Identification and characterization of a new soybean promoter induced by Phakopsora pachyrhizi, the causal agent of Asian soybean rust.

BACKGROUND: Phakopsora pachyrhizi is a biotrophic fungal pathogen responsible for the Asian soybean rust disease causing important yield losses in tropical and subtropical soybean-producing countries. P. pachyrhizi triggers important transcriptional changes in soybean plants during infection, with several hundreds of genes being either up- or downregulated. RESULTS: Based on published transcriptomic data, we identified a predicted chitinase gene, referred to as GmCHIT1, that was upregulated in the first hours of infection. We first confirmed this early induction and showed that this gene was expressed as early as 8 h after P. pachyrhizi inoculation. To investigate the promoter of GmCHIT1, transgenic soybean plants expressing the green fluorescence protein (GFP) under the control of the GmCHIT1 promoter were generated. Following inoculation of these transgenic plants with P. pachyrhizi, GFP fluorescence was detected in a limited area located around appressoria, the fungal penetration structures. Fluorescence was also observed after mechanical wounding whereas no variation in fluorescence of pGmCHIT1:GFP transgenic plants was detected after a treatment with an ethylene precursor or a methyl jasmonate analogue. CONCLUSION: We identified a soybean chitinase promoter exhibiting an early induction by P. pachyrhizi located in the first infected soybean leaf cells. Our results on the induction of GmCHIT1 promoter by P. pachyrhizi contribute to the identification of a new pathogen inducible promoter in soybean and beyond to the development of a strategy for the Asian soybean rust disease control using biotechnological approaches.

[Ethical recommendations for a difficult decision-making in intensive care units due to the exceptional situation of crisis by the COVID-19 pandemia: A rapid review & consensus of experts]. / Recomendaciones éticas para la toma de decisiones difíciles en las unidades de cuidados intensivos ante la situación excepcional de crisis por la pandemia por COVID-19: revisión rápida y consenso de expertos.

In view of the exceptional public health situation caused by the COVID-19 pandemic, a consensus work has been promoted from the ethics group of the Spanish Society of Intensive, Critical Medicine and Coronary Units (SEMICYUC), with the objective of finding some answers from ethics to the crossroads between the increase of people with intensive care needs and the effective availability of means.In a very short period, the medical practice framework has been changed to a 'catastrophe medicine' scenario, with the consequent change in the decision-making parameters. In this context, the allocation of resources or the prioritization of treatment become crucial elements, and it is important to have an ethical reference framework to be able to make the necessary clinical decisions. For this, a process of narrative review of the evidence has been carried out, followed by a unsystematic consensus of experts, which has resulted in both the publication of a position paper and recommendations from SEMICYUC itself, and the consensus between 18 scientific societies and 5 institutes/chairs of bioethics and palliative care of a framework document of reference for general ethical recommendations in this context of crisis.

Pacientes críticos al final de la vida: estudio multicéntrico en Unidades de Cuidados Intensivos españolas / End of life critical patients: A multicenter study in Spanish Intensive Care Units

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Craneoplastia con vendaje. nuevas formas de limitación del tratamiento de soporte vital y donación de órganos / Cranioplasty with bandaging. new forms of limitation of life support and organ donation

La mayoría de los órganos trasplantados proceden de donantes fallecidos en muerte encefálica (ME). En pacientes neurocríticos con lesiones catastróficas y craniectomía descompresiva (CD) que tienen una pésima evolución a pesar de todo el tratamiento, la CD puede llegar a ser una medida fútil que impida la evolución natural hacia la ME. Planteamos si realizar un vendaje compresivo pericraneal (craneoplastia con vendaje) puede ser una práctica éticamente correcta y comparable a otras formas habituales de limitación del tratamiento de soporte vital (LTSV).A partir de un caso clínico, realizamos una consulta al Comité de Ética Asistencial y a expertos bioéticos, formulando las siguientes cuestiones: 1) En pacientes que se decide la LTSV ¿es éticamente correcto realizar una craneoplastia con vendaje? 2) ¿Es preferible esta opción considerando una posible donación de órganos? Conclusiones 1) La craneoplastia con vendaje puede ser considerada una forma de LTSV éticamente aceptable y similar a otros procedimientos 2) Facilita la donación de órganos para trasplante, lo que aporta valor añadido por el bien social correspondiente 3) En estos casos, es necesario conocer las instrucciones previas del paciente y en su ausencia, obtener el consentimiento familiar por delegación tras un informe detallado del procedimiento (AU)

