A grounded theory study of the perceptions and meanings associated with gastrostomies among parents of children with palliative needs.

BACKGROUND: There is few literature on the difficulties and different meanings of gastrostomy tubes (GST) for parents of children with palliative needs, and what specific palliative care teams contribute to this process. AIM: To explore the process of information in the decision of performing a gastrostomy and the meanings that parents of children with palliative needs build around them. DESIGN: Semi-structured interviews which were transcribed and analysed using Grounded Theory. SETTING/PARTICIPANTS: Parents and caretakers of children admitted in Paediatric Palliative Care Unit of Madrid Autonomous Community (Spain) whose children bore a gastrostomy device. RESULTS: Two core categories arise ('Fight' and 'The child as a life-meaning generator'). In all the cases, the child supplied the meaning to go on, and the Palliative Care Unit (CPU) helped in the daily care of the child and solving problems derived from the handling of the GT. CONCLUSIONS: It is necessary to improve the process of giving bad news and to introduce models of health care that focus on parents and child as the center of palliative care. It is also necessary to develop educational programs that enable continuity of care at home for children with palliative needs.

Weight Gain and Somatization are Associated With the Onset of Gastroesophageal Reflux Diseases: Results of Two 5-year Follow-up Studies.

BACKGROUND: Although 2% to 4% of the population develop gastroesophageal reflux disease (GERD) annually, factors associated with the onset of GERD are scarcely known. OBJECTIVE: To assess whether such factors include weight gain and psychological distress. METHODS: Two cohorts (first: N=222; second N=754) drawn from 2 case-control studies were followed up for around 5 years. In 2004, all participants were directly interviewed using a validated questionnaire to collect data on body weight, height, GERD symptoms, and psychological distress. In 2009 to 2010, these same participants were again interviewed using the same methodology. RESULTS: The response rate was 83.3% in cohort 1 and 39.1% in cohort 2, after a follow-up of 4.3±0.7 and 5.6±0.3 years, respectively. The multivariate analysis showed only weight gain and psychological distress as being independently associated with the onset of GERD in both cohorts. Weight gain per kilogram showed an adjusted odds ratio (OR) of 1.21 (1.01-1.44) in the first cohort, and a gain of 5 kg or more showed an adjusted OR of 4.65 (1.72-12.53) in the second. Somatization scores showed an adjusted OR of 1.09 (1.04-1.15) in the first cohort (measured as Minnesota Multiphasic Personality Inventory 2 hypochondriasis score) and 2.88 (1.04-8.02) in the second (measured as psychosomatic symptoms score). Body mass index on attaining overweight or obese status was associated with the onset of GERD in the unadjusted but not in the adjusted analysis. CONCLUSIONS: Weight gain and somatization are the main factors associated with the onset of GERD. The association between GERD and obesity is just the ultimate consequence of gaining weight.

Expression of the ß-1,3-glucanase gene bgn13.1 from Trichoderma harzianum in strawberry increases tolerance to crown rot diseases but interferes with plant growth.

The expression of antifungal genes from Trichoderma harzianum, mainly chitinases, has been used to confer plant resistance to fungal diseases. However, the biotechnological potential of glucanase genes from Trichoderma has been scarcely assessed. In this research, transgenic strawberry plants expressing the ß-1,3-glucanase gene bgn13.1 from T. harzianum, under the control of the CaMV35S promoter, have been generated. After acclimatization, five out of 12 independent lines analysed showed a stunted phenotype when growing in the greenhouse. Moreover, most of the lines displayed a reduced yield due to both a reduction in the number of fruit per plant and a lower fruit size. Several transgenic lines showing higher glucanase activity in leaves than control plants were selected for pathogenicity tests. When inoculated with Colletotrichum acutatum, one of the most important strawberry pathogens, transgenic lines showed lower anthracnose symptoms in leaf and crown than control. In the three lines selected, the percentage of plants showing anthracnose symptoms in crown decreased from 61 % to a mean value of 16.5 %, in control and transgenic lines, respectively. Some transgenic lines also showed an enhanced resistance to Rosellinia necatrix, a soil-borne pathogen causing root and crown rot in strawberry. These results indicate that bgn13.1 from T. harzianum can be used to increase strawberry tolerance to crown rot diseases, although its constitutive expression affects plant growth and fruit yield. Alternative strategies such as the use of tissue specific promoters might avoid the negative effects of bgn13.1 expression in plant performance.

Is the reflux disease questionnaire useful for identifying GERD according to the Montreal definition?

