Are the health messages in schoolbooks based on scientific evidence? A descriptive study.

BACKGROUND Most textbooks contains messages relating to health. This profuse information requires analysis with regards to the quality of such information. The objective was to identify the scientific evidence on which the health messages in textbooks are based. METHODS The degree of evidence on which such messages are based was identified and the messages were subsequently classified into three categories: Messages with high, medium or low levels of evidence; Messages with an unknown level of evidence; and Messages with no known evidence. RESULTS 844 messages were studied. Of this total, 61% were classified as messages with an unknown level of evidence. Less than 15% fell into the category where the level of evidence was known and less than 6% were classified as possessing high levels of evidence. More than 70% of the messages relating to "Balanced Diets and Malnutrition", "Food Hygiene", "Tobacco", "Sexual behaviour and AIDS" and "Rest and ergonomics" are based on an unknown level of evidence. "Oral health" registered the highest percentage of messages based on a high level of evidence (37.5%), followed by "Pregnancy and newly born infants" (35%). Of the total, 24.6% are not based on any known evidence. Two of the messages appeared to contravene known evidence. CONCLUSION Many of the messages included in school textbooks are not based on scientific evidence. Standards must be established to facilitate the production of texts that include messages that are based on the best available evidence and which can improve children's health more effectively.

Consensus statement of the European guidelines on clinical management of HIV-1 tropism testing

Introduction: Testing for HIV tropism is recommended before prescribing a chemokine receptor blocker. To date, in most European countries HIV tropism is determined using a phenotypic test. Recently, new data have emerged supporting the use of a genotypic HIV V3-loop sequence analysis as the basis for tropism determination. The European guidelines group on clinical management of HIV-1 tropism testing was established to make recommendations to clinicians and virologists. Methods: We searched online databases for articles from Jan 2006 until March 2010 with the terms: tropism or CCR5-antagonist or CCR5 antagonist or maraviroc or vicriviroc. Additional articles and/or conference abstracts were identified by hand searching. This strategy identified 712 potential articles and 1240 abstracts. All were reviewed and finally 57 papers and 42 abstracts were included and used by the panel to reach a consensus statement. Results: The panel recommends HIV-tropism testing for the following indications: i) drug-naïve patients in whom toxicity or limited therapeutic options are foreseen; ii) patients experiencing therapy failure whenever a treatment change is considered. Both the phenotypic Enhanced Trofile assay (ESTA) and genotypic population sequencing of the V3-loop are recommended for use in clinical practice. Although the panel does not recommend one methodology over another it is anticipated that genotypic testing will be used more frequently because of its greater accessibility, lower cost and shorter turnaround time. The panel also provides guidance on technical aspects and interpretation issues. If using genotypic methods, triplicate PCR amplification and sequencing testing is advised using the G2P interpretation tool (clonal model) with an FPR of 10%. If the viral load is below the level of reliable amplification, proviral DNA can be used, and the panel recommends performing triplicate testing and use of an FPR of 10%. If genotypic DNA testing is not performed in triplicate the FPR should be increased to 20%. Conclusions: The European guidelines on clinical management of HIV-1 tropism testing provide an overview of current literature, evidence-based recommendations for the clinical use of tropism testing and expert guidance on unresolved issues and current developments. Current data support both the use of genotypic population sequencing and ESTA for co-receptor tropism determination. For practical reasons genotypic population sequencing is the preferred method in Europe.

Management of bleeding following major trauma: a European guideline

INTRODUCTION Evidence-based recommendations can be made with respect to many aspects of the acute management of the bleeding trauma patient, which when implemented may lead to improved patient outcomes. METHODS The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing guidelines for the management of bleeding following severe injury. Recommendations were formulated using a nominal group process and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) hierarchy of evidence and were based on a systematic review of published literature. RESULTS Key recommendations include the following: The time elapsed between injury and operation should be minimised for patients in need of urgent surgical bleeding control, and patients presenting with haemorrhagic shock and an identified source of bleeding should undergo immediate surgical bleeding control unless initial resuscitation measures are successful. A damage control surgical approach is essential in the severely injured patient. Pelvic ring disruptions should be closed and stabilised, followed by appropriate angiographic embolisation or surgical bleeding control, including packing. Patients presenting with haemorrhagic shock and an unidentified source of bleeding should undergo immediate further assessment as appropriate using focused sonography, computed tomography, serum lactate, and/or base deficit measurements. This guideline also reviews appropriate physiological targets and suggested use and dosing of blood products, pharmacological agents, and coagulation factor replacement in the bleeding trauma patient. CONCLUSION A multidisciplinary approach to the management of the bleeding trauma patient will help create circumstances in which optimal care can be provided. By their very nature, these guidelines reflect the current state-of-the-art and will need to be updated and revised as important new evidence becomes available.

