Traducción y validación del cuestionario multidimensional Disnea-12 / Translation and Validation of the Multidimensional Dyspnea-12 Questionnaire

Introducción: La disnea es un síntoma con un componente multidimensional, aunque las herramientas que se utilizan habitualmente para evaluarla no tienen en cuenta esta faceta. El cuestionario Disnea-12 valora la multidimensionalidad de la disnea, específicamente las dimensiones afectiva y sensorial. El objetivo de este estudio es validar el cuestionario Disnea-12 al español. Métodos: Se realizó una traducción del original en inglés al español y del español al inglés para verificar la equivalencia del texto. Posteriormente se verificó la comprensión del texto tras pasárselo a 10 pacientes. La fiabilidad y la validez del cuestionario se estudiaron en un grupo independiente de EPOC diagnosticados y clasificados por las guías GOLD de las consultas externas de neumología del Hospital Universitario Marqués de Valdecilla. Resultados: El grupo (n = 51) tenía una media de edad de 65 años y un FEV1 medio del 50%. Todos los pacientes entendieron las preguntas del cuestionario. El instrumento presentó consistencia interna de alfa = 0,937 y un coeficiente de correlación intraclase: 0,969; p<0,001. Se encontraron correlaciones estadísticamente significativas con las puntuaciones del HAD (HADansiedad r = 0,608 y HADdepresión r = 0,615), disnea de la mMRC (r = 0,592), T6MM (r = -0,445), FEV1 (r = -0,312), las 4 dimensiones de CRQ-SAS (disnea r = -0,626; fatiga r = -0,718; función emocional r = -0,663; control de enfermedad r = -0,740), el CAT (r = 0,669) y el índice de disnea basal (r = -0,615). Los grupos GOLD más sintomáticos (B y D) presentaron una puntuación 10,32 puntos mayor en el Disnea-12 (p < 0,001). Conclusión: El cuestionario Disnea-12 es un instrumento válido y fiable para evaluar la disnea de forma multidimensional (AU)

Introduction: Dyspnea is a multidimensional symptom, but this multidimensionality is not considered in most dyspnea questionnaires. The Dyspnea-12 takes a multidimensional approach to the assessment of dyspnea, specifically the sensory and the affective response. The objective of this study was to translate into Spanish and validate the Dyspnea-12 questionnaire. Methods: The original English version of the Dyspnea-12 questionnaire was translated into Spanish and backtranslated to analyze its equivalence. Comprehension of the text was verified by analyzing the responses of 10 patients. Reliability and validation of the questionnaire were studied in an independent group of COPD patients attending the pulmonology clinics of Hospital Universitario Marqués de Valdecilla, diagnosed and categorized according to GOLD guidelines. Results: The mean age of the group (n = 51) was 65 years and mean FEV1 was 50%. All patients understood all questions of the translated version of Dyspnea-12. Internal consistency of the questionnaire was alfa=0.937 and intraclass correlation coefficient was = .969; P < .001. Statistically significant correlations were found with HADS (anxiety r = .608 and depression r = .615), mMRC dyspnea (r = .592), 6MWT (r = -0.445), FEV1 (r = -0.312), all dimensions of CRQ-SAS (dyspnea r = -0.626; fatigue r = -0.718; emotional function r = -0.663; mastery r = -0.740), CAT (r = 0.669), and baseline dyspnea index (r = -0.615). Dyspnea-12 scores were 10.32 points higher in symptomatic GOLD groups (B and D) (P < .001). Conclusion: The Spanish version of Dyspnea-12 is a valid and reliable instrument to study the multidimensional nature of dyspnea (AU)

Translation and Validation of the Multidimensional Dyspnea-12 Questionnaire. / Traducción y validación del cuestionario multidimensional Disnea-12.

