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Pfister P, Garcia Wendel PD, Kim BS, Schuepbach RA, Steiger P, Camen G, Buehler PK. Coagulation side effects of enzymatic debridement in burned patients. Burns 2023; 49:1272-1281. [PMID: 36566096 DOI: 10.1016/j.burns.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/19/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Bromelain-based enzymatic debridement has emerged as a valuable option to the standard surgical intervention for debridement in burn injuries. Adverse effects on coagulation parameters after enzymatic debridement have been described. The purpose of this study was to compare the effect of enzymatic and surgical debridement on coagulation. METHODS Between 03/2017 and 02/2021 patients with burn injuries with a total body surface area (TBSA) ≥ 1% were included in the study. Patients were categorized into two groups: the surgically debrided group and the enzymatically debrided group. Coagulation parameters were assessed daily for the first seven days of hospitalization. RESULTS In total 132 patients with a mean TBSA of 17% were included in this study, of which 66 received enzymatic debridement and 66 received regular surgical-debridement. Patients receiving enzymatic debridement presented significantly higher factor-V concentration values over the first seven days after admission (p = <0.01). Regarding coagulation parameters, we found no difference in INR-, aPTT-, fibrinogen-, factor-XIII- and thrombocyte-concentrations over the first seven days (p = >0.05). CONCLUSION Enzymatic debridement in burned patients does not appear to increase the risk of coagulation abnormalities compared with the regular surgical approach.
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Affiliation(s)
- Pablo Pfister
- Institute of intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | | | - Bong Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital of Zurich, Zurich, Switzerland
| | | | - Peter Steiger
- Institute of intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Giovanni Camen
- Institute of intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Philipp Karl Buehler
- Institute of intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland; Center of Intensive Care Medicine, Cantonal Hospital Winterthur, Winterthur, Switzerland
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Vosáhlo J, Salus A, Smolko M, Němcová B, Nordmeyer V, Mikles M, Rau SM, Erik Johansen O. Oral enzyme combination with bromelain, trypsin and the flavonoid rutoside reduces systemic inflammation and pain when used pre- and post-operatively in elective total hip replacement: a randomized exploratory placebo-controlled trial. Ther Adv Musculoskelet Dis 2023; 15:1759720X231186875. [PMID: 37529332 PMCID: PMC10387799 DOI: 10.1177/1759720x231186875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/20/2023] [Indexed: 08/03/2023] Open
Abstract
Background Early mobilization after total hip replacement (THR) is key for fast recovery but is often limited by pain. Oral enzyme combinations (OECs) have demonstrated anti-inflammatory and pain-relieving effects. Objectives and design This prospective, randomized, double-blind, placebo-controlled exploratory trial evaluated the effects of pre- and post-operative use of OEC (90 mg bromelain, 48 mg trypsin, 100 mg rutoside) following elective THR, on post-operative recovery. Methods Candidates for primary elective cementless THR owing to osteoarthritis were eligible for participation [age ⩾50 years, body mass index 25-35 kg/m2, C-reactive protein (CRP) ⩽6 mg/L]. Following randomization to OEC or placebo, intervention started pre-operatively and continued onwards until day 42. Main outcomes included post-operative CRP levels (days 1-7), self-reported hip pain at rest (by 0-10 cm visual analogue scale on post-operative days 1-42), post-operative analgesic use [by cumulative analgesic consumption score (CACS) days 7-42], tolerability and adverse events. Results Patients (N = 34) were recruited from a tertiary orthopaedic hospital in the Czech Republic, of whom 33 completed the study (OEC/placebo: n = 15/18). Baseline characteristics across the groups were comparable. Compared with placebo, the OEC group had numerically lower CRP levels on post-operative days 1-7, including peak level [mean (standard deviation) OEC versus placebo: 81.4 (28.3) versus 106.7 (63.3) mg/L], which translated into a significant 32% lower CRP area under the curve (p = 0.034). The OEC group reported significantly less pain during post-operative days 1-7 versus placebo (analysis of variance treatment × visit [F(4) = 3.989]; p = 0.005). Analgesic use was numerically reduced as assessed through an accumulated CACS. No deleterious effects on haemorheological parameters were observed in either group. Conclusions Pre- and post-operative use of OEC significantly reduced CRP levels and patient self-reported pain. OEC may be an efficacious and safe treatment option to facilitate post-operative recovery following THR. Trial registration EudraCT number 2016-003078-41.
