AEDV Expert Document on the Management of Ulcerative Venereal Infections. / Documento de expertos de la AEDV sobre el manejo de infecciones venéreas ulcerativas.

Currently, ulcerative sexually transmitted infections, including syphilis, herpes simplex virus (HSV), lymphogranuloma venereum (LGV), chancroid, donovanosis and, more recently, monkeypox (MPOX), represent a growing challenge for health care professionals. The incidence of syphilis and LGV has increased in recent years in Spain. Additionally, HSV, syphilis and chancroid can also increase the risk of HIV acquisition and transmission. The population groups most vulnerable to these infections are young people, men who have sex with men (MSM) and commercial sex workers. It is important to make a timely differential diagnosis since genital, anal, perianal, and oral ulcerative lesions may pose differential diagnosis with other infectious and non-infectious conditions such as candidiasis vulvovaginitis, traumatic lesions, carcinoma, aphthous ulcers, Behçet's disease, fixed drug eruption, or psoriasis. For this reason, the dermatologist plays a crucial role in the diagnosis and management of sexually transmitted infections. This chapter presents the main epidemiological, clinical and therapeutic features associated with these infections.

Endoscopic findings unrelated to portal hypertension in patients with liver cirrhosis undergoing a varicose vein screening programme. / Hallazgos endoscópicos no relacionados con hipertensión portal en pacientes con cirrosis hepática sometidos a un programa de cribado de varices.

AIM: To determine the prevalence of endoscopic lesions unrelated with portal hypertension in patients with cirrhosis. PATIENTS AND METHODS: Cross-sectional study including a consecutive cohort of patients with liver cirrhosis enrolled in a screening program of oesophageal varices who underwent an upper gastrointestinal endoscopy from November, 2013, to November, 2018. Clinical predictors of endoscopic lesions unrelated to portal hypertension were analyzed by univariate and multivariate logistic regression. RESULTS: A total of 379 patients were included. The most frequent aetiology of liver disease was alcohol consumption (60.4%). The prevalence of endoscopic lesions unrelated with portal hypertension was 39.6% (n=150). Among 96 patients with peptic lesions, urease was obtained in 56.2% of patients (positive in 44.4% of them). The prevalence of endoscopic lesions unrelated to portal hypertension was not associated with age, gender, liver function or ultrasound findings of portal hypertension. The prevalence of endoscopic lesions unrelated to portal hypertension was not associated with age, gender, liver function or ultrasound findings of portal hypertension. Smokers had a trend to increased prevalence of endoscopic lesions unrelated to portal hypertension (43.2% vs. 34.6%; p=0.09), particularly peptic ulcer (6.4% vs. 0.6%; p=0.05) and peptic duodenitis (17.3% vs. 6.3%; p=0.002). Active smoking was the only independent predictor of peptic ulcer or duodenitis (OR=2.56; p=0.017). CONCLUSION: Active smoking is a risk factor for endoscopic lesions unrelated to portal hypertension. This finding should be further investigated to reassess endoscopic screening programs in cirrhotic smokers.

NSAIDs, gastrointestinal toxicity and inflammatory bowel disease. / AINE, toxicidad gastrointestinal y enfermedad inflamatoria intestinal.

Non-steroidal antiinflammatory drugs (NSAIDs) are currently one of the most widely used drugs. The use of NSAIDs is associated with gastrointestinal toxicity, affecting both upper gastrointestinal tract (peptic ulcer disease) and lower gastrointestinal tract (NSAID-induced enteropathy). NSAIDs use has been associated with an increased risk of clinical relapse in inflammatory bowel disease patients. In this article, we review the upper and lower gastrointestinal toxicity of NSAIDs, with a focus on the risks and specific data of these drugs in inflammatory bowel disease patients, giving recommendations for its appropriate use in the clinical practice. Although evidence is scarce, short-term use of NSAIDs appears to be safe, and the data available suggest that selective COX-2 inhibitors are the safer option. NSAIDs should be avoided as long-term treatment or with high doses, especially in patients with active inflammation.

Estrategias de protección antimicrobiana en el cuidado de heridas: evidencia para el uso de apósitos recubiertos con DACC.