INTRODUCTION: Dyspnea is a multidimensional symptom, but this multidimensionality is not considered in most dyspnea questionnaires. The Dyspnea-12 takes a multidimensional approach to the assessment of dyspnea, specifically the sensory and the affective response. The objective of this study was to translate into Spanish and validate the Dyspnea-12 questionnaire. METHODS: The original English version of the Dyspnea-12 questionnaire was translated into Spanish and backtranslated to analyze its equivalence. Comprehension of the text was verified by analyzing the responses of 10 patients. Reliability and validation of the questionnaire were studied in an independent group of COPD patients attending the pulmonology clinics of Hospital Universitario Marqués de Valdecilla, diagnosed and categorized according to GOLD guidelines. RESULTS: The mean age of the group (n=51) was 65 years and mean FEV1 was 50%. All patients understood all questions of the translated version of Dyspnea-12. Internal consistency of the questionnaire was α=0.937 and intraclass correlation coefficient was=.969; P<.001. Statistically significant correlations were found with HADS (anxiety r=.608 and depression r=.615), mMRC dyspnea (r=.592), 6MWT (r=-0.445), FEV1 (r=-0.312), all dimensions of CRQ-SAS (dyspnea r=-0.626; fatigue r=-0.718; emotional function r=-0.663; mastery r=-0.740), CAT (r=0.669), and baseline dyspnea index (r=-0.615). Dyspnea-12 scores were 10.32 points higher in symptomatic GOLD groups (B and D) (P<.001). CONCLUSION: The Spanish version of Dyspnea-12 is a valid and reliable instrument to study the multidimensional nature of dyspnea.

Duodenal mucosa FOXP3 expression in different etiologies of lymphocytic duodenosis.

BACKGROUND/AIMS: In celiac disease there is an increase of lymphocytes expressing FOXP3 in the intestinal mucosa associated with varying degrees of villous atrophy. Our aim was to evaluate FOXP3 expression in duodenal mucosa with lymphocytic enteritis according to aetiology and correlation with lymphocytes T-γδ. METHODS: We compared three adult patient groups suffering lymphocytic enteritis: celiacs following a gluten-free diet (n=12), first-degree relatives of celiac patients with genetic risks (n=14) and patients with functional dyspepsia (n=14), along with a control group not suffering from duodenal enteritis (n=16). The population of duodenal lymphocytes was analysed by immunohistochemistry assays for CD3+ characterisation and FOXP3 expression. Quantification of lymphocytes T-γδ in duodenal mucosa was performed by flow cytometry in fresh tissue samples. RESULTS: Presence of lymphocytes T-γδ was significantly higher in the group of celiac individuals compared to the group of relatives of these individuals (37.44 vs 5,52: p<0.0001) and the group with functional dyspepsia (37.44 vs 11.76: p=0.008). FOXP3 expression was also significantly higher in the celiac group than in the groups of relatives (18.85 vs 6.31; p=0.001) and functional dyspepsia patients (18.85 vs 7.61; p=0.023). The proportion of lymphocytes T-γδ and FOXP3- expressing lymphocytes was similar in the control group to that in the relatives or functional dyspepsia groups. CONCLUSIONS: Lymphocytic enteritis associated to celiac disease shows an increase of FOXP3 expression and lymphocytes T-γδ that is not detected in other etiologies of enteritis.

Pseudopoliposis colónica en enfermedad inflamatoria intestinal / Colonic pseudopolyposis in inflammatory bowel disease

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Coeliac disease and gastrointestinal symptom screening in adult first-degree relatives.

BACKGROUND AND AIM: The first-degree relatives (FDRs) of patients with coeliac disease are the main risk group for disease development. The study aims to evaluate the screening strategy in FDRs with negative coeliac serology based on human leukocyte antigen (HLA) genotyping, followed by duodenal biopsy, and to analyze the prevalence of gastrointestinal symptoms and the influence of gluten intake. METHODS: Adult FDRs with negative coeliac serology were invited to participate (n = 205), and a total of 139 completed the study protocol. HLA genotyping, transglutaminase antibody assessment, and duodenal biopsy were performed. Symptomatology was assessed using questionnaires during the various phases of dietary modification (baseline diet, gluten-free diet, and gluten overload). RESULTS: The study included 139 participants (mean age, 42 years; 53.2% women). HLA-DQ2/8 was positive in 78.4% of the participants (homozygous, 15.1%; heterozygous, 63.3%). Histopathological alterations were noted in 37.1% of participants who underwent duodenal biopsy (Marsh I, 32.7%; Marsh IIIa, 4.4%). At baseline, symptoms were observed in 45.7% of the participants, and the proportion decreased to 24.5% after the gluten-free diet (P < 0.001). Symptoms were not associated with the presence of histological alterations or genetic risk. However, younger age (odds ratio [OR] = 0.91), female sex (OR = 2.9), and the presence of autoimmune disorders (OR = 2.8) were independently associated with a significant symptom response to the gluten-free diet. CONCLUSIONS: Duodenal lymphocytosis and atrophy are frequently noted in FDRs, despite negative serological markers. In addition, gastrointestinal symptoms are commonly present and associated with gluten intake regardless of the histological pathology.

