Simplified risk-prediction for benchmarking and quality improvement in emergency general surgery. Prospective, multicenter, observational cohort study.

BACKGROUND AND AIMS: Emergency General Surgery (EGS) conditions account for millions of deaths worldwide, yet it is practiced without benchmarking-based quality improvement programs. The aim of this observational, prospective, multicenter, nationwide study was to determine the best benchmark cutoff points in EGS, as a reference to guide improvement measures. METHODS: Over a 6-month period, 38 centers (5% of all public hospitals) attending EGS patients on a 24-h, 7-days a week basis, enrolled consecutive patients requiring an emergent/urgent surgical procedure. Patients were stratified into cohorts of low (i.e., expected morbidity risk <33%), middle and high risk using the novel m-LUCENTUM calculator. RESULTS: A total of 7258 patients were included; age (mean ± SD) was 51.1 ± 21.5 years, 43.2% were female. Benchmark cutoffs in the low-risk cohort (5639 patients, 77.7% of total) were: use of laparoscopy ≥40.9%, length of hospital stays ≤3 days, any complication within 30 days ≤ 17.7%, and 30-day mortality ≤1.1%. The variables with the greatest impact were septicemia on length of hospital stay (21 days; adjusted beta coefficient 16.8; 95% CI: 15.3 to 18.3; P < .001), and respiratory failure on mortality (risk-adjusted population attributable fraction 44.6%, 95% CI 29.6 to 59.6, P < .001). Use of laparoscopy (odds ratio 0.764, 95% CI 0.678 to 0.861; P < .001), and intraoperative blood loss (101-500 mL: odds ratio 2.699, 95% CI 2.152 to 3.380; P < .001; and 500-1000 mL: odds ratio 2.875, 95% CI 1.403 to 5.858; P = .013) were associated with increased morbidity. CONCLUSIONS: This study offers, for the first time, clinically-based benchmark values in EGS and identifies measures for improvement.

MACVIA-LR (Fighting Chronic Diseases for Active and Healthy Ageing in Languedoc-Roussillon): A Success Story of the European Innovation Partnership on Active and Healthy Ageing.

The Région Languedoc Roussillon is the umbrella organisation for an interconnected and integrated project on active and healthy ageing (AHA). It covers the 3 pillars of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA): (A) Prevention and health promotion, (B) Care and cure, (C) and (D) Active and independent living of elderly people. All sub-activities (poly-pharmacy, falls prevention initiative, prevention of frailty, chronic respiratory diseases, chronic diseases with multimorbidities, chronic infectious diseases, active and independent living and disability) have been included in MACVIA-LR which has a strong political commitment and involves all stakeholders (public, private, patients, policy makers) including CARSAT-LR and the Eurobiomed cluster. It is a Reference Site of the EIP on AHA. The framework of MACVIA-LR has the vision that the prevention and management of chronic diseases is essential for the promotion of AHA and for the reduction of handicap. The main objectives of MACVIA-LR are: (i) to develop innovative solutions for a network of Living labs in order to reduce avoidable hospitalisations and loss of autonomy while improving quality of life, (ii) to disseminate the innovation. The three years of MACVIA-LR activities are reported in this paper.

Combining balneotherapy and health promotion to promote active and healthy ageing: the Balaruc-MACVIA-LR® approach.

Scaling up and replication of successful innovative integrated care models for chronic diseases is one of the targets of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA). MACVIA-LR® (MAladies Chroniques pour un VIeillissement Actif en Languedoc-Roussillon) is a Reference Site of the EIP on AHA. The main objective of MACVIA-LR® is to develop innovative solutions in order to (1) improve the care of patients affected by chronic diseases, (2) reduce avoidable hospitalization and (3) scale up the innovation to regions of Europe. The MACVIA-LR® project also aims to assess all possible aspects of medicine-including non-pharmacologic approaches-in order to maintain health and prevent chronic diseases. These approaches include hydrotherapy and balneotherapy which can be of great importance if health promotion strategies are considered. Balneotherapy at Balaruc-les-Bains focusses on musculoskeletal diseases and chronic venous insufficiency of the lower limbs. Each year, over 46,000 people attend an 18-day course related to a new falls prevention initiative combining balneotherapy and education. On arrival, each person receives a flyer providing information on the risk of fall and, depending on this risk, a course is proposed combining education and physical activity. A pilot study assesses the impact of the course 6 and 12 months later. This health promotion strategy for active and healthy ageing follows the FEMTEC (World Federation of Hydrotherapy and Climatotherapy) concept.

