Body composition assessment with ultrasound muscle measurement: optimization through the use of semi-automated tools in colorectal cancer

Colorectal cancer (CRC) is a disease with a high prevalence and major impact on global health. Body composition (BC) data are of great importance in the assessment of nutritional status. Ultrasound (US) is an emerging, accessible and non-invasive technique that could be an alternative when it is not feasible to perform computed tomography (CT). The aim of this study is to evaluate the correlation between CT, as a reference technique, and US of the rectus femoris (RF) as a "proof of concept," in a cohort of patients with CRC and assess the optimisation of results obtained by US when performed by our new semi-automated tool. A single-centre cross-sectional study including 174 patients diagnosed with CRC and undergoing surgery was carried out at the Vall d'Hebron Hospital. We found a strong correlation between CT and US of the RF area (r = 0.67; p < 0.005). The latter, is able to discriminate patients with worse prognosis in terms of length of hospital stay and discharge destination (AUC-ROC = 0.64, p 0.015). These results improve when they are carried out with the automatic tool (area AUC-ROC = 0.73, p 0.023), especially when normalised by height and eliminating patients who associate overflow. According to our results, the US could be considered as a valuable alternative for the quantitative assessment of muscle mass when CT is not feasible. These measurements are improved when measuring software is applied, such as "Bat" software.

Mid-trimester uterine artery Doppler for aspirin discontinuation in pregnancies at high risk for preterm pre-eclampsia: Post-hoc analysis of StopPRE trial

OBJECTIVE

To assess whether aspirin treatment can be discontinued in pregnancies with normal uterine artery pulsatility index (≤90th percentile) at 24-28 weeks.

DESIGN

Post-hoc analysis of a clinical trial.

SETTING

Nine maternity hospitals in Spain.

POPULATION OR SAMPLE

Pregnant individuals at high risk of pre-eclampsia at 11-13 weeks and normal uterine artery Doppler at 24-28 weeks.

METHODS

All participants received treatment with daily aspirin at a dose of 150 mg. Participants were randomly assigned, in a 1:1 ratio, either to continue aspirin treatment until 36 weeks (control group) or to discontinue aspirin treatment (intervention group), between September 2019 and September 2021. In this secondary analysis, women with a UtAPI >90th percentile at 24-28 weeks were excluded. The non-inferiority margin was set at a difference of 1.9% for the incidence of preterm pre-eclampsia.

MAIN OUTCOME MEASURES

Incidence of preterm pre-eclampsia.

RESULTS

Of the 1611 eligible women, 139 were excluded for UtAPI >90th percentile or if UtAPI was not available. Finally, 804 were included in this post-hoc analysis. Preterm pre-eclampsia occurred in three of 409 (0.7%) women in the aspirin discontinuation group and five of 395 (1.3%) women in the continuation group (-0.53; 95% CI -1.91 to 0.85), indicating non-inferiority of aspirin discontinuation.

CONCLUSIONS

Discontinuing aspirin treatment at 24-28 weeks in women with a UtAPI ≤90th percentile was non-inferior to continuing aspirin treatment until 36 weeks for preventing preterm pre-eclampsia.

Clinical effectiveness of routine first-trimester combined screening for pre-eclampsia in Spain with the addition of placental growth factor

INTRODUCTION

Pre-eclampsia affects 2%-8% of pregnancies and is one of the leading causes of maternal and perinatal morbidity and mortality. First-trimester screening using an algorithm that combines maternal characteristics, mean arterial blood pressure, uterine artery pulsatility index and biomarkers (pregnancy-associated plasma protein-A and placental growth factor) is the method that achieves a greater diagnostic accuracy. It has been shown that daily salicylic acid administration before 16 weeks in women at a high risk for pre-eclampsia can reduce the incidence of preterm pre-eclampsia. However, no previous studies have evaluated the impact of routine first-trimester combined screening for pre-eclampsia with placental growth factor after being implemented in the clinical practice.

MATERIAL AND METHODS

This was a multicenter cohort study conducted in eight different maternities across Spain. Participants in the reference group were prospectively recruited between October 2015 and September 2017. Participants in the study group were retrospectively recruited between March 2019 and May 2021. Pre-eclampsia risk was calculated between 11+0 and 13+6  weeks using the Gaussian algorithm combining maternal characteristics, mean arterial pressure, uterine arteries pulsatility index, pregnancy-associated plasma protein-A and placental growth factor. Patients with a risk greater than 1/170 were prescribed daily salicylic acid 150 mg until 36 weeks. Patients in the reference group did not receive salicylic acid during gestation.

RESULTS

A significant reduction was observed in preterm pre-eclampsia (OR 0.47; 95% CI: 0.30-0.73), early-onset (<34 weeks) pre-eclampsia (OR 0.35; 95% CI: 0.16-0.77), preterm small for gestational age newborn (OR 0.57; 95% CI: 0.40-0.82), spontaneous preterm birth (OR 0.72; 95% CI: 0.57-0.90), and admission to intensive care unit (OR 0.55; 95% CI: 0.37-0.81). A greater treatment adherence resulted in a significant reduction in adverse outcomes.

CONCLUSIONS

Routine first-trimester screening for pre-eclampsia with placental growth factor leads to a reduction in preterm pre-eclampsia and other pregnancy complications. Aspirin treatment compliance has a great impact on the effectiveness of this screening program.

Aspirin Discontinuation at 24 to 28 Weeks' Gestation in Pregnancies at High Risk of Preterm Preeclampsia: A Randomized Clinical Trial

Importance

Aspirin reduces the incidence of preterm preeclampsia by 62% in pregnant individuals at high risk of preeclampsia. However, aspirin might be associated with an increased risk of peripartum bleeding, which could be mitigated by discontinuing aspirin before term (37 weeks of gestation) and by an accurate selection of individuals at higher risk of preeclampsia in the first trimester of pregnancy.