Coeliac disease screening in first-degree relatives on the basis of biopsy and genetic risk.

BACKGROUND: Serological markers of coeliac disease (CD) lack diagnostic value to identify mild histopathological lesions mainly in adults at risk of CD. AIMS: The aim of this study was to evaluate the usefulness of human leukocyte antigen (HLA)-DQ2/8 genotyping, followed by duodenal biopsy for the detection of CD in adult first-degree relatives (FDRs) of patients with CD. MATERIALS AND METHODS: Ninety-two adult DQ2/8 positive FDRs were consecutively included. A duodenal biopsy was offered irrespective of the serology result or associated symptoms. The clinical features, associated autoimmune diseases and biochemical parameters were recorded. RESULTS: Sixty-seven FDRs (mean age 34 years) underwent a duodenal biopsy. Histopathological alterations were found in 32 (48%) and showed the following stages: 12 Marsh I (18%), one Marsh II (1.5%), four Marsh IIIA (6%), five Marsh IIIB (7.5%) and 10 Marsh IIIC (15%). Positive serological markers were present in 17/67 (25%), with only one showing Marsh I and the remainder presenting some degree of duodenal atrophy (Marsh III). In addition, 33/67 (54%) had gastrointestinal symptoms, with dyspepsia being the most prevalent. The distribution of symptoms, anaemia and autoimmune disease was independent of the duodenal histopathological stage. Serology-based screening would diagnose 50% of the cases showing any degree of CD spectrum and miss 6% of the cases with mucosal atrophy. CONCLUSION: Adult FDRs of patients with CD can benefit from a screening strategy on the basis of HLA-DQ genotyping, followed by a duodenal biopsy. Gastrointestinal symptoms and lymphocytic enteritis are common findings that may benefit from a gluten-free diet.

Linfoma intestinal de células T asociado a enteropatía y sin relación con enfermedad celíaca / Enteropathy-associated intestinal t-cell lymphoma without celiac disease

La enteropatía asociada a linfoma de células T tipo II es un linfoma intestinal infrequente. Presentamos el caso un varón de 73 años con diarrea y pérdida de peso. La biopsia duodenal presentaba atrofia e infiltrado de linfocitos irregulares. La inmunohistoquímica detectó positividad para CD3, CD8, CD56 con reordenamiento monoclonal del TCR. El genotipifación de HLA-DQ era DQ5/DQ9. El test para EBVRNA fue negativo. Antes del tratamiento específico quimioterápico ingresó por infección respiratoria, y falleció por causa independiente del linfoma. El diagnóstico diferencial de los procesos linfoproliferativos CD56-positivo incluye EATL tipo II, linfoma intestinal primario de células T/NK y linfoma de células T hepatoesplénico.El paciente presentaba CD8 y CD56+ marcadores que permiten descartar EALT tipo I. la genotipificación HLA-DQ no corresponde a enfermedad celíaca, y la biopsia presentaba proliferación de linfocitos con atipias. El linfoma intestinal primario de células T/NK se caracteriza principalmente por ausencia de CD8 y del reordenamiento monoclonal del TCR presentes en este caso(AU)