BACKGROUND: Scales for aiding physicians diagnose gastro-oesophageal reflux disease (GERD) have not been evaluated in terms of their ability to discriminate between troublesome symptoms (TS) and non-troublesome symptoms (NTS). Our objective is to evaluate the ability of the Reflux Disease Questionnaire (RDQ) to identify GERD according to referral of TS, in patients without previous proton pump inhibitor (PPI) treatment and in patients on PPI treatment. METHODS: Patients consulting physicians because of heartburn or acid regurgitation were recruited at 926 primary-care centres in Spain. They were asked to complete several questionnaires including the RDQ, and to define which of their symptoms were troublesome. Information on drug treatment was collected by the physician. We performed a receiver operating characteristic (ROC) curve analysis to ascertain the RDQ's optimum cut-point for identifying TS. RESULTS: 4574 patients were included, 1887 without PPI and 2596 on PPI treatment. Among those without PPI treatment, 1722 reported TS. The area under the curve (AUC) was 0.79 for the RDQ, and the optimum RDQ cut-point for identifying TS was 3.18 (sensitivity, 63.2%; specificity, 80.2%). A total of 2367 patients on PPI treatment reported TS, and the optimum RDQ cut-off value was 3.06 (sensitivity, 65.4%; specificity, 71.8%). CONCLUSIONS: An RDQ score higher than 3 shows good sensitivity and specificity for differentiating TS from NTS among patients without PPI or on PPI treatment. The RDQ is useful in primary care for diagnosis of GERD based on the Montreal definition.

Validation of a questionnaire for assessing fecal impaction in the elderly: impact of cognitive impairment, and using a proxy.

BACKGROUND: Studies on the epidemiology of fecal impaction are limited by the absence of a valid and reliable instrument to identify the condition in the elderly. Our aim is to validate a questionnaire for identifying fecal impaction in the elderly and to assess the impact of cognitive impairment and the aid of a proxy on its reliability. METHODS: We developed a 5 questions' questionnaire. The questionnaire was presented to twenty doctors to test its face validity. Feasibility was pre-tested with ten non institutionalized subjects who completed the questionnaire twice, once alone or with the help of a proxy, and another along with the researcher.For the validation of the questionnaire all residents in a single nursing-home were invited to participate, allowing the self-decision of using a proxy. Medical records of all subjects were abstracted without knowledge of subjects' answers and agreement between fecal impaction according to self-reported and medical records analyzed. Physical impairment was measured with the Barthel's test and cognitive impairment with the mini-mental test. RESULTS: In the face validity only minor changes in wording were suggested. In the feasibility pre-test all subjects were able to understand and complete the questionnaire and all questions were considered appropriate and easily understandable.One-hundred and ninety-nine of the 244 residents participated in the study (mean age 86,1 ± 6,6). One hundred and forty two subjects understood all questions; not understanding them was inversely associated with cognitive impairment score (aOR: 0.86; 95% CI: 0.82-0.91). One hundred and sixty decided to use a proxy; the use of a proxy was inversely associated with educative level (0.13 (0.02-0.72), minimental's score (0.85; 0.76-0.95) and Barthel's score (0.96; 0.94-0.99). Agreement between medical records and self-completed questionnaire was 85.9% (kappa 0.72 (0,62- 0,82). Disagreement was unrelated to education and cognitive impairment. CONCLUSIONS: Our simple questionnaire is reliable for identifying fecal impaction in the elderly by self-report. Limitation imposed by cognitive impairment is minimized with the aid of a proxy.

Advantages of early cholecystectomy in clinical practice of a terciary care center.

BACKGROUND: Despite a number of studies show the superiority of early over delayed cholecystectomy in the treatment of acute cholecystitis, there is still controversy over the time for intervention. This study aimed to assess the use of early versus delayed cholecystectomy for the treatment of acute cholecystitis in terms of complications, conversion to open surgery and mean hospital stay. METHOD: We collected patients with acute cholecystitis treated at a referral center for a year, and retrospectively analyzed the chosen therapeutic approach, the percentage of conversion of early cholecystectomy to open surgery, appearance of surgical complications, and mean hospital stay. RESULTS: The study included 117 patients, 44 women and 73 men, who had a mean age of 67.36+/-15.74 years. Early cholecystectomy was chosen in 31 (26.5%) and delayed cholecystectomy in 74 patients (63.2%). Of the 74 patients, 28 (37.8%) required emergency performance of delayed cholecystectomy, and 19 (25.7%) had not undergone surgery by the end of the study. While no differences were observed between early and delayed cholecystectomy in terms of surgical complications and conversion to open surgery, mean hospital stay was nevertheless significantly shorter in the early versus the delayed cholecystectomy group (8.32+/-4.98 vs 15.96+/-8.89 days). CONCLUSION: Under the routine working conditions of a hospital that is neither specially dedicated to the surgical treatment of acute cholecystitis nor provided with specific management guidelines, early cholecystectomy can reduce the hospital stay without increase of the conversion rate or complications.