Guía de práctica clínica para el cuidado de personas que sufren quemaduras

Publicaciones complementarias: Folleto: Guía de prevención y cuidados de las personas con quemaduras. Folleto desplegable: Guía rápida de consulta para el cuidado de personas que sufren quemaduras

New clinical practice guideline on enteral feeding in very low birth wieght infants; second part

INTRODUCTION: The nutrition of very low birth weight (VLBW) infants is aimed at promoting a similar growth to that occurring in the uterus. However, in practice this is difficult to achieve and extrauterine growth restriction is frequent. The current tendency is to avoid this restriction by means of early parenteral and enteral nutrition. Nonetheless, uncertainty about many of the practices related with nutrition has resulted in a great variation in the way it is undertaken. In 2009 and 2011 in our hospital there was an unexpected increase in necrotizing enterocolitis. To check to see wether our nutrition policy was involved, we underlook a systematic review and drewup clinical practice guidelines (CPG) about enteral feeding in VLBW infants. New considerations about the duration of the fortification and the use of probiotics have led to an update of these CPG. METHODS: A total of 21 clinical questions were designed dealing with the type of milk, starting age, mode of administration, rate and volume of the increments, fortification, use of probiotics and protocol. Afete conducting a systematic search of the available evidence, the information was contrasted and summarized in order to draw up the recommendations. The quality of the evidence and the strength of the recommendations were determined from the SIGN scale. COMMENT: These CPG aim to help physicians in their decision making. The protocolized application of wellproven measurements reduces the variation in clinical practice and improves results.

Dapagliflozina

Dapagliflozin is a new oral antidiabetic agent whose mechanism of action increases renal glucose excretion, independently of insulin secretion or insulin action. The efficacy of dapagliflozin is dependent on renal function. The use of dapagliflozin has been licensed to improve glycaemic control in patients with type 2 diabetes mellitus as: - monotherapy when diet and exercise alone do not provide adequate glycaemic control in patients for whom the use of metformin is considered inappropriate due to intolerance. - Add-on combination therapy with other glucose-lowering agents including insulin, when these, together with diet and exercise, do not provide adequate glycaemic control. Funding has been restricted to the use of dapagliflozin, prior approval, as dual therapy in combination with metformin. This report aims to assess the efficacy and safety of dapagliflozin in the treatment of type 2 diabetes mellitus, rate the added therapeutic value of dapagliflozin in type 2 diabetes mellitus and identify its current place in therapy. A systematic literature search was carried out, for the purpose of this evaluation, using PubMed, Embase, Cochrane and IDIS databases as well as other secondary sources of evidence-based medicine, therapeutic bulletins and national and international drug agencies. Following the critical reading and analysis of the selected articles, a summary is made out of the scientific evidence available, using Scottish Intercollegiate Guidelines Network (SIGN) criteria. Only one randomised clinical trial, out of the ten trials found, was considered to be a suitable comparison (versus a dual therapy in combination with the sulfonylurea glipizide in patients inadequately controlled with metformin, diet and exercise). No trials have evaluated variables of relevance to patients, except for safety variables. The main efficacy variable in the trials was the change from baseline in HbA1c, except for a study which evaluated the change from baseline in total body weight as main variable. Baseline characteristics of the patients enrolled in the trials significantly differ from those of the population with diabetes in our society which tend to be of an older age and have a longer history of type 2 diabetes mellitus. The major limitation of dapagliflozin derives from its mechanism of action, since its efficacy decreases as renal function declines. The use of dapagliflozin is not recommended in patients with moderate to severe renal impairment ((CrCl<60ml/min or GFG <60 ml/min/1.73 m2) nor in elderly patients, in which a decrease in renal function can be expected. The assessment of safety includes the incidence and rate of discontinuations due to adverse events, episodes of hypoglycaemia, signs or symptoms of genital and urinary tract infections, dehydration, hypovolaemia and hypotension. Further pharmacoepidemiological studies are to be carried out to clarify the long-term effects of dapagliflozin on renal function and the potential effect in the development of breast and bladder tumours. Dapagliflozin as monotherapy has not been evaluated against adequate comparators (sulfonylureas, pioglitazone, gliptins). In combination therapy with metformin, the efficacy of dapagliflozin was shown to be non-inferior to glipizide plus metformin, resulting in a mean reduction of 0.52% in HbA1c, with a difference of 0.00 among both groups (95% CI: -0.11 a 0.11). There are no comparative data against other second-line treatment options. As shown in the studies, the overall incidence of adverse events with dapagliflozin as monotherapy (21.5%) was similar to that observed with placebo, and greater to that observed with metformin (15.4%). Hypoglycaemia of any type was the adverse event more frequently reported. The incidence of severe hypoglycaemic events observed in most of the studies was low. The overall incidence of adverse events observed in the study that compared dapagliflozin+metformin against glipizide+metformin was similar for both groups (27%) and incidence of hypoglycaemic events with dapagliflozin (3.5%) was significantly lower to that observed with glipizide (40.8%). Reductions of body weight of about 2 to 3 kg and a slight decrease in blood pressure (1 to 5 mmHg) have been observed in all studies in the groups treated with dapagliflozin together with diet and exercise. Dosing scheme (every 24 hours) is similar to other oral antidiabetic agents and its cost is similar to that for gliptines and higher to that for sulfonylureas or generic pioglitazone. Funding has been limited to the use of dapagliflozin as dual therapy regimen in combination with metformin as an option for patients with contraindication or intolerance to sulfonylureas, such a those experiencing frequent hypoglycaemic events, weight loss associated risks, as long as they are under 75 years of age and have no moderate to severe renal impairment. In the light of the above, we consider dapagliflozin means no therapeutic innovation in the therapy of type 2 diabetes mellitus over other therapeutic alternatives available.

