Identifying gaps in the cascade of care for latent TB infection in a low-incidence setting.

BACKGROUND: The End TB Strategy calls for the global scale-up of treatment for latent TB infection (LTBI). We aimed to evaluate a nurse-led care programme for LTBI by identifying gaps in the care cascade in a low-incidence TB setting.METHODS: We included people at risk of TB over a 15-year period. We define three main outcomes in the LTBI care cascade: 1) attendance at the first appointment, 2) completion of the evaluation process, and 3) completion of treatment.RESULTS: We identified 6,126 individuals (2,369 TB contacts, 1,749 biological therapy candidates, and 2,008 transplant candidates). Overall, 5,938 (96.9%) attended, 5,872/5,938 (98.9%) completed the evaluation and 1,624/1,847 (87.9%) completed treatment. Pre-biological (aOR 2.32, 95% CI 1.54-3.49) and pre-transplant (aOR 1.82, 95% CI 1.20-2.76) candidates were more likely to attend the first appointment, while age was associated with completing the evaluation process (aOR 1.02, 95% CI 1.003-1.04). Female sex (aOR 1.47, 95% CI 1.08-1.99) was associated with completing the treatment.CONCLUSION: Successful assessment and treatment of LTBI is achievable when delivered as a part of a comprehensive, nurse-led, patient-centred programme in specialist TB clinics.

An incidental finding in newborn screening leading to the diagnosis of a patient with ECHS1 mutations.

Short-chain enoyl-CoA hydratase (ECHS1) is a mitochondrial beta-oxidation enzyme involved in the metabolism of acyl-CoA fatty acid esters, as well as in valine metabolism. ECHS1 deficiency has multiple manifestations, including Leigh syndrome early at birth or in childhood with poor prognosis, to cutis laxa, exercise-induced dystonia and congenital lactic acidosis. Here we describe the case of a newborn with mutations in ECHS1 that caught our attention after the incidental finding of 3-hydroxy-butyryl\3-hydroxy-isobutyryl\malonylcarnitine (C4OH\C3DC) and tiglylcarnitine (C5:1) on blood spot in the newborn screening (NBS) program. Diagnosis was suspected based on the analysis of organic acids on dried urine spot. A moderate increase of 2-methyl-2,3-dihydroxybutyric acid, was detected, which is a known marker of this disease. Exome analysis showed c.404A>G (p.Asn135Ser) mutation in homozygosis in the ECHS1 gene. The child was therefore admitted to the hospital. Initial examination showed little response to auditory stimuli and mild hypertonia of the extremities. Clinical deterioration was evident at 4 months of age, including neurological and cardiac involvement, and the patient died at 5 months of age. This case illustrates how an incidental detection in the NBS Program can lead to the diagnosis ECHS1 deficiency. Although it is a severe disease, with no treatment available, early detection would allow adequate genetic counseling avoiding the odyssey that suffered most of these families.

Nutrient attenuation dynamics in effluent dominated watercourses.

In-stream attenuation of dissolved and particulate forms of carbon, nitrogen and phosphorus are a crucial ecosystem service, especially in watercourses downstream of chemical pollution point-sources (i.e. wastewater treatment plants). Most chemical-fate models assume that attenuation is directly proportional to the concentration of available dissolved organic carbon, and inorganic nitrogen and phosphorus compounds in watercourses, but there are multiple evidences of saturation and even inhibition of attenuation at higher concentrations. Our current comprehension of nutrient attenuation kinetics in streams remains a limiting factor for the development and calibration of predictive models of the chemical fate of these compounds in rivers, thus hindering the development and implementation of more effective regulatory strategies. Here, we assessed the in-stream attenuation of dissolved organic carbon, inorganic nitrogen (NH4+, NO2-, NO3-) and phosphorus (PO43-) compounds at increasing concentrations of these compounds, and analyzed the interaction between attenuation kinetics and biofilm structure and function. Specifically, the net balances of these compounds were assessed in artificial streams exposed to eight treatments following the gradient of WWTP contribution to the river flow (0, 14, 29, 43, 58, 72, 86, and 100% of WWTP effluent water). Results indicate that biological in-stream attenuation by a given biofilm of an effluent dominated watercourse might be saturated if exposed for short periods to high nutrient concentrations such as during combined sewer overflow events, but that communities can adapt if exposed long enough to high concentrations, therefore avoiding or at least minimizing saturation. More attention should be therefore given to the management of effluent-dominated watercourses, as reductions in the temporal variability of the discharged wastewater by WWTP might enhance attenuation and thus reduce water quality issues downstream.

