Holistic evaluation of the environmental impacts of shipping in the sensitive region of Ria de Aveiro.

Shipping activity can be a substantial source of pollution and impact on the environment, including air, water and ecosystems, as well as adverse health and climatic effects. Due to the distribution of maritime transport activity routes in the EU, a large portion of the population is exposed to shipping pollution throughout Europe. The ongoing European project EMERGE aims to investigate and quantify these impacts over Europe, and in more detail, in specific case studies regions. The Aveiro lagoon region in Portugal is one of these case studies. This region is a Natura 2000 area, and also includes a medium-sized port. Both air quality and water modelling tools were applied to assess the impact of the emissions and discharges from shipping (to air and water) in the region in 2018. Additionally, ecotoxicological impacts were determined by bioassays to evaluate the impact of scrubber-water discharges on the most sensitive stages of marine invertebrates, and on the post-exposure feeding inhibition of crustacean and bivalve species. The results show that there was a substantial increase in atmospheric pollutant concentrations due to emissions attributed to shipping, which was most relevant for NOx and SO2 (up to a 30 % shipping contribution). There was no significant degradation of the water quality, mainly as the ships operating in this area did not have scrubber equipment. The ecotoxicological tests were performed with three samples of scrubber water, including one artificial sample and two samples collected on-board ships. If scrubber water would have been discharged in this area, the results indicated that the majority of the tested species would be exposed to lowest observed effect concentration (LOEC) for the different scrubber-water samples, as well as to substantial concentrations of metals, PAHs, and alkylated PAHs.

Percutaneous plate fixation of displaced proximal humerus fractures: Do minimally invasive techniques improve outcomes and reduce complications?

OBJECTIVE: The aim of this study was to analyze the outcomes and complications of minimally invasive plate osteosynthesis (MIPO) for displaced proximal humerus fractures and elucidate if the percutaneous technique reduces the rate of avascular necrosis (AVN) without jeopardizing fracture reduction. MATERIAL AND METHODS: 118 patients with a displaced proximal humerus fracture were treated with a polyaxial locking-plate through a standardized percutaneous approach. 73 % were women and mean age was 63 years (18-89) with an average follow-up of 51 months (12-256). There were 32 two-part fractures (27 %), 57 three-part fractures (48 %) and 24 four-part fractures (25 %). Shoulder function at the last follow-up, including ROM and ability to perform daily living activities, was objectively evaluated with an adjusted Constant Score (CS). Subjective patient satisfaction was rated with an Visual Analogic Scale from 0 to 10 and the degree of residual pain with a Verbal Rating Scale (VRS). Radiographic analysis at the most recent follow-up evaluated the presence of AVN, degree of residual medial calcar displacement, and the cervicodiaphiseal angle. RESULTS: Forty patients (34 %) had a complication, 25 of them (21 %) requiring further surgery. ROM at the last follow-up was 131° of elevation (40°-180°), 38° of external rotation (SD: 17.7) and internal rotation to L3. Average adjusted Constant Score was 68 (SD: 17.76). Twenty-one patients (18 %) complained of shoulder pain (14 moderate and 7 severe) and seven were not satisfied. Radiographically, 29 patients (25 %) had varus malunion and 17 patients (14 %) showed some degree of AVN. Patients with varus malunion (CS 64.3 versus 69.8, p = 0.16) and AVN (CS 56.9 versus 70.4, p = 0.005) had lower CS. The presence of a varus malunion was directly related to the degree of initial medial calcar displacement (p = 0.001) and deficient calcar reduction at surgery (p = 0.004). AVN was statistically more prevalent when the medial calcar was inadequately reduced (p = 0.01). CONCLUSIONS: MIPO surgery for proximal humerus fractures through an anterolateral approach does not reduce the rate of mechanical complications or AVN compared with standard ORIF techniques. Moreover, percutaneous plating may preclude adequate medial calcar reduction, leading to humeral head malunion and a worse clinical outcome.

[Impact of Spanish Public Health Measures on Emergency Visits and COVID- 19 diagnosed cases during the pandemic in Madrid].