Most of transplanted organs are obtained from brain death (BD) donors. In neurocritical patients with catastrophic injuries and decompressive craniectomy (DC), which show a dreadful development in spite of this treatment, DC could be a futile tool to avoid natural progress to BD. We propose if cranial compressive bandage (cranioplasty with bandage) could be an ethically correct practice, similar to other life-sustaining treatment limitation (LSTL) common methods. Based on a clinical case, we contacted with the Assistance Ethics Committee and some bioethics professionals asking them two questions: 1) Is ethically correct to perform acranioplasty with bandage in those patients with LSTL indication? 2) Thinking in organ donation possibility, is this option preferable? Conclusions 1) Cranioplasty with bandage could be considered an ethically acceptable LSTL practice, similar to other procedures. 2) It facilitates organ donation for transplant, which provides value-added because of its own social good. 3) In these cases, it is necessary to know previous patient's will or, in absentia, to obtain family consent after a detailed procedure report (AU)

Cranioplasty with bandaging. New forms of limitation of life support and organ donation.

Most of transplanted organs are obtained from brain death (BD) donors. In neurocritical patients with catastrophic injuries and decompressive craniectomy (DC), which show a dreadful development in spite of this treatment, DC could be a futile tool to avoid natural progress to BD. We propose if cranial compressive bandage (cranioplasty with bandage) could be an ethically correct practice, similar to other life-sustaining treatment limitation (LSTL) common methods. Based on a clinical case, we contacted with the Assistance Ethics Committee and some bioethics professionals asking them two questions: 1) Is ethically correct to perform a cranioplasty with bandage in those patients with LSTL indication? 2) Thinking in organ donation possibility, is this option preferable? Conclusions 1) Cranioplasty with bandage could be considered an ethically acceptable LSTL practice, similar to other procedures. 2) It facilitates organ donation for transplant, which provides value-added because of its own social good. 3) In these cases, it is necessary to know previous patient's will or, in absentia, to obtain family consent after a detailed procedure report.

Ética de las decisiones en resucitación cardiopulmonar / Ethics of the cardiopulmonary resuscitation decisions

La Resucitación Cardiopulmonar (RCP) se debe aplicar si está indicada, omitirse si no está o no ha sido previamente aceptada por el paciente y suspenderse si es inefectiva. Si la RCP se previera fútil, se registrará una Orden de No Intentar la Resucitación, que deberá ser conocida por los profesionales sanitarios que atienden al enfermo. Es aceptable limitar el soporte vital a los supervivientes con encefalopatía anóxica, si se descarta la posibilidad de que evolucionen a muerte encefálica. Tras la RCP se debe informar y apoyar a la familia del paciente, y revisar el procedimiento realizado para mejorarlo. Previa limitación del soporte vital se podría plantear cierto tipo de donación de órganos a corazón parado. Adquirir competencia en RCP precisa practicar con simuladores y, en ocasiones, sobre cadáveres recientes, siempre con permiso. La investigación sobre RCP es imprescindible, respetando leyes y normas éticas de excelencia (AU)

Cardiopulmonary Resuscitation (CPR) must be attempted if indicated, not done if it is not indicated or if the patient does not accept or has previously rejected it and withdrawn it if it is ineffective. If CPR is considered futile, a Do-Not-Resuscitate Order (DNR) will be recorded. This should be made known to all physicians and nurses involved in patient care. It may be appropriate to limit life-sustaining-treatments for patients with severe anoxic encephalopathy, if the possibility of clinical evolution to brain death is ruled out. After CPR it is necessary to inform and support families and then review the process in order to make future improvements. After limitation of vital support, certain type of non-heart-beating-organ donation can be proposed. In order to acquire CPR skills, it is necessary to practice with simulators and, sometimes, with recently deceased, always with the consent of the family. Research on CPR is essential and must be conducted according to ethical rules and legal frameworks (AU)

[Ethics of the cardiopulmonary resuscitation decisions]. / Ética de las decisiones en resucitación cardiopulmonar.