Objective

To determine whether aspirin discontinuation in pregnant individuals with normal soluble fms-like tyrosine kinase-1 to placental growth factor (sFlt-1:PlGF) ratio between 24 and 28 weeks of gestation was noninferior to aspirin continuation to prevent preterm preeclampsia.

Design, Setting, and Participants

Multicenter, open-label, randomized, phase 3, noninferiority trial conducted in 9 maternity hospitals across Spain. Pregnant individuals (n = 968) at high risk of preeclampsia during the first-trimester screening and an sFlt-1:PlGF ratio of 38 or less at 24 to 28 weeks of gestation were recruited between August 20, 2019, and September 15, 2021; of those, 936 were analyzed (intervention: n = 473; control: n = 463). Follow-up was until delivery for all participants.

Interventions

Enrolled patients were randomly assigned in a 1:1 ratio to aspirin discontinuation (intervention group) or aspirin continuation until 36 weeks of gestation (control group).

Main Outcomes and Measures

Noninferiority was met if the higher 95% CI for the difference in preterm preeclampsia incidences between groups was less than 1.9%.

Results

Among the 936 participants, the mean (SD) age was 32.4 (5.8) years; 3.4% were Black and 93% were White. The incidence of preterm preeclampsia was 1.48% (7/473) in the intervention group and 1.73% (8/463) in the control group (absolute difference, -0.25% [95% CI, -1.86% to 1.36%]), indicating noninferiority.

Conclusions and Relevance

Aspirin discontinuation at 24 to 28 weeks of gestation was noninferior to aspirin continuation for preventing preterm preeclampsia in pregnant individuals at high risk of preeclampsia and a normal sFlt-1:PlGF ratio.

Trial Registration

ClinicalTrials.gov Identifier: NCT03741179 and ClinicalTrialsRegister.eu Identifier: 2018-000811-26.

Shared risk factors for COVID-19 and preeclampsia in the first trimester: An observational study

INTRODUCTION

The association between preeclampsia and coronavirus disease 2019 (COVID-19) is under study. Previous publications have hypothesized the existence of shared risk factors for both conditions or a deficient trophoblastic invasion as possible explanations for this association. The primary aim of this study was to examine baseline risk factors measured in the first-trimester combined screening for preeclampsia in pregnant women with COVID-19 compared with the general population. A secondary aim of this study was to compare risk factors among patients with mild and severe COVID-19.

MATERIAL AND METHODS

This was an observational retrospective study conducted at Vall d'Hebron Hospital Campus (Catalonia, Spain). Study patients were 231 pregnant women undergoing the first-trimester screening for preeclampsia and positive for severe acute respiratory syndrome coronavirus 2 between February 2020 and September 2021. The reference cohort were 13 033 women of the general population from six centers across Catalonia from May 2019 to June 2021. Based on the need for hospitalization, patients were classified in two groups: mild and severe COVID-19. First-trimester screening for preeclampsia included maternal history, mean arterial blood pressure, mean uterine artery pulsatility index (UtAPI), placental growth factor (PlGF), and pregnancy-associated plasma protein-A (PAPP-A).

RESULTS

The proportion of cases at high risk for preeclampsia was significantly higher among the COVID-19 group compared with the general population (19.0% and 13.2%, respectively; p = 0.012). When analyzing risk factors for preeclampsia individually, women with COVID-19 had higher median body mass index (25.2 vs 24.5, p = 0.041), higher UtAPI multiple of the median (MoM) (1.08 vs 1.00, p < 0.001), higher incidence of chronic hypertension (2.8% vs 0.9%, p = 0.015), and there were fewer smokers (5.7% vs 11.6%, p = 0.007). The MoMs of PlGF and PAPP-A did not differ significantly between both groups (0.96 vs 0.97, p = 0.760 and 1.00 vs 1.01, p = 0.432; respectively).

CONCLUSIONS

In patients with COVID-19, there was a higher proportion of women at high risk for preeclampsia at the first-trimester screening than in the general population, mainly because of maternal risk factors, rather than placental signs of a deficient trophoblastic invasion.

Implementation of routine first-trimester combined screening for preeclampsia based on the Gaussian algorithm: A clinical effectiveness study

OBJECTIVE

To evaluate the clinical effectiveness of the routine first-trimester screening for preeclampsia (PE) after being implemented in six Catalan maternities.

METHODS

Participants in the reference group were recruited prospectively between October 2015 and September 2017. Participants in the study group were recruited retrospectively between November 2018 and May 2019, after implementing the screening program. PE risk was assessed between 11 + 0 and 13 + 6 weeks of gestation using the Gaussian algorithm combining maternal characteristics, mean arterial blood pressure, uterine artery pulsatility index, and maternal serum pregnancy-associated plasma protein-A. Women with a risk ≥1/137 were prescribed daily salicylic acid (150 mg) until 36 weeks of gestation.

RESULTS

Preterm PE occurred in 30 of 2641 participants (1.14%) in the reference group, as compared with 18 of 2848 participants (0.63%) in the study group (OR: 0.55; 95% CI, 0.31-0.99; P = 0.045). In the reference group, 37 participants (1.40%) were admitted to ICU, as compared with 23 participants (0.81%) in the study group (OR: 0.57; 95% CI, 0.34-0.96; P = 0.035).

CONCLUSION

The routine first-trimester PE screening can be implemented in a public healthcare setting, leading to a significant reduction in the incidence of preterm PE and of maternal ICU admission.