Vancomycin sorption on activated sludge Gram+ bacteria rather than on EPS; 3D Confocal Laser Scanning Microscopy time-lapse imaging.

Antibiotics-bacteria interactions depend on antibiotic concentration at the scale of bacteria. This study investigates how vancomycin penetrates into activated sludge flocs and can be sorbed on the bacteria and extracellular polymeric substances (EPS). The 3D structure of flocs was imaged using EPS autofluorescence. The green fluorescent BODIPY® FL vancomycin was introduced in a microscopic chamber containing activated sludge and penetration of vancomycin into the flocs by diffusion was observed using time-lapse microscopy. The penetration depended on the floc structure, as long and large pores could go through the whole flocs making preferential path. The antibiotic concentration into the flocs was also found to depend on the sorption rate. BODIPY® FL vancomycin was found to bind preferentially into Gram+ bacteria than on EPS. The vancomycin adsorption constant on bacteria according to the linear adsorption model, Kdbacteria was estimated to be 5 times higher (SD 2.6) than the adsorption constant on EPS KdEPS. These results suggest that antibiotic removal by sorption into wastewater treatment plants could change according to the amount of bacteria in the sludge. Moreover, antibiotic concentration at the scale of bacteria could be significantly higher than the concentration in the bulk solution and this should be taken into account when studying antibiotic activity or biodegradation.

Extreme liver surgery as treatment of liver tumors involving the hepatocaval confluence

Objective. Analyze the characteristics, surgical technique, morbidity and survival of patients treated with extreme liver surgery. Materials and methods. We present a series of consecutive patients with malignant liver tumors in hepatocaval confluence treated in a single center with extreme liver surgery (April 2008-March 2015). Data were collected prospectively and analyzed with SPSS 21.0. Results. 12 patients were included. 50 % were male and 50 % were female with a mean age of 59 ± 10 years old. The median of comorbidities was 7 according to the Charlson Age Comorbidity Index. The 75 % of the tumors were metastases, most of them from colorectal cancer. Most of the patients received neoadjuvant chemotherapy and in 58 % preoperative portal embolization was performed. Major hepatectomies were performed (66.7 % extended right hepatectomy, 33.3 % left extended hepatectomy). The 83.3 % of the patients needed vascular reconstruction. Postoperative morbidity was more than grade II in 50 % of the patients according to Dindo-Clavien classification. There was no intraoperative mortality. The postoperative mortality rate at 90 days was 33 % due to hepatic failure and biliary fistula. In December 2015, 33 % of the patients are still alive with a mean survival of 19 months (13-23) with an ECOG Performance Status of 0. Conclusion. Extreme liver surgery carries a high rate of morbidity and mortality that seem to increase with age and with higher tumor volumes, according to the literature. It is a therapeutic option to consider in patients with low comorbidity suffering from malignant neoplasms that involve the hepatocaval confluence, when no other treatment with curative intention can be performed (AU)

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Extreme liver surgery as treatment of liver tumors involving the hepatocaval confluence.

OBJECTIVE: Analyze the characteristics, surgical technique, morbidity and survival of patients treated with extreme liver surgery. MATERIALS AND METHODS: We present a series of consecutive patients with malignant liver tumors in hepatocaval confluence treated in a single center with extreme liver surgery (April 2008-March 2015). Data were collected prospectively and analyzed with SPSS 21.0. RESULTS: 12 patients were included. 50 % were male and 50 % were female with a mean age of 59 ± 10 years old. The median of comorbidities was 7 according to the Charlson Age Comorbidity Index. The 75 % of the tumors were metastases, most of them from colorectal cancer. Most of the patients received neoadjuvant chemotherapy and in 58 % preoperative portal embolization was performed. Major hepatectomies were performed (66.7 % extended right hepatectomy, 33.3 % left extended hepatectomy). The 83.3 % of the patients needed vascular reconstruction. Postoperative morbidity was more than grade II in 50 % of the patients according to Dindo-Clavien classification. There was no intraoperative mortality. The postoperative mortality rate at 90 days was 33 % due to hepatic failure and biliary fistula. In December 2015, 33 % of the patients are still alive with a mean survival of 19 months (13-23) with an ECOG Performance Status of 0. CONCLUSION: Extreme liver surgery carries a high rate of morbidity and mortality that seem to increase with age and with higher tumor volumes, according to the literature. It is a therapeutic option to consider in patients with low comorbidity suffering from malignant neoplasms that involve the hepatocaval confluence, when no other treatment with curative intention can be performed.