OBJECTIVE: Changes in Public Health recommendations may have changed the number of emergency visits and COVID-19 diagnosed cases in an Emergency Department in Madrid. METHODS: This retrospective case series study included all consecutive patients in a tertiary and urban ED in Madrid from 1st to 31st March. The sample was divided: NonCOVID-19, Non-investigated COVID-19, Possible COVID-19, Probable COVID-19, Confirmed COVID-19. Differences between public health periods were tested by ANOVA for each cohort, and by ANCOVA including the number of PCR tests (%) as covariate. RESULTS: A total of 7,163 (4,071 Non-COVID-19, 563 Non-investigated COVID-19, 870 Possible, 648 Probable and 1,011 Confirmed COVID-19) cases were included. Public Health measurements applied during each period showed a clear effect on the case proportion for the five cohorts. CONCLUSIONS: The variability of case definitions and diagnostic test criteria may have impact on the number of emergency visits and COVID-19 diagnosed cases in Emergency Department.

The impact of perimenopausal symptomatology, sociodemographic status and knowledge of menopause on women's quality of life.

BACKGROUND: A high percentage of menopausal and perimenopausal women suffer symptoms that deteriorate their quality of life (QoL) significantly. Many studies have focused on the relationship between perimenopausal symptoms and QoL, yet the results obtained have been inconclusive. The aim of this study is to evaluate the relationships among the symptoms of menopause, sociodemographic variables, knowledge of menopause and QoL. METHOD: Sociodemographic and clinical data was collected from interviews of 453 women in Madrid, and they also completed questionnaires related to perimenopausal symptomatology (MRS, MENQOL), knowledge of menopause and QoL. RESULTS: Although dependent on the assessment techniques, all the tools used indicated that more than half of the women studied suffered perimenopausal symptomatology: interview (59.1%), MENQOL (69.2%) and MRS (65.1%). Stronger symptoms were related to a worse QoL (R2 = 0.287 for MENQOL; R2 = 0.390 for MRS), being psychosocial/psychological and urogenital/sexual symptomatology, and educational level and knowledge about menopause the most strongly related to this parameter. Taking into account the main perimenopausal symptoms in Europe, psychosocial and sexual symptoms are also found to be strongly related to QoL. CONCLUSION: Perimenopausal symptomatology is frequent and intense, deteriorating women's QoL. While psychosocial and somatic/physical symptoms are the most frequent and intense, psychosocial/psychological and urogenital/sexual are those that best predict the individual's QoL. Educational level and knowledge about menopause are also related to a better QoL.

Carta al director sobre «Eficacia y seguridad de la aplicación del ácido tranexámico tópico en la artroplastia primaria no cementada de cadera: estudio prospectivo, aleatorizado, doble ciego y controlado» / Letter to the Editor on «Efficacy and safety of the topical application of tranexamic acid in primary cementless hip arthroplasty: prospective, randomised, double-blind and controlled study»

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Efficacy and safety of administering oral misoprostol by titration compared to vaginal misoprostol and dinoprostone for cervical ripening and induction of labour: study protocol for a randomised clinical trial.

BACKGROUND: Among the various methods available, the administration of prostaglandins is the most effective for inducing labour in women with an unfavourable cervix. Recent studies have compared treatment with various titrated doses of oral misoprostol with vaginal misoprostol or dinoprostone, indicating that the use of an escalating dose of an oral misoprostol solution is associated with a lower rate of caesarean sections and a better safety profile. The objective of this study is to assess which of these three therapeutic options (oral or vaginal misoprostol or vaginal dinoprostone) achieves the highest rate of vaginal delivery within the first 24 h of drug administration. METHODS: An open-label randomised controlled trial will be conducted in Araba University Hospital (Spain). Women at ≥41 weeks of pregnancy requiring elective induction of labour who meet the selection criteria will be randomly allocated to one of three groups: 1) vaginal dinoprostone (delivered via a controlled-release vaginal insert containing 10 mg of dinoprostone, for up to 24 h); 2) vaginal misoprostol (25 µg of vaginal misoprostol every 4 h up to a maximum of 24 h); and 3) oral misoprostol (titrated doses of 20 to 60 µg of misoprostol following a 3 h on + 1 h off regimen up to a maximum of 24 h). Both intention-to-treat analysis and per-protocol analysis will be performed. DISCUSSION: The proposed study seeks to gather evidence on which of these three therapeutic options achieves the highest rate of vaginal delivery with the best safety profile, to enable obstetricians to use the most effective and safe option for their patients. TRIAL REGISTRATION: NCT02902653 Available at: https://clinicaltrials.gov/show/NCT02902653 (7th September 2016).

Determination of Perioperative Blood Loss: Accuracy or Approximation?