Effects of the interaction between nutrient concentration and DIN:SRP ratio on geosmin production by freshwater biofilms

The global increase of cyanobacterial blooms occurrence has been associated with the presence of compounds that generate earthy and musty odor in freshwater systems, among which geosmin stands out. The lack of information on the factors associated to geosmin production by benthic organisms has driven the development of this study, whose main goal is to determine the effects of nutrient concentration and DIN:SRP ratio on geosmin formation and release. The experiment was performed in 18 microcosms under controlled conditions for 21 days, using a natural biofilm suspension from Ter river (NE, Spain) to promote biofilm settlement. Six treatments were set crossing three DIN:SRP ratios (A = 4:1, B = 16:1 and C = 64:1) with two nutrient concentrations (Low and High). After 7 days of experiment, geosmin was detected in biofilm, being higher under high nutrient concentration and low DIN:SRP ratio conditions. In this treatment, geosmin in biofilm reached its maximum concentration at day 16 (3.8 ± 0.9 ng/mg), decreasing at the end of the experiment (21d) due to cyanobacteria detachment and geosmin release into the water (136 ± 6 ng/L). Overall, this experimental study showed that high nutrient concentration and low DIN:SRP ratio favored the Oscillatoria genus development within biofilm communities, generating the optimal conditions for geosmin production. The interaction between these two factors was demonstrated to be a potential driver of benthic geosmin production and release, and should be monitored and controlled in rivers exploited for drinking water purposes.

Water Flow and Light Availability Influence on Intracellular Geosmin Production in River Biofilms

Hydro-morphological alterations in water bodies caused by climate change and human activities affects the ecosystem functioning and generate important water quality problems. Some of these alterations can generate an increase in cyanobacterial blooms, which are associated with the appearance of bad taste and odorous compounds such as geosmin. The factors that trigger their production are still unclear, and this inability to predict geosmin episodes provokes economic problems for water supply companies. This study aims to evaluate the effects of water flow and light availability on biofilm development and intracellular geosmin formation. A mesocosm experiment was performed between February–April, 2019. The mesocosms were a set of 10 outdoor 3 m long flumes, with a continuous water supply from the Ter river (Catalonia, NE Spain). Two light intensities were established: natural light and light reduced to 80%, combined with five gradual water flows from 0.09 to 1.10 L/s. Water samples were taken to analyze nutrients, and biofilm samples, to analyze geosmin concentration, chlorophyll a and the community. Geosmin in biofilm was detected in those treatments in which Oscillatoria sp. appeared. The concentration of intracellular geosmin was higher at lower water flows (0.09 and 0.18 L/s), and the highest (2.12 mg/g) was found in the flume with the lowest water flow (0.09 L/s) and irradiation (20%). This flume was the one that presented a greater concentration of Oscillatoria sp. (21% of the community). It stands out that, when geosmin in biofilm was found, the dissolved inorganic nitrogen and soluble reactive phosphorus ratio decreased, from an average of 417:1 to 14:1. This was mainly due to an increase in inorganic phosphorus concentration generated by a change in the nutrient uptake capacity of the community’s biofilm. The results obtained in this study indicated the potential implications for stream ecosystem management to control geosmin appearance. Likewise, they could be used as an early warning system, establishing that in times of drought, which lead to a general decrease in river water flow, the situation could be optimal for the appearance and development of geosmin producing cyanobacteria in low-flow areas near the river banks.

Impact of aspirin on trophoblastic invasion in women with abnormal uterine artery Doppler at 11-14 weeks: a randomized controlled study

OBJECTIVE

Defective trophoblastic invasion is a key feature in many cases of pre-eclampsia (PE). Uterine artery (UtA) Doppler is a validated non-invasive proxy for trophoblastic invasion. The aim of this study was to explore whether low-dose aspirin, administered from the first trimester, improves trophoblastic invasion, evaluated by UtA Doppler during the second and third trimesters in women defined as high risk by abnormal first-trimester UtA Doppler.

METHODS

This randomized Phase-II study had a triple-blind, parallel-arm, controlled design. Singleton pregnancies with abnormal mean UtA Doppler at 11-14 weeks and absence of other major risk factors for PE received 150 mg extended-release aspirin or identical-appearing placebo tablets from study inclusion to 28 weeks. Main outcome measure was UtA pulsatility index (PI) at 28 weeks' gestation. Secondary outcomes included frequency of development of PE and growth restriction/small-for-gestational age (SGA).

RESULTS

A total of 155 women completed the follow-up and were analyzed. No difference in mean UtA-PI was found between women in the aspirin and placebo groups at 28 weeks (mean UtA-PI Z-score (mean ± SD), 0.99 ± 1.48 vs 0.85 ± 1.25; P = 0.52). Seven women developed PE: four (5%) in the aspirin group and three (4%) in the placebo group. There was a trend toward lower incidence of SGA in the aspirin group (8.8% vs 17.3%; P = 0.11).

CONCLUSION

In women with defective trophoblastic invasion, as reflected by abnormal UtA Doppler, low-dose aspirin started in the first trimester does not have a significant effect on UtA impedance as pregnancy progresses; however, the study was underpowered to detect potential small effects . Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Pharmaceuticals and pesticides in reclaimed water: Efficiency assessment of a microfiltration-reverse osmosis (MF-RO) pilot plant

Water reuse is becoming a common practice in several areas in the world, particularly in those impacted by water scarcity driven by climate change and/or by rising human demand. Since conventional wastewater treatment plants (WWTPs) are not able to efficiently remove many organic contaminants and pathogens, more advanced water treatment processes should be applied to WWTP effluents for water reclamation purposes. In this work, a pilot plant based on microfiltration (MF) followed by reverse osmosis (RO) filtration was applied to the effluents of an urban WWTP. Both the WWTP and the pilot plant were investigated with regards to the removal of a group of relevant contaminants widely spread in the environment: 28 pharmaceuticals and 20 pesticides. The combined treatment by the MF-RO system was able to quantitatively remove the target micropollutants present in the WWTP effluents to values either in the low ng/L range or below limits of quantification. Monitoring of water quality of reclaimed water and water reclamation sources is equally necessary to design the most adequate treatment procedures aimed to water reuse for different needs.