Nutrients versus emerging contaminants-Or a dynamic match between subsidy and stress effects on stream biofilms.

Freshwater ecosystems are threatened by multiple anthropogenic stressors, which might be differentiated into two types: those that reduce biological activity at all concentrations (toxic contaminants), and those that subsidize biological activity at low concentrations and reduce it at high concentrations (assimilable contaminants). When occurring in mixtures, these contaminants can have either antagonistic, neutral or synergistic effects; but little is known on their joint effects. We assessed the interaction effects of a mixture of assimilable and toxic contaminants on stream biofilms in a manipulative experiment using artificial streams, and following a factorial design with three nutrient levels (low, medium or high) and either presence or absence of a mixture of emerging contaminants (ciprofloxacin, erythromycin, diclofenac, methylparaben, and sulfamethoxazole). We measured biofilm biomass, basal fluorescence, gross primary production and community respiration. Our initial hypotheses were that biofilm biomass and activity would: increase with medium nutrient concentrations (subsidy effect), but decrease with high nutrient concentrations (stress effect) (i); decrease with emerging contaminants, with the minimum decrease at medium nutrient concentrations (antagonistic interaction between nutrients subsidy and stress by emerging contaminants) and the maximum decrease at high nutrient concentrations (synergistic interaction between nutrients and emerging contaminants stress) (ii). All the measured variables responded linearly to the available nutrients, with no toxic effect at high nutrient concentrations. Emerging contaminants only caused weak toxic effects in some of the measured variables, and only after 3-4 weeks of exposure. Therefore, only antagonistic interactions were observed between nutrients and emerging contaminants, as medium and high nutrient concentrations partly compensated the harmful effects of emerging contaminants during the first weeks of the experiment. Our results show that contaminants with a subsidy effect can alleviate the effects of toxic contaminants, and that long-term experiments are required to detect stress effects of emerging contaminants at environmentally relevant concentrations.

Cardiac complications during pregnancy are better predicted with the modified WHO risk score.

BACKGROUND/OBJECTIVE: Several risk scores (RSs) have been used to stratify risk of cardiac complications (CCs) in pregnant patients with heart disease. We aimed to compare and contrast the accuracy of several RSs for predicting CC in this population. METHODS: Prospective inclusion of all consecutive pregnant patients with heart disease, and follow-up until 6 months postpartum. CCs were defined as primary if admission was required due to heart failure, arrhythmia or thromboembolic events, and secondary if the decline in NYHA class compared with baseline was >2 or urgent invasive cardiac procedures were needed. The discriminatory power of each RS was assessed by the area-under-the receiver-operating characteristic (ROC) curve (AUC). RESULTS: 179 patients, mean age: 32 years, accounted for 13.4% of CC (primary 11.7%, secondary 1.7%); the main diagnosis was congenital heart disease (CHD) in 68% followed by valvulopathies in 16%, arrhythmia in 7% and myocardiopathies in 5%. 22% (n=40) were classified as mWHO=1, 59% (n=105) mWHO=2 including subgroup 2-3, 14% (n=26) mWHO=3 and 4%(n=7) mWHO=4; 1 patient was unclassifiable. mWHO showed a better AUC (0.763) than CARPREG (0.67). For the CHD population, ZAHARA RS showed an AUC of 0.74, and Khairy an AUC of 0.632. CONCLUSIONS: mWHO was better at predicting CC than CARPREG; mWHO was also better at predicting CC than the specific CHD RS in the CHD subgroup. PRACTICE: There are an increasing number of pregnant women with HD. IMPLICATIONS: Improved prediction of CC risk during pregnancy can provide better preconception assessment in women with HD.

