Fortalezas sistémicas y necesidades en atención paliativa domiciliaria: explorando la complejidad / Systemic strengths and needs in palliative home care: exploring complexity

Objetivo Nos proponemos investigar la relación entre las fortalezas sistémicas y el lugar de muerte en atención domiciliaria de pacientes en final de vida. Método Estudio cuantitativo descriptivo longitudinal de pacientes atendidos por un equipo domiciliario de cuidados paliativos. Se analizó la ubicación de la muerte en relación con la complejidad detectada tras la primera valoración domiciliaria usando el modelo de complejidad HexCom. Para la comparación de proporciones utilizamos la prueba de ji cuadrado de Pearson. Resultados Participaron 464 pacientes (74,4% oncológicos), edad media 76,2años (DE: 13,2). El 53% presentaban dependencia funcional total o severa, el 30,8% estaban ya encamados en la primera valoración y el 59,7% fallecieron en domicilio. Las fortalezas influyen en el lugar de muerte, sobre todo la fortaleza del exosistema (equipo) (OR: 4,07 [1,92-8,63]), la del microsistema (tanto la fortaleza del paciente (0,51 [0,28-0,94]) como de cuidador (OR: 3,90 [1,48-10,25]), y la del cronosistema, relativo a la previsión de un curso progresivo (OR: 2,22 [1,37-3,60]). Conclusiones Para mejorar la asistencia a los pacientes en situación de final de vida y sus familias es necesaria una mirada sistémica del morir y de la muerte que incluya tanto necesidades como fortalezas. En este sentido, el marco sistémico propuesto por Bonfrenbrenner puede ser de utilidad para la práctica clínica. (AU)

Objective We aimed to investigate the relationship between systemic strengths and complexity in home care of end-of-life patients. Methods Quantitative descriptive longitudinal study of patients cared for at home by a palliative care team. Place of death was analyzed in relation to complexity, as determined by the HexCom complexity model after the initial home assessment. We used Pearson's chi-square test to analyze the comparison of proportions. Results Forty-six hundred patients (74.4% oncologic) with a mean age of 76.2years (SD 13.2) participated. Fifty-three percent had complete or severe functional dependence, 30.8% were already bedridden in the first assessment, and 59.7% died at home. Strengths influenced place of death, specifically exosystem (team) strength (OR: 4.07 [1.92-8.63]), microsystem (both patient 0.51 [0.28-0.94]) and caregiver (OR: 3.90 [1.48-10.25]), and chronosystem, related to prediction of progressive course (OR: 2.22 [1.37-3.60]). Conclusions To improve care for end-of-life patients and their families, a systemic view of dying and death that includes both needs and strengths is necessary. In this sense, the systemic framework proposed by Bonfrenbrenner can be useful for clinical practice. (AU)

Nutritive Value of Wheat Bran Diets Supplemented With Fresh Carrots and Wet Brewers' Grains in Yellow Mealworm.

We evaluated the effect of supplementation of a wheat bran (WB) diet with fresh carrots (FC) or wet brewer's grains (WBG) on the growth performance and chemical composition of Tenebrio molitor larvae. Additionally, a digestibility trial was performed to determine the nutritional value of the raw materials used. The control diet was based on WB-only. Two other diets were formulated in which WB was supplemented with FC (FC diet) or with WBG (WBG diet). The experiment was conducted in trays (12 per treatment) and lasted 90 d. Larval weight, feed intake, and excreted feces were controlled in each tray the experiment. The digestibility trial was performed from 48 to 62 d post-hatch. Results showed digestibility coefficients of ashes, crude protein, and gross energy were significantly higher in FC diet compared with the other diets. Consequently, both digestible energy (DE) and digestible protein (DP) contents of FC were also significantly higher than those obtained for WB and WBG diets (on av. +1.12 megajoule [MJ] DE and +9.15 g DP per kg dry matter [DM]; P < 0.003). Mealworms fed FC diet showed significantly higher final weight and average daily gain than those fed the WBG diet (+12.4%), being higher in WBG than in WB diet (+3.5%). Dietary treatment did not affect DM, ashes, ether extract, and crude protein content of mealworms obtained. Some dietary effects on amino acid and fatty acid composition were observed. This study provides novel data and a unique experimental approach to assess the nutritional value of raw materials in mealworms.

