Principales aplicaciones de la ecografía clínica en cuidados paliativos / Main applications of point-of care ultrasound in palliative care

El uso de la ecografía clínica, entendida como una extensión de la exploración física que ayuda a la toma de decisiones clínicas en tiempo real, se ha generalizado en diversas especialidades médicas y quirúrgicas. En los últimos años, los avances tecnológicos han permitido disponer de ecógrafos de bolsillo, económicamente asequibles, que pueden ser utilizados en el propio domicilio del paciente. En esta revisión se describen las principales aplicaciones de la ecografía clínica en cuidados paliativos, un escenario de potencial utilidad tanto para mejorar la certeza en el diagnóstico de procesos agudos intercurrentes, que producen un impacto en la calidad de vida del paciente, como para guiar la realización de procedimientos invasivos sin necesidad de desplazamientos al medio hospitalario. Para la implantación de la ecografía clínica en cuidados paliativos son necesarios programas formativos con objetivos concretos, definiendo curvas de aprendizaje y estableciendo alianzas con sociedades científicas de reconocida trayectoria docente, asistencial e investigadora para la acreditación de competencias (AU)

Combined with a physical examination, clinical ultrasound offers a valuable complement that can help guide clinical decision-making. In various medical and surgical specialties, it is increasingly used for diagnostic and therapeutic purposes. Due to recent technological advances, smaller and more affordable ultrasound machines are now being developed for use in home hospice care. The purpose of this paper is to describe how clinical ultrasound may be applied in Palliative Care, where it can be a valuable tool to assist the clinician in making better clinical decisions and to assist in accurately guiding palliative procedures. Furthermore, it can be used to identify unnecessary hospitalizations and prevent them from occurring. Training programs with specific objectives are necessary to implement clinical ultrasound in Palliative Care, as well as defining learning curves and promoting alliances with scientific societies that recognize the teaching, care and research trajectory for accreditation of competencies (AU)

How Truly Conserved Is the "Well-Conserved" Vertebrate Stress Response?

The vertebrate stress response is considered to be a highly conserved suite of responses that are evolved to help animals survive noxious environmental stimuli. The two major pathways of the stress response include the catecholamine release that is part of the autonomic nervous system and comprises the immediate fight-or-flight response, and the slower release of corticosteroids from the hypothalamic-pituitary-adrenal axis that help orchestrate longer-term responses. These two pathways are present in every vertebrate yet examined, and the anatomical and physiological architecture underlying these pathways are consistent. Despite these structural similarities, however, recent data indicate substantial temporal and species variation in the actual regulation of these pathways. For example, activation of both pathways varies seasonally in some species but not others, and responses of both pathways can be extensively modulated by an individual's previous experience. Consequently, even though the anatomy of the stress response is highly conserved, the activation and functional output is not highly conserved. Given this variation, it is perhaps not surprising that it is proving difficult to correlate individual stress responses with differences in fitness outcomes. This review summarizes the challenge of making broad generalized assumptions about fitness consequences of the stress response given the functional variation we observe.

Glucocorticoids and "Stress" Are Not Synonymous.

Reference to glucocorticoids as "stress hormones" has been growing in prevalence in the literature, including in comparative and environmental endocrinology. Although glucocorticoids are elevated in response to a variety of stressors in vertebrate animals, the primary functions of glucocorticoids are not responding to stressors and they are only one component of complex suite of physiological and behavioral responses to stressors. Thus, the use of the short-hand phrase "stress hormone" can be misleading. Further, simply measuring glucocorticoids is not equivalent to measuring a stress response, nor is manipulating glucocorticoids equivalent to exposing an animal to a stressor. In this commentary we highlight the problems with using functional names for hormones, and of treating cortisol or corticosterone as synonymous with stress. We provide recommendations to add clarity to the presentation of research on this topic, and to avoid conflation of glucocorticoids with stressors and the stress response in the design of experiments.

Los Glucocorticoides y el "Estrés" no Son Sinónimos (Glucocorticoids and "Stress" Are Not Synonymous) La referencia a los glucocorticoides como "hormonas del estrés" ha aumentado en prevalencia en la literatura, incluso en endocrinología comparativa y ecológica. Aunque los glucocorticoides están elevados en respuesta a una variedad de factores de estrés en animales vertebrados, las funciones primarias de los glucocorticoides no responden a los factores de estrés y son solo un componente de un conjunto complejo de respuestas fisiológicas y de comportamiento a los factores de estrés. Por lo tanto, el uso de la frase abreviada "hormona del estrés" puede ser engañoso. Además, simplemente medir glucocorticoides no es equivalente a medir una respuesta al estrés, ni manipular glucocorticoides equivalente a exponer a un animal a un factor estresante. En este comentario destacamos los problemas con el uso de nombres funcionales para las hormonas y con el tratamiento del cortisol o la corticosterona como sinónimo de estrés. Brindamos recomendaciones para agregar claridad a la presentación de investigaciones sobre este tema y para evitar la combinación de glucocorticoides con factores estresantes y la respuesta al estrés en el diseño de los experimentos. Translated to Spanish by J. Heras (herasj01@gmail.com).

