Challenges in Septic Shock: From New Hemodynamics to Blood Purification Therapies

Sepsis and septic shock are associated with high mortality, with diagnosis and treatment remaining a challenge for clinicians. Their management classically encompasses hemodynamic resuscitation, antibiotic treatment, life support, and focus control; however, there are aspects that have changed. This narrative review highlights current and avant-garde methods of handling patients experiencing septic shock based on the experience of its authors and the best available evidence in a context of uncertainty. Following the first recommendation of the Surviving Sepsis Campaign guidelines, it is recommended that specific sepsis care performance improvement programs are implemented in hospitals, i.e., "Sepsis Code" programs, designed ad hoc, to achieve this goal. Regarding hemodynamics, the importance of perfusion and hemodynamic coherence stand out, which allow for the recognition of different phenotypes, determination of the ideal time for commencing vasopressor treatment, and the appropriate fluid therapy dosage. At present, this is not only important for the initial timing, but also for de-resuscitation, which involves the early weaning of support therapies, directed elimination of fluids, and fluid tolerance concept. Finally, regarding blood purification therapies, those aimed at eliminating endotoxins and cytokines are attractive in the early management of patients in septic shock.

Decrease in Mortality after the Implementation of a Hospital Model to Improve Performance in Sepsis Care: Princess Sepsis Code

Sepsis is a time-dependent disease whose prognosis is influenced by early diagnosis and therapeutic measures. Mortality from sepsis remains high, and for this reason, the guidelines of the Surviving Sepsis Campaign recommend establishing specific care programs aimed at patients with sepsis. We present the results of the application of a hospital model to improve performance in sepsis care, called Princess Sepsis Code, with the aim of reducing mortality. A retrospective study was conducted using clinical, epidemiological, and outcome variables in patients diagnosed with sepsis from 2015 to 2022. A total of 2676 patients were included, 32% of whom required admission to the intensive care unit, with the most frequent focus of the sepsis being abdominal. Mortality in 2015, at the beginning of the sepsis code program, was 24%, with a declining rate noted over the study period, with mortality reaching 17% in 2022. In the multivariate analysis, age > 70 years, respiratory rate > 22 rpm, deterioration in the level of consciousness, serum lactate > 2 mmol/L, creatinine > 1.6 mg/dL, and the focus of the sepsis were identified as variables independently related to mortality. The implementation of the Princess Sepsis Code care model reduces the mortality of patients exhibiting sepsis and septic shock.

Sepsis Stewardship: The Puzzle of Antibiotic Therapy in the Context of Individualization of Decision Making

The main recent change observed in the field of critical patient infection has been universal awareness of the need to make better use of antimicrobials, especially for the most serious cases, beyond the application of simple and effective formulas or rigid protocols. The increase in resistant microorganisms, the quantitative increase in major surgeries and interventional procedures in the highest risk patients, and the appearance of a significant number of new antibiotics in recent years (some very specifically directed against certain mechanisms of resistance and others with a broader spectrum of applications) have led us to shift our questions from "what to deal with" to "how to treat". There has been controversy about how best to approach antibiotic treatment of complex cases of sepsis. The individualized and adjusted dosage, the moment of its administration, the objective, and the selection of the regimen are pointed out as factors of special relevance in a critically ill patient where the frequency of resistant microorganisms, especially among the Enterobacterales group, and the emergence of multiple and diverse antibiotic treatment alternatives have made the appropriate choice of antibiotic treatment more complex, requiring a constant updating of knowledge and the creation of multidisciplinary teams to confront new infections that are difficult to treat. In this article, we have reviewed the phenomenon of the emergence of resistance to antibacterials and we have tried to share some of the ideas, such as stewardship, sparing carbapenems, and organizational, microbiological, pharmacological, and knowledge tools, that we have considered most useful and effective for individualized decision making that takes into account the current context of multidrug resistance. The greatest challenge, therefore, of decision making in this context lies in determining an effective, optimal, and balanced empirical antibiotic treatment.

