay. The annual cost of hospital care was €693.8 million.

CONCLUSIONS

Despite the decreasing trends described in the general population, hospital mortality rate was constant among hospitalized patients during the study period. The higher hospital mortality rate described among females should be considered in further studies and protocol revisions.

Recent Trends in Cardiovascular Mortality in Rio de Janeiro State Health Regions and Capital

Fundamento:

A mortalidade por doenças cardiovasculares (DCV) vem mostrando tendência à estabilização em alguns países, incluindo o Brasil e o estado do Rio de Janeiro, após décadas de queda. Não encontramos análises detalhadas dessa tendência para o estado do Rio de Janeiro.

Objetivo:

Analisar as tendências da mortalidade prematura e tardia por doenças do aparelho circulatório (DAC), doença isquêmica do coração (DIC) e doença cerebrovascular (DCBV) por sexo nas regiões de saúde do estado do Rio de Janeiro e capital (1996-2016).

Métodos:

Dados de óbitos e população foram obtidos no DATASUS/MS. Taxas foram compensadas por códigos mal definidos, corrigidos pelos códigos cardiovasculares mal definidos e ajustadas por sexo e idade pelo método direto. O Joinpoint Trend Analysis Software foi empregado para calcular a variação percentual anual (APC) e variação percentual anual média (AAPC). Foram consideradas para o estudo APC e AAPC significativamente diferentes de zero, calculadas por um teste de student com significância de 5%.

Resultados:

A mortalidade por DIC estabilizou ou até aumentou em pelo menos 50% das localidades analisadas (EAPC ≥0). Nas regiões Norte e Noroeste, nenhuma mudança foi observada. Para DCBV, apenas uma região apresentou estabilidade na mortalidade (EAPC próximo a 0). Para as outras regiões, a taxa continuou a diminuir (APC <0) até 2016.

Conclusão:

Esses resultados observados no Rio de Janeiro devem se repetir em várias regiões brasileiras e apontam para a necessidade de uma resposta na abordagem dos comportamentos no estilo de vida. Os médicos da atenção primária devem estar familiarizados com a tendência desfavorável da doença isquêmica do coração entre os adultos mais jovens e rastrear ativamente os fatores de risco para DCV, com atenção especial às mulheres.

Structure of communities in semantic networks of biomedical research on disparities in health and sexism

Introducción.

Como una iniciativa para mejorar la calidad de la atención sanitaria, en la investigación biomédica se ha incrementado la tendencia centrada en el estudio de las disparidades en salud y sexismo.

Objetivo.

Caracterizar la evidencia científica sobre la disparidad en salud definida como la brecha existente entre la distribución de la salud y el posible sesgo por sexo en el acceso a los servicios médicos.

Materiales y métodos.

Se hizo una búsqueda simultánea de la literatura científica en la base de datos Medline PubMed de dos descriptores fundamentales: Healthcare disparities y Sexism. Posteriormente, se construyó una red semántica principal y se determinaron algunas subunidades estructurales (comunidades) para el análisis de los patrones de organización de la información. Se utilizó el programa de código abierto Cytoscape para el analisis y la visualización de las redes y el MapEquation, para la detección de comunidades. Asimismo, se desarrolló código ex profeso disponible en un repositorio de acceso público.

Resultados.

El corpus de la red principal mostró que los términos sobre las enfermedades del corazón fueron los descriptores de condiciones médicas más concurrentes. A partir de las subunidades estructurales, se determinaron los patrones de información relacionada con las políticas públicas, los servicios de salud, los factores sociales determinantes y los factores de riesgo, pero con cierta tendencia a mantenerse indirectamente conectados con los nodos relacionados con condiciones médicas.

Conclusiones.

La evidencia científica indica que la disparidad por sexo sí importa para la calidad de la atención de muchas enfermedades, especialmente aquellas relacionadas con el sistema circulatorio. Sin embargo, aún se percibe un distanciamiento entre los factores médicos y los sociales que dan lugar a las posibles disparidades por sexo.