[Long-term outcomes of children treated with continuous renal replacement therapy]. / Evolución a largo plazo de los niños tratados con técnicas de depuración extrarrenal continua.

INTRODUCTION: The objective of this study is to analyze long-term outcomes and kidney function in children requiring continuous renal replacement therapy (CRRT) after an acute kidney injury episode. PATIENTS AND METHODS: A retrospective observational study was performed using a prospective database of 128 patients who required CRRT admitted to the pediatric intensive care unit between years 2006 and 2012. The subsequent outcomes were assessed in those surviving at hospital discharge. RESULTS: Of the 128 children who required RRT in the pediatric intensive care unit, 71 survived at hospital discharge (54.4%), of whom 66 (92.9%) were followed up. Three patients had chronic renal failure prior to admission to the NICU. Of the 63 remaining patients, 6 had prolonged or relapses of renal function disturbances, but only one patient with atypical Hemolytic Uremic Syndrome developed end-stage renal failure. The rest had normal kidney function at the last check-up. CONCLUSIONS: Most of surviving children that required CRRT have a positive outcome later on, presenting low mortality rates and recovery of kidney function in the medium term.

Prevalence of vertebral fractures and minor vertebral deformities evaluated by DXA-assisted vertebral fracture assessment (VFA) in a population-based study of postmenopausal women: the FRODOS study.

UNLABELLED: Population-based studies performed with vertebral fracture assessment (VFA) morphometric technology are lacking in postmenopausal osteoporosis. In this study, we show a lower than expected prevalence of vertebral fractures, a high prevalence of minor vertebral deformities, and a clear association with clinical and densitometric parameters indicating the usefulness of this approach. INTRODUCTION: Adequate epidemiological data on the prevalence of vertebral fractures (VF) is essential in studies of postmenopausal osteoporosis. Routine DXA-assisted VFA may be useful to determine the presence of VF. However, population-based studies performed with this technology are lacking. We aimed to assess the prevalence of VF and minor deformities in 2,968 postmenopausal women aged 59-70 years from a population-based cohort. METHODS: VFA and bone mineral density (BMD) measurements were conducted, and McCloskey criteria (vertebral heights under 3 SD from reference values) confirmed with the Genant method were used to define VF. Additionally, minor vertebral deformities (vertebral heights between -2 and -2.99 SD) were evaluated. RESULTS: The prevalence of VF was 4.3%, and 17% of the participants had minor vertebral deformities. Low BMD was frequently observed in women with VF, with 4%, and 42% of participants showing osteoporosis and osteopenia. Minor vertebral deformities were observed in nearly 40% of women with VF. Multivariate logistic regression analysis showed that age, history of previous fracture, osteoporotic BMD, receiving anti-osteoporotic treatment, and current use of glucocorticoids were significantly associated with VF. CONCLUSIONS: Although the VFA approach showed a lower than expected prevalence of VF in our cohort, its association with clinical and densitometric parameters may be useful to identify women at risk for developing fragility fractures and may therefore justify its use in longitudinal studies. The high prevalence of minor vertebral deformities detected in patients with VF indicates the need to evaluate this type of deformity as a risk factor for further skeletal fractures.

An antibiotic-resistant class 3 integron in an Enterobacter cloacae isolate from hospital effluent.

Hospital effluents are involved in dissemination of antibiotic-resistant integrons. We describe here a new class 3 integron, In3-5, detected in an Enterobacter cloacae isolate retrieved from a random French hospital effluent sample collected in 2009. In3-5 carries two gene cassettes: the new blaOXA -256 and an aac(6')-Ib variant, respectively conferring resistance to ß-lactams and aminoglycosides. In3-5 is located on an IncQ-like backbone plasmid. Class 3 integrons could thus be involved in the dissemination of antibiotic resistance in both clinical settings and the environment, and could participate in the exchange of antibiotic-resistance genes between these two ecosystems.

Monitoring of slaughterhouse wastewater biodegradation in a SBR using fluorescence and UV-Visible absorbance.

