The experiences of older individuals providing care to older dependents: A phenomenological study in Spain.

OBJECTIVE: Non-professional care provided in domestic settings by a family member or someone from the close environment and without a connection to a professional care service, is increasingly assumed by older people, mainly the spouses of those requiring care. The aim of this study was to describe the experience of older people providing care at home to older dependents. METHODS: A qualitative study was carried out to describe and explore the experience of older people, caregivers of dependent older people in the home. RESULTS: Four themes emerged as a result of the analysis: interpersonal relationships established in the caregivers' immediate environment; the need and request for public and private resources; consequences of providing care during old age; and adaptation to the circumstance of being a caregiver during old age. Older people who provide home-based care, experience their situation as stressful, feel that it limits their daily life, deprives them of their freedom, and affects their interpersonal relationships and social activities. DISCUSSION: Older caregivers learn quickly and can manage the skills issues. The volume of work is their challenge. Interpersonal relationships are altered depending on the length of time spent together and the demand for care. Public services and benefits are not adapted to the demands of caregivers or dependent persons.

Diseño y validación del Índice de Evaluación de Casos Complejos (IECC), un instrumento para identificar pacientes complejos / Design and validation of the Complex Case Evaluation Index, an instrument to identify complex patients

Fundamento: Desarrollar y validar un instrumento específico de identificación de pacientes complejos, elÍndice de Evaluación de Casos Complejos (IECC). Métodos: Estudio instrumental con dos fases: 1) Elaboración del instrumento: se definieron y operacionalizaronlas variables extraídas de la literatura que, posteriormente, fueron sometidas al juicio de expertos. El IECCincluyó catorce variables divididas en dos dimensiones:complejidad del manejo clínico y complejidad del manejo comunitario. 2) Estudio psicométrico: evaluaciónde la fiabilidad por equivalencia entre observadores (rPearson), de la validez de criterio respecto al sistema declasificación Clinical Risk Groups (CRG) y de la validezde constructo a través de grupos conocidos y a travésdel estudio de conglomerados jerárquicos. Los análisisse realizaron con el paquete estadístico SPSS.v.17. Resultados: La fiabilidad entre observadores para lasubescala clínica fue r = 0,97, para la subescala comunitaria r = 0,74 y para la puntuación total r = 0,89. El 88,4%(n = 458) de los 518 casos identificados como complejospor el IECC fueron categorizados por el sistema CRG enlas categorías de más complejidad clínica (niveles 6 a9). Los resultados sustentan la validez de constructode la escala. El análisis de conglomerados mostró dosclusters diferentes, aunque relacionados. Conclusión: El IECC es un índice breve y de fácil aplicación, con una buena adecuación conceptual y evidencias de su fiabilidad y validez dirigido a la detección depacientes con necesidades complejas.(AU)

Background: The aim was to develop and validate theComplex Case Assessment Index (CCAI), a specific instrument to identify complex patients. Methods: Instrumental study in two phases: 1) Development of the scale: the variables extracted from theliterature were firstly defined and operationalized, andthen submitted for expert judgment. The CCAI included14 variables divided into two dimensions: complexity ofclinical management and complexity of community management. 2) Psychometric study: evaluation of the reliability and validity of the scale by equivalence betweenobservers (Pearson’s r), criterion validity with respect tothe Clinical Risk Groups (CRG) classification system, andconstruct validity through known groups and study ofhierarchical clusters were examined. The analyses werecarried out with the SPSS version 17 statistical package. Results: Reliability by equivalence between observers was r = 0.97 for the clinical subscale, r = 0.74 for thecommunity subscale, and r = 0.89 for the total score.The CCAI identified 518 cases as complex; 458 of them(88.4%) were categorized by the CRG system in the categories of greatest clinical complexity (levels 6 to 9).The results support the construct validity of the scale.The cluster analysis showed two different, although related, clusters. Conclusion: The CCAI is a fast and easy-to-use index,with good conceptual adequacy and evidence of reliability and validity for screening patients with complexneeds.(AU)

[Design and validation of a complex case evaluation index].