BACKGROUND: Antimicrobial resistance (AMR) is one of the most serious health threats globally. The development of new antimicrobials is not keeping pace with the evolution of resistant microorganisms, and novel ways of tackling this problem are required. One of such initiatives has been the development of antimicrobial stewardship programmes (AMS). The use of wound dressings that employ a physical sequestration and retention approach to reduce bacterial burden offers a novel approach to support AMS. Bacterial-binding by dressings and their physical removal can minimise their damage and prevent the release of harmful endotoxins. OBJECTIVE: To highlight AMS to promote the correct use of antimicrobials and to investigate how dialkylcarbamyl chloride (DACC)-coated dressings can support AMS. METHOD: MEDLINE, Cochrane Database of Systematic Reviews, and Google Scholar were searched to identify articles relating to AMS, and the use of wound dressings in the prevention and treatment of wound infections. The evidence supporting alternative wound dressings that can reduce bioburden and prevent wound infection in a way that does not kill or damage the microorganisms were reviewed. RESULTS: The evidence demonstrated that using bacterial-binding wound dressings that act in a physical manner (eg, DACC-coated dressings) to preventing infection in both acute and hard-to-heal wounds does not exacerbate AMR and supports AMS. CONCLUSION: Some wound dressings work via a mechanism that promotes the binding and physical sequestration and removal of intact microorganisms from the wound bed (eg, a wound dressing that uses DACC technology to prevent/reduce infection). They provide a valuable tool that aligns with the requirements of AMS by effectively reducing wound bioburden without inducing/selecting for resistant bacteria.

ANTECEDENTES: Normalmente, las infecciones son tratadas con antimicrobianos (antibióticos, antisépticos, etc.). La resistencia antimicrobiana (AMR, por sus siglas en inglés) se ha convertido en una de las amenazas del siglo XXI más graves para la salud mundial. Las heridas pueden ser una fuente de infección al permitir la entrada libre de microorganismos dentro del cuerpo, incluyendo bacterias resistentes a antimicrobianos. El desarrollo de nuevos antimicrobianos (especialmente, antibióticos) no está siguiendo el ritmo de la evolución de microorganismos resistentes y de formas novedosas de abordar este problema con la urgencia que demanda. Una de estas iniciativas ha sido el desarrollo de programas de protección antimicrobiana (AMS, por sus siglas en inglés), que brindan capacitación a los trabajadores del área de la salud y controlan la prescripción, enfocándose en los antimicrobianos para reducir la probabilidad de que se produzca AMR. El uso de apósitos para herida que utilizan el aislamiento físico y el abordaje de retención, en vez de agentes antimicrobianos, para reducir la carga bacteriana ofrecen un abordaje novedoso para apoyar a los AMS. La fijación bacteriana por los apósitos y su retiro físico, en lugar de la muerte activa, minimiza su daño y, además, previene la liberación de endotoxinas dañinas. OBJETIVO: Resaltar los AMS para la promoción del uso correcto de antimicrobianos e investigar cómo los apósitos recubiertos con cloruro de dialquilcarbamilo (DACC) pueden ayudar a cubrir las metas de los AMS. MÉTODO: Se realizaron búsquedas en las bases de datos de revisiones sistemáticas, Medline, Cochrane y Google Scholar con el fin de identificar artículos publicados que describan los datos relacionados con los AMS, y el uso de una gran variedad de apósitos para heridas para la prevención y/o tratamiento de infecciones de la herida. La evidencia que respalda a los apósitos para heridas alternativos que pueden reducir la biocarga y prevenir y/o tratar la infección de heridas de forma tal que no maten ni dañen a los microorganismos (por ejemplo, fijándose activamente y retirando intactos a los microorganismos de las heridas) fue posteriormente revisada de forma oral. CONCLUSIÓN: Algunos apósitos para heridas actúan a través de mecanismos que promueven la fijación y absorción física, aislamiento y retiro de microorganismos intactos de la base de la herida (por ejemplo, un apósito para heridas que utiliza la tecnología DACC para prevenir/reducir la infección). Esta es una herramienta valiosa que cumple con los requisitos del AMS (por ejemplo, reducción del uso de antimicrobianos en esquemas de tratamiento de heridas) al reducir la biocarga de la herida sin inducir/seleccionar bacterias resistentes.

Uso de colágeno y terapia de presión negativa en una úlcera de pie diabético: caso de estudio.