The aim of this study was to demonstrate that the effectiveness of slaughterhouse wastewater treatment by activated sludge could be enhanced through the use of optical techniques, such as UV-Visible absorbance and fluorescence spectroscopy, to estimate the hydraulic retention time necessary to remove the biodegradable chemical oxygen demand (COD). Two experiments were conducted. First, a batch aerobic degradation was performed on four wastewater samples collected from four different cattle processing sites in order to study the changes in the spectroscopic properties of wastewater during biodegradation. Second, a sequencing batch reactor was used in order to confirm that the wastewater fluorescence could be successfully used to monitor wastewater biodegradation in a pilot-scale experiment. Residual blood was the main source of organic matter in the wastewater samples. The absorbance at 416 nm, related to porphyrins, was correlated to the COD during wastewater biodegradation. The tryptophan-like/fulvic-like fluorescence intensity ratio was related to the extent of biodegradation. The COD removal efficiency ranged from 74% to 94% with an hydraulic retention time (HRT) of 23 h. A ratio of tryptophan-like/fulvic-like fluorescence intensities higher than 1.2 indicated incomplete biodegradation of the wastewater and the need to increase the HRT.

[Assessment of learning in blind orotracheal intubation with Fastrach masks using a cumulative sum curves (CuSum) in the SimMan Universal Simulator]. / Evaluación del aprendizaje de intubación orotraqueal a ciegas a través de mascarillas Fastrach mediante curvas de sumas acumulativas (CuSum) en el Simulador Universal SimMan.

OBJECTIVE: To assess training in blind intubation with the Fastrach laryngeal mask in a simulation model by applying the cumulative sums (CuSum) method. MATERIAL AND METHODS: Six anaesthesiology resident doctors, with no previous experience of the technique, participated, three in their first year, and three in the second. The study was conducted with the help of the SimMan Universal Simulator. Fifty attempts by each one of them over a four month period, divided into two stages: the first 20 with minimum airway difficulty, and the next 30 with limitations of flexion-extension movements to <80°. An unacceptable failure rate was set at 10% after a second failed attempt. The time limit set to be considered a success was 60seconds. RESULTS: A total of 120 attempts in the first stages, and the remaining 180 in the second were analysed individually, all managing to achieve acceptable success rates of 90%: 84% in the first attempt and 13.33% in the second. A total of 2.66% failures were recorded. The learning curve showed that the residents began to achieve an acceptable 90% success rate in case number 25±11.76 of the 50 attempts. CONCLUSIONS: This statistical method and the SimMan simulator, used together, have demonstrated to be very useful tools in assessing learning curves in this technique.

Evaluación del aprendizaje de intubación orotraqueal a ciegas a través de mascarillas Fastrach mediante curvas de sumas acumulativas (CuSum) en el Simulador Universal SimMan / Assessment of learning in blind orotracheal intubation with Fastrach masks using a cumulative sum curves (CuSum) in the SimMan Universal Simulator

Objetivos: Evaluar el aprendizaje de intubación a ciegas a través de mascarilla laríngea Fastrach en un modelo de simulación, mediante la aplicación del método de sumas acumulativas CuSum. Material y métodos: Participaron seis médicos residentes de Anestesiología, tres en su primer año y tres en el segundo, sin experiencia previa en la técnica. El estudio se realizó con la ayuda del Simulador Universal SimMan. A lo largo de 4 meses, se registraron 50 intentos en cada uno de ellos, divididos en dos etapas: los primeros 20 con mínima dificultad de vía aérea y los siguientes 30 con limitación a los movimientos de flexoextensión a < 80°. Se aceptó como índice inaceptable de fallo el 10% tras un segundo intento fallido. El límite temporal fijado para considerarlo éxito fue de 60 s. Resultados: Se analizaron 120 intentos en la primera etapa y los 180 restantes en la segunda, individualmente; todos lograron unos índices aceptables de éxito del 90%: el 84% en el primer intento y el 13,33% en el segundo. Se registró un 2,66% de fallos del total. La curva de aprendizaje mostró que los residentes lograron alcanzar el índice aceptable de éxito del 90% como media en el caso número 25 ± 11,76, de 50 casos. Conclusiones: Se ha demostrado que este método estadístico y el simulador SimMan utilizados conjuntamente son unas herramientas muy útiles en la evaluación del aprendizaje de esta técnica(AU)