Moving bed biofilm reactor as an alternative wastewater treatment process for nutrient removal and recovery in the circular economy model.

Over the last years, an increasing concern has emerged regarding the eco-friendly management of wastewater. Apart from the role of wastewater treatment plants (WWTPs) for wastewater and sewage sludge treatment, the increasing need of the recovery of the resources contained in wastewater, such as nutrients and water, should be highlighted. This would allow for transforming a wastewater treatment plant (WWTP) into a sustainable technological system. The objective of this review is to propose a moving bed biofilm reactor (MBBR) as a novel technology that contributes to the circularity of the wastewater treatment sector according to the principles of circular economy. In this regard, this paper aims to consider the MBBR process as the initial step for water reuse, and nutrient removal and recovery, within the circular economy model.

[How to convince the head of department and managing director of the importance of specialised headache clinics]. / Como convencer al jefe de servicio y al gerente de la importancia de las unidades/consultas especializadas de cefaleas.

In spite that headache is, by far, the most frequent reason for neurological consultation and that the diagnosis and treatment of some patients with headache is difficult, the number of headache clinics is scarce in our country. In this paper the main arguments which should allow us, as neurologists, to defend the necessity of implementing headache clinics are reviewed. To get this aim we should first overcome our internal reluctances, which still make headache as scarcely appreciated within our specialty. The facts that more than a quarter of consultations to our Neurology Services are due to headache, that there are more than 200 different headaches, some of them actually invalidating, and the new therapeutic options for chronic patients, such as OnabotulinumtoxinA or neuromodulation techniques, oblige us to introduce specialised headache attendance in our current neurological offer. Even though there are no definite data, available results indicate that headache clinics are efficient in patients with chronic headaches, not only in terms of health benefit but also from an economical point of view.

TITLE: Como convencer al jefe de servicio y al gerente de la importancia de las unidades/consultas especializadas de cefaleas.A pesar de que la cefalea es, con diferencia, el principal motivo neurologico de consulta, y de la complejidad diagnostica y terapeutica de algunos pacientes, el numero de consultas monograficas de cefalea (CC) y de unidades de cefalea (UC) es muy reducido en nuestro pais. En este articulo pasaremos revista a los principales argumentos que nos permitan, como neurologos, defender la necesidad de la implementacion de una CC/UC, dependiendo de la poblacion que se debe atender, en todos nuestros servicios de neurologia. Para ello deberemos, en primer lugar, vencer las reticencias internas, que hacen que la cefalea sea aun poco apreciada y atractiva dentro de nuestra especialidad. El hecho de que la cefalea justifique mas de un cuarto de las consultas a un servicio de neurologia estandar de nuestro pais y de que existan mas de 200 cefaleas diferentes, algunas de ellas realmente invalidantes, y las nuevas opciones de tratamiento para pacientes cronicos, como la OnabotulinumtoxinA para la migraña cronica o las tecnicas de neuromodulacion, obligan a introducir dentro de nuestras carteras de servicios la asistencia especializada en cefaleas. Aunque no disponemos de datos incontrovertibles, existen ya datos suficientes en la literatura que indican que esta atencion es eficiente en pacientes con cefaleas cronicas no solo en terminos de salud, sino tambien desde el punto de vista economico.

Archaeal community dynamics and abiotic characteristics in a mesophilic anaerobic co-digestion process treating fruit and vegetable processing waste sludge with chopped fresh artichoke waste.