Use of collagen and negative pressure wound therapy in a diabetic foot ulcer: a case study SINOPSIS: The following case study describes the use of a collagen layer in combination with negative pressure wound therapy in a diabetic foot ulcer, treated in a hospital in Chile. The wound reduced 58% in size in the first 10 weeks of treatment, reaching complete healing in the following 14 weeks. The treatment carried out avoided amputation of the foot of the patient who, at 64 years of age, maintained his independence and quality of life.

Resumen: El siguiente caso de estudio describe el uso de una capa de colágeno en combinación con terapia de presión negativa en una úlcera de pie diabético, tratada en un hospital de Chile. La herida redujo su tamaño 58% en las primeras 10 semanas, y alcanzó la cicatrización completa en las siguientes 14 semanas. El tratamiento realizado evitó la amputación del pie del paciente que, a sus 64 años, mantuvo su independencia y calidad de vida.

Determinantes sociales y demográficos relacionados con la cicatrización de heridas en un centro de asistencia y educación en enfermería.

OBJECTIVE: Analyse the social and demographic variables that affect healing in patients with hard-to-heal wounds. METHOD: This retrospective study looked at 349 patient records of people with hard-to-heal wounds at an educational and care centre in San Pablo, Brazil, between 1994 and 2015. Healing was measured using the Pressure Ulcer Scale for Healing (PUSH). RESULTS: A total of 128 patient records were included. Most had identified themselves as white (62%), with an incomplete education (31%), household income under three minimum wages (86%), diabetes mellitus (61%), and systemic hypertension (58.4%). The PUSH scale varied between 4-7. The healing rate was 60%. Patients with white/yellow skin had 3.43 more chances to achieve healing (p<0,001). CONCLUSION: The social determinants observed were similar to Brazil's major inequality indicators. Statistical significance for white/yellow skin colour related to wound healing was observed. Nursing consultations contributed in achieving wound healing.

OBJETIVO: Analizar los determinantes sociodemográficos que influyen en la evolución de los pacientes con heridas de difícil cicatrización. MÉTODO: Este estudio epidemiológico retrospectivo analizó 349 historias clínicas de personas con heridas de difícil cicatrización en un centro de asistencia y educación en enfermería en San Pablo, Brasil, entre 1994 y 2015. Se usó la escala Pressure Ulcer Scale for Healing (PUSH) para evaluar la cicatrización. RESULTADOS: Se analizaron datos de 128 personas, la mayoría, adultos mayores. Los participantes se autodeclararon blancos (62%), con educación básica incompleta (31%), ingresos económicos familiares de hasta tres salarios mínimos (86%), diabetes mellitus (61%), e hipertensión arterial sistémica (58,4%). La escala PUSH varió entre 4 y 17 puntos (0­17 posibles), y el puntaje medio en la última valoración fue de, aproximadamente, 12. La tasa de cicatrización fue 60%. El color de piel blanca/amarilla aumentó 3,43 veces las chances de lograr la cicatrización (p<0,001). CONCLUSIÓN: Los atributos sociales estudiados se asemejan a los principales indicadores de inequidades sociales en salud en Brasil. Se observó significancia estadística para los colores de piel blanca/amarilla, relacionados con la cicatrización de la herida. La consulta de enfermería contribuyó en lograr la cicatrización de las heridas. CONFLICTO DE INTERÉS: Ninguno.

Uso de apósitos con TLC-NOSF en el manejo de la úlcera de pie diabético, basado en la revisión de la evidencia y la práctica clínica.

Management of diabetic foot ulcers with a TLC-NOSF dressing, based on evidence and clinical practice The incidence of diabetic foot ulcers (DFU) has increased in the past decade, both in Chile and worldwide, as a result of the progressive growth in diabetes prevalence. Because DFU are associated with a high risk of infection and amputation, it is crucial to choose effective and evidence-based treatments. A dressing combining technology lipidocolloid with nano-oligo saccharide factor (TLC-NOSF) has demonstrated its effectiveness in managing DFU. This article reviews the evidence around TLC-NOSF and its implementation in clinical practice.

CONFLICTO DE INTERÉS: FSS recibió pagos personales de Laboratorios UrgoMedical por ponencias y actividades. RCG es empleada de Laboratorios UrgoMedical. APP declara no tener conflicto de interés.

Uso de una matriz autóloga en el tratamiento de úlceras de pie diabético, con espectroscopia de infrarrojo cercano y medidor de pH dérmico.