Glucocorticóides e "Stress" Não São Sinônimos (Glucocorticoids and "Stress" Are Not Synonymous) A referência aos glicocorticóides como "hormônios do estresse" vem se tornando prevalente em literatura, inclusive na endocrinologia comparada e ecológica. Embora os glicocorticóides sejam elevados em resposta a uma variedade de estressores em vertebrados, as funções primárias de glicocorticóides são a de não responder aos causadores do stress e eles são apenas um componente dentro de um complexo conjunto de respostas fisiológicas e comportamentais aos estressores. Assim, o uso da frase curta "hormônio do estresse" pode ser errôneo. Além disso, simplesmente medir glicocorticóides não é equivalente a medir uma resposta ao estresse, nem a manipulação de glicocorticoides é equivalente a expor um animal a um estressor. Neste comentário, destacamos os problemas com o uso de nomes funcionais para hormônios e o tratamento de cortisol ou corticosterona como sinônimos de estresse. Nós provemos recomendações para adicionar clareza à apresentação de pesquisas deste tópico e para evitar a o tratamento direto de glicocorticoides como estressores e a resposta ao estresse no planejamento de experimentos. Translated to Portuguese by Diego Vaz (dbistonvaz@vims.edu).

A test of reactive scope: Reducing reactive scope causes delayed wound healing.

Reactive scope predicts that all animals have an adaptive ability to respond to stressors in their environment, termed reactive homeostasis, and that only when an animal's response to stressful stimuli exceeds a certain threshold (homeostatic overload) will stress have pathological effects. While this framework has successfully helped interpret effects of stressors on wildlife, no study has designed an experiment to directly test this framework. This study was designed to expose house sparrows (Passer domesticus) to treatments that would result in varying ranges of reactive homeostasis during chronic stress, which based on the reactive scope model should cause birds with the lowest reactive homeostasis range to exhibit signs of pathology during a subsequent challenge. To modulate the reactive homeostasis range, we altered allostatic load of birds by exposing them to chronic stress while either elevating, blocking, or not manipulating corticosterone. After concluding chronic stress treatments, birds were exposed to the subsequent challenge of a superficial wound. Individuals treated with corticosterone during chronic stress (high allostatic load) experienced the most pathology, including both weight loss and slower wound healing. Unmanipulated birds (medium allostatic load) also experienced weight loss but had normal healing rates, while birds with blocked corticosterone (low allostatic load) had minimal weight loss and normal healing rates. Our results indicate that increased allostatic load reduces the reactive homeostasis range, thereby causing individuals to cross the homeostatic overload threshold sooner, and thus support the reactive scope framework.

Wound-healing ability is conserved during periods of chronic stress and costly life history events in a wild-caught bird.

Chronic stress, potentially through the actions of corticosterone, is thought to directly impair the function of immune cells. However, chronic stress may also have an indirect effect by influencing allocation of energy, ultimately shifting resources away from the immune system. If so, the effects of chronic stress on immune responses may be greater during energetically-costly life history events. To test whether the effects of chronic stress on immune responses differ during expensive life history events we measured wound healing rate in molting and non-molting European starlings (Sturnus vulgaris) exposed to control or chronic stress conditions. To determine whether corticosterone correlated with wound healing rates before starting chronic stress, we measured baseline and stress-induced corticosterone and two estimates of corticosterone release and regulation, negative feedback (using dexamethasone injection), and maximal capacity of the adrenals to secrete corticosterone (using adrenocorticotropin hormone [ACTH] injection). After 8days of exposure to chronic stress, we wounded both control and chronically stressed birds and monitored healing daily. We monitored nighttime heart rate, which strongly correlates with energy expenditure, and body mass throughout the study. Measures of corticosterone did not differ with molt status. Contrary to work on lizards and small mammals, all birds, regardless of stress or molt status, fully-healed wounds at similar rates. Although chronic stress did not influence healing rates, individuals with low baseline corticosterone or strong negative feedback had faster healing rates than individuals with high baseline corticosterone or weak negative feedback. In addition, wound healing does appear to be linked to energy expenditure and body mass. Non-molting, chronically stressed birds decreased nighttime heart rate during healing, but this pattern did not exist in molting birds. Additionally, birds of heavier body mass at the start of the experiment healed wounds more rapidly than lighter birds. Finally, chronically stressed birds lost body mass at the start of chronic stress, but after wounding all birds regardless of stress or molt status started gaining weight, which continued for the remainder of the study. Increased body mass could suggest compensatory feeding to offset energetic or resource demands (e.g., proteins) of wound healing. Although chronic stress did not inhibit healing, our data suggest that corticosterone may play an important role in mediating healing processes and that molt could influence energy saving tactics during periods of chronic stress. Although the experiment was designed to test allostasis, interpretation of data through reactive scope appears to be a better fit.