Impact of outdoor air pollution on severity and mortality in COVID-19 pneumonia

The relationship between exposure to air pollution and the severity of coronavirus disease 2019 (COVID-19) pneumonia and other outcomes is poorly understood. Beyond age and comorbidity, risk factors for adverse outcomes including death have been poorly studied. The main objective of our study was to examine the relationship between exposure to outdoor air pollution and the risk of death in patients with COVID-19 pneumonia using individual-level data. The secondary objective was to investigate the impact of air pollutants on gas exchange and systemic inflammation in this disease. This cohort study included 1548 patients hospitalised for COVID-19 pneumonia between February and May 2020 in one of four hospitals. Local agencies supplied daily data on environmental air pollutants (PM10, PM2.5, O3, NO2, NO and NOX) and meteorological conditions (temperature and humidity) in the year before hospital admission (from January 2019 to December 2019). Daily exposure to pollution and meteorological conditions by individual postcode of residence was estimated using geospatial Bayesian generalised additive models. The influence of air pollution on pneumonia severity was studied using generalised additive models which included: age, sex, Charlson comorbidity index, hospital, average income, air temperature and humidity, and exposure to each pollutant. Additionally, generalised additive models were generated for exploring the effect of air pollution on C-reactive protein (CRP) level and SpO2/FiO2 at admission. According to our results, both risk of COVID-19 death and CRP level increased significantly with median exposure to PM10, NO2, NO and NOX, while higher exposure to NO2, NO and NOX was associated with lower SpO2/FiO2 ratios. In conclusion, after controlling for socioeconomic, demographic and health-related variables, we found evidence of a significant positive relationship between air pollution and mortality in patients hospitalised for COVID-19 pneumonia. Additionally, inflammation (CRP) and gas exchange (SpO2/FiO2) in these patients were significantly related to exposure to air pollution.

Relevant SARS-CoV-2 viremia is associated with COVID-19 severity: Prospective cohort study and validation cohort

Early kinetics of SARS-CoV-2 viral load (VL) in plasma determined by quantitative reverse-transcription polymerase chain reaction (RT-PCR) was evaluated as a predictor of poor clinical outcome in a prospective study and assessed in a retrospective validation cohort. Prospective observational single-center study including consecutive adult patients hospitalized with COVID-19 between November 2020 and January 2021. Serial plasma samples were obtained until discharge. Quantitative RT-PCR was performed to assess SARS-CoV-2 VL. The main outcomes were in-hospital mortality, admission to the Intensive Care Unit (ICU), and their combination (Poor Outcome). Relevant viremia (RV), established in the prospective study, was assessed in a retrospective cohort including hospitalized COVID-19 patients from April 2021 to May 2022, in which plasma samples were collected according to clinical criteria. Prospective cohort: 57 patients were included. RV was defined as at least a twofold increase in VL within ≤2 days or a VL > 300 copies/ml, in the first week. Patients with RV (N = 14; 24.6%) were more likely to die than those without RV (35.7% vs. 0%), needed ICU admission (57% vs. 0%) or had Poor Outcome (71.4% vs. 0%), (p < 0.001 for the three variables). Retrospective cohort: 326 patients were included, 18.7% presented RV. Patients with RV compared with patients without RV had higher rates of ICU-admission (odds ratio [OR]: 5.6 [95% confidence interval [CI]: 2.1-15.1); p = 0.001), mortality (OR: 13.5 [95% CI: 6.3-28.7]; p < 0.0001) and Poor Outcome (OR: 11.2 [95% CI: 5.8-22]; p < 0.0001). Relevant SARS-CoV-2 viremia in the first week of hospitalization was associated with higher in-hospital mortality, ICU admission, and Poor Outcome. Findings observed in the prospective cohort were confirmed in a larger validation cohort.

SARS-CoV-2 Viremia Precedes an IL6 Response in Severe COVID-19 Patients: Results of a Longitudinal Prospective Cohort

BACKGROUND

Interleukin 6 (IL6) levels and SARS-CoV-2 viremia have been correlated with COVID-19 severity. The association over time between them has not been assessed in a prospective cohort. Our aim was to evaluate the relationship between SARS-CoV-2 viremia and time evolution of IL6 levels in a COVID-19 prospective cohort.