OBJECTIVE: Evaluate the efficiency of an autologous whole blood clot (WBC) matrix on diabetic foot ulcers (DFU), and analyse its immune response with near-infrared spectroscopy (NIRS) and pH measurement. METHOD: Three patients were treated with a WBC. The matrix was produced at the point of care, using a WBC system. A WBC gel was formed and applied onto the wounds. The gel remained in place with primary and secondary dressings. RESULTS: Wound-size reduction was 70% after two applications, 97.6% after three applications, and 90.9% after four applications. The NIRS skeletal muscle oxygen saturation (StO2) increased in all cases. CONCLUSION: The autologous matrix was efficient in treating DFU. The wound area surface reduced after each application and wound healing was achieved in all cases. More studies are needed to understand the benefits of using a WBC matrix on DFU.

OBJETIVO: Evaluar la eficacia de una matriz autóloga en el tratamiento de úlceras de pie diabético (UPD) de difícil cicatrización, y analizar la respuesta inmune a la aplicación de la matriz con un escáner de infrarrojo cercano (NIRS, por sus siglas en inglés) y un medidor de pH dérmico. MÉTODO: Tres pacientes fueron tratados con una matriz de coágulo de sangre completa (WBC, por sus siglas en inglés) autóloga. La matriz se realizó en el punto de atención, mezclando la sangre del paciente con una suspensión coloidal de gluconato de calcio/caolín, e inyectándola en una bandeja de coagulación. Se formó un gel de WBC y se aplicó a las heridas. El gel de WBC se mantuvo en su lugar con apósitos primarios y secundarios. RESULTADOS: Hubo una reducción del tamaño de las UPD de 70% tras dos aplicaciones, 97,6% después de tres aplicaciones, y 90,9% tras cuatro aplicaciones. El NIRS midió un aumento en la saturación de oxígeno tisular. No hubo reacciones adversas. CONCLUSIÓN: La matriz autóloga fue eficaz en el tratamiento de las UPD. La superficie de las UPD se redujo después de cada aplicación y se logró el cierre completo de las heridas. Se necesitan más ensayos clínicos para comprender mejor los beneficios de la matriz de WBC en UPD. CONFLICTO DE INTERÉS: RedDress Ltd. (Pardes-Hanna, Israel) proporcionó los suministros y materiales del estudio. Bennett Health Inc. ayudó con el desarrollo del protocolo y capacitó al personal sobre la aplicación del producto para coágulos sanguíneos. JA es accionista de Bennett Health Inc. No hubo interés financiero para ninguno de los investigadores o participantes.

[Effectiveness of double-layered compression therapy against crepe bandage for healing venous ulcers in primary care. Randomized clinical trial]. / Efectividad de la terapia compresiva de doble capa frente al vendaje de crepé en la cicatrización de úlceras venosas en atención primaria. Ensayo clínico aleatorizado.

OBJECTIVE: To evaluate if the two-layer bandage is more effective than the crepe bandage in the healing of venous ulcers after 12 weeks of follow-up. DESIGN: Randomized multicentre controlled clinical trial. LOCATION: 22 Primary Health Centers of Madrid. PARTICIPANTS: Over 18 years old, with diagnosis of venous ulcers. 93 patients were randomized, 56 in the double layer group and 37 in the crepe group. Withdrawals: 16 in double layer group, 7 in crepe group. INTERVENTIONS: Control group: usual clinical practice: treatment of the wound and bandage with crepe. Experimental group: same usual clinical practice for wound treatment and bandage with double layer. MAIN MEASUREMENTS: Primary outcome: complete healing at 12 weeks. SECONDARY OUTCOMES: severity of ulceration, health-related quality of life, adverse events. Blind evaluation of the response variable. RESULTS: Complete healing: in crepe group, 25, 67.5% (95% CI 50.2-81.9) and in double layer group, 32, 57.1% (95% CI 43.2-70.3). No evidence of a difference in both groups, RR=1.10 (95% CI 0.864-1.424). The basal severity of the ulcers is associated with the healing time. HR=0.86 (95% CI 0.78-0.94). Our data showed a significant improvement in health-related quality of life, total and in the of cosmesis and emotional dimensions. No evidence of a difference in both groups. We didn't find serious adverse events in any of the groups. CONCLUSIONS: We didn't find significant differences in the healing between the two bandages evaluated. Both are appropriate for ulcer healing and to improve the health-related quality of life.