Hydrological variation modulates pharmaceutical levels and biofilm responses in a Mediterranean river

The Llobregat is a Mediterranean river that is severely impacted by anthropogenic pressures. It is characterized by high flow variability which modulates its chemical and biological status. The present work evaluates the effects of flow changes on the concentration of pharmaceutically active compounds (PhACs) and their relationship to cellular parameters of river biofilms. To this end, at two selected sampling sites at the lower course of the Llobregat river, surface water samples were collected twice a week over two hydrologically different periods exhibiting low and high river flows. Higher levels of PhACs were detected at the downstream sampling site. Irrespective of the flow regime, analgesics, anti-inflammatories and lipid regulators were the most abundant substances at both sampling sites with total concentrations of up to 1,000 ng/L and 550 ng/L at the upstream and downstream sites, respectively. Antibiotics (fluoroquinolones) and psychiatric treatment drugs were also detected at high levels in the second campaign achieving concentrations of up to 500 ng/L. The principal component analysis (PCA) performed with the PhACs concentrations of the two campaigns revealed differences in the various therapeutic groups depending on sampling site and period. After a flash flood event during the second sampling period, dilution of PhACs occurred, but their average concentrations measured before the flood were restored within two weeks. For the majority of compounds, PhAC concentrations displayed an inverse relationship with river discharge The effects of water containing different concentrations of PhACs on biofilm communities were evaluated and related to flow regime variations. Translocation of biofilm communities from a less to a more polluted site of the river demonstrated an increase in bacteria mortality in the translocated biofilms. After the flood, extracellular peptidase activity and chlorophyll-a concentration were significantly reduced, and biofilm growth rate was significantly lower.

Assessment of multi-chemical pollution in aquatic ecosystems using toxic units: compound prioritization, mixture characterization and relationships with biological descriptors

Chemical pollution is typically characterized by exposure to multiple rather than to single or a limited number of compounds. Parent compounds, transformation products and other non-targeted compounds yield mixtures whose composition can only be partially identified by monitoring, while a substantial proportion remains unknown. In this context, risk assessment based on the application of additive ecotoxicity models, such as concentration addition (CA), is rendered somewhat misleading. Here, we show that ecotoxicity risk information can be better understood upon consideration of the probabilistic distribution of risk among the different compounds. Toxic units of the compounds identified in a sample fit a lognormal probability distribution. The parameters characterizing this distribution (mean and standard deviation) provide information which can be tentatively interpreted as a measure of the toxic load and its apportionment among the constituents in the mixture (here interpreted as mixture complexity). Furthermore, they provide information for compound prioritization tailored to each site and enable prediction of some of the functional and structural biological variables associated with the receiving ecosystem. The proposed approach was tested in the Llobregat River basin (NE Spain) using exposure and toxicity data (algae and Daphnia) corresponding to 29 pharmaceuticals and 22 pesticides, and 5 structural and functional biological descriptors related to benthic macroinvertebrates (diversity, biomass) and biofilm metrics (diatom quality, chlorophyll-a content and photosynthetic capacity). Aggregated toxic units based on Daphnia and algae bioassays provided a good indication of the pollution pattern of the Llobregat River basin. Relative contribution of pesticides and pharmaceuticals to total toxic load was variable and highly site dependent, the latter group tending to increase its contribution in urban areas. Contaminated sites' toxic load was typically dominated by fewer compounds as compared to cleaner sites where more compounds contribute.

Establishing potential links between the presence of alkylphenolic compounds and the benthic community in a European river basin

INTRODUCTION

Concentrations of alkylphenolic compounds (APCs) in water and sediments were related to the composition and functional descriptors of the benthic community (biofilm and macroinvertebrates).

MATERIALS AND METHODS

Samples were collected in four sampling campaigns at seven sampling points in the lower Llobregat catchment area (NE Spain). Water and sediment samples underwent chemical target analysis for nine APCs, which are known to disrupt the endocrine system.

RESULTS AND DISCUSSIONS

APCs were the main stressors on the diatom community but not on the macroinvertebrate community.

CONCLUSIONS

Benthic invertebrates were mostly affected by the general physicochemical water characteristics (where conductivity was a surrogate). Nonylphenol only had an influence on the diatom community in water but not in the remaining compartments, probably because of the low concentrations observed in the environment.

Triclosan persistence through wastewater treatment plants and its potential toxic effects on river biofilms

Triclosan is a commonly used bactericide that survives several degradation steps in WWTP (wastewater treatment plants) and potentially reaches fluvial ecosystems. In Mediterranean areas, where water scarcity results in low dilution capacity, the potential environmental risk of triclosan is high. A set of experimental channels was used to examine the short-term effects of triclosan (from 0.05 to 500μgL⁻¹) on biofilm algae and bacteria. Environmentally relevant concentrations of triclosan caused an increase of bacterial mortality with a no effect concentration (NEC) of 0.21μgL⁻¹. Dead bacteria accounted for up to 85% of the total bacterial population at the highest concentration tested. The toxicity of triclosan was higher for bacteria than algae. Photosynthetic efficiency was inhibited with increasing triclosan concentrations (NEC=0.42μgL⁻¹), and non-photochemical quenching mechanisms decreased. Diatom cell viability was also affected with increasing concentrations of triclosan. Algal toxicity may be a result of indirect effects on the biofilm toxicity, but the clear and progressive reduction observed in all the algal-related endpoints suggest the existence of direct effects of the bactericide. The toxicity detected on the co-occurring non-target components of the biofilm community, the capacity of triclosan to survive through WWTP processes and the low dilution capacity that characterizes Mediterranean systems extend the relevance of triclosan toxicity beyond bacteria in aquatic habitats.