METHODS

Secondary analysis from a prospective cohort including COVID-19 hospitalized patients from Hospital Universitario La Princesa between November 2020 and January 2021. Serial plasma samples were collected from admission until discharge. Viral load was quantified by Real-Time Polymerase Chain Reaction and IL6 levels with an enzyme immunoassay. To represent the evolution over time of both variables we used the graphic command twoway of Stata.

RESULTS

A total of 57 patients were recruited, with median age of 63 years (IQR [53-81]), 61.4% male and 68.4% Caucasian. The peak of viremia appeared shortly after symptom onset in patients with persistent viremia (more than 1 sample with > 1.3 log10 copies/ml) and also in those with at least one IL6 > 30 pg/ml, followed by a progressive increase in IL6 around 10 days later. Persistent viremia in the first week of hospitalization was associated with higher levels of IL6. Both IL6 and SARS-CoV-2 viral load were higher in males, with a quicker increase with age.

CONCLUSION

In those patients with worse outcomes, an early peak of SARS-CoV-2 viral load precedes an increase in IL6 levels. Monitoring SARS-CoV-2 viral load during the first week after symptom onset may be helpful to predict disease severity in COVID-19 patients.

Ceftobiprole medocaril

Ceftobiprole medocaril is a broad-spectrum 5th-generation cephalosporin with activity against Gram-positives such as methicillin-resistant Staphylococcus aureus and penicillin-resistant Streptococcus pneumoniae, and against Gram-negatives such as Pseudomonas aeruginosa. The recommended dose is 500 mg every 8 h in 2-hour infusions. Various clinical trials have demonstrated its usefulness in the treatment of community-acquired pneumonia and nosocomial pneumonia, with the exception of ventilator-associated pneumonia. In summary, it is a very useful antibiotic for the treatment of pneumonia.

Immune treatment in COVID-19

Current immune treatment directed to avoid viral replication relies mainly in convalescent plasma and monoclonal antibodies (mAbs). No clinical benefit for convalescent plasma has been reported in a meta-analysis and systematic review compared to standard of care. MAbs are recombinant proteins capable to bind with SARS-CoV-2 preventing its entrance into cells. Several mAbs have shown reduction in viral load and/ or progression of the disease such as casirivimab-imdevimab, bamlanivimab-etesevimab and sotrovimab. After the apparition of Omicron variant, it has been reported that sotrovimab retained its activity whereas the other two combinations exhibited loss of neutralizing activity. Several aspects as the target population, timing and doses, serological patient status and evolution of variants still require attention, monitorization and further studies for knowledge gaps.

Sepsis Code: dodging mortality in a tertiary hospital

Introducción

En el hospital de La Princesa comienza el “Código Sepsis” (CSP) en el año 2015, como un grupo multidisciplinar que dota al personal sanitario de herramientas clínicas, analíticas y organizativas, con el objetivo de la detección y el tratamiento precoz del paciente con sepsis. El objetivo de este estudio es evaluar el impacto de la implantación de CSP en la mortalidad y determinar las variables asociadas con un aumento de la misma.

Material y métodos

Se realizó un estudio analítico retrospectivo de los pacientes con activación de la alerta CSP de 2015 a 2018. Se recogieron variables clínico-epidemiológicas, parámetros analíticos y factores de gravedad como el ingreso en Unidades de Cuidados Críticos (UCC) y la necesidad de aminas. La significación estadística se estableció en una p < 0,05.

Resultados

Se incluyeron 1.121 pacientes. La estancia media fue de 16 días y un 32% requirieron ingreso en UCC. La mortalidad mostró una tendencia lineal descendente estadísticamente significativa del 24% en 2015 hasta el 15% en 2018. Las variables predictivas de mortalidad con asociación estadísticamente significativa fueron el lactato > 2 mmol/L, la creatinina > 1,6 mg/dL y la necesidad de aminas.

Conclusiones

La implementación de Código Sepsis disminuye la mortalidad de los pacientes con sepsis y shock séptico. La presencia de una cifra de lactato > 2 mmol/L, los niveles de creatinina > 1,6 mg/dL y/o la necesidad de administrar aminas en las primeras 24 horas, se asocian con un aumento de la mortalidad en el paciente con sepsis.