A review of myocardial ischaemia/reperfusion injury: Pathophysiology, experimental models, biomarkers, genetics and pharmacological treatment

Cardiovascular diseases are known to be the most fatal diseases worldwide. Ischaemia/reperfusion (I/R) injury is at the centre of the pathology of the most common cardiovascular diseases. According to the World Health Organization estimates, ischaemic heart disease is the leading global cause of death, causing more than 9 million deaths in 2016. After cardiovascular events, thrombolysis, percutaneous transluminal coronary angioplasty or coronary bypass surgery are applied as treatment. However, after restoring coronary blood flow, myocardial I/R injury may occur. It is known that this damage occurs due to many pathophysiological mechanisms, especially increasing reactive oxygen types. Besides causing cardiomyocyte death through multiple mechanisms, it may be an important reason for affecting other cell types such as platelets, fibroblasts, endothelial and smooth muscle cells and immune cells. Also, polymorphonuclear leukocytes are associated with myocardial I/R damage during reperfusion. This damage may be insufficient in patients with co-morbidity, as it is demonstrated that it can be prevented by various endogenous antioxidant systems. In this context, the resulting data suggest that optimal cardioprotection may require a combination of additional or synergistic multi-target treatments. In this review, we discussed the pathophysiology, experimental models, biomarkers, treatment and its relationship with genetics in myocardial I/R injury. SIGNIFICANCE OF THE STUDY: This review summarized current information on myocardial ischaemia/reperfusion injury (pathophysiology, experimental models, biomarkers, genetics and pharmacological therapy) for researchers and reveals guiding data for researchers, especially in the field of cardiovascular system and pharmacology.

The serum uric acid level in females may be a better indicator of metabolic syndrome and its components than in males in a Japanese population

BACKGROUND

Although the level of uric acid (UA) is higher in males, increased UA level in females was reported to be closely associated with prevalence of metabolic syndrome (Mets) leading to atherosclerotic cardiovascular disease (ASCVD). Few data exist regarding the gender diferences in relationship between the serum UA levels and cardo-metabolic risk in the Japanese population, which generally contains a lower proportion of obesity than Western populations.

METHODS

This cross-sectional study was designed to investigate, by gender, the association between the serum UA level and abdominal obesity, and thereby cardio-metabolic risk i.e. presence of Mets and its components using a sample of 8567 apparently healthy subjects females: n = 3334, males: n = 5233 at the Health Planning Center of Nihon University Hospital between September 2015 and August 2016.

RESULTS

Receiver operating characteristic analysis was performed to reveal the accuracy of serum UA level as a predictor of abdominal obesity based on the Japanese criteria of Mets (females vs. males: area under the curve, 0.751 vs 0.609). Furthermore, the serum UA level and proportion of abdominal obesity rose with increasing age in females; in males, however, these parameters did not change in parallel with age. Furthermore, the serum UA levels in females reflected a status of cardio-metabolic risk when compared with males in a multi-logistic regression analysis. It is particularly worth noting that in the above-mentioned multivariate logistic regression analysis, the odds ratio of hyperuricemia in females was generally 1.3-2.5 times higher than that in males.

CONCLUSIONS

Compared with males, increased serum UA level in females might be involved in abdominal obesity and cardio-metabolic risk, possibly leading to the development of ASCVD even in a Japanese population. This may be due to gender differences affecting the development of abdominal obesity and changes in the serum UA levels with age.

CLINICAL TRIAL REGISTRATION

UMIN (http://www.umin.ac.jp/) Study ID:　UMIN000035901retrospectively registered 1 March 2018.

Substitution of sugar-sweetened beverages for other beverages and the risk of developing coronary heart disease: Results from the Harvard Pooling Project of Diet and Coronary Disease