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Affiliation(s)
- Jiří Vosáhlo
- Orthopaedic and Traumatology Department, Jihlava Hospital, Jihlava, Czech Republic
| | - Adam Salus
- Orthopaedic and Traumatology Department, Jihlava Hospital, Jihlava, Czech Republic
| | - Michael Smolko
- Orthopaedic and Traumatology Department, Jihlava Hospital, Jihlava, Czech Republic
| | - Barbora Němcová
- Rehabilitation Department, Jihlava Hospital, Jihlava, Czech Republic
| | - Veit Nordmeyer
- Clinical Department for Trauma Surgery, University Hospital Tulln, Tulln, Austria
| | - Milos Mikles
- Clinical Department for Trauma Surgery, University Hospital Tulln, Tulln, Austria
| | | | - Odd Erik Johansen
- Nestlé Health Science, Avenue Nestle 55, Vevey, Vaud 1800, Switzerland
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Grünherz L, Michienzi R, Schaller C, Rittirsch D, Uyulmaz S, Kim BS, Giovanoli P, Lindenblatt N. Enzymatic debridement for circumferential deep burns: the role of surgical escharotomy. Burns 2023; 49:304-309. [PMID: 36604280 DOI: 10.1016/j.burns.2022.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/22/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Circumferential deep burns carry a high risk for a burn induced compartment syndrome. It was recently shown that an enzymatic bromelain-based debridement with Nexobrid® is a safe and efficient procedure to release pressure in deep circumferential extremity burns reducing the need for surgical escharotomy. We therefore herein aimed to analyze the conceptual relation between Nexobrid® and surgical escharotomy. PATIENTS AND METHODS We conducted a retrospective study on all patients with circumferential deep partial-thickness or full-thickness burns requiring immediate escharotomy that was either performed by surgical incision or Nexobrid®. Medical records of 792 patients that were treated at the burn center of the University Hospital Zurich between 2016 and 2021 were analyzed. RESULTS Overall, 62 patients with circumferential deep partial-thickness or full-thickness burns who received preventive decompression either by Nexobrid® (N = 29) or surgical escharotomy (N = 33), were included. Whilst distribution of age, sex, BMI and type of injury showed no difference between the groups, the ABSI score, TBSA, percentage of third degree burns and mortality were significantly higher in patients who received a surgical escharotomy. CONCLUSION While the use of Nexobrid® to prevent burn induced compartment syndrome has steadily increased, surgical escharotomies were predominantly performed in severely burned patients with a high degree of full-thickness burns. Thus, higher mortality in this patient group needs to be considered with caution and is mainly attributed to the higher TBSA. Although evidence is lacking for the use of Nexobrid® for larger body areas exceeding 15%, escharotomy is also the more reliable and faster approach in such critically burned patients.
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Affiliation(s)
- Lisanne Grünherz
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Ramona Michienzi
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Claudine Schaller
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Daniel Rittirsch
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Semra Uyulmaz
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Nicole Lindenblatt
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland.
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Rajan PK, Dunna NR, Venkatabalasubramanian S. A comprehensive overview on the anti-inflammatory, antitumor, and ferroptosis functions of bromelain: an emerging cysteine protease. Expert Opin Biol Ther 2022; 22:615-625. [PMID: 35176951 DOI: 10.1080/14712598.2022.2042250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Bromelain belongs to the cysteine protease endopeptidase class of enzymes isolated from the stem and fruit tissue component of Ananas comosus. The commercial and translational therapeutic potential of bromelain is ever increasing due to its augmented stability, easier purification, and salubrious pan-cancer effects. AREAS COVERED This paper presents the current state of knowledge about the isolation methods of bromelain, its safety, efficacy and tolerability. In addition, bromelains<apos;> role in eliciting pharmacological effects and its healing ability to mitigate cancer side effects based on accumulated in vitro, in vivo, and clinical evidence is relatively considerable. EXPERT OPINION Identification of molecular targets and crucial signalling pathways that bromelain regulates suggest it genuinely prospects for combating cancer and mitigation of chemotherapy or radiotherapy mediated side effects. Further research on the development of bromelain-entrapped drug delivery systems for augmented enzyme stability, processing ability and translational potential against cancer can be beneficial.