Procedural pain and anxiety in pediatric patients in a Mexican dental clinic.

BACKGROUND: In dental examining rooms, children experience diagnostic and therapeutic pain related to dental procedures that may be associated with anxiety. Therefore, the main objective of the present study was to evaluate anxiety and pain levels related to dental procedures in children. METHODS: Children in a Mexican pediatric dental clinic rated their dental anxiety using the Modified Dental Anxiety Scale (MDAS), the Children's Fear Survey Schedule Dental Subscale (CFSS-DS) and a 100-mm Visual Analogue Scale (VAS). Pain was evaluated with the VAS. RESULTS: A total of 437 children with a mean age of 9.8 (±2.2) years were evaluated. Four hundred eighty-one dental procedures were completed. The averages in the MDAS and the CFSS-DS were 8.5 (±3.4) and 22.7 (±7.6), respectively. Of all dental procedures, 275 (57.2 %) were rated as stressful prior to their realization, 222 (46.2 %) were stressful during their realization and 175 (36.4 %) were rated as painful. Overall, 12.6 % of the painful events were rated as severe, 25.1 % were rated as moderate, and 62.3 % were rated as slight. CONCLUSION: This study provides data on common procedures performed in dental clinics that cause pain and anxiety in children and young adolescents. Dentistry must consider the best non-pharmacological and pharmacological interventions to reduce dental anxiety and pain.

Effect of different treatments on the ability of α-lactalbumin to form nanoparticles.

Nanoparticles of bovine α-lactalbumin (α-LA) prepared by desolvation and glutaraldehyde crosslinking are promising carriers for bioactive compounds in foods. The objective of this work was to study the effect of changes in hydrophobic interactions by using different desolvating agents (acetone, ethanol, or isopropanol) and the use of a heat or high-pressure treatment step before the desolvation process on the size, structure, and properties of α-LA nanoparticles. In all cases, a high average particle yield of 99.63% was obtained. Smaller sizes (152.3 nm) can be obtained with the use of acetone as the desolvating agent and without any pretreatment. This is the first time that α-LA nanoparticles in the size range of 100 to 200 nm have been obtained. These nanoparticles, with an isoelectric point of 3.61, are very stable at pH values >4.8, based on their ζ-potential, although their antioxidant activity is weak. The use of the desolvating agent with the smallest polarity index (isopropanol) produced the largest particles (293.4 to 324.9 nm) in all cases. These results support the idea that controlling hydrophobic interactions is a means to control the size of α-LA nanoparticles. No effect of pretreatment on nanoparticle size could be detected. All types of nanoparticles were easily degraded by the proteolytic enzymes assayed.

Study of the inactivation of Escherichia coli and pectin methylesterase in mango nectar under selected high hydrostatic pressure treatments.

High hydrostatic pressure (HHP) was applied to fresh mango nectar (FMN) and sterilized mango nectar (SMN) to inactivate Escherichia coli and pectin methylesterase (PME). Pressure was applied at 275, 345 and 414 MPa. The come-up time (CUT) as well as 1, 2 and 4 min of treatment times were applied at the selected pressure to evaluate the inactivation effect on E. coli and PME. Total plate counts (TPC) were also evaluated in FMN. Results showed that mesophiles are inactivated in FMN to an important degree (up to 4 log) only with the CUT; the highest inactivation for mesophiles (7 log) was reported at 414 MPa after 4 min. Meanwhile, for E. coli 345 and 414 MPa after 2 and 1 min, respectively, were able to inactivate all viable cells in FMN. However, in SMN after 4 min at 275 MPa all cells of E. coli were also inactivated, showing the protective effect of the media between FMN and SMN. The PME showed its resistance to be inactivated with high pressure, showing the highest decrease in enzymatic activity (45%) after 4 min at 345 MPa but with an important activation at the highest pressure (414 MPa).

Effects of high hydrostatic pressure on the structure of bovine alpha-lactalbumin.