BACKGROUND: The aim was to develop and validate the Complex Case Assessment Index (CCAI), a specific instrument to identify complex patients. METHODS: Instrumental study in two phases: 1) Development of the scale: the variables extracted from the literature were firstly defined and operationalized, and then submitted for expert judgment. The CCAI included 14 variables divided into two dimensions: complexity of clinical management and complexity of community management. 2) Psychometric study: evaluation of the reliability and validity of the scale by equivalence between observers (Pearson's r), criterion validity with respect to the Clinical Risk Groups (CRG) classification system, and construct validity through known groups and study of hierarchical clusters were examined. The analyses were carried out with the SPSS version 17 statistical package. RESULTS: Reliability by equivalence between observers was r?=?0.97 for the clinical subscale, r?=?0.74 for the community subscale, and r?=?0.89 for the total score. The CCAI identified 518 cases as complex; 458 of them (88.4%) were categorized by the CRG system in the categories of greatest clinical complexity (levels 6 to 9). The results support the construct validi-ty of the scale. The cluster analysis showed two different, although related, clusters. CONCLUSION: The CCAI is a fast and easy-to-use index, with good conceptual adequacy and evidence of reliability and validity for screening patients with complex needs.

Nutritional screening in a case management program for community-living older individuals at high risk of hospital admission.

BACKGROUND: The prevalence of malnutrition in older persons depends on the healthcare setting. In recent years, hospital-based case management programs (CM Programs) targeting individuals in the community with chronic multimorbidity and high use of hospital resources (admissions or emergency visits) have been developed in many countries to reduce the need for complex health care. The objective of this study was to assess the prevalence of risk of malnutrition, using the Short Form of the Mini-Nutritional assessment, of community dwelling patients included in a chronic CM Program. Factors associated with malnutrition risk were also explored. METHODS: Patients included in a hospital-based integrated CM Program for older persons at high risk for hospital readmission after an index admission were studied. MNA-SF was used at program inclusion to assess the risk of malnutrition. An array of factors potentially associated with malnutrition were explored (including feeding route, use of dental prosthesis, dysphagia, consistency of foods, specific therapeutic diets, use of oral nutritional supplements, polypharmacy, falls, and other diseases and geriatric syndromes). RESULTS: 791 participants were included, mean age 79.8 years, 50.1% females. Risk of malnutrition was present in 44.9%. Participants at risk of malnutrition were more frequently female, had a lower BMI, were less likely to be fed orally and used more nutritional supplements. They also had a higher prevalence of dysphagia, needing changes in food consistency or using specific therapeutic diets, and had dementia or cancer more frequently. They also showed a higher need for palliative care. CONCLUSIONS: Risk of malnutrition in patients included in a CM Program is higher than in non-selected community dwelling older individuals. This information may help inform screening policies in similar populations at risk of hospital readmission.

First Report of 'Candidatus Liberibacter solanacearum' in Carrot in Mainland Spain.