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Affiliation(s)
- Prajitha K Rajan
- Department of Genetic Engineering, College of Engineering and Technology, SRM Institute of Science and Technology, SRM Nagar, Kattankulathur, 603203, Kanchipuram, Chennai, India
| | - Nageswara Rao Dunna
- Cancer Genomics Laboratory, Department of Biotechnology, School of Chemical and Biotechnology, SASTRA - Deemed University, Thanjavur, 613401, India
| | - Sivaramakrishnan Venkatabalasubramanian
- Department of Genetic Engineering, College of Engineering and Technology, SRM Institute of Science and Technology, SRM Nagar, Kattankulathur, 603203, Kanchipuram, Chennai, India
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Ke K, Pillai K, Mekkawy AH, Akhter J, Badar S, Valle SJ, Morris DL. The effect of intraperitoneal administration of BromAc on blood parameters: phase 1 study. Discov Oncol 2021; 12:25. [PMID: 35201475 PMCID: PMC8777505 DOI: 10.1007/s12672-021-00418-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 07/19/2021] [Indexed: 11/05/2022] Open
Abstract
Intraperitoneal administration of BromAc (bromelain + acetylcysteine) is currently undergoing a phase 1 clinical trial for pseudomyxoma peritonei at our institution. This study reports on analysis of routine blood parameters before and after treatment for a series of 25 patients in this trial. Blood parameters assessed included full blood count, electrolytes, urea, and creatinine, liver function tests, coagulation studies, as well as inflammatory markers (CRP). Certain parameters such as CRP, and white cell count, were significantly elevated after treatment whilst serum albumin level was reduced indicating an inflammatory reaction. However, liver enzymes, coagulation studies, and other parameters were not affected. Therefore, there are no additional safety signals evident upon analysis of routine blood parameter testing.
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Affiliation(s)
- Kevin Ke
- Department of Surgery, St. George Hospital, Kogarah, NSW, 2217, Australia
- Mucpharm Pty Ltd, Kogarah, NSW, 2217, Australia
| | - Krishna Pillai
- Department of Surgery, St. George Hospital, Kogarah, NSW, 2217, Australia
- Mucpharm Pty Ltd, Kogarah, NSW, 2217, Australia
| | - Ahmed H Mekkawy
- Department of Surgery, St. George Hospital, Kogarah, NSW, 2217, Australia
- Mucpharm Pty Ltd, Kogarah, NSW, 2217, Australia
| | - Javed Akhter
- Department of Surgery, St. George Hospital, Kogarah, NSW, 2217, Australia
- Mucpharm Pty Ltd, Kogarah, NSW, 2217, Australia
| | - Samina Badar
- Department of Surgery, St. George Hospital, Kogarah, NSW, 2217, Australia
- St George & Sutherland Clinical School, University of New South Wales, Sydney, NSW, 2217, Australia
| | - Sarah J Valle
- Department of Surgery, St. George Hospital, Kogarah, NSW, 2217, Australia
- Mucpharm Pty Ltd, Kogarah, NSW, 2217, Australia
| | - David L Morris
- Department of Surgery, St. George Hospital, Kogarah, NSW, 2217, Australia.
- Mucpharm Pty Ltd, Kogarah, NSW, 2217, Australia.
- St George & Sutherland Clinical School, University of New South Wales, Sydney, NSW, 2217, Australia.
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Pattnaik M, Pandey P, Martin GJO, Mishra HN, Ashokkumar M. Innovative Technologies for Extraction and Microencapsulation of Bioactives from Plant-Based Food Waste and their Applications in Functional Food Development. Foods 2021; 10:279. [PMID: 33573135 PMCID: PMC7911848 DOI: 10.3390/foods10020279] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 02/07/2023] Open
Abstract
The by-products generated from the processing of fruits and vegetables (F&V) largely are underutilized and discarded as organic waste. These organic wastes that include seeds, pulp, skin, rinds, etc., are potential sources of bioactive compounds that have health imparting benefits. The recovery of bioactive compounds from agro-waste by recycling them to generate functional food products is of increasing interest. However, the sensitivity of these compounds to external factors restricts their utility and bioavailability. In this regard, the current review analyses various emerging technologies for the extraction of bioactives from organic wastes. The review mainly aims to discuss the basic principle of extraction for extraction techniques viz. supercritical fluid extraction, subcritical water extraction, ultrasonic-assisted extraction, microwave-assisted extraction, and pulsed electric field extraction. It provides insights into the strengths of microencapsulation techniques adopted for protecting sensitive compounds. Additionally, it outlines the possible functional food products that could be developed by utilizing components of agricultural by-products. The valorization of wastes can be an effective driver for accomplishing food security goals.