The effects of high hydrostatic pressure (HHP) processing (at 200 to 600 MPa, 25 to 55 degrees C, and from 5 to 15 min) on some structural properties of alpha-lactalbumin was studied in a pH range of 3.0 to 9.0. The range of HHP processes produced a variety of molten globules with differences in their surface hydrophobicity and secondary and tertiary structures. At pH values of 3 and 5, there was a decrease in the alpha-helix content concomitant with an increase in beta-strand content as the pressure increased. No changes in molecular size due to HHP-induced aggregation were detected by sodium dodecyl sulfate-PAGE. All samples showed higher thermostability as the severity of the treatment increased, indicating the formation of a less labile structure related to the HHP treatment.

Microstructure of fat globules in whole milk after thermosonication treatment.

The structure of fat globules in whole milk was studied after heat and thermosonication treatments to observe what happens during these processes at the microscopic level using scanning electron microscopy. Raw whole milk was thermosonicated in an ultrasonic processor-Hielscher UP400S (400 W, 24 kHz, 120 microm amplitude), using a 22-mm probe at 63 degrees C for 30 min. Heat treatment involved heating the milk at 63 degrees C for 30 min. Color and fat content were measured to correlate the images with analytical measurements. The results showed that the surface of the fat globule was completely roughened after thermosonication. Ultrasound waves were responsible for disintegrating the milk fat globule membrane (MFGM) by releasing the triacylglycerols. Furthermore, the overall structure of milk after sonication showed smaller fat globules (smaller than 1 microm) and a granular surface. This was due to the interaction between the disrupted MFGM and some casein micelles. Minor changes in the aspect of the globules between thermal and raw milks were detected. Color measurements showed higher L* values for sonicated samples. Sonicated milk was whiter (92.37 +/- 0.20) and generally showed a better degree of luminosity and homogenization compared to thermal treated milk (88.25 +/- 0.67) and raw milk (87.82 +/- 0.18). Fat content analysis yielded a higher value after sonication (4.24%) compared to untreated raw milk (4.04%) because fat extraction is more efficient after sonication. The advantages of thermosonicated milk are that it can be pasteurized and homogenized in just 1 step, it can be produced with important cost savings, and it has better characteristics, making thermosonication a potential processing method for milk and most other dairy products.

Edible coatings for fresh-cut fruits.

The production of fresh-cut fruits is increasingly becoming an important task as consumers are more aware of the importance of healthy eating habits, and have less time for food preparation. A fresh-cut fruit is a fruit that has been physically altered from its original state (trimmed, peeled, washed and/or cut), but remains in a fresh state. Unfortunately since fruits have living tissue, they undergo enzymatic browning, texture decay, microbial contamination, and undesirable volatile production, highly reducing their shelf life if they are in any way wounded. Edible coatings can be used to help in the preservation of minimally processed fruits, providing a partial barrier to moisture, oxygen and carbon dioxide, improving mechanical handling properties, carrying additives, avoiding volatiles loss, and even contributing to the production of aroma volatiles.

Quality and safety aspects of PEF application in milk and milk products.

The articles published to date on the possibilities of applying the new PEF technology to milk and milk products are summarized in a review that presents them in chronological order and grouped on the basis of the factor studied (microorganism, enzyme, quality parameter, or shelf-life). An accompanying table shows details of the equipment and process corresponding to each article in chronological order.

Síndrome de intestino corto en adultos. Tratamiento nutricional / The short bowel syndrome in adults. Nutritional treatment

El síndrome de intestino corto es un cuadro clínico caracterizado por hipoabsorción grave que aparece fundamentalmente tras resecciones intestinales extensas. Como complicaciones fundamentales, produce diarrea, desnutrición, pérdida de peso, deshidratación y déficit de electrolitos, vitaminas y oligoelementos. En el intestino se producen cambios adaptativos para aumentar la absorción de nutrientes. Mientras tanto, los enfermos precisarán un soporte nutricional adecuado, inicialmente con nutrición parenteral total, y algunos la necesitarán toda la vida. Los avances en el campo de la nutrición han mejorado el pronóstico de estos pacientes. Se están estudiando también diversas técnicas quirúrgicas. La más desarrollada es el trasplante intestinal, aunque, debido a su alta morbimortalidad, todavía está indicado sólo en los pacientes con síndrome de intestino corto que precisen mantenerse con nutrición parenteral domiciliaria y hayan desarrollado complicaciones importantes relacionadas con ésta o con el fallo intestinal (AU)

Pectin methyl esterase and natural microflora of fresh mixed orange and carrot juice treated with pulsed electric fields.