Does grazing pressure modify diuron toxicity in a biofilm community?

Herbicides affect the structure and functional parameters of fluvial biofilm. Diuron is toxic to primary producers and disrupts endocrine activity. Here, we studied the interaction between this toxicant and several biological compartments in a simple food chain composed of herbivores (the snail Physella [Costatella] acuta) and biofilm. We used indoor experimental channels to which Diuron was added at a realistic concentration (2 mug/L). Bacterial survival and chlorophyll-a and photosynthetic activity were analyzed in the biofilm. We monitored biomass, mortality, reproduction, and motility as end points in the freshwater snail P. acuta. Our results showed that bacterial survival and photosynthetic activity were sensitive to Diuron. Snails were not affected by the herbicide at the concentration tested. No significant interactions between the toxicant and grazers were observed on the biofilm. Reproductive traits, however, were slightly affected, indicating a possible endocrine disruption.

Fluvial biofilms: A pertinent tool to assess beta-blockers toxicity

Among increasingly used pharmaceutical products, beta-blockers have been commonly reported at low concentrations in rivers and littoral waters of Europe and North America. Little is known about the toxicity of these chemicals in freshwater ecosystems while their presence may lead to chronic pollution. Hence, in this study the acute toxicity of 3 beta-blockers: metoprolol, propranolol and atenolol on fluvial biofilms was assessed by using several biomarkers. Some were indicative of potential alterations in biofilm algae (photosynthetic efficiency), and others in biofilm bacteria (peptidase activity, bacterial mortality). Propranolol was the most toxic beta-blocker, mostly affecting the algal photosynthetic process. The exposure to 531microg/L of propranolol caused 85% of inhibition of photosynthesis after 24h. Metoprolol was particularly toxic for bacteria. Though estimated No-Effect Concentrations (NEC) were similar to environmental concentrations, higher concentrations of the toxic (503microg/L metoprolol) caused an increase of 50% in bacterial mortality. Atenolol was the least toxic of the three tested beta-blockers. Effects superior to 50% were only observed at very high concentration (707mg/L). Higher toxicity of metoprolol and propranolol might be due to better absorption within biofilms of these two chemicals. Since beta-blockers are mainly found in mixtures in rivers, their differential toxicity could have potential relevant consequences on the interactions between algae and bacteria within river biofilms.

Bridging levels of pharmaceuticals in river water with biological community structure in the Llobregat River basin (northeast Spain)

A wide range of human pharmaceuticals are present at low concentrations in freshwater systems, particularly in sections of polluted river. These compounds show high biological activity, often associated with a high stability. These characteristics imply a potential impact of these substances on aquatic biota even when present at low environmental concentrations. Low flow conditions in Mediterranean rivers, most of which flow through densely populated areas and are subjected to intensive water use, increase the environmental risk of these emergent compounds. Here, we studied whether pharmaceuticals in river water affect the local benthic community structure (diatoms and invertebrates). For this purpose, we analyzed the occurrence of pharmaceuticals along the Llobregat River and examined the benthic community structure (diatoms and invertebrates) of this system. Some pharmaceutical products in the Llobregat River registered concentrations greater than those cited in the literature. Multivariate analyses revealed a potential causal association between the concentrations of some anti-inflammatories and beta-blockers and the abundance and biomass of several benthic invertebrates (Chironomus spp. and Tubifex tubifex). Further interpretation in terms of cause-and-effect relationships is discussed; however, it must be always taken with caution because other pollutants also may have significant contributions. Combined with further community experiments in the laboratory, our approach could be a desirable way to proceed in future risk management decisions.

Effects of low concentrations of the phenylurea herbicide diuron on biofilm algae and bacteria

A system of recirculating channels was used in this study to examine the long-term effects (29d) of environmentally realistic concentrations of the herbicide diuron (from 0.07 to 7 microg L(-1)) on biofilm communities. The autotrophic activity of biofilms was affected by this herbicide, as reflected by a marked decrease in the photosynthetic efficiency. Diuron exposure also increased chlorophyll-a content and reduced the biovolume of diatom taxa at low concentrations. The effects on bacteria were also remarkable. Bacterial abundance was reduced after a week of exposure to the herbicide at a range of concentrations. Effects were on the number of live bacteria and on the increase in the leucine-aminopeptidase activity. It is suggested that inputs of herbicides to the river ecosystem at low concentrations may cause a chain of effects in the biofilm, which include inhibitory effects on algae but also indirect effects on the relationships between biofilm components.