Features of aerobic granular sludge formation treating fluctuating industrial saline wastewater at pilot scale

A pilot-scale sequencing batch reactor, with a working volume of 3 m³, was installed in a fish cannery to develop aerobic granular sludge treating the produced effluents. Depending on the nitrogen (N) and organic matter (COD) concentration, the effluents were named in this study as medium-low-strength (Stage I) and high-strength (Stage II) wastewater. The composition of the wastewater was found to be a crucial factor to select granule-forming organisms. With medium-low-strength wastewater as feeding, the first granules were observed after 30 days, but the extremely high COD/N ratios of the wastewater provoked the overgrowth of filamentous bacteria after 4 months of operation (Stage I). When treating high-strength wastewater, stable aggregates with good settleability appeared, but well-shaped granules were not observed since the granulation process was not completed. The system was able to remove both COD (70-95%) and N (30-90%) treating both types of effluents. Biomass growth was the main N removal pathway. The reactor was found to be robust against factory production stops and, thus, a suitable alternative to treat wastewater from industries with discontinuous operation.

Short-term neuropsychiatric outcomes and quality of life in COVID-19 survivors

BACKGROUND

The general medical impacts of coronavirus (COVID-19) are increasingly appreciated. However, its impact on neurocognitive, psychiatric health and quality of life (QoL) in survivors after the acute phase is poorly understood. We aimed to evaluate neurocognitive function, psychiatric symptoms and QoL in COVID-19 survivors shortly after hospital discharge.

METHODS

This was a cross-sectional analysis of a prospective study of hospitalized COVID-19 survivors followed up for 2 months after discharge. A battery of standardized instruments evaluating neurocognitive function, psychiatric morbidity and QoL (mental and physical components) was administered by telephone.

RESULTS

Of the 229 screened patients, 179 were included in the final analysis. Amongst survivors, the prevalence of moderately impaired immediate verbal memory and learning was 38%, delayed verbal memory (11.8%), verbal fluency (34.6%) and working memory (executive function) (6.1%), respectively. Moreover, 58.7% of patients had neurocognitive impairment in at least one function. Rates of positive screening for anxiety, depression and post-traumatic stress disorder were 29.6%, 26.8% and 25.1%, respectively. In addition, 39.1% of the patients had psychiatric morbidity. Low QoL for physical and mental components was detected in 44.1% and 39.1% of patients respectively. Delirium and psychiatric morbidity were associated with neurocognitive impairment, and female gender was related with psychiatric morbidity.

CONCLUSION

Hospitalized COVID-19 survivors showed a considerable prevalence of neurocognitive impairment, psychiatric morbidity and poor QoL in the short term. It is uncertain if these impacts persist over the long term.

Does the feeding strategy enhance the aerobic granular sludge stability treating saline effluents?

The development and stability of aerobic granular sludge (AGS) was studied in two Sequencing Batch Reactors (SBRs) treating fish canning wastewater. R1 cycle comprised a fully aerobic reaction phase, while R2 cycle included a plug-flow anaerobic feeding/reaction followed by an aerobic reaction phase. The performance of the AGS reactors was compared treating the same effluents with variable salt concentrations (4.97-13.45 g NaCl/L) and organic loading rates (OLR, 1.80-6.65 kg CODs/(m³·d)). Granulation process was faster in R2 (day 34) than in R1 (day 90), however the granular biomass formed in the fully aerobic configuration was more stable to the variable feeding composition. Thus, in R1 solid retention times (SRT), up to 15.2 days, longer than in R2, up to 5.8 days, were achieved. These long SRTs values helped the retention of nitrifying organisms and provoked the increase of the nitrogen removal efficiency to 80% in R1 while it was approximately of 40% in R2. However, the presence of an anaerobic feeding/reaction phase increased the organic matter removal efficiency in R2 (80-90%) which was higher than in R1 with a fully aerobic phase (75-85%). Furthermore, in R2 glycogen-accumulating organisms (GAOs) dominated inside the granules instead of phosphorous-accumulating organisms (PAOs), suggesting that GAOs resist better the stressful conditions of a variable and high-saline influent. In terms of AGS properties an anaerobic feeding/reaction phase is not beneficial, however it enables the production of a better quality effluent.