Cardiopulmonary Resuscitation (CPR) must be attempted if indicated, not done if it is not indicated or if the patient does not accept or has previously rejected it and withdrawn it if it is ineffective. If CPR is considered futile, a Do-Not-Resuscitate Order (DNR) will be recorded. This should be made known to all physicians and nurses involved in patient care. It may be appropriate to limit life-sustaining-treatments for patients with severe anoxic encephalopathy, if the possibility of clinical evolution to brain death is ruled out. After CPR it is necessary to inform and support families and then review the process in order to make future improvements. After limitation of vital support, certain type of non-heart-beating-organ donation can be proposed. In order to acquire CPR skills, it is necessary to practice with simulators and, sometimes, with recently deceased, always with the consent of the family. Research on CPR is essential and must be conducted according to ethical rules and legal frameworks.

Validation of the Spanish version of the liver disease quality of life instrument among candidates for liver transplant.

OBJECTIVE: To validate a Spanish version of the Liver Disease Quality of Life Questionnaire (LDQOL 1.0) among patients awaiting hepatic transplantation. METHODS: This observational, cross-sectional study was performed between May 2002 and June 2006. We included ambulatory or hospitalized patients aged 18 or over with chronic liver disease awaiting transplantation. Patients completed the LDQOL 1.0. The feasibility of the LDQOL for clinical use was tested by examining the administration time and values for the questionnaire's 12 disease-specific scales. Reliability was tested by examining the internal consistency of the scales (Cronbach's alpha). Known group validity was tested by examining the questionnaire's ability to discriminate between patients with hepatocellular (HCC), liver cirrhosis (CH), hepatitis C virus infection, and alcohol-induced CH. RESULTS: A total of 200 patients were included in the analysis. Their mean age (SD) was 52.6 (9.8) years; 73% of the sample were men. The most common indication for liver transplant was HCC (34%). The mean (SD) time to complete the LDQOL 1.0 was 35 minutes (21 minutes). Over 20% of patients scored at the ceiling (maximum possible score) on seven of the 12 disease-specific scales. Floor effects were less marked. All dimensions had Cronbach alpha coefficients over 0.60. The lowest value (0.64) was found in the sexual problems (women) dimension. Patients with HCC had significantly higher scores on several scales, including symptoms of liver disease (P = .000), effects of liver disease (P = .000), concentration (P = .002), memory (P = .015), quality of social interaction (P = .030), sleep (P = .000), loneliness (P = .043), and stigma (P = .028). Statistically significant differences were found between HCC patients and alcohol-induced CH patients in only two dimensions. CONCLUSIONS: Among pretransplant patients, the Spanish version of the LDQOL 1.0 showed substantial ceiling effects and the length of administration makes its application in clinical practice difficult. This preliminary analysis showed good internal consistency for the disease-specific scales and acceptable known group validity.

[Cost of quality in Intensive Medicine. Guidelines for clinical management]. / Costes de la calidad en Medicina Intensiva. Guía para gestores clínicos.

OBJECTIVE: This article reviews the utility and applicability of available systems in order to calculate general and quality costs in clinical services settings. METHODS: Review of techniques to calculate costs in Intensive Care Units (ICUs) according to analytical accounting approaches. RESULTS: The methodological development is complemented with the results of its application in the ICU of the Miracle's Hospital showing the structure of costs and the results obtained with this methodology when analyzing the costs of activities related to quality improvement. CONCLUSIONS: The effort to implement systems focused to analyze general and quality costs will result in a benefit of those participating in the healthcare system: citizens, professionals, managers, and "financials" since that which is only a legitimate demand today will be a inexcuseable commitment of the healthcare professionals from the society tomorrow.