In the summer of 2008, symptoms of leaf curling with yellow, bronze, and purple discoloration, twisting of petioles, stunting of shoots and tap roots, and proliferation of secondary roots were observed in 18 commercial carrot (Daucus carota L.) fields (~62 ha) severely infested with psyllids (mainly Bactericera sp.) from 52 fields (297 ha) located in Alicante and Albacete provinces of Spain. Incidence of symptomatic plants was variable among fields. Similar symptoms were observed in 2009, 2010, and 2011. Symptoms resembled those associated with phytoplasma, spiroplasma, or the bacterium 'Candidatus Liberibacter solanacearum' infections in carrot (1-4). Aster yellows and stolbur phytoplasmas and Spiroplasma citri have previously been reported from carrot in mainland Spain but liberibacter infection has not been documented in this region (1). Studies were conducted to determine if 'Ca. L. solanacearum' was associated with the symptoms. Petiole samples of symptomatic carrot plants were collected in 2009 (25 from 9 fields in Alicante and Albacete provinces) and early 2010 (21 from 8 fields in Alicante, Albacete, and Valencia provinces) from symptomatic fields where incidence ranged from 50 to 90%. In addition, one sample collected in 2008 in Alicante was included in the assay. Also, samples were collected from five asymptomatic carrot plants. Total DNA was extracted from 0.5 g of petiole tissue of each sample with the CTAB extraction buffer method (3,4). DNA extractions were analyzed by PCR assay using primer pairs OA2/OI2c and CL514F/R to amplify a portion of 16S rDNA and rplJ/rplL ribosomal protein genes, respectively, of 'Ca. L. solanacearum' (3,4). DNA samples were also tested for phytoplasmas and S. citri by nested-PCR assays using primer pairs P1/P7 followed by R16F2n/R16R2n and ScR16F1/ScR16R1 followed by ScR16F1A/ScR16R2, respectively (2). A 1,168-bp fragment of 16S rDNA was detected in DNA extracted from 1, 12, and 12 symptomatic samples collected in 2008, 2009, and 2010, respectively, suggesting the presence of 'Ca. L. solanacearum' in the carrot samples. A 669-bp rplJ/rplL fragment also was amplified from DNA of the same samples. Liberibacter was not detected in asymptomatic plants. Eight and two samples were infected with S. citri and aster yellows phytoplasmas, respectively. Three samples were infected with S. citri and 'Ca. L. solanacearum' and one sample was infected with all three pathogens. Three amplicons obtained from the PCR assays with both primer pairs from carrot samples collected in 2009 and 2010 were sequenced directly. BLAST analysis of the 16S rDNA sequences (GenBank Nos. HQ454302, HQ454303, and HQ454304) showed 99% nucleotide identity to those of 'Ca. L. solanacearum' amplified from carrot in Finland (GU373049). The rplJ/rplL nucleotide sequences (HQ454305, HQ454306, and HQ454307) were 97% identical to sequences of the analogous rplJ/rplL 'Ca. L. solanacearum' ribosomal protein gene from carrot in Finland (GU373051). To our knowledge, this is the first report of 'Ca. L. solanacearum' in carrot in mainland Spain and also the first evidence of mixed infections of S. citri, 'Ca. L. solanacearum', and phytoplasmas in carrot. References: (1) M. C. Cebrián et al. Plant Dis. 94:1264, 2010. (2) I.-M. Lee et al. Plant Dis. 90:989, 2006. (3) J. E. Munyaneza et al. J. Econ. Entomol. 103:1060, 2010. (4) J. E. Munyaneza et al. Plant Dis. 94:639, 2010.

First Report of Spiroplasma citri in Carrot in Europe.

In 2008 and 2009, symptoms of curling, yellow and purple discoloration of leaves, stunting of shoots and tap roots, and formation of bunchy, fibrous secondary roots were observed in commercial carrot (Daucus carota L.) fields located in several production areas of Spain (Alicante, Albacete, Segovia, and Valladolid). Incidence of this disease was almost 100% in individual affected fields. Similar symptoms were reported from 1997 to 1998 in various carrot production areas of Spain (the Canary Islands, Segovia, and Madrid) and were associated with infection of stolbur and aster yellows phytoplasmas (2). Moreover, the observed symptoms resembled those caused by Spiroplasma citri in carrots affected by the carrot purple leaf disease recently reported in the United States (4). Studies were conducted to investigate whether S. citri and phytoplasmas were associated with the observed carrot symptoms. Total DNA was extracted from 0.5 g of phloem tissue of 13 symptomatic and 3 asymptomatic plants with DNeasy Plant Mini Kit (Qiagen, Valencia, CA). DNA samples were analyzed by nested-PCR assays using primers pair P1/P7 (1) and R16F2n/R16R2n (3) for phytoplasmas and ScR16F1/ScR16R1 followed by ScR16F1A/ScR16R2 (4) for S. citri detection. DNA of a known strain of S. citri (Sediag, Longvic, France) was used as a positive control of the assay. Analyses revealed that 8 of the 13 symptomatic plants tested positive for S. citri; the plants were collected from three different provinces of Spain, namely, Alicante, Valladolid, and Segovia. Two symptomatic plants were double infected by S. citri and a phytoplasma strain belonging to the Aster yellows group (16SrI), subgroup 16SrI-A. However, none of the symptomatic plants presented single infection with phytoplasmas. S. citri identity was determined by sequencing two nested PCR products (1.1 kb) that yielded identical sequences deposited in the GenBank database (Accession Nos. HM124555 and HM124556). BLAST analysis showed 100% nt identity with a sequence of S. citri from carrot (Accession No. DQ112019) associated with the new carrot disease referred to as 'carrot purple leaf reported in Washington State (4). To our knowledge, this is the first report of S. citri associated with carrot in Europe. References: (1) S. Deng and C. Hiruki. J. Microbiol. Methods 14:53, 1991. (2) M. I. Font et al. Bol. San. Veg. Plagas 25:415, 1999. (3) I. M. Lee et al. Int. J. Syst. Bacteriol. 48:1153, 1998. (4) I. M. Lee et al. Plant Dis. 90:989, 2006.