Benefit of an electronic medical record-based alarm in the optimization of stress ulcer prophylaxis.

BACKGROUND: The use of stress ulcer prophylaxis (SUP) has risen in recent years, even in patients without a clear indication for therapy. AIM: To evaluate the efficacy of an electronic medical record (EMR)-based alarm to improve appropriate SUP use in hospitalized patients. METHODS: We conducted an uncontrolled before-after study comparing SUP prescription in intensive care unit (ICU) patients and non-ICU patients, before and after the implementation of an EMR-based alarm that provided the correct indications for SUP. RESULTS: 1627 patients in the pre-intervention and 1513 patients in the post-intervention cohorts were included. The EMR-based alarm improved appropriate (49.6% vs. 66.6%, p<0.001) and reduced inappropriate SUP use (50.4% vs. 33.3%, p<0.001) in ICU patients only. These differences were related to the optimization of SUP in low risk patients. There was no difference in overt gastrointestinal bleeding between the two cohorts. Unjustified costs related to SUP were reduced by a third after EMR-based alarm use. CONCLUSIONS: The use of an EMR-based alarm improved appropriate and reduced inappropriate use of SUP in ICU patients. This benefit was limited to optimization in low risk patients and associated with a decrease in SUP costs.

Curación de úlceras venosas crónicas inducida con un hidrogel de aloe vera, sorbitol, alantoína y glicerol.

OBJETIVO: Evaluar la eficacia de un hidrogel compuesto con aloe vera, sorbitol, alantoína y glicerol, y estudiar clínicamente los niveles de interleucina 6 (IL-6) para el tratamiento de úlceras venosas (UV). MÉTODO: Se realizó un ensayo clínico no aleatorizado de un solo brazo en 10 sujetos. Cada sujeto fue tratado con el hidrogel durante ocho semanas. Tras completar el período de seguimiento, se realizó una evaluación final de las puntuaciones clínicas y moleculares de cada paciente, que se comparó con los datos iniciales. RESULTADOS: Los pacientes tratados con el hidrogel presentaron una reducción media del área de la UV de -1,12 cm5 (±2,53), reducción media del volumen de -1,47 cm6 (±3,43) y valor medio de IL-6 perilesional de -1,81 pg/mL (±8,07). También, se encontró una reducción media de la puntuación de la gravedad clínica venosa (VCSSr) de -9,3 (±2,62) y de la puntuación del dolor en la escala visual analógica (VAS) de -5,5 (±2,22). CONCLUSIÓN: La IL-6 es un indicador molecular útil para la vigilancia de la cicatrización de heridas. El tratamiento con un hidrogel a base de aloe vera, sorbitol y alantoína favorece la cicatrización de la herida, mejora la calidad de vida y reduce los niveles de dolor de la UV. CONFLICTO DE INTERÉS: El investigador principal, Dr Jorge Ulloa, declara recepción de recursos para investigación por parte de Humany Care. Este proyecto fue financiado por Humany Care.

Curación de úlceras venosas crónicas inducida con un hidrogel de aloe vera, sorbitol, alantoína y glicerol.

OBJETIVO: Evaluar la eficacia de un hidrogel compuesto con aloe vera, sorbitol, alantoína y glicerol, y estudiar clínicamente los niveles de interleucina 6 (IL-6) para el tratamiento de úlceras venosas (UV). MÉTODO: Se realizó un ensayo clínico no aleatorizado de un solo brazo en 10 sujetos. Cada sujeto fue tratado con el hidrogel durante ocho semanas. Tras completar el período de seguimiento, se realizó una evaluación final de las puntuaciones clínicas y moleculares de cada paciente, que se comparó con los datos iniciales. RESULTADOS: Los pacientes tratados con el hidrogel presentaron una reducción media del área de la UV de -1,12 cm5 (±2,53), reducción media del volumen de -1,47 cm6 (±3,43) y valor medio de IL-6 perilesional de -1,81 pg/mL (±8,07). También, se encontró una reducción media de la puntuación de la gravedad clínica venosa (VCSSr) de -9,3 (±2,62) y de la puntuación del dolor en la escala visual analógica (VAS) de -5,5 (±2,22). CONCLUSIÓN: La IL-6 es un indicador molecular útil para la vigilancia de la cicatrización de heridas. El tratamiento con un hidrogel a base de aloe vera, sorbitol y alantoína favorece la cicatrización de la herida, mejora la calidad de vida y reduce los niveles de dolor de la UV. CONFLICTO DE INTERÉS: El investigador principal, Dr Jorge Ulloa, declara recepción de recursos para investigación por parte de Humany Care. Este proyecto fue financiado por Humany Care.