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Affiliation(s)
- Monalisha Pattnaik
- Agricultural and Food Engineering Department, Indian Institute of Technology Kharagpur, Kharagpur 721302, West Bengal, India; (M.P.); (P.P.); (H.N.M.)
| | - Pooja Pandey
- Agricultural and Food Engineering Department, Indian Institute of Technology Kharagpur, Kharagpur 721302, West Bengal, India; (M.P.); (P.P.); (H.N.M.)
- School of Chemistry, The University of Melbourne, Parkville, VIC 3010, Australia
- Department of Chemical Engineering, The University of Melbourne, Parkville, VIC 3010, Australia;
| | - Gregory J. O. Martin
- Department of Chemical Engineering, The University of Melbourne, Parkville, VIC 3010, Australia;
| | - Hari Niwas Mishra
- Agricultural and Food Engineering Department, Indian Institute of Technology Kharagpur, Kharagpur 721302, West Bengal, India; (M.P.); (P.P.); (H.N.M.)
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Safety of enzymatic debridement in extensive burns larger than 15% total body surface area. Burns 2020; 47:796-804. [PMID: 33143989 DOI: 10.1016/j.burns.2020.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 09/28/2020] [Accepted: 10/12/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Bromelain-based enzymatic debridement has emerged as an alternative to surgical eschar removal. Indications include partial thickness, mixed pattern, and full-thickness burns. Enzymatic debridement has been approved by the European Medicines Agency for treating burn wounds affecting <15% total body surface area (TBSA). Data and evidence for the treatment of areas >15% TBSA in one session is scarce. The aim of this retrospective study was to retrospectively analyze off-label use of enzymatic debridement in a single burn center for large TBSA burns. METHODS Between 01/2017 and 12/2018, 59 patients with partial- to full-thickness burns underwent enzymatic debridement in a single center study. Patients were categorized into two groups: the regular use group with a treated area less than 15% TBSA and the off-label group (OG) with larger TBSA debrided in one session. Treatment was evaluated for systemic inflammatory reaction, bleeding, hemodynamic instability and electrolyte shifts. RESULTS In total, 49 patients were treated in the regular use group with a median application area of 6% (IQR 2.5-9.5) and 10 patients were treated in the off-label group with a median application area of 18% (IQR 15-19) TBSA. We found no significant differences regarding blood pressure, body temperature or hemodynamic stability during and after enzymatic debridement. No treatment-related serious adverse events were observed in either group. Catecholamine use was similar in both groups. No differences in leukocyte counts, CRP, PCT and lactate prior to application and during the following three days were observed. Sodium, potassium, chloride and phosphate levels did not differ. We found no evidence of an electrolyte shift. Survival was 49 of 49 patients (100%) in the RG and 7 of 10 patients (70%) in the OG (p = 0.004). CONCLUSION Enzymatic debridement did not result in any expected or unexpected side effects in the patient groups investigated. These preliminary results indicate the potential safety of bromelain-based enzymatic debridementin the treatment of burns greater than 15% TBSA.
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Abstract
Thromboelastography (TEG) has been used for decades to guide transfusion therapy during cardiac and hepatic surgeries. Renewed interest and improved technology have led to wider applications of TEG in other areas of hemostasis. To correctly interpret the data generated and to validate outcomes, it is important to improve the understanding of the differences in the currently available assay procedures, the issues related to sample activation, and the importance of the use of appropriate controls. Current TEG assays use a variety of samples and can vary slightly in the procedures. In this chapter, we very briefly review TEG applications and discuss interpretations, normal ranges, and reference controls, and we explain the method of TEG run using standard citrated native blood samples. We provide detailed technical steps and tips. We discuss precautions and issues related to the assay, which we hope can guide toward better application and data interpretation.
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