CONSENSUS ON THE APPLICATION AND CARE OF BROMELAIN-BASED ENZYMATIC DEBRIDEMENT ON BURNS.

Treatment of burned patients involves early excision of the burn. The approach to this excision has changed since bromelain-based enzymatic debridement was introduced. This treatment option reduces complications from the surgical procedure and improves scar quality. It is indicated for partial and full thickness burns. It is important to agree on the nursing care before, during and after enzymatic debridement treatment to ensure an optimal preparation and maintenance of the wound bed for later treatment to be most successful. A multi-centre Delphi study was conducted with enzymatic debridement nursing care on burned patient experts. A coordinating group developed a 29-item questionnaire based on clinical guidelines and experience. Two question rounds were asked, reaching consensus on answers > 70%. Nine panellists from nine leading burns centres in Spain participated. The aim was to develop a national consensus on enzymatic debridement treatment based on clinical practice and evidence from almost 1500 cases. The experts reached 29 agreements on different aspects of treatment and patient condition: general considerations about the treatment, burned patient admission, treatment prior to enzymatic debridement, applying debridement, removing enzymatic debridement and the post-enzymatic debridement phase. The expert consensus on nursing care of the burn patient and application of bromelain-based enzymatic debridement includes general recommendations for the patient before, during and after application and the planning of localised care after debridement. This consensus document supports knowledge on enzymatic debridement technique, increasing safety in clinical nursing practice and ensuring successful treatment for the patient.

L'excision précoce est la référence dans le traitement des brûlures. Sa technique a été transformée par le débridement enzymatique à la bromélaïne. Cette technique, indiquée dans les brûlures intermédiaires et profondes, réduit les complications chirurgicales et améliore la qualité cicatricielle. La qualité des soins locaux, avant, pendant et après l'application de bromélaïne, est un paramètre important d'efficacité. Nous avons organisé une étude basée sur la méthode Delphi auprès de 9 experts de 9 CTB espagnols. Le groupe de coordination a réalisé un questionnaire à 29 items à partir des recommandations et de leur expérience (quasiment 1 500 cas au total). Deux séances ont été organisées, dans le but d'obtenir les agréments de plus de 70% des participants. Un consensus a été obtenu sur les 29 questions posées, se rapportant aux généralités, aux critères d'admission, au traitement avant bromélaïne, à son application, à son retrait et aux soins ultérieurs. Les recommandations de soins locaux consécutives recouvrent les phases avant, pendant et après utilisation. Elles permettent une amélioration de l'efficacité et de la sécurité du débridement enzymatique.

El dolor en los pacientes hospitalizados: estudio transversal de la información, la evaluación y el tratamiento / Pain in hospitalized patients: cross-sectional study on information, evaluation and treatment

Objetivo: Para proponer e implementar acciones de mejora en el manejo del control del dolor en los centros hospitalarios del IMAS (Institut Municipal d’Assitència Sanitaria), la Comisión de Evaluación y Tratamiento del Dolor, elaboró un cuestionario dirigido a los pacientes ingresados en sus centros, que complementó un estudio previo destinado a conocer la opinión y la actitud de los profesionales hospitalarios. Material y métodos: Estudio transversal realizado mediante encuesta de opinión y revisión de historia clínica. Las preguntas se agruparon en 5 categorías: información recibida acerca de la importancia de manifestar y tratar su dolor; métodos utilizados en su evaluación; repercusión en las actividades de la vida diaria hospitalaria; tratamiento aplicado, y satisfacción con el proceso de la gestión del dolor. Se incluyeron 325 entrevistas realizadas a pacientes adultos con ingreso superior a 48 h, se excluyeron los que presentaban dificultad de comunicación y los ingresados en psiquiatría en los que su médico no consideró oportuna la entrevista. La selección de camas fue aleatoria y el cálculo de la muestra se realizó estratificado por centro y áreas (agudos médicos, agudos quirúrgicos, larga estancia y psiquiatría). Se realizó un análisis descriptivo. Resultados: Un 42,2% de los pacientes refirió no haber recibido ningún tipo de información acerca de la importancia de manifestar su dolor. A un 62,8% se le había preguntado sobre la intensidad de su dolor, siendo el método más utilizado una escala categórica (48,5%), seguido de la escala verbal numérica (35,8%). Un 76,9% de los pacientes había presentado algún tipo de dolor durante su ingreso, y de éstos un 22% no había solicitado atención por dicho motivo...(AU)