This study evaluated the feasibility of obtaining methane in anaerobic digestion (AD) from the waste products generated by the processing of fruit and vegetables. During the first phase (0-55 d) of the AD using sludge from fruit and vegetable processing, an average value of 244±88 L kg(-1) dry matter d(-1)of biogas production was obtained, and methane content reached 65% of the biogas. Co-digestion with chopped fresh artichoke wastes in a second phase (55-71 d) enhanced biogas production, and resulted in an average value of 354±68 L kg(-1) dry matter d(-1), with higher methane content (more than 70%). The archaeal community involved in methane production was studied using the ANAEROCHIP microarray and real-time PCR. Results indicated that species of Methanosaeta and Methanosarcina were important during the AD process. Methanosarcina numbers increased after the addition of chopped fresh artichoke, while Methanosaeta numbers decreased.

A preclinical and clinical study of mycophenolate mofetil in pancreatic cancer.

A high throughput screening for anticancer activity of FDA approved drugs identified mycophenolic acid (MPA), an inhibitor of inositol monophosphate dehydrogenase (IMPDH) as an active agent with an antiangiogenesis mode of action. Exposure of pancreatic cancer cell lines to MPA resulted in growth inhibition and reduced the expression of VEGF that was reversed by supplementing the media with guanosine supporting and IMPDH-dependant mechanism. In preclinical in vivo study, MPA showed a moderate inhibition of tumor growth in a panel of 6 human derived pancreatic cancer xenografts but reduced the expression of VEGF. To investigate the effects of MPA in human pancreatic cancer, a total of 12 patients with resectable pancreatic cancer (PDA) received increasing doses of mycophenolate mofetil (MMF) in cohorts of 6 patients each from 5-15 days prior to surgical resection. Treatment was well tolerated with one episode of grade 1 muscle pain, one episode of grade 2 lymphopenia (2 gr/day dose) and one episode of grade 2 elevantion in LFT (all in the 2 gr./day dose). Patients recovered from surgery uneventfully with no increased post-operative complications. Assessment of CD31, VEGF, and TUNEL in resected specimens compared to a non treated control of 6 patients showed no significant variations in any of the study endpoints. In conclusion, this study shows the feasibility of translating a preclinical observation to the clinical setting and to explore a drug mechanism of action in patients. MPA, however, did not show any hints of antiangiogenesis of anticancer clinical activity questioning if this agent should be further developed in PDA.

Community impacts of Prosopis juliflora invasion: biogeographic and congeneric comparisons.

We coordinated biogeographical comparisons of the impacts of an exotic invasive tree in its native and non-native ranges with a congeneric comparison in the non-native range. Prosopis juliflora is taxonomically complicated and with P. pallida forms the P. juliflora complex. Thus we sampled P. juliflora in its native Venezuela, and also located two field sites in Peru, the native range of Prosopis pallida. Canopies of Prosopis juliflora, a native of the New World but an invader in many other regions, had facilitative effects on the diversity of other species in its native Venezuela, and P. pallida had both negative and positive effects depending on the year, (overall neutral effects) in its native Peru. However, in India and Hawaii, USA, where P. juliflora is an aggressive invader, canopy effects were consistently and strongly negative on species richness. Prosopis cineraria, a native to India, had much weaker effects on species richness in India than P. juliflora. We carried out multiple congeneric comparisons between P. juliflora and P. cineraria, and found that soil from the rhizosphere of P. juliflora had higher extractable phosphorus, soluble salts and total phenolics than P. cineraria rhizosphere soils. Experimentally applied P. juliflora litter caused far greater mortality of native Indian species than litter from P. cineraria. Prosopis juliflora leaf leachate had neutral to negative effects on root growth of three common crop species of north-west India whereas P. cineraria leaf leachate had positive effects. Prosopis juliflora leaf leachate also had higher concentrations of total phenolics and L-tryptophan than P. cineraria, suggesting a potential allelopathic mechanism for the congeneric differences. Our results also suggest the possibility of regional evolutionary trajectories among competitors and that recent mixing of species from different trajectories has the potential to disrupt evolved interactions among native species.