BACKGROUND: Various different interventions can be used to reduce surgical blood loss; however, there is no "gold standard" for accurately measuring the volume of perioperative blood loss, and this makes it difficult to assess the efficacy of these interventions. METHODS: We used data from a previous multicenter double-blind randomized clinical trial in patients undergoing total hip arthroplasty in which we compared 2 regimens for administering tranexamic acid versus placebo. We assessed direct measures (external blood loss) and indirect estimates (using the formulas of Bourke, Gross, Mercuriali, and Camarasa and a new formula we have developed) using analysis of variance to compare estimated volumes of blood loss among the study groups. In addition, intraclass correlation coefficients (ICCs) and Bland-Altman diagrams were used to compare the estimated volumes of blood loss obtained with each formula. RESULTS: The mean estimated external blood loss was 909 ± 324 mL, and the mean estimates of blood loss calculated using the formulas of Gross, Bourke and Smith, and Camarasa were 1308 ± 555, 1091 ± 454, and 1641 ± 945 mL, respectively, whereas we obtained a value of 1511 ± 919 mL with the new formula at day 2. In all cases, the results favored the use of tranexamic acid (P < .0001). Comparing results of the new and other formulas, we found moderate-to-low agreement (in terms of ICCs) except for that of Camarasa (ICC: 0.992). The limits of agreement with the new formula ranged from -378 to 93 in the case of the comparison with Camarasa's formula and from -2226 to 959 for external blood loss, the difference depending on the magnitude of the estimate to a large extent. CONCLUSIONS: Formulas that take into account both anthropometric and laboratory parameters are useful for evaluating the efficacy of interventions aiming to decrease blood loss but do not ensure that the values obtained are sufficiently accurate for absolute measuring.

Management, prevention and treatment of canine leishmaniosis in north-eastern Spain: an online questionnaire-based survey in the province of Girona with special emphasis on new preventive methods (CaniLeish vaccine and domperidone).

Knowledge of how canine leishmaniosis (CanL) is being managed clinically and its epidemiology is very important, since dogs are the main reservoir of human leishmaniosis. This study reports the results obtained through a questionnaire-based survey of veterinary practitioners in Girona province, a recognised, but non-documented endemic area in north-eastern Spain. The primary objective was to obtain data on the clinical management of CanL, focusing particularly on new preventive methods and therapeutic tools. The results show an extensive routine management of CanL cases and a widespread use of the CaniLeish (Virbac) vaccine and domperidone (Leisguard, Esteve). Adverse reactions were detected by a vast majority of the vaccine users (82 per cent), the most frequent being local reactions, apathy, fever and gastroenteritis. All the respondents had treated confirmed cases, and the therapeutic protocol most used was the combination of meglumine antimoniate (Glucantime, Merial) and allopurinol (Zyloric, GlaxoSmithKline).

Intradomiciliary and peridomiciliary captures of sand flies (Diptera: Psychodidae) in the leishmaniasis endemic area of Chapare province, tropic of Cochabamba, Bolivia.

In South America, cutaneous leishmaniasis is the most frequent clinical form of leishmaniasis. Bolivia is one of the countries with higher incidence, with 33 cases per 100,000 individuals, and the disease is endemic in 70% of the territory. In the last decade, the number of cases has increased, the age range has expanded, affecting children under 5 years old, and a similar frequency between men and women is found. An entomological study with CDC light traps was conducted in three localities (Chipiriri, Santa Elena and Pedro Domingo Murillo) of the municipality of Villa Tunari, one of the main towns in the Chapare province (Department of Cochabamba, Bolivia). A total of 16 specimens belonging to 6 species of the genus Lutzomyia were captured: Lu. aragaoi, Lu. andersoni, Lu. antunesi, Lu. shawi, Lu. yuilli yuilli and Lu. auraensis. Our results showed the presence of two incriminated vectors of leishmaniasis in an urbanized area and in the intradomicile. More entomological studies are required in the Chapare province to confirm the role of vector sand flies, the intradomiciliary transmission of the disease and the presence of autochthonous cases of cutaneous leishmaniasis.

Growing teratoma syndrome after ovarian inmature teratoma: a case report and review of the literature.

Growing teratoma syndrome is an uncommon complication of malignant germ cell cancer, characterised by the development of large tumours during or after chemotherapy, despite normalisation of tumour marker levels and metastasis, which contain only mature teratoma. Given its low incidence, little is data available. The authors present the case of a 15-year-old girl with a growing teratoma and the literature review outlines the current knowledge of its pathogenesis, common sites, diagnosis, natural course, treatment, and prognosis.