[Spontaneous duodenal perforation in a radical prostatectomy patient]. / Perforación duodenal espontánea en paciente intervenido de prostatectomía radical.

Radical prostatectomy is a well known treatment for prostate cancer, with a low incidence of early postoperative complications. Our case is a 54 year old patient diagnosed with prostate adenocarcinoma, Gleason score 3+3=6 with 8 ng/ml of PSA, treated by retropubic prostatectomy, who suffered spontaneous perforation of the duodenum. We chose a conservative management, resolved in 30 days. When dealing with a surgical patient all kinds of complications must be taken into account by performing the minimum tests that will enable a sure diagnosis to be achieved. The usual treatment is surgery or conservative management, depending on the case and the patient.

Adenoma nefrogénico prostático. A propósito de un caso / Prostatic nephrogenic adenoma. A case report

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Inventory and vertical migration of 90Sr fallout and 137Cs/90Sr ratio in Spanish mainland soils.

In this paper the inventory of (90)Sr in 34 points distributed along the Spanish peninsular territory is presented. Obtained values range between 173 Bq/m(2) and 2047 Bq/m(2). From these data set and those (137)Cs data obtained in a previous work the (137)Cs/(90)Sr activity ratio has been established, laying this value between 0.9 and 3.6. Also the migration depth of both radionuclides has been analysed obtaining for (137)Cs an average value 57% lower than that obtained for (90)Sr. Additionally, this paper presents the results obtained in 11 sampling points in which the activity vertical profile has been measured. These profiles have been analysed to state the behaviour of strontium in soils and after, by using a convective-diffusive model, the parameters of the model which governs the vertical migration of (90)Sr in the soil, v (apparent convection velocity) and D (apparent diffusion coefficient) have been evaluated. Mean values obtained are 0.20 cm/year and 3.67 cm(2)/year, respectively.

Inventory and vertical migration of ¹³7Cs in Spanish mainland soils.

In this study the total activity of (137)Cs deposited per unit area over the Spanish peninsular territory was analysed using a 150 × 150 km(2) mesh grid, with samples taken from 29 points. The deposited activities ranged between 251 and 6074 Bq/m(2). A linear relationship was obtained between these values and the mean annual rainfall at each sampling point which allowed a map to be drawn, using GIS software, which shows the distribution of total deposited (137)Cs activity across the Spanish mainland. At twelve of these sampling points the vertical migration profile of (137)Cs was obtained. These profiles are separated into two groups with different behaviour, one of which includes clay and loam soils and the other containing sandy soils. For both groups of profiles the parameters of the convective-diffusive model, which describes the vertical migration of (137)Cs in the soil, v (apparent convection velocity) and D (apparent diffusion coefficient) were calculated.

Chronic psychological stress alters body weight and blood chemistry in European starlings (Sturnus vulgaris).

One hallmark of chronic stress is a decrease in body weight that rebounds once chronic stress is alleviated. We applied chronic psychological stress by exposing European starlings (Sturnus vulgaris) to a previously validated chronic stress protocol (CSP) consisting of 4 different randomly applied stressors per day. Experimental design consisted of a 21 day CSP (CSP1), a 60day recovery (R1), a second 14 day CSP (CSP2), and a second 30 day recovery (R2). Body weight decreased by approximately 5% during CSP1, but overshot to 5-10% above initial body weight during R1. To investigate underlying mechanisms, we periodically measured 12 biochemical analytes, including aspartate aminotransferase (AST), creatine kinase (CK), bile acids, total protein, albumin, globulin, glucose, uric acid, calcium (Ca(++)), phosphorus (PHOS), potassium (K(+)), and sodium (Na(+)). AST and CK increased at the beginning of CSP1, suggesting muscle breakdown. Additionally, decreases in albumin and total protein paired with stable uric acid, but no associated change in glucose, suggested protein breakdown as a secondary energy source. Changes in blood parameters that occurred during CSP1 did not reverse during R1. During CSP2 and R2, weight loss and gain occurred in different proportions. CSP2 produced an approximate 15% decrease in body weight, but R2 resulted in only re-gaining 5% of this weight, although this was equivalent to the pre-CSP1 weight. In summary, protein metabolism appeared to mediate weight loss during chronic stress, but over-gaining weight was not a good indicator of recovery.