Type II enteropathy-associated T-cell lymphoma (EATL) is an uncommon intestinal lymphoma. We report the case of a 73-year-old man with diarrhea and weight loss. Duodenal biopsy showed atrophy and infiltration of irregular lymphocytes. Immunohistochemistry was positive for CD3, CD8, and CD56 with monoclonal TCR rearrangement. The HLA-DQ genotype was DQ5/DQ9. The Epstein-Barr virus RNA test was negative. Before specific chemotherapy could be administered, the patient was admitted to hospital for a respiratory infection and died from a cause unrelated to his lymphoma. The differential diagnosis of CD56-positive lymphoproliferative processes include type II EATL, primary T-cell/natural killer-cell intestinal lymphoma and hepatosplenic T-cell lymphoma. The patient had CD8 y CD56+ markers that allowed type I EATL to be excluded. The HLA-DQ genotype did not correspond to celiac disease and the biopsy showed proliferation of lymphocytes with atypia. The primary intestinal T-cell/natural killer-cell lymphoma was characterized mainly by the absence of CD8 and monoclonal reassortment of the TCR present in this case (AU)

[Enteropathy-associated intestinal t-cell lymphoma without celiac disease]. / Linfoma intestinal de células T asociado a enteropatía y sin relación con enfermedad celíaca.

Type II enteropathy-associated T-cell lymphoma (EATL) is an uncommon intestinal lymphoma. We report the case of a 73-year-old man with diarrhea and weight loss. Duodenal biopsy showed atrophy and infiltration of irregular lymphocytes. Immunohistochemistry was positive for CD3, CD8, and CD56 with monoclonal TCR rearrangement. The HLA-DQ genotype was DQ5/DQ9. The Epstein-Barr virus RNA test was negative. Before specific chemotherapy could be administered, the patient was admitted to hospital for a respiratory infection and died from a cause unrelated to his lymphoma. The differential diagnosis of CD56-positive lymphoproliferative processes include type II EATL, primary T-cell/natural killer-cell intestinal lymphoma and hepatosplenic T-cell lymphoma. The patient had CD8 y CD56+ markers that allowed type I EATL to be excluded. The HLA-DQ genotype did not correspond to celiac disease and the biopsy showed proliferation of lymphocytes with atypia. The primary intestinal T-cell/natural killer-cell lymphoma was characterized mainly by the absence of CD8 and monoclonal reassortment of the TCR present in this case.

Manejo enfermero en el síndromeposresección transuretral de próstata(síndrome post-RTUP) / Syndrome management nurse in post-TURP

La resección transuretral es una técnica sencilla en cirugíaurológica de vías inferiores para tumores de próstata, sinotra patología de vías inferiores, con posibilidad deresección completa, en la cual se utiliza, normalmente,anestesia locorregional, y cuya complicación másimportante es el síndrome post-RTUP (posreseccióntransuretral de próstata). Al ser una técnica sencilla y laaplicación de la anestesia ser locorregional, los pacientesintervenidos pasan un corto período de tiempo en laUnidad de Reanimación; es por ello, que el profesional deEnfermería de la Unidad de Cirugía Urológica debe estarfamiliarizado con una de las complicaciones de la RTUP,como es el síndrome post-RTUP, para ello se llevó a cabo lavaloración de las intervenciones realizadas en el HospitalUniversitario Severo Ochoa, de Leganés, Madrid, en el año2008, donde los resultados alcanzaban un 6,49% depacientes con síndrome post-RTUP, dentro de losreferentes bibliográficos establecidos entre el 1% y el 7%;para llegar a la elaboración de un plan de cuidadosenfermeros estandarizado en el síndrome post-RTUP, paraimplementarse en un futuro en nuestra Unidad, teniendocomo objetivo general el conocimiento, por parte delpersonal de enfermería de la misma, de todas las posiblescomplicaciones que este tipo de intervenciones puede llegara desarrollar, que sirva además como uno de los protocolosenfermeros del propio centro donde desarrollamos nuestraactividad enfermera, así como que sirva de base paraactuaciones futuras en otros centros de nuestro medio (AU)