Electrochemical and spectroscopic investigation of counterions exchange in polyelectrolyte brushes.

Scanning electrochemical microscopy (SECM) is employed to characterize the transport of redox-active probe ions through quenched polyelectrolyte brushes. The counterion exchange through polyelectrolyte brushes is also investigated by infrared spectroscopy in attenuated total reflection (FTIR-ATR), X-ray photolectron spectroscopy (XPS), and cyclic voltammetry (CV). The synthesis of poly(methacryloyloxy)ethyl trimethylammonium chloride (PMETAC) brushes is performed using surface-initiated atom transfer radical polymerization followed by in situ quaternization reaction. The chloride (Cl(-)) counterions of the positively charged polymer brush are exchanged by ferrocyanide (Fe(CN)(6)(4-)) and ferricyanide (Fe(CN)(6)(3-)) ions that are both detectable by spectroscopy and electrochemically active. A good agreement is found when comparing the results obtained by spectroscopic (FTIR-ATR and XPS) and electrochemical (SECM and CV) methods. The counterions exchange is completely reversible and reproducible. We show that (Fe(CN)(6)(4-)) and (Fe(CN)(6)(3-)) species form stable ion pairs with the quaternary ammonium groups of the polymer brush. The transport of iodide (I(-)) redox-active ions is also investigated. In all cases (ferrocyanide, ferricyanide, or iodide), we find that chloride counterions are partially replaced by electroactive ions. This partial exchange may be attributed to an osmotic effect, since the external salt concentration for the exchange is much lower than the counterion concentration inside the brush.

Synthesis and swelling behavior of pH-responsive polybase brushes.

We synthesize polybase brushes and investigate their swelling behavior. Poly(2-(dimethylamino)ethyl methacrylate)) (PDMAEMA) brushes are prepared by the "grafting from" method using surface-initiated Atom Transfer Radical Polymerization to obtain dense brushes with relatively monodisperse chains (PDI = 1.35). In situ quaternization reaction can be performed to obtain poly(2-(trimethylamino)ethyl methacrylate)) (PTMAEMA) brushes. We determine the swollen thickness of the brushes using ellipsometry and neutron reflectivity techniques. Brushes are submitted to different solvent conditions to be investigated as neutral brushes and weak and strong polyelectrolyte brushes. The swelling of the brushes is systematically compared to scaling models. It should be pointed out that the scaling analysis of different types of brushes (neutral polymer and weak and strong polyelectrolyte brushes) is performed with identical samples. The scaling behavior of the PDMAEMA brush in methanol and the PTMAEMA brush in water is in good agreement with the predicted scaling laws for a neutral polymer brush in a good solvent and a polyelectrolyte brush in the osmotic regime. The salt-induced contraction of the quaternized brush is observed for high salt concentration, in agreement with the predicted transition between the regimes of the osmotic brush and the salted brush. From the crossover concentration, we calculate the effective charge ratio of the brush following the Manning counterion condensation. We also use PDMAEMA brushes as pH-responsive polybase brushes. The swelling behavior of the polybase brush is intermediate with respect to the behavior of the neutral polymer brush in a good solvent and the behavior of the quenched polyelectrolyte brush, as expected. The effective charge ratio of the PDMAEMA brush is determined as a function of pH using the scaling law of the polyelectrolyte brush in the osmotic regime.