Costes de la calidad en Medicina Intensiva. Guía para gestores clínicos / Cost of quality in Intensive Medicine. Guidelines for clinical management

Objetivo. Este artículo revisa la utilidad y aplicabilidad de los sistemas disponibles para calcular los costes generales y los costes de la calidad de los servicios clínicos hospitalarios. Métodos. Revisión de técnicas para calcular los costes en las Unidades de Cuidados Intensivos (UCI) mediante diferentes enfoques de la contabilidad analítica para tal fin. Resultados. El desarrollo metodológico se complementa con los resultados de aplicación en la UCI del Hospital del Milagro presentándose su estructura de costes y los datos obtenidos con esta metodología al analizar los costes resultantes de las actividades de mejora de la calidad en la UCI del Hospital del Milagro. Conclusiones. El esfuerzo para implementar sistemas de análisis de los costes en general y de los costes de la calidad en particular redundará en beneficio de los actores del sistema sanitario: ciudadanos, profesionales, gestores y financiadores, ya que lo que hoy sólo son legítimas demandas más o menos en ciernes, mañana será un compromiso ineludible de los profesionales asistenciales ante la sociedad

Objective. This article reviews the utility and applicability of available systems in order to calculate general and quality costs in clinical services settings. Methods. Review of techniques to calculate costs in Intensive Care Units (ICUs) according to analytical accounting approaches. Results. The methodological development is complemented with the results of its application in the ICU of the Miracle's Hospital showing the structure of costs and the results obtained with this methodology when analyzing the costs of activities related to quality improvement. Conclusions. The effort to implement systems focused to analyze general and quality costs will result in a benefit of those participating in the healthcare system: citizens, professionals, managers, and financials since that which is only a legitimate demand today will be a inexcusable commitment of the healthcare professionals from the society tomorrow

Multicenter study of the multiple organ dysfunction syndrome in intensive care units: the usefulness of Sequential Organ Failure Assessment scores in decision making.

OBJECTIVE: This study examined the incidence and mortality of multiple organ dysfunction syndrome (MODS) in intensive care units, evaluated the limitation of life support in these patients, and determined whether daily measurement of the Sequential Organ Failure Assessment (SOFA) is useful for decision making. DESIGN AND SETTING: Prospective, observational study in 79 intensive care units. PATIENTS AND PARTICIPANTS: Of the 7,615 patients admitted during a 2-month period we found 1,340 patients to have MODS. MEASUREMENTS AND RESULTS: We recorded mortality and length of stay in the intensive care unit and the hospital and the maximum and minimum total SOFA scores during MODS. Limitation of life support in MODS patients was also evaluated. Stepwise logistic regression was used to determine the factors predicting mortality. The in-hospital mortality rate in patients with MODS was 44.6%, and some type of limitation of life support was applied in 70.6% of the patients who died. The predictive model maximizing specificity included the following variables: maximum SOFA score, minimum SOFA score, trend of the SOFA for 5 consecutive days, and age over 60 years. The model diagnostic yield was: specificity 100%, sensitivity 7.2%, positive predictive value 100%, and negative predictive value 57.3%; the area under the receiver operating characteristic curve was 0.807. CONCLUSIONS: This model showed that in our population with MODS those older than 60 years and with SOFA score higher than 9 for at least 5 days were unlikely to survive.

Recomendaciones del grupo de bioética de la SEMICYUC sobre el consentimiento informado en UCI / Recommendations of the Bioethics Group of the Spanish Society of Intensive Care Medicine and Coronary Units regarding informed consent in the intensive care unit

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Los criterios de ingreso en UCI del paciente con EPOC. Documento de reflexión SEMICYUC-SEPAR / Criteria for admission to the intensive care unit of patients with EPOC. A SEMICYUC-SEPAR

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Synergistic sedation with propofol and midazolam in intensive care patients after coronary artery bypass grafting.