Neuromodulation of the posterolateral hypothalamus for the treatment of chronic refractory cluster headache: Experience in five patients with a modified anatomical target.

INTRODUCTION: Deep brain stimulation (DBS) of the posterior hypothalamus has been found to be effective in the treatment of refractory chronic cluster headache (CCH). METHODS: We report the long-term outcomes of five patients with refractory CCH on whom stimulation of a modified target of approximately 3 mm in radius, which included the posterolateral hypothalamus, the fasciculus mammillotegmentalis, the fasciculus mammillothalamicus and the fasciculus medialis telencephali, was performed. The stereotaxic coordinates were 4 mm from the third ventricle wall, 2 mm from behind the mid-intercommissural point and 5 mm from under the intercommissural line. RESULTS: All patients became pain-free for 1-2 weeks after the procedure, but then needed an average of 54 days to optimize stimulation parameters. After a mean follow-up of 33 months, two remain pain-free, two have an excellent response (>90% decrease in attack frequency) and in one the attacks have been reduced by half. There were no serious adverse events. Permanent myosis and euphoria/well-being feeling were seen in three patients. Other adverse events, such as diplopia, dizziness, global headache of cervical dystonia, were seen transiently related to an increase in stimulation parameters. Attacks reappeared transiently in two patients as a result of cable rupture and when the stimulator was disconnected. CONCLUSIONS: Our results supports the efficacy of DBS in very refractory CCH with a slightly modified hypothalamic target conceived to avoid the lateral ventricle wall so as to extend the stimulated brain area and to decrease the morbidity of potential haemorrhagic complications.

Citrus compost and its water extract for cultivation of melon plants in greenhouse nurseries. Evaluation of nutriactive and biocontrol effects.

Two different types of citrus composts, and their water extracts, were tested with regard to their utilisations as partial substitutes for peat in growing media for melon seedlings in greenhouse nurseries. Both compost showed higher plant growth than peat. Compost composed by citrus waste and green residue (C2) showed greater plant growth than compost obtained from the same organic matrices mentioned above further the addition of sludge obtained from citrus industry (C1). Compost C2 showed a greater auxinic effect than C1 and it was the only one that showed cytokinic effect. Both composts also demonstrated a biocontrol effect against Fusarium oxysporum for melon plants: the effects were also higher in C2 than in C1. Higher number of isolated fungi was active against F. oxysporum in compost C2, than compost C1. No different bacterial biocontrol efficacy was observed between both composts. The water extracts of both composts gave lower plant yields than their solid matrices, their relative effects being similar to those of the solid composts (C2 extract gave higher plant yields than the extract from C1). The biocontrol effects of compost water extracts followed the same trend.

Lumbar bone mineral density after kidney transplantation: a three-year prospective study.

Osteopenia is a common complication after transplantation. However, prospective long-term studies are scarce and most were performed in patients on cyclosporine and high-dose steroids. In 65 patients with functioning grafts, 41 males and 24 females, 50 on tacrolimus-based immunosuppression and 15 on cyclosporine-based immunosuppression, bone mineral density (BMD) was measured in the lumbar spine (L2-L4) and femoral neck (FN) using dual X-ray absorptiometry (DEXA) in the first month after transplantation (baseline) and at 1, 2, and 3 years. At baseline, BMD was similar to the control population both in L2-L4 (z score = -0.421) and in FN (z score = -0.518). During the follow-up, 3 types of patterns were identified: BMD increased in L2-L4 in 25 patients (38.5%), remained stable in 20 patients (30.8%), and decreased in 20 patients (30.8%). BMD losses appeared mainly during the first year (0.964 +/- 0.162 baseline; 0.904 +/- 0.161 at 1 year, 0.886 +/- 0.140 at 3 years; analysis of variance [ANOVA] P < .001). However, the improvement was maintained throughout the follow-up (0.860 +/- 0.176 g/cm2 at baseline; 0.901 +/- 0.161 at 1 year; 0.954 +/- 0.178 at 3 years; ANOVA P < .001) and there was a parallel increase of BMD in FN (0.712 +/- 0.144 at baseline; 0.744 +/- 0.249 at 1 year; 0.826 +/- 0.184 at 3 years; ANOVA P < .01). There were no differences between both groups in graft function, intact parathyroid hormone (iPTH) levels, number of postmenopausal women, or steroid doses. About one third of patients had bone loss during the first year after transplantation. We were unable to identify any risk factor for this complication in patients on low-dose steroids.