Monitoring the effect of chemicals on biological communities. The biofilm as an interface

Biofilms can be regarded as early warning systems for detection of the effects of toxicants on aquatic systems, because they have been successfully used for detection of other environmental stressors (e.g. pH, salinity, organic pollution). A variety of methods is used for detection of the effects of toxicants by use of biofilms. The methods range from structurally-based to functionally-based, and from in vitro-based to systemic approaches. Physiological approaches may be appropriate for detection of acute effects. Among these methods, photosynthesis is more related to the effect of toxicants affecting algal communities, directly or indirectly, and extracellular enzyme activity is less specific. Selecting one or the other may depend on the suspected direct effect of the toxicant. Integrated studies have revealed the relevance of toxicants to top-down or bottom-up regulation of the biofilm community. Persistent or chronic effects should affect other biofilm indicators, for example growth or biomass-related factors (e.g. chlorophyll), or community composition. Among these, community composition might better reflect the effects of the toxicant(s), because this may cause a shift from a sensitive to a progressively tolerant community. Community composition-based approaches do not usually adequately reflect cause-effect relationships and require complementary analysis of properties affected in the short-term, for example physiological properties. The current array of methods available must be wisely combined to disentangle the effects of chemicals on biofilms, and whether these effects are transient or persistent, to successfully translate the chemical action of toxicants into the effect they might have on the river ecosystem.

Social inequalities in perinatal mortality in a Southern European city

The objective of this study was to describe and explain inequalities in perinatal mortality by educational level and occupational social class in Barcelona for the years 1993-1997. This was a case-control study. Cases were singleton perinatal deaths, controls were singleton live births obtained from a 2% random sample of births. The association among educational level, social class, other confounding and explanatory variables and perinatal mortality was studied through crude and adjusted odds ratios (OR) obtained by logistic regression. The study comprised 423 cases and 1032 controls. The model with mother's age and educational level showed that women with primary education had an OR of 1.75 (95% CI: 1.26-2.42), this association disappearing when explanatory variables were included. We also found inequalities by educational level in fetal mortality. These results point out the need to improve the living conditions, behavioural factors and also the management of pregnancy, labour and the health care of the newborn of these mothers with greater risk.

[Characteristics of pregnant women and routine antenatal care in Barcelona, 1994-1999]

OBJECTIVE

To analyse socio-demographic and pregnancy-control aspects of pregnant women residents in Barcelona city and their evolution during the period 1994-1999 using the controls of the Barcelona Birth Defects Registry.

METHODS

The information was collected by mean of an interview to the mother and from hospital records. The Mantel-Haenszel method for lineal association was used to analyse trends. A chi-squared test for proportions was used to compare pregnancy-control variables between public and private centers.

RESULTS

Data on 1,337 pregnant women were obtained. An increasing proportion of women older than 34 years is observed, from 19% in 1994-95 to 25% in 1998-99. An increase in the social class and a decrease of housewives is noticed. 40% of pregnancies were not planned and half of these finished in induced abortion. These proportions are higher in less than 25 and more than 39 years old mothers. 97% had their first obstetrical visit during the first trimester, almost all had at least an obstetrical ultrasound with a mean of 5.2, although 25% of the mothers did not undergo an ecography during the 5th month. An increase of invasive procedures and caesarean sections (C-section) is shown, with 33% of C-sections in the 98-99 period. The medical control of pregnancies is higher in mothers delivering in private centers, which are 55% of the total.

CONCLUSIONS

There is a high lack of pregnancy planning, as well as an increasing pregnancy medicalization, with positive (first trimester visit) and debatable aspects (obstetrical ultrasound, caesarean section and invasive procedures).

[Exactness of the birth registry of Barcelona regarding birth weight and weeks of gestation]

OBJECTIVE

The aim of the study is to know the accuracy of the variables birth weight and gestational age in the Barcelona Birth Registry. Hospital medical records are used as gold standard.

METHODS

A representative sample (n = 1,932) was selected from all the residents born in the city of Barcelona between 1st of May and 31st of December of 1996. The variables birth weight and gestational age were evaluated. Exhaustivity, sensitivity, specificity and predictive value for these variables were calculated.

RESULTS

The Registry shows a high exhaustivity for the study variables. The lowest value of sensitivity corresponds to premature births (65.1%) and the lowest value of specificity to term births (63.9%). The predictive value positive was 77.5% for preterm births and 76.7% for term births.

CONCLUSIONS

In general, exhaustivity and accuracy of the Barcelona Birth Registry are high, but sensitivity for preterm births in the Registry is lower. However, the corresponding maternal and child health indicators do not vary in an important manner.

[Validation of perinatal causes of death in death certificates]

OBJECTIVE

The objective of this study was to assess the validity of perinatal causes of death in death certificates and the influence of some variables related to perinatal mortality.

PATIENTS AND METHODS

All perinatal deaths having occurred in Barcelona in 1994 and reported in death certificates were included. Additional sources of information were certificates of abortions and also other documents such as autopsy reports and medical records, that served as references to determine the most reliable or standard cause of death (SBC) The SBC was determined by a group of experts. The validity was assessed by comparing the cause of death as stated in the death certificate (BC) and the SBC, calculating the general agreement, the detection rate (DR) or sensitivity and the confirmation rate (CR) or positive predictive value. The chi-square test was used to compare proportions.

RESULTS

In 166 (91.2%) of the 182 cases, the BC and SBC were assigned to the same group of the International Classification of Diseases. For congenital defects, the DR was 85.7 (95% CI: 75.1-96.3) and the CR was 81.8 (95% CI: 70.4-93.2). For problems in the perinatal period the DR was 95.6 (95% CI: 92.1-99.1) and the CR was 94.9 (95% CI: 91.2-98.6). Both were considered reliable causes. These rates were similar for the different categories of other variables (birth weight, gestational age, vital status, sex, hospital of birth, autopsy and mother's age). Nevertheless, in the study of detailed causes (3 digits of the International Classification of Diseases) the general agreement was much lower (40.1%). Except for the congenital defects of the nervous system, the remaining causes of death had a low validity.

CONCLUSIONS

This study shows the low validity of detailed causes of perinatal death reported in death certificates. It is necessary to improve the completion and coding of death certificates following the WHO recommendations.