Valoración de la implementación de programa de ahorro de sangre en cirugía ortopédica / Assessment of the introduction of a blood management program in orthopaedic surgery

Objetivo. Describir el impacto de la introducción de un programa de ahorro de sangre (PAS) en las transfusiones, estancias hospitalarias y complicaciones debidas a la artroplastia total de cadera (ATC) y artroplastia total de rodilla (ATR). Material y métodos. Estudio observacional retrospectivo en el Hospital Universitario Araba, de 2006 a 2011. Se recogieron todas las ATR y ATC. La variable principal fue el porcentaje de pacientes transfundidos con sangre alogénica. Como variables secundarias se recogió la media de bolsas transfundidas, transfusiones totales (alogénica y/o autóloga), las complicaciones (totales y específicas), la edad y el sexo de los pacientes, hemoglobina prequirúrgica y al alta y la estancia hospitalaria. Resultados. Se incluyeron un total un total de 825 ATC y 875 ATR. Tanto en ATC (47,6% en 2006 y 30,6% en 2011; p = 0,013) como ATR (33,6% en 2006 y 16,2% en 2011; p < 0,001) se produjo una disminución significativa en las transfusiones alogénicas. Las transfusiones totales también disminuyeron en ATC (65,7% en 2006 y 39,5% en 2011; p < 0,001) y ATR (38,3% en 2006 y 17,2% en 2011; p < 0,001). La estancia disminuyó en ambas cirugías (p = 0,038 en ATC y p < 0,0001 en ATR). En 2006 fue de 9,2 ± 2,9 días en ATC y 11,1 ± 4,7 días en ATR, mientras que en 2011 fue de 8,7 ± 4,2 y 9,5 ± 3,4 días para ATC y ATR respectivamente. Conclusiones. La implementación del PAS, y sus aportaciones consecutivas, ha reducido significativamente el porcentaje de pacientes que requieren transfusiones, tanto alogénicas como autólogas. La estancia media disminuyó aunque no pueda establecerse el impacto del PAS en las mismas (AU)

Objective. To assess the impact of implementing a Patient Blood management program (PBM) on transfusion rates, hospital stay, and complications for total hip arthroplasty (THA) and total knee arthroplasty (TKA). Material and methods. A retrospective, observational study was conducted in Araba University Hospital from 2006 to 2011. All THA and TKA were included. The percentage of patients transfused with allogeneic blood was the primary endpoint. The mean of transfused blood bags, overall transfusion, complications (both overall and specific), patient age and sex, pre-operative and discharge hemoglobin, and hospital stay were recorded. Results. A total of 825 THA and 875 TKA were included. Both THA (47.6% in 2006 and 30.6% in 2011; P = .013) and TKA (33.6% in 2006 and 16.2% in 2011; P < .001) showed a significant decrease of allogeneic transfusion. The overall transfusion rate was also reduced in THA (65.7% in 2006 and 39.5% in 2011; P < .001) and TKA (38.3% in 2006 and 17.2% in 2011; P < .001). Hospital stay was reduced in both types of surgeries (P < .038 in THA and P < .0001 in TKA). In 2006 it was 9.2 ± 2.9 days for THA and 11.1 ± 4.7 days for TKA, whereas in 2011 it was 8.7 ± 4.2 and 9.5 ± 3.4 days for THA and TKA, respectively. Conclusions. Our patient blood management has decreased the percentage of patients that need both allogeneic and autologous transfusion in a statistically significant way. Although the mean hospital stay decreased, the impact of the PBM cannot be established (AU)

Assessment of the introduction of a blood management program in orthopaedic surgery.