Objective: To assess training in blind intubation with the Fastrach laryngeal mask in a simulation model by applying the cumulative sums (CuSum) method. Material and methods: Six anaesthesiology resident doctors, with no previous experience of the technique, participated, three in their first year, and three in the second. The study was conducted with the help of the SimMan Universal Simulator. Fifty attempts by each one of them over a four month period, divided into two stages: the first 20 with minimum airway difficulty, and the next 30 with limitations of flexion-extension movements to <80°. An unacceptable failure rate was set at 10% after a second failed attempt. The time limit set to be considered a success was 60 seconds. Results: A total of 120 attempts in the first stages, and the remaining 180 in the second were analysed individually, all managing to achieve acceptable success rates of 90%: 84% in the first attempt and 13.33% in the second. A total of 2.66% failures were recorded. The learning curve showed that the residents began to achieve an acceptable 90% success rate in case number 25±11.76 of the 50 attempts. Conclusions: This statistical method and the SimMan simulator, used together, have demonstrated to be very useful tools in assessing learning curves in this technique(AU)

Impact of copper and cadmium on aerobic and anaerobic digestibility of sonicated sludge.

The effects of the introduction of a sludge reduction process such as ultrasound on batch aerobic and anaerobic biodegradability after exposition to two metals (copper and cadmium) were investigated. The specific energy of ultrasonic treatment applied to the sludge was 200,000 kJ kg TS(-1). Ultrasonic treatment led to floc size reduction and to organic matter solubilization. Low copper (< 5 mg L(-1)) and cadmium (< 1 mg L(-1)) concentration improved aerobic biodegradability. For high metal concentration the maximal instantaneous biogas production rate q(max) inhibition by copper and cadmium was modeled by a saturation-type relationship under aerobic and anaerobic conditions. Under aerobic conditions, respiration inhibition was not affected by sonication. Cadmium inhibition (74%) was more than copper (58%). The positive effect of sonication on CO2 production was maintained after metal introduction. Under anaerobic conditions, metal introduction cancelled out the positive effect of the treatment. The sonicated sludge was 16% less sensitive to copper inhibition but 10% more sensitive to cadmium inhibition compared to non sonicated sludge.

Nursing workload predictors in Catalonia (Spain): a home care cohort study

Objective: To identify the characteristics of chronic patients and their environment in order to predictthe nursing workload required 1 year after their inclusion in a home care program.Methods: A longitudinal study was carried out in 72 primary health care teams in Catalonia (Spain)with a 1-year follow-up of 1,068 home care patients over 64 years old. The variables collected fromeach patient included data on health and social status (Charlson and Barthel indexes and the Pfeiffer,Braden and Gijon scales), carer overburden (Zarit scale), hospital admissions, use of emergency services,self-perceived health (SF-12) and the number of health worker visits.Results: Patients received 7.2 (SD 10.4) visits per year from their nurse-in-charge, out of a total of 8.7 (SD13.1) nursing visits per year. Risk factors for receiving more nursing visits at home were male gender(IRR = 1.42, 95%CI: 1.20-1.67), dependency for daily activities (IRR = 1.65, 95%CI: 1.29-2.13), decubitusulcers (IRR = 4.03, 95%CI: 2.27-7.14) and receiving emergency medical care at home (IRR = 1.65, 95%CI:1.31-2.07). In contrast, patients with major cognitive impairment (IRR = 0.78, 95%CI: 0.63-0.98) had alower probability of receiving nursing visits at home.Conclusions: Workload can be predicted by patients’ clinical characteristics. The positive correlation ofworkload with variables related to disease severity and the negative correlation with variables relatedto cognitive impairment show that home care nursing in Catalonia is basically demand-oriented (AU)