Sugar-sweetened beverage (SSB) intake is associated with metabolic disorders. The reduction of SSB intake has been promoted to prevent death and disability from chronic diseases. We investigated the association between SSB intake and the risk of coronary events and death, and assessed if substitution of coffee, tea, milk, fruit juice and artificially-sweetened beverages (ASB) for SSBs was associated with a reduced risk of coronary events and death. This was a follow-up study in which data from six studies were pooled and standard observational analyses were performed. Diet intake was assessed at baseline by food-frequency questionnaires. Hazard ratios (HRs) with 95% confidence intervals for the incidence of coronary events and deaths were calculated by Cox proportional hazards regression. The effect of substituting another beverage for SSBs was calculated by taking the difference in the individual effect estimates. During the median 8.2-year follow-up, 4248 coronary events and 1630 coronary deaths were documented among 284,345 individuals. 355 ml daily increase of SSB intake was associated with an increased risk of coronary events (HR: 1.08; 95%CI: 1.02, 1.14) and possibly coronary death (HR: 1.05; 95%CI: 0.96, 1.16). Substitution analyses suggested that replacing SSBs with coffee (HR: 0.93; 95%CI: 0.87, 1.00) or ASB (HR: 0.89; 95%CI: 0.83, 0.97), might be associated with a lower risk of developing coronary events. We found that SSB intake was associated with an increased risk of coronary events and possibly coronary death. Our findings also suggest that replacing SSB's with ASBs or coffee may lower the risk of developing CHD.

Gender Differences in Patient-Reported Outcomes Among Adults With Atherosclerotic Cardiovascular Disease

Background

Atherosclerotic cardiovascular disease (ASCVD) accounts for approximately one third of deaths in women. Although there is an established relationship between positive patient experiences, health‐related quality of life, and improved health outcomes, little is known about gender differences in patient‐reported outcomes among ASCVD patients. We therefore compared gender differences in patient‐centered outcomes among individuals with ASCVD.

Methods and Results

Data from the 2006 to 2015 Medical Expenditure Panel Survey, a nationally representative US sample, were used for this study. Adults ≥18 years with a diagnosis of ASCVD, ascertained by International Classification of Diseases, Ninth Revision (ICD‐9) codes and/or self‐reported data, were included. Linear and logistic regression were used to compare self‐reported patient experience, perception of health, and health‐related quality of life by gender. Models adjusted for demographics, socioeconomic status, and comorbidities. There were 21 353 participants included, with >10 000 (47%‐weighted) of the participants being women, representing ≈11 million female adults with ASCVD nationwide. Compared with men, women with ASCVD were more likely to experience poor patient–provider communication (odds ratio 1.25 [95% confidence interval 1.11–1.41]), lower healthcare satisfaction (1.12 [1.02–1.24]), poor perception of health status (1.15 [1.04–1.28]), and lower health‐related quality of life scores. Women with ASCVD also had lower use of aspirin and statins, and greater odds of ≥2 Emergency Department visits/y.

Conclusions

Women with ASCVD were more likely to report poorer patient experience, lower health‐related quality of life, and poorer perception of their health when compared with men. These findings have important public health implications and require more research towards understanding the gender‐specific differences in healthcare quality, delivery, and ultimately health outcomes among individuals with ASCVD.

Sex-specific differences in the intracellular proteome of human endothelial cells from dizygotic twins

Differences between men and women are being continuously identified in many human diseases. The underlying reasons are not yet fully understood. Beside the influence of endogenous hormones and life style, intrinsic sex-specific dimorphisms at the cellular level may also play a role. HUVECs from twin pairs of opposite sex provide an excellent tool to address the question of sex-specific differences at the molecular level. We compared for the first time protein levels of male and female HUVECs from dizygotic twins using a proteomic approach. To investigate differences under basal and stress conditions, cells were either left untreated or wounded and serum starved for different time points. Approximately 10% of all proteins monitored showed significant sexual dimorphisms in their level under the different conditions tested. The majority of the proteins displayed a higher abundance in female cells. The magnitude of the difference in protein levels between male and female cells was rather small. The most prominent differences throughout all conditions were observed for several X-chromosome encoded proteins with higher levels in female (UBA1, HDHD1) or in male cells (G6PD). Proteins involved in basic cellular processes, such as gene expression and translation (e.g. HMGN1, SRP54) displayed sex-specific levels in particular conditions only. SIGNIFICANCE: This study provides novel insights into sexual dimorphic protein levels in HUVECs from twin pairs of the opposite sex. The findings identify proteins with sex-specific differences in their levels under different cell culture conditions. The study also highlights the presence of X-chromosome encoded proteins escaping X-chromosomal inactivation. The results emphasize the need to consider the cellular sex of male and female HUVECs in in vitro experiments.