Biopesticide effect of green compost against fusarium wilt on melon plants.

AIMS: The biopesticide effect of four green composts against fusarium wilt in melon plants and the effect of soil quality in soils amended with composts were assayed. METHODS AND RESULTS: The composts consisted of pruning wastes, with or without addition of coffee wastes (3/1 and 4/1, dry wt/dry wt) or urea (1000/1, dry wt/dry wt). In vitro experiments suggested the biopesticide effect of the composts against Fusarium oxysporum, while only the compost of pine bark and urea (1000/1dry wt/dry wt) had an abiotic effect. Melon plant growth with composts and F. oxysporum was one to four times greater than in the non-amended soil, although there was no significant decrease in the level of the F. oxysporum in the soil. The addition of composts to the soil also improved its biological quality, as assessed by microbiological and biochemical parameters: ATP and hydrolases involved in the P (phosphatase), C (beta-glucosidase) and N (urease) cycles. CONCLUSIONS: Green composts had greater beneficial characteristics, improved plant growth and controlled fusarium wilt in melon plants. These composts improve the soil quality of semi-arid agricultural soils. SIGNIFICANCE AND IMPACT OF THE STUDY: Biotic and abiotic factors from composts have been tested as responsible of their biopesticide activity against fusarium wilt.

Everolimus: un inmunosupresor con propiedades antiproliferativas / Everolimus: immunosuppression with antilymphoproliferative therapy

No disponible

Primary hypothalamic-third ventricle lymphoma. Case report and review of the literature.

Primary central nervous system lymphomas (PCNSL) are infrequent tumors and their presentation as a solitary hypothalamic-third ventricle mass can be considered exceptional. We report the case of a 57-year-old woman with progressive visual deterioration, diabetes insipidus and mental confusion. She had a diffuse and homogeneous tumoral lesion involving the third ventricle and the adjacent hypothalamic area with marked enhancement after contrast administration on both, competed tomography scan and magnetic resonance images. It was approached and partially resected by the translamina terminalis route. Histological diagnosis proved to be a diffuse non-Hodgkin lymphoma and the patient subsequently was treated with adjuvant radiotherapy and chemotherapy. Followup examination showed visual acuity recover but persistent confessional state. Eight similar well described cases reported in the literature are reviewed with a description of the major diffenciating features of this neurological entity. Treatment of PCNSL remains a challenge, and the topographical location within the hypothalamic-third ventricle area is even more complex.

Neuroimaging diagnosis of Tolosa-Hunt syndrome: MRI contribution.

OBJECTIVE: To present our experience in the neuroradiological diagnosis of six patients with Tolosa-Hunt syndrome. METHODS: Computerized tomograms and MRI, with and without contrast enhancement, of the cranium and orbits of patients fulfilling IHS criteria for the diagnosis of Tolosa-Hunt syndrome were analyzed. RESULTS: Standard CT scan, with and without contrast enhancement, disclosed an enlarged cavernous sinus in one patient and was normal in the remaining five. In comparison, MRI was clearly abnormal in the four patients on whom it was performed, showing a convex enlargement of the symptomatic cavernous sinus by an abnormal tissue isointense with gray matter on short TR/TE images and iso-hypointense on long TR/TE scans. This abnormal tissue markedly increased in signal intensity after contrast injection and, in two patients, extended into contiguous regions, mainly the orbital apex and subtemporal fossa ipsilaterally. One patient had follow-up studies after successful treatment with corticosteroids. Although diminished in size, the abnormal tissue was still visible on MRI after 3 months of treatment and only disappeared after 6 months of treatment. CONCLUSIONS: These MRI findings help in the differential diagnosis of the Tolosa-Hunt syndrome from conditions such as meningioma, lymphoma, and sarcoidosis, as well as confirming the similarities of the Tolosa-Hunt syndrome and orbital pseudotumor. In the presence of painful ophthalmoplegia, the finding by MRI of cavernous sinus enlargement, with the herein described signal and extension characteristics and slow resolution with corticosteroid treatment, is highly suggestive of the Tolosa-Hunt syndrome.