Clinical outcomes of Ghanaian Buruli ulcer patients who defaulted from antimicrobial therapy.

OBJECTIVES: Buruli ulcer (BU) is a tropical skin disease caused by infection with Mycobacterium ulcerans, which is currently treated with 8 weeks of streptomycin and rifampicin. The evidence to treat BU for a duration of 8 weeks is limited; a recent retrospective study from Australia suggested that a shorter course of antimicrobial therapy might be equally effective. We studied the outcomes of BU in a cohort of Ghanaian patients who defaulted from treatment and as such received less than 8 weeks of antimicrobial therapy. METHODS: A number of days of antimicrobial therapy and patient and lesion characteristics were recorded from charts from a cohort of BU patients treated at Nkawie-Toase hospital between 2008 and 2012. Patients who defaulted from treatment were retrieved, and lesion characteristics and functional limitations were recorded. RESULTS: About 54% of patients defaulted from therapy or wound care. Forty-seven defaulters with follow-up completed had received <56 days of antibiotics. 84% of these patients healed after 32 days or less of antibiotics. There appeared to be an increased rate of healing in smaller lesions; 94% of WHO category I lesions had healed after 32 days or less of antibiotics. CONCLUSION: Although numbers were small, and a potential for bias exists, our findings suggest that a reduction in the duration of antimicrobial therapy in BU in small, early lesions is feasible. These findings can serve as a basis for future well-designed studies.

Advances in gastrointestinal bleeding. / Avances en hemorragia gastrointestinal.

The main innovations of the latest meeting of the Gastroenterological Association (2016) concerning upper gastrointestinal bleeding from the clinician's perspective can be summarised as follows: a) The Glasgow-Blatchford scale has the best accuracy in predicting the need for surgical intervention and hospital mortality; b) Prognostic scales for non-variceal upper gastrointestinal bleeding are also useful for lower gastrointestinal bleeding; c) Preliminary data suggest that treatment with hemospray does not seem to be superior to current standard treatment in controlling active peptic ulcer bleeding; d) Either famotidine or a proton pump inhibitor may be effective in preventing haemorrhagic recurrence in patients taking aspirin, but this finding needs to be confirmed in further studies; e) There was confirmation of the need to re-introduce antiplatelet therapy as early as possible in patients with antiplatelet-associated gastrointestinal bleeding in order to prevent cardiovascular mortality; f) Routine clinical practice suggests that gastrointestinal or cardiovascular complications with celecoxib or traditional NSAIDs are very low; g) Dabigatran is associated with an increased incidence of gastrointestinal bleeding compared with apixaban or warfarin. At least half of the episodes are located in the lower gastrointestinal tract; h) Implant devices for external ventricular circulatory support are associated with early gastrointestinal bleeding in up to one third of patients; the bleeding is often secondary to arteriovenous malformations.

[The adapting of a care plan after Kennedy terminal ulcer diagnosis]. / Adecuación del plan de cuidados ante el diagnóstico de úlcera terminal de Kennedy.

A 69 year old man was admitted to the Intensive Care Unit (ICU) from the Emergency Department due to severe respiratory failure. Due to unsuccessful non-invasive mechanical ventilation, endotracheal intubation was performed. A category I ulcer in coccyx was detected 48h after admission. Eight hours later, a double erythema (the second one darker than the first one) with displacement between 30-45° over the bony prominence suggested there was a deep tissue injury. The lesion progressed rapidly during the next 24h. The shape and the rapid evolution of the injury lead us to diagnose a Kennedy terminal ulcer (KTU). At 72h after the admission, and once the causes of acute decompensation were ruled out, limitation of life-sustaining treatment was decided. An individualised plan of care was drawn up with the aim of identifying problems in a patient with KTU evolving from a critical to a terminal situation. Our overall objectives (NOC) were to adapt the care plan based on a realistic approach. Nursing interventions (NIC) included actions such as pain management, conservative treatment of the injury, agony care and support to help the family to make decisions. CONCLUSION: The diagnosis of KTU helped the health care team in the decision-making process when they considered limiting the life support, as well as in the adapting of the care plan to the actual situation.