Transurethral resection is a simple technique in lower tracturological surgery for prostate tumors, with no otherpathology of the lower airways, with the possibility ofcomplete resection, which is typically used, local anesthesia,and whose most important complication is the syndromepost-TURP (post-TURP). As a simple technique andapplication of anesthesia to be locoregional patientsundergoing spend a short period of time in thereanimation unit, is therefore, that the business of NursingUrologic Surgery Unit should be familiar with one ofcomplications of TURP, such as post-TURP syndrome, forit was carried out the evaluation of interventions at theUniversity Hospital Severo Ochoa, Leganés, Madrid, in2008, where the score reached 6, 49% of patients withpost-TURP syndrome, within the bibliographic referencesestablished between 1% and 7%, to reach the developmentof a standardized nursing care plan in the post-TURPsyndrome, to be implemented in a future where our unit,having as objective knowledge, by the nursing staff of thesame, all the possible complications that such interventionsmay develop, which also serves as one of the nursesprotocols to the centre where we do business nurse and as abasis for future actions in other centers of our environment (AU)

Dynamics of non-conventional intraepithelial lymphocytes-NK, NKT, and γδ T-in celiac disease: relationship with age, diet, and histopathology.

BACKGROUND: Intraepithelial lymphocytes (IEL) are a heterogeneous population of lymphocytes raised in celiac disease (CD), whose role in CD pathogenesis remains to be defined. AIMS: To investigate how the age of diagnosis, diet, and the severity of the histological lesions are related to the changes observed in unconventional IEL populations. METHODS: Prospective analysis of 101 confirmed celiac patients from a single center, including 66 at diagnosis (45 children, 21 adults) and 112 non-celiac controls (12 children, 100 adults). IEL from duodenal biopsies were studied by six-color flow cytometry. The results were analyzed in relationship with age, diet (gluten intake), and histopathology (Marsh type). RESULTS: In comparison with respective age controls, both children and adult patients showed duodenal intraepithelial lymphocytosis with significant differences in every single non-conventional IEL population: CD3+ TCR γδ, NK (CD3-, CD16+, CD56+), NKT (CD3+, CD161+, CD56+), and iNKT (CD3+ Vα24) (P < 0.001 for all). Gluten intake was not only directly associated with severe atrophy, but also with decreased percentages of NK (P = 0.02), NKT (P = 0.003), and iNKT (P = 0.03). Changes in iNKT and γδ IEL were more marked in celiac children compared with celiac adults (P = 0.02 and 0.01, respectively). In contrast, increased CD3+ TCR γδ were diet- and Marsh grade-independent. CONCLUSIONS: The typical phenotypical profile of intraepithelial lymphocytosis in untreated pediatric and adult celiacs consists of increased CD3+ TCR γδ populations with decreased NK, NKT, and iNKT cells. NK, NKT, and iNKT IEL, but not γδ IEL, are dynamic populations associated with diet, age, and histopathology.

Cuidados enfermeros en paciente geriátrico con síndrome de Stevens-Johnson relacionado con levofloxacino: a propósitode un caso / Nursing care in elderly with Stevens-Johnson Syndrome related to levofloxacin: case approach

El Síndrome de Stevens-Johnson (SSJ) es una enfermedad dermatológica rara con afectación mucocutánea y sistémica, siendo la forma más grave de eritema exudativo multiforme y presentándose como una variante de la necrólisis epidérmica tóxica relacionado con etiologíamúltiple. Presentamos el caso de una paciente geriátrica de 84 años de edad, presentado SSJ relacionado con la toma de levofloxacino. La complejidad de cuidados que requirió en una unidad de hospitalización, así como la escasez de referentes bibliográficos en nuestro medio nos conllevaron a elaborar este plan de cuidados enfermeros (AU)

Stevens-Johnson Syndrome (SJS) is a rare dermatological disease with mucocutaneous and systemic involvement,with the mose severe forme of SJS, presenting as a variant of toxic epidermal necrolysis related to a multiple etiology.We report a case of geriatric patient 84 years of age present the syndrome associated with taking levofloxacin. The complexity of care require in an inpatient unit, and the paucity of references in our environment led us to develop this plan of nursing (AU)

Primary liver carcinoid tumour with a Zollinger Ellison syndrome - an unusual diagnosis: a case report.