Objetivo: Identificar las características basales de los pacientes crónicos y su entorno que predicen la cargade trabajo de enfermería durante el a˜no siguiente a su inclusión en un programa de atención domiciliaria(ATDOM).Métodos: Estudio longitudinal realizado en 72 equipos de atención primaria de salud en Catalu˜na.Seguimiento durante un a˜no de 1068 pacientes de ATDOM mayores de 64 a˜nos de edad. Variables recogidas:nivel de salud y situación social (test de Charlson, Barthel, Pfeiffer, Braden y Gijón); sobrecarga delcuidador (Test de Zarit); ingresos hospitalarios y visitas a urgencias; estado subjetivo de salud (SF-12);visitas de los profesionales de salud.Resultados: Los pacientes recibieron 7,2 (DE: 10,4) visitas anuales de su enfermera habitual. Observamosque tienen más riesgo de recibir visitas de enfermería los pacientes varones (IRR = 1,42, IC95%: 1,20-1,67), con dependencia para las actividades de la vida diaria (IRR = 1,65, IC95%: 1,29-2,13), afectados porúlceras por decúbito (IRR = 4,03, IC95%: 2,27-7,14) y que precisaron servicios de atención de urgencia adomicilio (IRR = 1,65, IC95%: 1,31-2,07). Por otro lado, los pacientes con deterioro cognitivo importantetienen menos probabilidad de recibir visitas de su enfermera (IRR = 0,78, IC95%: 0,63-0,98).Conclusiones: Las características clínicas de los pacientes permiten predecir la carga de trabajo de enfermería.Esta relación positiva de la carga de trabajo con las variables relacionadas con la gravedad de laenfermedad y la relación negativa con el deterioro cognitivo muestra que la enfermería domiciliaria enCataluña está básicamente orientada a la demanda(AU)

Nursing workload predictors in Catalonia (Spain): a home care cohort study.

OBJECTIVE: To identify the characteristics of chronic patients and their environment in order to predict the nursing workload required 1 year after their inclusion in a home care program. METHODS: A longitudinal study was carried out in 72 primary health care teams in Catalonia (Spain) with a 1-year follow-up of 1,068 home care patients over 64 years old. The variables collected from each patient included data on health and social status (Charlson and Barthel indexes and the Pfeiffer, Braden and Gijon scales), carer overburden (Zarit scale), hospital admissions, use of emergency services, self-perceived health (SF-12) and the number of health worker visits. RESULTS: Patients received 7.2 (SD 10.4) visits per year from their nurse-in-charge, out of a total of 8.7 (SD 13.1) nursing visits per year. Risk factors for receiving more nursing visits at home were male gender (IRR=1.42, 95%CI: 1.20-1.67), dependency for daily activities (IRR=1.65, 95%CI: 1.29-2.13), decubitus ulcers (IRR=4.03, 95%CI: 2.27-7.14) and receiving emergency medical care at home (IRR=1.65, 95%CI: 1.31-2.07). In contrast, patients with major cognitive impairment (IRR=0.78, 95%CI: 0.63-0.98) had a lower probability of receiving nursing visits at home. CONCLUSIONS: Workload can be predicted by patients' clinical characteristics. The positive correlation of workload with variables related to disease severity and the negative correlation with variables related to cognitive impairment show that home care nursing in Catalonia is basically demand-oriented.

Techno-economic evaluation of thermal treatment, ozonation and sonication for the reduction of wastewater biomass volume before aerobic or anaerobic digestion.

Aerobic and anaerobic digestions were compared with different sludge reduction processes such as ultrasonic, ozone, and thermal treatments. Each treatment was tested under the following conditions to improve batch aerobic or anaerobic digestion: ultrasound (200,000kJkgTS(0)(-1)), thermal (40 degrees C, 60 degrees C, 90 degrees C for 90 min, 120 degrees C 15 min, 1 bar), and ozonation (0.1gO(3)gTS(0)(-1)). The different pretreatments induced organic matter solubilisation and intrinsic sludge reduction (total suspended solids): ultrasound (47%), thermal 90 degrees C (16%), ozone (15%), thermal 60 degrees C (9%), thermal 40 degrees C (5%), autoclave (120 degrees C) (4.2%). TSS (and also VSS) solubilisation were found to be highly correlated to the pretreatment ability to break the flocs rather than to specific energy input. The total values of TSS reduction ranged from 57% to 71% under aerobic conditions and from 66% to 86% under anaerobic conditions. TSS solubilisation after pretreatment can be considered as a predictive parameter of sludge volume reduction enhancement after aerobic or anaerobic digestion while specific energy input did not show anything or negligible impact. In our experimental conditions, ultrasound and ozone led to the best TSS removal improvement after both aerobic (30% and 20%) and anaerobic digestion (20%). Ultrasonic and ozone pretreatments prior to aerobic or anaerobic digestion led to the best reduction of the specific energy required for removing 1 kg of TSS compared to the control. Anaerobic digestion was globally more effective (compare to aerobic digestion) in enhancing sludge production reduction.