Cardiovascular protection in females linked to estrogen-dependent inhibition of arterial stiffening and macrophage MMP12

Arterial stiffening is a consequence of aging and a cholesterol-independent risk factor for cardiovascular disease (CVD). Arterial stiffening and CVD show a sex bias, with men more susceptible than premenopausal women. How arterial stiffness and sex interact at a molecular level to confer risk of CVD is not well understood. Here, we used the sexual dimorphism in LDLR-null mice to show that the protective effect of female sex on atherosclerosis is linked to reduced aortic stiffness and reduced expression of matrix metalloproteinase-12 (MMP12) by lesional macrophages. Deletion of MMP12 in LDLR-null mice attenuated the male sex bias for both arterial stiffness and atherosclerosis, and these effects occurred despite high serum cholesterol. Mechanistically, we found that oxidized LDL stimulates secretion of MMP12 in human as well as mouse macrophages. Estrogen antagonizes this effect by downregulating MMP12 expression. Our data support cholesterol-independent causal relationships between estrogen, oxidized LDL-induced secretion of macrophage MMP12, and arterial stiffness that protect against atherosclerosis in females and emphasize that reduced MMP12 functionality can confer atheroprotection to males.

Gender and Race Disparities in Cardiovascular Disease Risk Factors among New York City Adults: New York City Health and Nutrition Examination Survey (NYC HANES) 2013-2014

While gender and racial/ethnic disparities in cardiovascular disease (CVD) risk factors have each been well characterized, few studies have comprehensively examined how patterns of major CVD risk factors vary and intersect across gender and major racial/ethnic groups, considered together. Using data from New York City Health and Nutrition Examination Survey 2013-2014-a population-based, cross-sectional survey of NYC residents ages 20 years and older-we measured prevalence of obesity, hypertension, hypercholesterolemia, smoking, and diabetes across gender and race/ethnicity groups for 1527 individuals. We used logistic regression with predicted marginal to estimate age-adjusted prevalence ratio by gender and race/ethnicity groups and assess for potential additive and multiplicative interaction. Overall, women had lower prevalence of CVD risk factors than men, with less hypertension (p = 0.040), lower triglycerides (p < 0.001), higher HDL (p < 0.001), and a greater likelihood of a heart healthy lifestyle, more likely not to smoke and to follow a healthy diet (p < 0.05). When further stratified by race/ethnicity, however, the female advantage was largely restricted to non-Latino white women. Non-Latino black women had significantly higher risk of being overweight or obese, having hypertension, and having diabetes than non-Latino white men or women, or than non-Latino black men (p < 0.05). Non-Latino black women also had higher total cholesterol compared to non-Latino black men (184.4 vs 170.5 mg/dL, p = 0.010). Despite efforts to improve cardiovascular health and narrow disparities, non-Latino black women continue to have a higher burden of CVD risk factors than other gender and racial/ethnic groups. This study highlights the importance of assessing for intersectionality between gender and race/ethnicity groups when examining CVD risk factors.

Sex-associated differences in baseline urinary metabolites of healthy adults

The biological basis for gender variability among disease states is not well established. There have been many prior efforts attempting to identify the unique urine metabolomic profiles associated with specific diseases. However, there has been little advancement in investigating the metabolomic differences associated with gender, which underlies the misconception that risk factors and treatment regimens should be the same for both male and female patients. This present study aimed to identify biologically-meaningful baseline sex-related differences using urine samples provided by healthy female and male participants. To elucidate whether urinary metabolic signatures are globally distinct between healthy males and females, we applied metabolomics profiling of primary metabolism with comprehensive bioinformatics analyses on urine samples from 60 healthy males and females. We found that levels of α-ketoglutarate and 4-hydroxybutyric acid increased 2.3-fold and 4.41-fold in males compared to females, respectively. Furthermore, chemical similarity enrichment analysis revealed that differentially expressed metabolites, such as saturated fatty acids, TCA, and butyrates, were significantly related to the gender effect. These findings indicate that there are baseline sex-related differences in urinary metabolism, which should be considered in biomarker discovery, diagnosis, and treatment of bladder diseases, such as interstitial cystitis.