[The underreporting of perinatal mortality: 10 years' experience of active surveillance in Barcelona]

BACKGROUND

Perinatal mortality is considered a good effectiveness health care indicator during pregnancy, deliver and early perinatal period. The aims of this investigation were to describe the magnitude and tendency of underreporting perinatal mortality in Barcelona, Spain from 1985 to 1994 and to determine underreporting predictive variables.

SUBJECTS AND METHODS

Perinatal deaths between 1985 and 1994 were studied according to WHO international statistics criteria and deaths from 1988 to 1994 were also studied according to the WHO national statistics criteria. Sources of information were: Statistical Deaths Certificates and the Active Surveillance Registry that collect information about perinatal deaths directly from hospitals. A perinatal death was considered underreported if it was registered in the Active Surveillance Register but not in the Statistical Death Certificate.

RESULTS

24.5% perinatal deaths were underreported from 1985 to 1995 (according to international statistics criteria) and 24.9% from 1988 to 1994 (according national statistics criteria). In both periods underreporting decreased. Deaths in the first 24 hours of live (OR = 1.8; CI 95% = 1-3), newborns weight between 1,000 and 1,499 g (OR = 1.5; CI 95% = 0.6-3.8), hospitals with mortality registry (OR = 4; CI 95% = 2.2-7.1) and the first years of the study (OR = 0.7; CI 95% = 0.7-0.8) were predictive of underreporting.

CONCLUSIONS

Underreporting perinatal deaths decreased during the study period. Deaths of newborns with low birth weight and who lived less than 24 hours were more underreported. The work developed by Active Surveillance Registry contributed to the decense of underreporting perinatal deaths.

Ventilator-associated pneumonia by Staphylococcus aureus. Comparison of methicillin-resistant and methicillin-sensitive episodes

All episodes of ventilator-associated pneumonia (VAP) caused by Staphylococcus aureus were prospectively analyzed for a 30-mo period. Methicillin-sensitive S. aureus (MSSA) was isolated in 38 episodes and methicillin-resistant S. aureus (MRSA) in 11 others. The two groups were similar regarding sex, severity of underlying diseases, prior surgery, and presence of renal failure, diabetes, cardiopathy, and coma. MRSA-infected persons were more likely to have received steroids before developing infection (relative risk [RR] = 3.45, 95% confidence interval [CI] = 1.38-8.59), to have been ventilated > 6 d (RR = 2.03, 95% CI = 1.36-3.03), to have been older than 25 yr (RR = 1.50, 95% CI = 1.09-2.06), and to have had preceding chronic obstructive pulmonary disease (RR = 2.76, 95% CI = 0.89-8.56) than MSSA-infected patients. MSSA-infected persons were more likely than MRSA-infected patients to have cranioencephalic trauma (RR = 1.94, 95% CI = 1.22-3.09). All patients with MRSA VAP had previously received antibiotics, compared with only 21.1% of those with MSSA infection (p < 0.000001). The incidence of empyema was similar in both groups; nevertheless, the presence of bacteremia and septic shock was more frequent in the MRSA group. Finally, mortality directly related to pneumonia was significantly higher among patients with MRSA episodes (RR = 20.72, 95% CI = 2.78-154.35). This analysis was repeated for monomicrobial episodes, and the difference remained statistically significant. We conclude that MRSA and MSSA strains infect patients with different demographic profiles; previous antibiotic therapy is the most important risk factor for developing MRSA infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for infection by Pseudomonas aeruginosa in patients with ventilator-associated pneumonia

OBJECTIVE

to investigate the epidemiology of infection by Pseudomonas aeruginosa in patients with ventilator-associated pneumonia (VAP).

DESIGN

prospective clinical study.

SETTING

a medical-surgical ICU in a university hospital.

PATIENTS

we followed-up 568 mechanically ventilated patients and 83 episodes of VAP with etiologic diagnosis in 72 patients were retained for analysis.

RESULTS

Ps. aeruginosa was isolated in 22 (26.5%) episodes in 18 patients. Of these episodes 7 were directly responsible for death. Using logistic regression analysis, the risk of VAP due to Ps. aeruginosa was increased in patients with chronic obstructive pulmonary disease (relative risk (RR) = 29.9, 95% confidence interval (CI) = 4.86-184.53), a mechanical ventilation period longer than 8 days (RR = 8.1, 95% CI = 1.01-65.40) and prior use of antibiotics (RR = 5.5, 95% CI = 0.88-35.01).

CONCLUSIONS

patients with VAP and these factors have a greater risk of infection by Ps. aeruginosa and empirical therapy for these episodes should include anti-pseudomonal activity until etiologic diagnosis is established.

Nosocomial bacteremia in a medical-surgical intensive care unit: epidemiologic characteristics and factors influencing mortality in 111 episodes

OBJECTIVE

To analyze the epidemiology and factors influencing mortality of ICU-acquired bacteremia.

DESIGN

Prospective clinical study.

SETTING

A medical-surgical ICU in an university hospital.

PATIENTS

We recorded variables from 111 consecutive ICU-acquired episodes for a 3-year period.

RESULTS

The attack rate was 1.9 episodes per 100 patient-days. The commonest isolates were coagulase-negative staphylococci, Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli. Intravascular catheters were the most frequent source of infection. Overall mortality was 31.5%, and 65.7% of all deaths were directly attributable to infection. Bacteremia from intra-abdominal, lower respiratory tract or unknown origin were associated with a poor prognosis. A logistic regression analysis defined intraabdominal origin (p = 0.01, OR = 15.7) and presence of shock (p = 0.04, OR = 3.3) as independently influencing the risk of death. No significant differences were found for the remaining variables studied.