[Gastrointestinal bleeding]. / Hemorragia gastrointestinal.

In the Digestive Disease Week in 2015 there have been some new contributions in the field of gastrointestinal bleeding that deserve to be highlighted. Treatment of celecoxib with a proton pump inhibitor is safer than treatment with nonselective NSAID and a proton pump inhibitor in high risk gastrointestinal and cardiovascular patients who mostly also take acetylsalicylic acid. Several studies confirm the need to restart the antiplatelet or anticoagulant therapy at an early stage after a gastrointestinal hemorrhage. The need for urgent endoscopy before 6-12 h after the onset of upper gastrointestinal bleeding episode may be beneficial in patients with hemodynamic instability and high risk for comorbidity. It is confirmed that in Western but not in Japanese populations, gastrointestinal bleeding episodes admitted to hospital during weekend days are associated with a worse prognosis associated with delays in the clinical management of the events. The strategy of a restrictive policy on blood transfusions during an upper GI bleeding event has been challenged. Several studies have shown the benefit of identifying the bleeding vessel in non varicose underlying gastric lesions by Doppler ultrasound which allows direct endoscopic therapy in the patient with upper GI bleeding. Finally, it has been reported that lower gastrointestinal bleeding diverticula band ligation or hemoclipping are both safe and have the same long-term outcomes.

Management of BU-HIV co-infection.

BACKGROUND: Buruli Ulcer (BU)-HIV co-infection is an important emerging management challenge for BU disease. Limited by paucity of scientific studies, guidance for management of this co-infection has been lacking. METHODS: Initiated by WHO, a panel of experts in BU and HIV management developed guidance principles for the management of BU-HIV co-infection based on review of available scientific evidence, current treatment experience, and global recommendations established for management of HIV infection and tuberculosis. RESULTS: The expert panel agreed that all BU patients should be offered quality provider-initiated HIV testing and counselling. In areas with high prevalence of malaria and/or bacterial infections, all patients with HIV co-infection should be started on cotrimoxazole preventative therapy. Combination antibiotic treatment for BU should be commenced before starting antiretroviral therapy (ART) and provided for 8 weeks duration. The suggested combination is rifampicin (10 mg/kg daily up to a maximum of 600 mg/day) plus streptomycin (15 mg/kg daily). An alternative regimen is rifampicin plus clarithromycin (7.5 mg/kg twice daily up to a maximum of 1000 mg daily) although due to drug interactions with antiretroviral drugs this regimen should be used with caution. ART should be initiated in all BU-HIV co-infected patients with symptomatic HIV disease (WHO clinical stage 3 or 4) regardless of CD4 cell count and in asymptomatic individuals with CD4 count ≤500 cells/mm(3) . If CD4 count is not available, BU-HIV co-infected individuals with category 2 or 3 BU disease should be offered ART. For eligible individuals, ART should be commenced as soon as possible within 8 weeks after commencing BU treatment, and as a priority in those with advanced HIV disease (CD4 ≤ 350 cells/mm(3) or WHO stage 3 or 4 disease). All co-infected patients should be actively screened for tuberculosis before commencing BU treatment and before starting ART. Programmes should implement a monitoring and reporting system to document the outcomes of BU-HIV interventions. CONCLUSIONS: Knowledge of the clinical and epidemiological interactions between BU and HIV disease is limited. While awaiting more urgently needed evidence, current management practice of both diseases has been useful to build simple 'common sense' preliminary guidance on how to manage BU-HIV co-infection.

[Diseases linked to Helicobacter pylori infection]. / Enfermedades relacionadas con la infección por Helicobacter pylori.