Sex Differences in Outcomes after Stroke in Patients with Diabetes in Ontario, Canada

BACKGROUND

Outcomes after stroke in those with diabetes are not well characterized, especially by sex and age. We sought to calculate the sex- and age-specific risk of cardiovascular outcomes after ischemic stroke among those with diabetes.

METHODS

Using population-based demographic and administrative health-care databases in Ontario, Canada, all patients with diabetes hospitalized with index ischemic stroke between April 1, 2002, and March 31, 2012, were followed for death, stroke, and myocardial infarction (MI). The Kaplan-Meier survival analysis and Fine-Gray competing risk models estimated hazards of outcomes by sex and age, unadjusted and adjusted for demographics and vascular risk factors.

RESULTS

Among 25,495 diabetic patients with index ischemic stroke, the incidence of death was higher in women than in men (14.08 per 100 person-years [95% confidence interval [CI], 13.73-14.44] versus 11.89 [11.60-12.19]) but was lower after adjustment for age and other risk factors (adjusted hazard ratio [HR], .95 [.92-.99]). Recurrent stroke incidence was similar by sex, but men were more likely to be readmitted for MI (1.99 per 100 person-years [1.89-2.10] versus 1.58 [1.49-1.68] among females). In multivariable models, females had a lower risk of readmission for any event (HR, .96 [95% CI, .93-.99]).

CONCLUSIONS

In this large, population-based, retrospective study among diabetic patients with index stroke, women had a higher unadjusted death rate but lower unadjusted incidence of MI. In adjusted models, females had a lower death rate compared with males, although the increased risk of MI among males persisted. These findings confirm and quantify sex differences in outcomes after stroke in patients with diabetes.

A Retrospective Observational Study of Anesthetic Induction Dosing Practices in Female Elderly Surgical Patients: Are We Overdosing Older Patients?

BACKGROUND/OBJECTIVES

Despite guidelines suggesting a 25-50 % reduction in induction doses of intravenous anesthetic agents in the elderly (≥65 years), we hypothesized that practitioners were not sufficiently correcting drug administration for age, contributing to an increased incidence of hypotension in older patients undergoing general anesthesia.

STUDY DESIGN

We conducted a retrospective, observational study in a tertiary-care academic hospital. The study included 768 female patients undergoing gynecologic surgeries who received propofol-based induction of general anesthesia.

MAIN OUTCOME MEASURES

Weight-adjusted anesthetic induction dosing, age-associated differences in dosing by ASA-PS (American Society of Anesthesiology-Physical Status), and hemodynamic outcomes between younger (18-64 years, n = 537) and older (≥65 years, n = 231) female patients were analyzed.

RESULTS

Older patients received lower doses of propofol and midazolam than younger patients (propofol: 2.037 ± 0.783 vs 2.322 ± 0.834 mg/kg, p < 0.001; midazolam: 0.013 ± 0.014 vs 0.023 ± 0.042 mg/kg, p < 0.001). However, practitioners still consistently exceeded the FDA recommended dose (1-1.5 mg/kg) of propofol for elderly patients. There was no significant difference in the doses of fentanyl administered between the two age groups (1.343 ± 0.744 vs 1.363 ± 0.763 μg/kg, p = 0.744), and doses of fentanyl in older patients exceeded the recommended dose (0.5-1.0 μg/kg). Corresponding to observed overdosing of induction agents, older patients experienced larger decreases in post-induction blood pressure and were more likely to receive vasopressor therapy.

CONCLUSIONS

Anesthetic induction doses of fentanyl and propofol were not sufficiently corrected in older patients in accordance with recommendations. Significantly greater frequency of post-induction hypotension occurred amongst older patients. Quality improvement efforts may lead to improved outcomes in this vulnerable population.