OBJECTIVES: To evaluate and compare the clinical efficacy, impact on hemodynamics, safety profiles, and cost of combined administration of propofol and midazolam (synergistic sedation) vs. midazolam and propofol administered as sole agents, for sedation of mechanically ventilated patients after coronary artery bypass grafting. DESIGN: Prospective, controlled, randomized, double-blind clinical trial. SETTING: Intensive care unit of SCIAS-Hospital de Barcelona. PATIENTS: Seventy-five mechanically ventilated patients who underwent coronary artery bypass graft surgery under low-dose opioid anesthesia. INTERVENTIONS: According to the double-blind method, patients were randomly assigned to receive propofol (n = 25), midazolam (n = 25), or propofol combined with midazolam (n = 25). Infusion rates were adjusted to stay between 8 and 11 points on Glasgow Coma Score modified by Cook and Palma. MEASUREMENTS AND MAIN RESULTS: Mean +/- SD duration of sedation was 14.4 +/- 1.5 hrs, 14.1 +/- 1.1 hrs, and 14.7 +/- 1.9 hrs for the propofol, midazolam, and synergistic groups, respectively. The induction dose was 0.55 +/- 0.05 mg/kg for propofol as sole agent, 0.05 +/- 0.01 mg/kg for midazolam as sole agent, and 0.22 +/- 0.03 mg/kg for propofol administered in combination with 0.02 +/- 0.00 mg/kg of midazolam (p = .001). The maintenance dose was 1.20 +/- 0.03 mg/kg/hr for propofol as sole agent, 0.08 +/- 0.01 mg/kg/hr for midazolam as sole agent, and 0.50 +/- 0.09 mg/kg/hr for propofol administered in combination with 0.03 +/- 0.01 mg/kg/hr of midazolam (p < .001). All sedative regimens achieved similar efficacy in percentage of hours of adequate sedation (93% for propofol, 88% for midazolam, and 90% for the synergistic group, respectively). After induction, both propofol and midazolam groups had significant decreases in systolic blood pressure, diastolic blood pressure, left atrial pressure, and heart rate. Patients in the synergistic group had significant bradycardia throughout the study, without impairment in other hemodynamic parameters. Patients sedated with propofol or synergistic regimen awoke sooner and could be extubated before those patients sedated with midazolam (0.9 +/- 0.3 hrs and 1.2 +/- 0.6 hrs vs. 2.3 +/- 0.8 hrs, respectively, p = .01). Synergistic sedation produced cost savings of 28% with respect to midazolam and 68% with respect to propofol. CONCLUSIONS: In the study conditions, the new synergistic treatment with propofol and midazolam administered together is an effective and safe alternative for sedation, with some advantages over the conventional regimen with propofol or midazolam administered as sole agents, such as absence of hemodynamic impairment, >68% reduction in maintenance dose, and lower pharmaceutical cost.

Efficacy and safety of two new methods of rapid intravenous detoxification in heroin addicts previously treated without success.

BACKGROUND: New methods of rapid opiate detoxification, under intravenous sedation, can detoxify heroin-addicted patients in 24 hours. Their clinical application has been limited by the lack of studies establishing both efficacy and safety. METHOD: In a randomised, controlled study, 300 treatment-refractory, heroin-addicted patients received rapid intravenous detoxification treatment (naloxone infusion, 0.06-0.08 mg/kg, then oral naltrexone 50 mg/day) under either monitored light intravenous sedation or unmonitored deep intravenous sedation. RESULTS: All patients were successfully detoxified and 93% remained abstinent one month later. Severity of withdrawal, according to the Wang Scale modified by Loimer, was 4.9 (s.d. 3.0) points in the light sedation group and 4.8 (s.d. 2.9) in the deep sedation group (P = 0.26). Two patients (1.3%) in the light sedation group and four (2.6%) in the deep sedation group required tracheal intubation (P = 0.31). There was only one severe complication, a case of nosocomial aspirative pneumonia which improved with antibiotic treatment. CONCLUSIONS: Successful rapid intravenous detoxification can be achieved using relatively light levels of sedation.