Dependencia funcional y deterioro cognitivo de pacientes con cáncer avanzado atendidos en domicilio / No disponible

Objetivo: evaluar la dependencia funcional y deterioro cognitivo de los pacientes con cáncer avanzado atendidos en sus domicilios dentro de un programa de cuidados paliativos desarrollado por una Unidad de Hospitalización a Domicilio perteneciente a un hospital de tercer nivel («agudos»). Material y método: se analizan 1.423 pacientes que corresponden a la totalidad de enfermos de cáncer avanzado atendidos por la unidad entre enero de 2000 y diciembre de 2005. Resultados: destaca la fuerte dependencia física y marcado deterioro cognitivo de los pacientes al ingreso en programa con media de índice de Barthel de 34 y test de Pfeiffer mayor de 4 en el 50% de los casos. La estancia media fue de 12,5 días (DS 18). El 56% (797) de los pacientes falleció en su propio domicilio, el 10,8 (153) reingresó en nuestro hospital y el 6,8 (97) se derivó a una Unidad de Cuidados Paliativos de hospital sociosanitario. Los pacientes que fallecieron en el domicilio eran mayores (71 años) que los que reingresaron en el hospital (66) (p < 0,01) y presentaron al ser incluidos en programa mayor nivel de dependencia funcional (Barthel medio: 22,3 y 49,5 respectivamente, p < 0,001) y deterioro cognitivo (Pfeiffer medio 5,8 vs. 2,5, p < 0,001). Conclusiones: la complejidad relacionada con la dependencia funcional y el deterioro cognitivo de los pacientes y, como consecuencia, con la carga de cuidados que necesitan, no determina el lugar de la muerte. La edad de los enfermos es un factor modulador de la ubicación del paciente a lo largo de la evolución de su enfermedad (AU)

Objective: To assess functional dependence and cognitive deterioration in patients with advanced cancer cared for at home as part of a palliative care programme developed by a Hospitalisation at Home Unit at a level-three (acute) hospital. Material and method: 1,423 patients were analyzed, representing all patients with advanced cancer cared for at the Unit between January 2000 and December 2005. Results: It was noted that patients had major physical dependence and marked cognitive deterioration when they entered the program, since 50% of cases presented a mean of 34 on the Barthel index and over 4 in Pfeiffer's test. Mean stay was 12.5 days (SD 18). 56% of patients (797) died at home, 10.8% (153) were readmitted to our hospital, and 6.8% (97) were referred to a palliative care unit of a socio-sanitary hospital. Patients who died at home were older (71 years) than those who were readmitted to hospital (66) (p < 0.01), and on entry to the program they displayed a higher level of functional dependence (Barthel mean: 22.3 and 49.5 respectively, p < 0.001) and cognitive deterioration (Pfeiffer mean 5.8 vs.2.5, p < 0.001). Conclusions: The complexity of patients' functional dependence and cognitive deterioration, and the resulting care burden, does not determine the place of death. Patient age is a regulatory factor with regard to where patients are cared for as their disease progresses (AU)

Incarceración retroperitoneal del yeyuno en una hernia paramesocólica izquierda / Retroperitoneal jejunun incarceration in left paramesocolic hernia