Translation, cultural adaptation and validation of a Spanish version of the Irritable Bowel Syndrome Severity Score.

BACKGROUND: the Irritable Bowel Syndrome Severity Score (IBSSS) is a questionnaire only available in English that classifies IBS patients according to the severity of their symptoms and can be used to guide and monitor the treatment. AIMS: to adapt and validate into Spanish the English version of the IBSSS questionnaire. METHODS: the Spanish version of the questionnaire was obtained through a process of translation-evaluation of the comprehensibility and back translation. In a later phase we evaluated the applicability(n = 15), reproducibility (n = 31) and sensitivity to change (n = 40) of the Spanish version of the questionnaire. Finally we evaluated an alternative version of the ISBSS using a numerical scoring system instead of the original analog visual scale (n = 40). RESULTS: the Spanish version of the IBSSS showed an excellent reproducibility (r = 0.81 for global score) and an adequate sensitivity to change: a decrease of 45 points or more identified worsening of IBS with a 70.6% sensitivity and 87.5% specificity; an increase of 45 points or more identified improvement of IBS with a 85.7% sensitivity and 87.5% specificity. The severity score was practically the same regardless of the scoring system used (r = 0.96). CONCLUSIONS: the Spanish version of the IBSSS is a reproducible tool that is able to identify relevant changes over the course of the disease. The use of a numerical scoring system is a valid alternative to the visual scale that improves the applicability of the questionnaire to situations when the written communication is limited or not possible.

[Hospital admissions into paediatric palliative care: A retrospective study]. / Ingresos hospitalarios en cuidados paliativos pediátricos: estudio retrospectivo.

INTRODUCTION: Patients may be admitted to hospital by paediatric palliative care units (PPCU) for different reasons, due to their different needs and clinical problems. The objective of this study is to present the data of patients admitted to the PPCU of the Autonomous Community of Madrid. METHODS: Descriptive retrospective study was conducted by reviewing the clinical records of the PPCU between January 2011 and December 2016. RESULTS: Of 499 patients attended in this period, 166 (33%) were admitted to hospital at some point, generating a total of 314 episodes. Respiratory problems (34%) were the main cause of admission. Gastrostomy intervention (23 patients) was the commonest reason for a surgical admission. In this period, 46 patients died during hospitalisation. The highest frequencies of death, according to the admission cause, were respiratory problems (18 out 46) and end-of-life care (11 out 46). More than half (59%) of admissions lasted less than 7 days and 88% were 15 days or less. CONCLUSIONS: The causes and characteristics of the hospital admissions at a PPCU are heterogeneous, with respiratory problems being the most common cause of admission. The duration of the hospitalisation appears to be similar to that described for acute palliative care units. The creation of a specific PPCU that can refer their patients for hospital admission might help to improve continuity of care.

Exploring the Use of Fruit Callus Culture as a Model System to Study Color Development and Cell Wall Remodeling during Strawberry Fruit Ripening.

Cell cultures derived from strawberry fruit at different developmental stages have been obtained to evaluate their potential use to study different aspects of strawberry ripening. Callus from leaf and cortical tissue of unripe-green, white, and mature-red strawberry fruits were induced in a medium supplemented with 11.3 µM 2,4-dichlorophenoxyacetic acid (2,4-D) under darkness. The transfer of the established callus from darkness to light induced the production of anthocyanin. The replacement of 2,4-D by abscisic acid (ABA) noticeably increased anthocyanin accumulation in green-fruit callus. Cell walls were isolated from the different fruit cell lines and from fruit receptacles at equivalent developmental stages and sequentially fractionated to obtain fractions enriched in soluble pectins, ester bound pectins, xyloglucans (XG), and matrix glycans tightly associated with cellulose microfibrils. These fractions were analyzed by cell wall carbohydrate microarrays. In fruit receptacle samples, pectins were abundant in all fractions, including those enriched in matrix glycans. The amount of pectin increased from green to white stage, and later these carbohydrates were solubilized in red fruit. Apparently, XG content was similar in white and red fruit, but the proportion of galactosylated XG increased in red fruit. Cell wall fractions from callus cultures were enriched in extensin and displayed a minor amount of pectins. Stronger signals of extensin Abs were detected in sodium carbonate fraction, suggesting that these proteins could be linked to pectins. Overall, the results obtained suggest that fruit cell lines could be used to analyze hormonal regulation of color development in strawberry but that the cell wall remodeling process associated with fruit softening might be masked by the high presence of extensin in callus cultures.