Chronic stress alters glucocorticoid receptor and mineralocorticoid receptor mRNA expression in the European starling (Sturnus vulgaris) brain.

Although the glucocorticoid response to acute short-term stress is an adaptive physiological mechanism that aids in the response to and survival of noxious stimuli, chronic stress is associated with a negative impact on health. In wild-caught European starlings (Sturnus vulgaris), chronic stress alters the responsiveness of hypothalamic-pituitary-adrenal (HPA) axis as measured by the acute corticosterone response. In the present study, we investigated potential underlying neuroendocrine mechanisms by comparing glucocorticoid receptor and mineralocorticoid receptor mRNA expression in the brains of chronically and nonchronically-stressed starlings. Hypothalamic paraventricular nucleus, but not hippocampal, glucocorticoid receptor mRNA expression in chronically-stressed birds was significantly lower compared to controls, suggesting changes in the efficacy of corticosterone negative feedback. In addition, chronically-stressed birds showed a significant decrease in hippocampal MR mRNA expression. Together, these results suggest that chronic stress changes the brain physiology of wild birds and provides important information for the understanding of the underlying mechanisms that result in dysregulation of the HPA axis in wild animals by chronic stress.

Estado de la provisión de cuidados nutricionales al paciente quemado. Auditoría de procesos en un Servicio de Quemados de un hospital terciario / Current status of nutritional care provision to burnt patients. Processes audit of a burnt patients department from a tertiary hospital

Justificación: La respuesta al tratamiento médico-quirúrgico del paciente quemado pudiera depender tanto de los estragos provocados por la agresión térmica, a saber las demandas metabólicas incrementadas, la aparición del Síndrome de Respuesta Inflamatoria Sistémica, y las infecciones microbianas; como de las prácticas culturales incluidas dentro de los procesos institucionales de cuidados nutricionales. Objetivo: Evaluar cómo la conducción de los procesos nutricionales de evaluación e intervención influye sobre los indicadores de la efectividad terapéutica de los Servicios de Quemados. Serie de estudio: Cuarenta y dos pacientes atendidos con una superficie corporal quemada (SCQ) > 10 por ciento, entre enero del 2001-diciembre del 2003, en el Servicio de Quemados del Hospital Clínico Quirúrgico Hermanos Ameijeiras (Ciudad La Habana, Cuba). Métodos: Los procesos nutricionales de evaluación e intervención conducidos en el paciente quemado se auditaron mediante revisión de las historias clínicas. Los procesos auditados se declararon como Completados (o no). El grado de completamiento del proceso se relacionó con las tasas de complicaciones y mortalidad, y el índice de hospitalización predicho de la SCQ. Resultados: Los procesos nutricionales de evaluación e intervención se completaron en el 49,4 por ciento y 22,6por ciento de las historias auditadas, respectivamente. El registro evolutivo del peso corporal se asoció con una menor mortalidad. La evaluación nutricional temprana y un aporte energético suficiente en lesionados con SCQ > 20 por ciento se asociaron con menores tasas de complicaciones y un mejor cumplimiento del índice de hospitalización. Conclusiones: Este trabajo constituye la primera aproximación al comportamiento del Servicio de Quemados de la institución, como antesala del diseño e implementación de un programa de mejoría continua de la calidad en la atención médica......(AU)

Rationale: Response of the burned patient to surgical medical treatment might depend not only upon the damages brought about by thermal agression, namely, increased metabolic requirements, onset of the Systemic Inflamatory Response Syndrome, and microbial infections, but also the cultural practices embedded within nutritional care institutional processes. Goal: To assess how conduction of nutritional care processes of assessment and intervention may influence therapeutical effectiveness indicators of hospital Burn Services. Study serie: Forty-two patients with a Burn Body Surface Area (BBSA) > 10 percent assisted at the Burn Service of the Hermanos Ameijeiras Clinical Surgical Hospital (La Habana, Cuba), between January 2001-December 2003. Methods: Nutritional care of assessment and intervention conducted upon the burn patient were audited after reviewing clinical charts. The audited processes were declared as Completed (or not). Completeness of the process was related to complications and mortality rates, and length of hospital stay predicted from BBSA. Results: Nutritional care processes of assessment and intervention were completed in 49.4 percent and 22.6 percent of the audited charts, respectively. Prospective recording of patient's body weight was associated with lower mortality. Early nutritional assessment and sufficient energy supply to patients with BBSA > 20percent were associated with lower complications rates and better compliance with BBSA-predicted length of stay. Conclusions: This work is the first enquiry into the behaviour of the institution's Burn Service, in anticipation of the design and implementation of a medical care Continuous Quality Improvement Program. In spite of the current state of nutritional care processes completeness, their observance might favorably influence the Service's effectiveness indicators(AU)