Objective: To propose and implement strategies to improve pain management in hospitals belonging to the Municipal Institute of Healthcare (Instituto Municipal de Asistencia Sanitaria, Barcelona, Spain), the Committee for Pain Evaluation and Treatment developed a questionnaire to be used in patients admitted to these centers to complement a previous survey of opinions and attitudes among hospital staff. Material and methods: We performed a cross-sectional opinion survey and review of medical records. The questions were grouped into five categories: information given to the patient on the importance of reporting and treating pain, the methods used to assess pain, the effect on activities of daily living during hospitalization, the treatment applied and satisfaction with pain management. A total of 325 adult patients hospitalized for more than 48 hours were surveyed. Patients with communication difficulties were excluded, as were psychiatric patients if the treating physician considered participation inappropriate. Patients were selected randomly. In the calculation of sample size, stratification was by hospital and patient type (acutely ill medical or surgical patients, long-stay patients and psychiatric patients). Descriptive statistics were compiled. Results: No information about the importance of reporting pain was received by 42.2% of the patients; 62.8% had been asked about pain intensity, the most frequent method used being a categorical scale (48.5%), followed by a verbal-numerical scale (35.8%). Most patients (76.9%) experienced some type of pain during admission; of these, 22% did not seek help for pain management. Overall, 85.8% of the patients felt that their pain had received sufficient attention, while 33.3% reported moderate or considerable limitation of daily activities due to pain while in hospital...(AU)

Ochratoxin A-producing fungi from grapes intended for liqueur wine production.

The ochratoxigenic mycobiota of grapes intended for liqueur wines from four Spanish vineyards were studied. The specific wine-making technology of these wines requires overripening of the grapes on the vine or extended post-harvest exposure of the grapes in the sun. In every vineyard, samples were taken at three different developmental stages: veraison, harvesting time and after over-ripening. With the maturation of the berries there was a clear increase of Aspergillus spp. In the last sampling time studied, they were isolated from the 90.3% of the plated berries. Black aspergilli (mainly A. niger aggregate and A. carbonarius) were predominant among the different Aspergillus spp. isolated and constituted 98.5% of the total Aspergillus strains isolated. At harvesting time and after over-ripening, the percentage of colonized berries with A. carbonarius exceeded that of Aspergillus niger aggregate. Due to their low frequency of isolation, Penicillium spp. and Aspergillus spp. outside black aspergilli are not an important source of ochratoxin A in grapes for liqueur wine production. On the contrary, 98.5% of the A. carbonarius isolates screened were able to produce ochratoxin A. Although the possible participation of different ochratoxin A-producing species may occur, our results confirm that A. carbonarius is the most important source of ochratoxin A in liqueur wines, increasing its occurrence along the ripening of grapes.

Ochratoxigenic species from Spanish wine grapes.

The ochratoxigenic mycobiota of grapes belonging to representative wine regions located along the Mediterranean coast of Spain at different developmental stages was identified. During the development of the berries, the occurrence of Aspergillus spp. increased while the percentage of berries contaminated by non-ochratoxin A (OTA) producing species such as Alternaria spp. and Cladosporium spp. decreased. Penicillium verrucosum, the only confirmed Penicillium spp. that is able to produce OTA, was not isolated. The contamination by OTA-producing species comes from the surface of the berries and not from the inner fruit. Black aspergilli were predominant among the different Aspergillus spp. isolated. All the Aspergillus carbonarius isolates were able to produce OTA at different concentrations. None of the isolates belonging to Aspergillus niger aggregate and to Aspergillus japonicus var. aculeatus were able to produce OTA. These results are a strong evidence of the contribution of A. carbonarius in the OTA contamination in wine grapes, mainly at the last developmental stages of the berries.

What is the source of ochratoxin A in wine?

During a microvinification trial using natural mouldy grapes from a research experimental vineyard, ochratoxin A (OTA) contaminated white wine was obtained. Potential OTA-producing mycobiota of grape samples used in this microvinification process was assessed. Only Aspergillus carbonarius isolates were detected as producers of OTA. Our report is a strong evidence of the contribution of A. carbonarius in the OTA contamination in wine.