The effects of pulsed electric fields (PEFs) on pectin methyl esterase (PME), molds and yeast, and total flora in fresh (nonpasteurized) mixed orange and carrot juice were studied. The PEF effect was more extensive when juices with high levels of initial PME activity were subjected to treatment and when PEF treatment (at 25 kV/cm for 340 micros) was combined with a moderate temperature (63 degrees C), with the maximum level of PME inactivation being 81.4%. These conditions produced 3.7 decimal reductions in molds and yeast and 2.4 decimal reductions in total flora. Experimental inactivation data for PME, molds and yeast, and total flora were fitted to Bigelow, Hülsheger, and Weibull inactivation models by nonlinear regression. The best fit (lowest mean square error) was obtained with the Weibull model.

Weibull distribution function based on an empirical mathematical model for inactivation of Escherichia coli by pulsed electric fields.

The pulsed electric field inactivation kinetics of Escherichia coli suspended in orange juices with three different concentrations of carrot juice (0, 20, and 60%) was studied. Electric field strengths ranged from 25 to 40 kV/cm, and treatment times ranged from 40 to 340 micros. Experimental data were fitted to Bigelow, Hülsheger, and Weibull distribution functions, and the Weibull function provided the best fit (with the lowest mean square error). The dependency of each model's kinetic constant on electric field strength and carrot juice concentration was studied. A secondary model was developed to describe the relationship of Weibull parameters a and n to electric field strength and carrot juice concentration. An empirical mathematical model based on the Weibull distribution function, relating the natural logarithm of the survival fraction to treatment time, electric field strength, and carrot juice concentration, was developed. Parameters were estimated by a nonlinear regression. The results of this study indicate that the error rate for the model's predictions was 6.5% and that the model was suitable for describing E. coli inactivation.

Low-fat set yogurt made from milk subjected to combinations of high hydrostatic pressure and thermal processing.

The combined use of high hydrostatic pressure (300 to 676 MPa, 5 min) and thermal treatment (85 degrees C, 30 min) in milk for the manufacture of low-fat yogurt was studied. The objective was to reduce syneresis and improve the rheological properties of yogurt, reducing the need for thickeners and stabilizers. The use of high hydrostatic pressure alone, or after thermal treatment, reduced the lightness and increased the viscosity of skim milk. However, milk recovered its initial lightness and viscosity when thermal treatment was applied after high hydrostatic pressure. The MALDI-TOF spectra of skim milk presented monomers of whey proteins after a treatment of 676 MPa for 5 min. Yogurts made from skim milk subjected to 400 to 500 MPa and thermal treatment showed increased yield stress, resistance to normal penetration, and elastic modulus, while having reduced syneresis when compared to yogurts from thermally treated or raw milks. The combined use of thermal treatment and high hydrostatic pressure assures extensive whey protein denaturation and casein micelle disruption, respectively. Although reaggregation of casein submicelles occurs during fermentation, the net effect of the combined HHP and thermal treatment is the improvement of yogurt yield stress and reduction of syneresis.

Reduction of protease activity in milk by continuous flow high-intensity pulsed electric field treatments.

High-intensity pulsed electric field (HIPEF) is a non-thermal food processing technology that is currently being investigated to inactivate microorganisms and certain enzymes, involving a limited increase of food temperature. Promising results have been obtained on the inactivation of microbial enzymes in milk when suspended in simulated milk ultrafiltrate. The aim of this study was to evaluate the effectiveness of continuous HIPEF equipment on inactivating a protease from Bacillus subtilis inoculated in milk. Samples were subjected to HIPEF treatments of up to 866 micros of squared wave pulses at field strengths from 19.7 to 35.5 kV/cm, using a treatment chamber that consisted of eight colinear chambers connected in series. Moreover, the effects of different parameters such as pulse width (4 and 7 micros), pulse repetition rates (67, 89, and 111 Hz), and milk composition (skim and whole milk) were tested. Protease activity decreased with increased treatment time or field strength and pulse repetition rate. Regarding pulse width, no differences were observed between 4 and 7 micros pulses when total treatment time was considered. On the other hand, it was observed that milk composition affected the results since higher inactivation levels were reached in skim than in whole milk. The maximum inactivation (81%) was attained in skim milk after an 866-micros treatment at 35.5 kV/cm and 111 Hz.