The Relationship Between Atherogenic Index and Carotid Artery Atherosclerosis in Familial Mediterranean Fever

Familial Mediterranean fever (FMF) is a disease characterized by chronic inflammation. Atherogenic index of plasma (AIP) is a logarithmic value of the triglyceride to high-density lipoprotein cholesterol ratio and it is a good marker for atherosclerotic heart disease and cardiac risk. In this study, we investigated subclinical atherosclerosis and cardiac risks in patients with FMF. Patients with FMF (78 men and 84 women) and healthy controls (74 men and 82 women) were included in this study. The AIP values of the patients were calculated and carotid intima-media thicknesses (cIMTs) were measured. The cIMT ( P < .001) and AIP ( P < .001) values of patients with FMF were higher than the values of the control group. There was a positive correlation between cIMT and AIP values ( r = .304, P < .001). In regression analysis, we detected an independent relationship between cIMT and AIP (β = .248, P = .001). Atherogenic index of plasma may be highly correlated with the subclinical atherosclerosis. Particularly, male patients with FMF may have a high cardiac risk.

Ischemia/Reperfusion

Ischemic disorders, such as myocardial infarction, stroke, and peripheral vascular disease, are the most common causes of debilitating disease and death in westernized cultures. The extent of tissue injury relates directly to the extent of blood flow reduction and to the length of the ischemic period, which influence the levels to which cellular ATP and intracellular pH are reduced. By impairing ATPase-dependent ion transport, ischemia causes intracellular and mitochondrial calcium levels to increase (calcium overload). Cell volume regulatory mechanisms are also disrupted by the lack of ATP, which can induce lysis of organelle and plasma membranes. Reperfusion, although required to salvage oxygen-starved tissues, produces paradoxical tissue responses that fuel the production of reactive oxygen species (oxygen paradox), sequestration of proinflammatory immunocytes in ischemic tissues, endoplasmic reticulum stress, and development of postischemic capillary no-reflow, which amplify tissue injury. These pathologic events culminate in opening of mitochondrial permeability transition pores as a common end-effector of ischemia/reperfusion (I/R)-induced cell lysis and death. Emerging concepts include the influence of the intestinal microbiome, fetal programming, epigenetic changes, and microparticles in the pathogenesis of I/R. The overall goal of this review is to describe these and other mechanisms that contribute to I/R injury. Because so many different deleterious events participate in I/R, it is clear that therapeutic approaches will be effective only when multiple pathologic processes are targeted. In addition, the translational significance of I/R research will be enhanced by much wider use of animal models that incorporate the complicating effects of risk factors for cardiovascular disease. © 2017 American Physiological Society. Compr Physiol 7:113-170, 2017.

Instrumento para la valoración de síntomas coronarios en la mujer

<p>Objetivo: Diseñar y validar un instrumento para la valoración de los síntomas en la mujer con enfermedad coronaria, enmarcada en la Teoría de los Síntomas Desagradables Metodología: Estudio metodológico, psicométrico, orientado por los Síntomas, concepto central de la Teoría de los Síntomas Desagradables de Lenz y colaboradores. Se realizó una crítica teórica del constructo elegido, demostrando su utilidad en la investigación y en la práctica disciplinar. Se ponderaron 260 evidencias por medio de una rigurosa crítica metodológica y empírica, aplicando el Sistema de Revisión Integrativa articulada al Modelo Conceptual Empírico de Fawcett y Garity. Se obtuvieron 30 piezas investigativas utilizadas para la construcción de los ítems. A los síntomas de Lenz se suman los síntomas psicosociales reportados en mujeres con enfermedad coronaria, generándose un primer instrumento compuesto por 87 ítems. Resultados: Se realizó una Validación de Contenido de expertos: Modelo Escobar y Cuervo 2008 (análisis estadístico SPSS 20) obteniéndose un Coeficiente de Correlación de Kendall de 0,682 (0,05), con buena concordancia entre jueces. El Modelo de Lawshe normalizado por Tristán 2008 reportó una Content Validity Ratio de 0,57 y un Index Validity Content de 0,797, demostrando que los ítems son unidades de análisis esenciales. Finalmente, la Validación Facial realizada mediante una prueba piloto a 21 mujeres que cumplieron los criterios de inclusión permitió la discriminación semiótica de los ítems, obteniéndose un instrumento compuesto por 67 ítems. Conclusiones: Éste es un remanente investigativo que requiere nuevas validaciones para elevar su capacidad psicométrica.</p>