[Screening for bone disease risk with clinical factors in women after physiologic menopause]. / Cribado de riesgo óseo mediante factores clínicos en mujeres tras menopausia fisiológica.

BACKGROUND: Densitometric screening for osteoporosis in postmenopausal women has not been demonstrated cost-effective. We have tried to identify clinical factors for screening previous to densitometry avoiding unnecessary explorations. SETTING: outpatient clinics of a menopausal unit in a 450-bed general hospital. Cross-sectional study, in two steps, of two groups of 140 and 284 women attending for physiological menopause. A clinical questionnaire, physical data and lumbar densitometry (Hologic QDR 1000) were obtained classifying the cases as "normal" or "low bone mass" (osteopenia or osteoporosis) according with the WHO criteria. In the first group a logistic regression analysis was done to identify predictive factors for abnormal densitometry, then validated in the second group. Sensitivity, specificity, predictive values (PV) and classification ability of clinical factors were analyzed. RESULTS: Four factors were independent predictors of abnormal densitometry: age > 51 (odds ratio [OR] = 6.64; 95% CI, 2.36-18.7); body weight < 70 kg (OR = 4.32; 95% CI, 1.71-10.09); years of fertility < 32 (OR = 3.77; 95% CI, 1.36-10.04), and number of live births > 2 (OR = 3.47; 95% CI, 1.27-9.53). Presence of one factor offers: sensitivity 91.9%; specificity 15%; positive PV 66.6%, and negative PV 50%, whereas the presence of two factors offers: sensitivity 62.7%; specificity 70%; positive PV 79.9%, and negative PV 50.3%. Clinical screening allows, when two factors are present, to avoid a 35.5% of densitometries and the false-negative cases represent 18%. CONCLUSIONS: Detection of bone-risk clinical factors (abnormal densitometry) yields a screening, previous to densitometry, that avoids at least one third of explorations in women with physiological menopause, improving the efficiency of the test.

Piroxicam fast-dissolving dosage form vs diclofenac sodium in the treatment of acute renal colic: a double-blind controlled trial.

OBJECTIVE: To assess the possible therapeutic effect of 40 mg sublingual piroxicam (fast-dissolving dosage form, FDDF) compared with intramuscular 75 mg diclofenac, as a reference drug, on acute renal colic in a randomized, double-blind controlled clinical trial. PATIENTS AND METHODS: Eighty patients were assigned to one of two treatment groups; one received an intramuscular injection with 0.2 mL distilled water and two sublingual tablets of 20 mg piroxicam FDDF, and the other received an intramuscular injection with 75 mg diclofenac sodium and two sublingual tablets of placebo. Pain intensity was evaluated by the patient using a visual analogue scale and by the observers. Vital signs at baseline and 30 min after the administration of the study drugs were also recorded. RESULTS: The overall efficacy of the treatment was 81%; nine patients in the piroxicam and six in the diclofenac group (no significant difference) required rescue treatment. Compared with baseline levels, the pain relief was significant (P < 0.001) at 30 min in both groups. Twenty-two patients in the piroxicam and 25 in the diclofenac group attained complete pain relief at 30 min, as evaluated by the observer (no significant difference). Both treatments were similarly effective in decreasing vital signs, mainly systolic blood pressure, heart and respiratory rates. However, when the percentage change was compared between the groups, piroxicam significantly decreased the respiratory rate (P < 0.03). CONCLUSION: Piroxicam FDDF is as effective as parenteral diclofenac in emergency renal colic treatment. Furthermore, its ease of self-administration increases patient compliance and potential use in general practice.

Idiopathic bilateral diaphragmatic paralysis: effectiveness of bilevel intermittent positive airway pressure.

A 49-year-old woman presented with idiopathic bilateral diaphragmatic paralysis. The patient benefited from bilevel intermittent positive airway pressure-type assisted ventilation with rapid, excellent and long-lasting results. This case emphasizes the need for correct diagnosis and therapeutic management, particularly with a bilevel intermittent positive airway pressure-type home ventilation technique, in idiopathic bilateral diaphragmatic paralysis.