Below is a summary of the main conclusions that came from reports presented at this year's Digestive Disease Week (2014) relating to Helicobacter pylori infection. Despite the undeniable decline of the infection's frequency, in the near future, developed countries--or at least some sub-populations--will continue to have a significant prevalence of the infection. Clarithromycin, metronidazole and quinolone resistance rates are considerably high in most countries and these rates are on the rise. The eradication of H. pylori improves symptoms of functional dyspepsia, although only in a minority of patients; adding antidepressants to eradication therapy could improve long-term response. In patients who were admitted with gastrointestinal bleeding from peptic ulcers, it is necessary to thoroughly study the presence of H. pylori infection and administer eradication therapy as early as possible. Eradication of H. pylori in patients undergoing endoscopic resection of early-stage gastric cancer reduces incidence of metachronous tumors. We have some diagnostic innovations, such as carrying out various techniques--a rapid urease test, culture or PCR--based on gastric samples obtained by scraping the mucosa. The effectiveness of conventional triple therapy is clearly insufficient and continues to decline. The superiority of sequential therapy over conventional triple therapies has not been definitively established. Concomitant therapy is simpler and more effective than sequential therapy. Optimized concomitant therapy (with high doses of proton-pump inhibitors [PPI] and over 14 days) is highly effective, more so than standard concomitant therapy. For patients who are allergic to penicillin, 2 treatment options were essentially described: PPI-clarithromycin-metronidazole (clarithromycin-sensitive strains) and quadruple therapy with bismuth (when the bacterial sensitivity is unknown). If conventional triple therapy fails, second-line therapy with levofloxacin is effective and is also easier and better tolerated than quadruple therapy with bismuth. Triple therapy with levofloxacin is also a promising alternative if sequential or concomitant therapy fails. New-generation quinolones, such as moxifloxacin, could be useful as part of rescue eradication therapy. Even after 3 eradication therapies have failed, a fourth empirical rescue therapy (with rifabutin) could be effective. The eradication of H. pylori can finally be obtained in the vast majority of patients by using a rescue strategy of up to 4 consecutive empirical therapies, without conducting bacterial cultures.

[Safe prescription recommendations for non steroidal anti-inflammatory drugs: Consensus document ellaborated by nominated experts of three scientific associations (SER-SEC-AEG)]. / Recomendaciones para una prescripción segura de antiinflamatorios no esteroideos: documento de consenso elaborado por expertos nominados por 3 sociedades científicas (SER-SEC-AEG).

This article outlines key recommendations for the appropriate prescription of non steroidal anti-inflammatory drugs to patients with different musculoskeletal problems. These recommendations are based on current scientific evidence, and takes into consideration gastrointestinal and cardiovascular safety issues. The recommendations have been agreed on by experts from three scientific societies (Spanish Society of Rheumatology [SER], Spanish Association of Gastroenterology [AEG] and Spanish Society of Cardiology [SEC]), following a two-round Delphi methodology. Areas that have been taken into account encompass: efficiency, cardiovascular risk, gastrointestinal risk, liver risk, renal risk, inflammatory bowel disease, anemia, post-operative pain, and prevention strategies. We propose a patient management algorithm that summarizes the main aspects of the recommendations.

[Correlation between body mass index and development of pressure ulcers in intensive care medicine]. / Relación entre el índice de masa corporal y el desarrollo de úlcera por presión en Medicina Intensiva.

OBJECTIVES: This study aims to evaluate the association between body mass index (BMI), incidence and severity of pressure ulcers (PU) in patients admitted to the Intensive Care Unit (ICU), and describe the differential prognosis of patients with PU and factors that modify it. MATERIAL AND METHODS: Case-control study with observation period of 15 months. We collected baseline variables, prognostic scales, therapies and clinical outcome. Univariate analysis was performed for each outcome variable between cases and controls using the appropriate hypothesis test depending on the nature of the variables. ROC curve for BMI and PU. Logistic regression with PU as dependent variable and the covariates that reached p<0.05 in the bivariate analysis. Correlation using Pearson or Spearman was made between BMI, albumin, days to diagnosis of UPP, immobilization, and PU degree. Significance level at p <0.05. RESULTS: 77 patients developed PU and 231 controls were chosen. The cases had higher APACHE II (p=0.043) and SAPS 3 (p=0.023), length of stay in ICU and mechanical ventilation (p<0.001). BMI≥40 was associated with UPP (p=0.024 OR=3.23 CI95% 1.17-8.93). There was a significant association between PU degree, length of stay and MV (p<0,001), but not with immobilization, dynamic support surface and death rate. Multivariate analysis found association between PU, length of MV (p=0.013, OR 1.08, CI95% 1.01-1.16) and kidney replacement therapy (p=0.013, OR 3.55 CI95% 1.31-9.64), with BMI≥40 as a confounding factor. CONCLUSIONS: Length of mechanical ventilation and renal replacement therapy are risk factors for pressure ulcer development, and BMI≥40 acts as a confounding factor. PU development and its maximum degree are not associated with a worse prognosis.