Bone mineral density in children and adolescents with diabetes mellitus type 1 of recent onset.

There is still controversy over the impact of diabetes control and duration on bone mass and growth parameters in children and adolescents with insulin-dependent diabetes mellitus (IDDM). The aim of this study was to assess bone mineral density (BMD) at axial and appendicular sites, in children with noncomplicated IDDM of recent onset, and its relation to metabolic control and auxological parameters (weight, height, and puberal stage). Fifty-five young Spanish IDDM, otherwise healthy patients (26 males, aged (SD 9.7 +/- 4.3 years) and 29 females, aged (SD 11.2 +/- 3.8 years) were studied. Duration of diabetes was 1-13.8 years. Two hundred eighty-two age-matched, healthy, Spanish children served as controls. HbA1 was assayed by high pressure liquid chromatography (HPLC) and BMD was measured using dual X-ray absorptiometry (DXA) densitometry at the spine and forearm. Results showed a Gaussian BMD distribution of patients according to sex and age, without sexual-stage differences. There was no correlation between BMD and glycated hemoglobin (average life disease or last HbA1 values) or duration of the disease; moreover, no differences in bone mass were found between <3 and >/=3 years of disease duration. Diabetes impact index (mean HbA1 x duration of disease in months) showed no significant influence of diabetes control on BMD. We could not demonstrate any impact of diabetes on BMD and growth parameters in children with IDDM of short duration.

K+ pore structure revealed by reporter cysteines at inner and outer surfaces.

The structure of the carboxyl half of the pore-forming region of Kv2.1 was studied by replacing each of 15 consecutive residues between positions 383 and 369 with a reporter cysteine residue. Extracellular application of charged, membrane-impermeant methanethiosulfonates irreversibly modified currents at four cysteine-substituted positions, K382, Y380, I379, and D378. Intracellular exposure to methanethiosulfonate ethyltrimethylammonium revealed another set of reactive mutants (V374, T373, T372, and T370). Our results indicate that positions 378 and 374 are exposed at outer and inner mouths of the channel, respectively, and immersed in the aqueous phase. In contrast to present topological models, the 383-369 region appears to span the pore mainly as a nonperiodic structure.

Preventive effects of hyperbaric oxygen in cluster headache.

The effect of a 2-week course of hyperbaric oxygen on both the duration and frequency of cluster headache attacks was tested in four patients suffering from chronic cluster headache with no clear response to pharmacological treatments. Two patients (two courses in one case) dramatically improved while on hyperbaric oxygen treatment, this positive response remaining for 2 and 31 days posttreatment. Case 3 only improved in frequency, while the remaining patient showed no benefit. These findings suggest that daily hyperbaric oxygen treatment can be used as a transient preventive treatment for desperate cluster headache sufferers.

Evidence of somatotopic organization of the sensory thalamus based on infarction in the nucleus ventralis posterior.

BACKGROUND: This is to describe a restricted sensory syndrome of unique distribution due to thalamic infarct. CASE DESCRIPTION: We report a case of pure sensory disturbance involving the left intraoral and perioral regions and the tips of the thumb and forefinger of the left hand. Magnetic resonance imaging revealed a small infarct in the contralateral thalamus, presumably affecting the nucleus ventralis posterior. CONCLUSIONS: This patient provides an excellent correlation between clinical findings and thalamic representation of body surface as established during stereotactic procedures.