New clinical practice guideline on enteral feeding in very low birth weight infants; first part.

The nutrition of very low birth weight (VLBW) infants is aimed at promoting a similar growth to that occurring in the uterus. However, in practice this is difficult to achieve and extrauterine growth restriction is frequent. The current tendency is to avoid this restriction by means of early parenteral and enteral nutrition. Nonetheless, uncertainty about many of the practices related with nutrition has resulted in a great variation in the way it is undertaken. In 2009 and 2011 in our hospital there was an unexpected increase in necrotizing enterocolitis. To check to see whether our nutrition policy was involved, we undertook a systematic review and drew up clinical practice guidelines (CPG) about enteral feeding in VLBW infants. New considerations about the duration of the fortification and the use of probiotics have led to an update of these CPG. METHODS: A total of 21 clinical questions were designed dealing with the type of milk, starting age, mode of administration, rate and volume of the increments, fortification, use of probiotics and protocol. After conducting a systematic search of the available evidence, the information was contrasted and summarized in order to draw up the recommendations. The quality of the evidence and the strength of the recommendations were determined from the SIGN scale. COMMENT: These CPG aim to help physicians in their decision making. The protocolized application of well-proven measurements reduces the variation in clinical practice and improves results.

Validación de la versión española del cuestionario sobre la práctica basada en la evidencia en enfermería

Background: The lack of adequate instruments prevents the possibility of assessing the competence of health care staff in evidence-based decision making and further, the identification of areas for improvement with tailored strategies. The aim of this study is to report about the validation process in the Spanish context of the Evidence-Based Practice Questionnaire (EBPQ) from Upton y Upton. Methods: A multicentre, cross-sectional, descriptive psychometric validation study was carried out. For cultural adaptation, a bidirectional translation was developed, accordingly to usual standards. The measuring model from the questionnaire was undergone to contrast, reproducing the original structure by Exploratory Factorial Analysis (EFA) and Confirmatory Factorial Analysis (CFA), including the reliability of factors. Results: Both EFA (57.545% of total variance explained) and CFA (chi2=2359,9555; gl=252; p<0.0001; RMSEA=0,1844; SRMR=0,1081), detected problems with items 7, 16, 22, 23 and 24, regarding to the original trifactorial version of EBPQ. After deleting some questions, a reduced version containing 19 items obtained an adequate factorial structure (62.29% of total variance explained), but the CFA did not fit well. Nevertheless, it was significantly better than the original version (chi2=673.1261; gl=149; p<0.0001; RMSEA=0.1196; SRMR=0.0648). Conclusions: The trifactorial model obtained good empiric evidence and could be used in our context, but the results invite to advance with further refinements into the factor “attitude”, testing it in more contexts and with more diverse professional profiles.

Probióticos y prebióticos en la práctica clínica.