CONCLUSIONS

Epidemiology and etiology of ICU-acquired bacteremia does not differ seriously in respect to nosocomial bacteremia among unselected populations, although it is associated with a greater incidence and overall mortality. Presence of shock is the most important modificable variable affecting the outcome.

Impact of previous antimicrobial therapy on the etiology and outcome of ventilator-associated pneumonia

OBJECTIVE

To define the influence of prior antibiotic use on the etiology and mortality of ventilator-associated pneumonia (VAP).

SETTING

A university hospital medical-surgical ICU.

DESIGN

Prospective clinical study.

METHODS

Over a 35-month period, we prospectively studied 129 consecutive episodes of VAP. Etiologic diagnosis was established using a protected specimen brush and quantitative culture techniques. We examined prognostic factors by univariate and multivariate analyses using a statistical software package (SPSS).

RESULTS

The rate of VAP caused by Gram-positive cocci or Haemophilus influenzae was statistically lower (p < 0.05) in the patients who had received antibiotics previously, while the rate of VAP caused by Pseudomonas aeruginosa was statistically higher (p < 0.01). Patients died of causes directly related to the infection in 18 (14.0 percent) episodes, P aeruginosa being isolated in 9 of these fatal cases. Indeed, we found that 27.7 percent (15/54) of patients who had received prior antimicrobial therapy before the onset of pneumonia died, compared with only 4.0 percent (3/75) of those who did not. In the univariate analysis, the variables significantly associated with attributable mortality were age older than 45 years, use of corticosteroids, presence of shock, hospital day of VAP over 9, antecedent COPD, and a prior antibiotic use. A step-forward logistic regression analysis defined only prior antibiotic use (p < 0.0001, OR = 9.2) as significantly influencing the risk of death from VAP. The same result was obtained when severity was included in the model. However, prior antibiotic use entirely dropped out as a significant risk factor when the etiologic agent was included in the regression equation.

CONCLUSIONS

Distribution of infecting microorganisms responsible for VAP differs in patients who received prior antimicrobial therapy, and this factor determines a higher mortality rate. We suggest a restrictive antibiotic policy in mechanically ventilated patients with the purpose of reducing the risk of death from VAP.

Nosocomial pneumonia in critically ill comatose patients: need for a differential therapeutic approach

The purpose of this prospective clinical study was to determine the incidence, bacteriology and outcome of lower respiratory tract infections developed among 208 consecutive, critically ill comatose patients, hospitalized in a university hospital, medical-surgical intensive care unit, over a three year period. Nosocomial pneumonia developed in 53 (25%) patients after a mean of 8.1 days (range 3-31 days). Furthermore, there were five superinfections, raising the mean incidence to 28%. One patient developed secondary bacteraemia, and another two had septic shock. Fifteen (28%) patients from the pneumonia group died, and six of these deaths were considered to be directly related to nosocomial pneumonia. Identification of the causative agent, using the protected specimen brush technique, was possible in 42 episodes; in 10 (24%) of these cases more than one microorganism was isolated. Gram-positive cocci represented 53% of isolates, and Staphylococcus aureus accounted for 78% of all Gram-positive cocci, being the most frequent microorganism in this population. In conclusion, nosocomial pneumonia is a common complication of critically ill comatose patients. Its characteristic aetiological spectrum in this population should affect antibiotic prescription. Consequently, we suggest including antimicrobial drugs which are active against S. aureus in the empirical regimen until aetiological diagnosis is established.

Pneumonia due to Haemophilus influenzae among mechanically ventilated patients. Incidence, outcome, and risk factors

Incidence and potential risk factors for pneumonia due to Haemophilus influenzae in adults treated with mechanical ventilation in a medical-surgical ICU were investigated. Diagnosis was established in 91 episodes and H influenzae was isolated in 20 of them. Mean onset of ventilator-associated pneumonia (VAP) due to H influenzae was 10.8 days after intubation. Six patients with H influenzae VAP died in the ICU. Of 13 risk factors for developing VAP due to H influenzae, an absence of prior antibiotic treatment was the only variable which had statistical significance (p < 0.001). In these mechanically ventilated patients, Haemophilus influenzae was a common causative agent for VAP, frequently associated with Gram-positive cocci. Episodes of H influenzae VAP were associated with a lower mortality compared with other etiologies. The epidemiologic and clinical findings indicate that patients without a prior antimicrobial treatment have increased susceptibility to infections of the airway by H influenzae.

Nosocomial pneumonia in critically ill comatose patients: need for a differential therapeutic approach

The purpose of this prospective clinical study was to determine the incidence, bacteriology and outcome of lower respiratory tract infections developed among 208 consecutive, critically ill comatose patients, hospitalized in a university hospital, medical-surgical intensive care unit, over a three year period. Nosocomial pneumonia developed in 53 (25%) patients after a mean of 8.1 days (range 3-31 days). Furthermore, there were five superinfections, raising the mean incidence to 28%. One patient developed secondary bacteraemia, and another two had septic shock. Fifteen (28%) patients from the pneumonia group died, and six of these deaths were considered to be directly related to nosocomial pneumonia. Identification of the causative agent, using the protected specimen brush technique, was possible in 42 episodes; in 10 (24%) of these cases more than one microorganism was isolated. Gram-positive cocci represented 53% of isolates, and Staphylococcus aureus accounted for 78% of all Gram-positive cocci, being the most frequent microorganism in this population. In conclusion, nosocomial pneumonia is a common complication of critically ill comatose patients. Its characteristic aetiological spectrum in this population should affect antibiotic prescription. Consequently, we suggest including antimicrobial drugs which are active against S. aureus in the empirical regimen until aetiological diagnosis is established.