[Health problems also explain social services use in home care]. / Los problemas de salud también explican la utilización de servicios sociales en atención domiciliaria.

OBJECTIVE: To identify which social and health variables are associated with receiving social services in patients included in home care programmes with the implementation of the Dependence Law. DESIGN: Cross-sectional study. SETTING: 72 primary health care teams in Catalonia. PATIENTS: Patients over 64 years old with chronic diseases in home care programmes in Catalonia. MEASUREMENTS: Health status variables: Charlson, Barthel, Pfeiffer, Braden and Gijon, data from their carer (Zarit), self perception of health (SF-12), health professional visits, as well as: emergency visits, temporary admissions, and final results such as death or definitive admission in a nursing home or a hospital. RESULTS: A total of 1068 patients were included, 46.8% of the patients received some kind of social service, public or private. We observed that the variables related to receive some kind of social services are: high dependence (Barthel test), pressure sores and home care rehabilitation. Barthel test is highly associated with having social problems (Gijon test), living without an informal carer, more than 2 GP visits and having additional private health care. CONCLUSIONS: To be more fair, the evaluation of the provisions of the Dependence Law should also consider the health status of the patient. With the implementation of this law we can observe difficulties in access to social services for middle class patients. These patients do not have access to public social assistance and cannot pay for a private one. Social services are still an alternative to family care.

Los problemas de salud también explican la utilización de servicios sociales en atención domiciliaria / Health problems also explain social services use in home care

Objetivo: identificar las variables relacionadas con el hecho de recibir servicios sociales de carácter público o privado antes de la implantación de la Ley de Dependencia en pacientes recluidos en sus domicilios. Diseño: estudio descriptivo transversal. Emplazamiento: 72 equipos de atención primaria de Cataluña (EAP). Participantes: pacientes mayores de 64 años, no institucionalizados atendidos por un programa de atención domiciliaria de los EAP. Mediciones principales: de cada paciente se registraron: comorbilidad, estado funcional, estado cognitivo, si tenía úlceras por presión, salud subjetiva, valoración social, utilización de servicios sociales y sanitarios formales e informales, sobrecarga del cuidador, ingresos en residencias, hospitales o urgencias, además del número de visitas de profesionales santiarios. Resultados: participan 1.068 pacientes, el 46,8% recibe algún servicio social. Las variables relacionadas con la prestación de servicios sociales son: el grado de dependencia (Barthel), las úlceras por presión y recibir rehabilitación a domicilio. El test de Barthel está firmemente asociado a la problemática social (Gijón), carecer de cuidador informal, más de dos visitas de médico de familia y tener sanidad privada adicional. Conclusiones: para ser más equitativa, la valoración de las prestaciones de la Ley de Dependencia debería considerar también el estado de salud. Antes de la aplicación de esta ley se intuye una dificultad de acceso a los servicios sociales formales para las clases medias que no acceden a las prestaciones públicas ni pueden pagarlas. Las prestaciones sociales son todavía una alternativa a la atención familiar(AU)

Objective: To identify which social and health variables are associated with receiving social services in patients included in home care programmes with the implementation of the Dependence Law. Design: Cross-sectional study. Setting: 72 primary health care teams in Catalonia. Patients: Patients over 64 years old with chronic diseases in home care programmes in Catalonia. Measurements: Health status variables: Charlson, Barthel, Pfeiffer, Braden and Gijon, data from their carer (Zarit), self perception of health (SF-12), health professional visits, as well as: emergency visits, temporary admissions, and final results such as death or definitive admission in a nursing home or a hospital. Results: A total of 1068 patients were included, 46.8% of the patients received some kind of social service, public or private. We observed that the variables related to receive some kind of social services are: high dependence (Barthel test), pressure sores and home care rehabilitation. Barthel test is highly associated with having social problems (Gijon test), living without an informal carer, more than 2 GP visits and having additional private health care. Conclusions: To be more fair, the evaluation of the provisions of the Dependence Law should also consider the health status of the patient. With the implementation of this law we can observe difficulties in access to social services for middle class patients. These patients do not have access to public social assistance and cannot pay for a private one. Social services are still an alternative to family care(AU)