This article revises the concepts of prebiotics, probiotics and symbiotics, and their use in different situations of daily clinical practice. With a high level of evidence, it is concluded that the use of certain strains of probiotics significantly reduces the risk for antibiotic-induced diarrhea. Although further studies are needed, the use of probiotics, prebiotics, and symbiotics in people suffering from inflammatory bowel disease (particularly ulcerative colitis, and pouchitis) might improve the rates of remission induction/maintenance. The administration of probiotics and symbiotics to patients with liver transplant, severe acute pancreatitis, and intensive and surgical care patients, emerges as a promising therapeutic option that seems to reduce the number of infections; however, it is currently no possible to establish evidence-based recommendations, with a need for a higher number of better designed works. About safety of probiotics and symbiotics, the benefits/risks ratio clearly favors the former since the risk for infection is low, even in immunosuppressed patients. There are, however, selected groups of patients in which caution is advised.

Manual básico para una atención en Salud mental basada en la evidencia.

Publicado en la página web del Servicio Andaluz de Salud: http://www.juntadeandalucia.es/servicioandaluzdesalud (Servicio Andaluz de salud/principal/La organización/publicaciones)

Sources of pre-analytical variations in yield of DNA extracted from blood samples: analysis of 50,000 DNA samples in EPIC.

The European Prospective Investigation into Cancer and nutrition (EPIC) is a long-term, multi-centric prospective study in Europe investigating the relationships between cancer and nutrition. This study has served as a basis for a number of Genome-Wide Association Studies (GWAS) and other types of genetic analyses. Over a period of 5 years, 52,256 EPIC DNA samples have been extracted using an automated DNA extraction platform. Here we have evaluated the pre-analytical factors affecting DNA yield, including anthropometric, epidemiological and technical factors such as center of subject recruitment, age, gender, body-mass index, disease case or control status, tobacco consumption, number of aliquots of buffy coat used for DNA extraction, extraction machine or procedure, DNA quantification method, degree of haemolysis and variations in the timing of sample processing. We show that the largest significant variations in DNA yield were observed with degree of haemolysis and with center of subject recruitment. Age, gender, body-mass index, cancer case or control status and tobacco consumption also significantly impacted DNA yield. Feedback from laboratories which have analyzed DNA with different SNP genotyping technologies demonstrate that the vast majority of samples (approximately 88%) performed adequately in different types of assays. To our knowledge this study is the largest to date to evaluate the sources of pre-analytical variations in DNA extracted from peripheral leucocytes. The results provide a strong evidence-based rationale for standardized recommendations on blood collection and processing protocols for large-scale genetic studies.

Effectiveness of core stability exercises and recovery myofascial release massage on fatigue in breast cancer survivors: a randomized controlled clinical trial.

The purpose of the present paper was to evaluate the effects of an 8-week multimodal program focused on core stability exercises and recovery massage with DVD support for a 6-month period in physical and psychological outcomes in breast cancer survivors. A randomized controlled clinical trial was performed. Seventy-eight (n = 78) breast cancer survivors were assigned to experimental (core stability exercises plus massage-myofascial release) and control (usual health care) groups. The intervention period was 8 weeks. Mood state, fatigue, trunk curl endurance, and leg strength were determined at baseline, after the last treatment session, and at 6 months of followup. Immediately after treatment and at 6 months, fatigue, mood state, trunk curl endurance, and leg strength exhibited greater improvement within the experimental group compared to placebo group. This paper showed that a multimodal program focused on core stability exercises and massage reduced fatigue, tension, depression, and improved vigor and muscle strength after intervention and 6 months after discharge.

Management of bleeding and coagulopathy following major trauma: an updated European guideline.

INTRODUCTION: Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient. When these recommendations are implemented patient outcomes may be improved. METHODS: The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document represents an updated version of the guideline published by the group in 2007 and updated in 2010. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature. RESULTS: Key changes encompassed in this version of the guideline include new recommendations on the appropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patients in the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline also includes recommendations and a discussion of thromboprophylactic strategies for all patients following traumatic injury. The most significant addition is a new section that discusses the need for every institution to develop, implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. The remaining recommendations have been re-evaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies. CONCLUSIONS: A comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensure that established protocols are consistently implemented will ensure a uniform and high standard of care across Europe and beyond.

Núm 6, diciembre de 2013

Artículos destacados: Buenas prácticas en gestión clínica: Plan de prevención y atención a la parada cardiorrespiratoria en el Hospital Materno-Infantil de Málaga. Modelo de atención socio sanitaria: optimización de recursos y coordianción de la asistencia a pacientes institucionalizados en la residencia Manuel Ridruejo. Aplicación para la dispensación de medicamentos biológicos para el tratamiento de los pacientes con psoriasis (ADISBIO). Análisis de las prescripciones farmacológicas potencialmente inapropiadas en pacientes mayores en Atención Primaria. Boletín informativo sobre prácticas clínicas basadas en la mejor evidencia científica. Atención integral al paciente en situación terminal. Sala de acompañamiento.