Presentamos un caso de hernia paramesocólica (HPM) izquierda (HPMI) y revisamos la literatura. El paciente tenía 14 años y había padecido episodios de dolor abdominal recidivante (DAR) desde los tres años de edad. A los cuatro años fue operado por supuesto reflujo gastroesofágico mediante técnica de Nissen. En los 3 y los 13 años de edad fue atendido y/o ingresado en hospitales un total de 17 ocasiones por graves crisis de dolor abdominal recidivantes. A los 13 años le fue practicada una laparoscopia sin supuestos hallazgos patológicos. En un nuevo tránsito digestivo superior, que finalmente valoró el vaciamiento gástrico se observó una incarceración paraduodenal de asas del yeyuno que obstruían parcialmente la segunda porción de duodeno. Las características anatómicas de este caso, con incarceración paraduodenal del yeyuno y obstrucción duodenal no las hemos encontrado publicadas previamente. En la amplia literatura revisada, se confirma que, casi todos los casos clínicos publicados -más de 500- han padecido crisis de DAR, diagnosticándose en edades tardías y, la mayoría, en situaciones de urgencia. Ello produce una mortalidad superior al 20 por ciento y, a veces daños intestinales irreparables.En las hernias paraduodenales existe aún un bajo índice de sospecha diagnóstica, con retrasos y errores diagnósticos que pueden originar graves lesiones. En los pacientes con síndrome de DAR, debe siempre incluirse el diagnóstico digestivo completo a una tumografía computerizada (TC). (AU)

[Left paramesocolic hernia with retroperitoneal incarceration of jejunum]. / Incarceración retroperitoneal del yeyuno en una hernia paramesocólica izquierda.

We present a case left paramesocolic hernia and review the literature. The patients was a 14 years old male and had suffered periods of relapses into abdominal pain from the age of three. When for years old he was operated on using the Nisses technique. Also a laparoscopy had already been performed on this same patient when he was 13 years old, without discovering any pathological conditions. In a new upper gastrointestinal serie, realized one year later, a retroperitoneal incarceration and a paraduodenal loop of jejunum was observed, which obstructed, partially the second part of the duodenum. We have not found the anatomical characteristics of this case in any previous report. In the ample literature pressured, it was confirmed that almost all the clinical cases, previously published had suffered a relapse abdominal pain crisis, diagnosed in advanced states and in/or emergency situations. This produces a mortality rate higher than 20% and or irreparable digestive damage. In cases involving paraduodenal hernias, there exists a low rate of diagnostic suspicion. These delays and diagnostic errors cause irreparable damage. In those patients who suffer relapses into abdominal pain syndrome, one should always include the differential diagnosis of PMH, applying a complete gastrointestinal serie or a CT-Scan with contrast.

Osteocondritis de la cabeza femoral (enfermedad de panner) / Osteochondritis of femoral head (Panner's Disease)

No disponible

[Ureteral valve associated with pyeloureteral stenosis]. / Válvula de ureter asociada a estenosis pieloureteral.

We report a case of ureteric valve associated with pyeloureteral obstruction, exhibited as fistula after pyeloplasty. We analyst different features of ureteric valves: anatomical, location, symptoms and associated congenital anomalies. The writer consider necessary to achieve the sounding of ureteral stretch during the operation of pyeloplasty.

[Esophageal atresia associated with cystic duplication of the esophagus]. / Atrésie oesophagienne associée à une duplication kystique d'oesophage.

A rare case of esophageal atresia associated with esophageal duplication cyst is reported. The cyst duplication was recognized and successfully resected at primary thoracotomy for repair of esophageal atresia. This case is believed to be the second reported instance where both lesions could be treated concomitantly at first thoracotomy.

Portoenterostomy diversion. Experimental study in antireflux technique.

Ascending cholangitis was induced in dogs by performing a biliodigestive Roux-Y anastomosis. Then two valvular antireflux mechanisms were performed on separate groups of these dogs with the aim of preventing the onset of ascending cholangitis. One was performed by a laterolateral plicature at the intestinal anastomosis and the other by invagination of the mucosa in the nonworking loop that had been anastomosed to the bile duct. All the dogs underwent analytic tests over a period of 3 months and histopathologic tests at the end of the study period. Results showed cholangitis and pericholangitis in the liver biopsy specimens of the group with no antireflux valve, to a lesser degree in the group with laterolateral plicature, and almost none in the animals with the invaginated valve.