Nutrient drink test: A promising new tool for irritable bowel syndrome diagnosis.

BACKGROUND: Irritable bowel syndrome (IBS) is a highly prevalent condition. It is diagnosed on the basis of chronic symptoms after the clinical and/or investigative exclusion of organic diseases that can cause similar symptoms. There is no reproducible non-invasive test for the diagnosis of IBS, and this raises diagnostic uncertainty among physicians and hinders acceptance of the diagnosis by patients. Functional gastrointestinal (GI) syndromes often present with overlapping upper and lower GI tract symptoms, now believed to be generated by visceral hypersensitivity. This study examines the possibility that, in IBS, a nutrient drink test (NDT) provokes GI symptoms that allow a positive differentiation of these patients from healthy subjects. AIM: To evaluate the NDT for the diagnosis of IBS. METHODS: This prospective case-control study compared the effect of two different nutrient drinks on GI symptoms in 10 IBS patients (patients) and 10 healthy controls (controls). The 500 kcal high nutrient drink and the low nutrient 250 kcal drink were given in randomized order on separate days. Symptoms were assessed just before and at several time points after drink ingestion. Global dyspepsia and abdominal scores were derived from individual symptom data recorded by two questionnaires designed by our group, the upper and the general GI symptom questionnaires, respectively. Psycho-social morbidity and quality of life were also formally assessed. The scores of patients and controls were compared using single factor analysis of variance test. RESULTS: At baseline, IBS patients compared to controls had significantly higher levels of GI symptoms such as gastro-esophageal reflux (P = 0.05), abdominal pain (P = 0.001), dyspepsia (P = 0.001), diarrhea (P = 0.001), and constipation (P = 0.001) as well as higher psycho-social morbidity and lower quality of life. The very low incidence of GI symptoms reported by control subjects did not differ significantly for the two test drinks. Compared with the low nutrient drink, IBS patients with the high nutrient drink had significantly more dyspeptic symptoms at 30 (P = 0.014), 45 (P = 0.002), 60 (P = 0.001), and 120 min (P = 0.011). Dyspeptic symptoms triggered by the high nutrient drink during the first 120 min gave the best differentiation between healthy controls and patients (area under receiver operating curve of 0.915 at 45 min for the dyspepsia score). Continued symptom monitoring for 24 h did not enhance separation of patients from controls. CONCLUSION: A high NDT merits further evaluation as a diagnostic tool for IBS.

A nation-wide study of prevalence and risk factors for fecal impaction in nursing homes.

BACKGROUND: There are no existing studies that provide data regarding the epidemiology of, and risk factors for, fecal impaction, either in the general population or in any sub-group of people. OBJECTIVE: Estimate the prevalence of and factors associated with fecal impaction on a representative sample of the institutionalized elderly population. DESIGN: Two-phase study. Phase 1: pilot study validating the methodology in which all residents of a single nursing home participated. Phase 2: national multi-center cross-sectional study. SETTING: 34 randomly selected nursing homes. MEASUREMENTS: The presence of fecal impaction and associated factors were evaluated using three different tools: data collected from medical records; a self-completion questionnaire filled out by the subjects or a proxy; and a rectal examination. SUBJECTS: Older subjects living in nursing homes. RESULTS: The prevalence of chronic constipation was 70.7% (95%CI: 67.3-74.1%), of which 95.9% of patients were properly diagnosed and 43.1% were properly controlled. The prevalence of FI according to patient history was 47.3% (43.6-51.0%) and 6.6% (4.7-8.5%) according to rectal examination. Controlled constipation (OR: 9.8 [5.2-18.4]) and uncontrolled constipation (OR: 37.21 [19.7-70.1]), the number of medications (OR: 1.2 [1.1-1.3]), reduced functional capacity (OR: 0.98 [0.97-0.99]) and the occasional use of NSAIDs were independent risk factors for fecal impaction. CONCLUSIONS: Constipation affects more than 70% of people living in nursing homes. Although it is properly diagnosed in more than 95% of cases, the disease is only controlled in less than 50%. Constipation, especially when not controlled, is the most significant risk factor leading to fecal impaction, which is prevalent in almost 50% of this population.