OBJECTIVE: To assess the impact of implementing a Patient Blood management program (PBM) on transfusion rates, hospital stay, and complications for total hip arthroplasty (THA) and total knee arthroplasty (TKA). MATERIAL AND METHODS: A retrospective, observational study was conducted in Araba University Hospital from 2006 to 2011. All THA and TKA were included. The percentage of patients transfused with allogeneic blood was the primary endpoint. The mean of transfused blood bags, overall transfusion, complications (both overall and specific), patient age and sex, pre-operative and discharge hemoglobin, and hospital stay were recorded. RESULTS: A total of 825 THA and 875 TKA were included. Both THA (47.6% in 2006 and 30.6% in 2011; P=.013) and TKA (33.6% in 2006 and 16.2% in 2011; P<.001) showed a significant decrease of allogeneic transfusion. The overall transfusion rate was also reduced in THA (65.7% in 2006 and 39.5% in 2011; P<.001) and TKA (38.3% in 2006 and 17.2% in 2011; P<.001). Hospital stay was reduced in both types of surgeries (P<.038 in THA and P<.0001 in TKA). In 2006 it was 9.2±2.9 days for THA and 11.1±4.7 days for TKA, whereas in 2011 it was 8.7±4.2 and 9.5±3.4 days for THA and TKA, respectively. CONCLUSIONS: Our patient blood management has decreased the percentage of patients that need both allogeneic and autologous transfusion in a statistically significant way. Although the mean hospital stay decreased, the impact of the PBM cannot be established.

Risk factors for foot-and-mouth disease in Tanzania, 2001-2006.

We developed a model to quantify the effect of factors influencing the spatio-temporal distribution of foot-and-mouth disease (FMD) in Tanzania. The land area of Tanzania was divided into a regular grid of 20 km × 20 km cells and separate grids constructed for each of the 12-month periods between 2001 and 2006. For each year, a cell was classified as either FMD positive or negative dependent on an outbreak being recorded in any settlement within the cell boundaries. A Bayesian mixed-effects spatial model was developed to assess the association between the risk of FMD occurrence and distance to main roads, railway lines, wildlife parks, international borders and cattle density. Increases in the distance to main roads decreased the risk of FMD every year from 2001 to 2006 (ORs ranged from 0.43 to 0.97). Increases in the distance to railway lines and international borders were, in general, associated with a decreased risk of FMD (ORs ranged from 0.85 to 0.99). Increases in the distance from a national park decreased the risk of FMD in 2001 (OR 0.80; 95% CI 0.68-0.93) but had the opposite effect in 2004 (OR 1.06; 95% CI 1.01-1.12). Cattle population density was, in general, positively associated with the risk of FMD (ORs ranged from 1.01 to 1.30). The spatial distribution of high-risk areas was variable and corresponded to endemic (2001, 2002 and 2005) and epidemic (2003, 2004 and 2006) phases. Roads played a dominant role in both epidemiological situations; we hypothesize that roads are the main driver of FMD expansion in Tanzania. Our results suggest that FMD occurrence in Tanzania is more related to animal movement and human activity via communication networks than transboundary movements or contact with wildlife.

Respuesta de los autores a la Carta al Director en relación con el artículo «Osteoporosis posmenopáusica: prevención primaria o medicación excesiva» / Authors’ response to the Letter to the Editor as regards the article ‘‘Post-menopausal osteoporosis: Primary prevention or excessive medication’’

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Remifentanil versus placebo for analgesia during external cephalic version: a randomised clinical trial.

BACKGROUND: Breech presentation occurs in up to 3% of pregnancies at term and may be an indication for caesarean delivery. External cephalic version can be effective in repositioning the fetus in a cephalic presentation, but may be painful for the mother. Our aim was to assess the efficacy of remifentanil versus placebo for pain relief during external cephalic version. METHODS: A randomized, double-blind, controlled trial that included women at 36-41 weeks of gestation with non-cephalic presentations was performed. Women were randomized to receive either a remifentanil infusion at 0.1 µg/kg/min and demand boluses of 0.1 µg/kg, or saline placebo. The primary outcome was the numerical rating pain score (0-10) after external cephalic version. RESULTS: Sixty women were recruited, 29 in the control group and 31 in the remifentanil group. There were significant differences in pain scores at the end of the procedure (control 6.5 ± 2.4 vs. remifentanil 4.7 ± 2.5, P = 0.005) but not 10 min later (P = 0.054). The overall success rate for external cephalic version was 49% with no significant differences between groups (remifentanil group 54.8% vs. control group 41.3%, P = 0.358). In the remifentanil group, there was one case of nausea and vomiting, one of drowsiness and three cases of fetal bradycardia. In the control group, there were three cases of nausea and vomiting, one of dizziness and nine cases of fetal bradycardia. CONCLUSION: Intravenous remifentanil with bolus doses on demand during external cephalic version achieved a reduction in pain and increased maternal satisfaction. There were no additional adverse effects, and no difference in the success rate of external cephalic version or the incidence of fetal bradycardia.