Kinetic model for the inactivation of Lactobacillus plantarum by pulsed electric fields.

The kinetics of Lactobacillus plantarum inactivation by pulsed electric fields (PEF) was studied in two different growth stages (exponential and stationary), but in the same reference medium (0.6% peptone water). Electric field intensity and treatment time varied from 20 to 28 kV/cm and 30 to 240 micros, respectively. The experimental data showed that cells in the exponential growth stage were more sensitive to PEF treatment than those in the stationary stage. The inactivation data were adjusted to the Bigelow and Hülsheger models and the Weibull frequency distribution function, and constants were calculated for both growth stages in each model. The models were tested and their accuracy was assessed by using the Accuracy Factor. According to this parameter, the Weibull frequency distribution function gave better fittings for the inactivation by PEF than Bigelow or Hülsheger models. On the other hand, the Bigelow model gave a good accuracy factor and is simpler.

Food processing by high hydrostatic pressure.

The use of high hydrostatic pressures (HHP) for food processing is finding increased application within the food industry. One of the advantages of this technology is that because it does not use heat, sensory, and nutritional attributes of the product remain virtually unaffected, thus yielding products with better quality than those processed traditional methods. HHP have the ability to inactivate microorganisms as well as enzymes responsible for shortening the life of a product. In addition to lengthening the shelf-life of food products, HHP can modify functional properties of components such as proteins, which in turn can lead to the development of new products. Equipment for large-scale production of HHP processed products are commercially available nowadays. Guacamole, sliced ham, oysters, and fruit juices are some of the products currently available on the market. HHP technology is one of the most promising nonthermal processes.

Effects of high intensity pulsed electric field and thermal treatments on a lipase from Pseudomonas fluorescens.

Milk and dairy products may contain microorganisms capable of secreting lipases that cause sensory defects and technological problems in the dairy industry. In this study, the effects of thermal and high-intensity pulsed electric field (HIPEF) treatments on an extracellular lipase from Pseudomonas fluorescens, suspended in a simulated skim milk ultrafiltrate (SMUF) have been evaluated. Heat treatments applied were up to 30 min from 50 to 90 degrees C. HIPEF treatments were carried out using pilot plant facilities in a batch or continuous flow mode, where treatment chambers consisted of parallel and coaxial configuration, respectively. Samples were subjected to up to 80 pulses at electric field intensities ranging from 16.4 to 37.3 kV/cm. This resulted in a lipase that was quite resistant to heat and also to HIPEF. High (75 degrees C-15 s) and low pasteurization treatments (63 degrees C-30 min) led to inactivations of 5 and 20%, respectively. Using the batch-mode HIPEF equipment, a 62.1% maximum activity depletion was achieved after 80 pulses at 27.4 kV/cm. However, when HIPEF treatments were applied in the continuous flow mode, an inactivation rate of just 13% was achieved, after applying 80 pulses at 37.3 kV/cm and 3.5 Hz. The results of both heat and HIPEF treatments on enzyme inactivation were adjusted with good agreement to a first-order kinetic model (R2 > 62.3%).

Study of inactivation of Lactobacillus plantarum in orange-carrot juice by means of pulsed electric fields: comparison of inactivation kinetics models.

The inactivation kinetics of Lactobacillus plantarum was studied in orange-carrot juice using high intensity pulsed electric fields. The results indicated that under the treatment conditions applied, 28.6, 32.0, and 35.8 kV/cm and treatment times ranging from 10.2 to 46.3 micros, the inactivation of L. plantarum obtained was up to 2.5 decimal reductions. Experimental and literature data were fitted to Bigelow, Hülsheger et al. and Peleg models and to Weibull frequency distribution function. Weibull was the one that best interpreted the data with accuracy factor values closer to 1.