Carcinoids are neuroendocrine tumours which may secrete hormones like gastrin, insulin, ACTH, etc. Liver is a common site for metastasis of carcinoid origin and an unusual site for a primary carcinoid tumour to arise.We present the case of a 51-year-old Caucasian man with diarrhoea, weight loss, duodenum ulcers and a liver mass in ultrasonography. A primary hepatic carcinoid tumour with a Zollinger Ellison syndrome was diagnosed. Surgery resection was performed and the patient remained free of symptoms two years after, with normalisation of gastrin levels.Primary hepatic carcinoid tumour represents an uncommon diagnosis, based on radiological and pathological features. The exclusion of different primary locations is necessary. Once associated with a Zollinger Ellison syndrome, diagnose may be more complicated and challenging since only 7 cases of hepatic carcinoids with gastrin secretion were reported in medical literature.A review of medical literature is performed and diagnoses tools that should be used for an accurate diagnosis and available treatment approaches are commented here.

Duodenal biopsy may be avoided when high transglutaminase antibody titers are present.

AIM: To evaluate the predictive value of tissue transglutaminase (tTG) antibodies for villous atrophy in adult and pediatric populations to determine if duodenal biopsy can be avoided. METHODS: A total of 324 patients with celiac disease (CD; 97 children and 227 adults) were recruited prospectively at two tertiary centers. Human IgA class anti-tTG antibody measurement and upper gastrointestinal endoscopy were performed at diagnosis. A second biopsy was performed in 40 asymptomatic adults on a gluten-free diet (GFD) and with normal tTG levels. RESULTS: Adults showed less severe histopathology (26% vs 63%, P < 0.0001) and lower tTG antibody titers than children. Levels of tTG antibody correlated with Marsh type in both populations (r = 0.661, P < 0.0001). Multiple logistic regression revealed that only tTG antibody was an independent predictor for Marsh type 3 lesions, but clinical presentation type and age were not. A cut-off point of 30 U tTG antibody yielded the highest area under the receiver operating characteristic curve (0.854). Based on the predictive value of this cut-off point, up to 95% of children and 53% of adults would be correctly diagnosed without biopsy. Despite GFDs and decreased tTG antibody levels, 25% of the adults did not recover from villous atrophy during the second year after diagnosis. CONCLUSION: Strongly positive tTG antibody titers might be sufficient for CD diagnosis in children. However, duodenal biopsy cannot be avoided in adults because disease presentation and monitoring are different.

Age-related clinical, serological, and histopathological features of celiac disease.

BACKGROUND: Celiac disease (CD) is a common disorder in children and adults. However, limited data are available when comparing differences between both populations. AIMS: To prospectively evaluate and compare the clinical and histological features present at diagnosis in a cohort of celiac children and adults. METHODS: Consecutive new cases diagnosed between 2000 and 2006 were prospectively included (66 children and 54 adults). The clinical spectrum was categorized in two groups: (a) typical (malabsorption, chronic diarrhea, or failure to thrive) and (b) oligosymptomatic (abdominal pain, anemia, hypertransaminasemia, or screening in risk groups or in relatives). The histological results were divided into mild (i.e., Marsh I, II, and IIIA) and severe (i.e., Marsh IIIB, IIIC). In all cases, the human antitissue transglutaminase IgA antibodies (TTGA) were determined. RESULTS: Overall, a female/male ratio (2.6:1) was observed. This ratio was significantly higher in adults (5.7:1) than in children (1.6:1) (P= 0.009). Typical symptoms were present in 62.5% children versus 31% adults (P= 0.01). The average time to diagnosis after the appearance of symptoms was 7.6 months for children and 90 months for adults (P < 0.001). TTGA levels were higher in children and correlated with age (P < 0.001) and with the degree of villous atrophy (P < 0.001). Histological analysis revealed a marked atrophy in 86% children versus 52% adults (P < 0.001). The degree of villous atrophy was inversely correlated with age (P < 0.001). Classic symptoms were also associated with more severe villous atrophy. CONCLUSIONS: At initial diagnosis, CD shows age-related differences, which consist of more evident clinical and histological features in children. Furthermore, IgA TTGA levels correlate both with the degree of villous atrophy and with the patient's age.