EXPERIMENTAL EVALUATION OF NEUTRON SHIELDING MATERIALS

A new proposed design of neutron shielding material-based on the commercial material Borotron UH050 with an addition of Al(OH)3-is evaluated in order to determine if its neutron and gamma shielding properties match those of a reference material, NS4FR. Neutron and gamma dosimetry measurements are performed, as well as neutron spectrometry measurements and Monte Carlo simulations. Negligible differences are found between the materials for neutron shielding, while significant differences are found for gamma shielding. The effect of Al(OH)3 addition to Borotron UH050 is to reduce neutron shielding properties while increasing gamma shielding properties. The resulting material is as efficient as NS4FR for neutron shielding but less efficient for gamma shielding-thicknesses 20% higher are required to match gamma shielding properties of NS4FR. Monte Carlo models of the materials are validated based on the performed measurements of neutron spectra and neutron and gamma ambient dose equivalent.

Chemotherapy-induced response of liver hemangiomas in a patient with a germ cell tumor: a case report

Liver hemangiomas are the most common benign primary tumors of the liver. Due to their high prevalence, incidental finding of hemangiomas during radiological workup of oncologic patients is not uncommon. We present the case of a patient diagnosed of an ovarian immature teratoma and hepatic lesions with typical radiological appearance of hemangiomas that decreased in size during adjuvant chemotherapy with BEP regimen (cisplatin, etoposide and bleomycin). Chemotherapy-induced shrinkage of hepatic hemangiomas can mimic the response of liver metastases to chemotherapy and may induce erroneous interpretations. The purpose of this report is to describe a chemotherapy-induced response of liver hemangiomas, especially when BEP combination is used. To date this observation has been barely reported in the literature and, to our knowledge, this is the first documented case of chemotherapy-induced response of liver hemangiomas in a patient diagnosed of an ovarian immature teratoma.

Short- and long-term orange dye effects on ammonium oxidizing and anammox bacteria activities

The effects of orange azo dye over ammonia oxidizing bacteria (AOB) and anammox bacteria activities were tested. Performed batch tests indicated that concentrations lower than 650 mg_orange/L stimulated AOB activity, while anammox bacteria activity was inhibited at concentrations higher than 25 mg_orange/L. Long-term performance of a continuous stirred tank reactor (CSTR) for the partial nitritation and a sequencing batch reactor (SBR) for the anammox process was tested in the presence of 50 mg_orange/L. In the case of the partial nitritation process, both the biomass concentration and the specific AOB activity increased after 50 days of orange azo dye addition. Regarding the anammox process, specific activity decreased down to 58% after 12 days of operation with continuous feeding of 50 mg_orange/L. However, the anammox activity was completely recovered only 54 days after stopping the dye addition in the feeding. Once the biomass was saturated the azo dye adsorption onto the biomass was insignificant in the CSTR for the partial nitritation process fed with 50 mg_orange/L. However, in the SBR the absorption was determined as 6.4 mg_orange/g volatile suspended solids. No biological decolorization was observed in both processes.

Biomass aggregation influences NaN3 short-term effects on anammox bacteria activity

The main bottleneck to maintain the long-term stability of the partial nitritation-anammox processes, especially those operated at low temperatures and nitrogen concentrations, is the undesirable development of nitrite oxidizing bacteria (NOB). When this occurs, the punctual addition of compounds with the capacity to specifically inhibit NOB without affecting the process efficiency might be of interest. Sodium azide (NaN₃) is an already known NOB inhibitor which at low concentrations does not significantly affect the ammonia oxidizing bacteria (AOB) activity. However, studies about its influence on anammox bacteria are unavailable. For this reason, the objective of the present study was to evaluate the effect of NaN₃ on the anammox activity. Three different types of anammox biomass were used: granular biomass comprising AOB and anammox bacteria (G1), anammox enriched granules (G2) and previous anammox granules disaggregated (F1). No inhibitory effect of NaN₃ was measured on G1 sludge. However, the anammox activity decreased in the case of G2 and F1. Granular biomass activity was less affected (IC₅₀ 90 mg/L, G2) than flocculent one (IC₅₀ 5 mg/L, F1). Summing up, not only does the granular structure protect the anammox bacteria from the NaN₃ inhibitory effect, but also the AOB act as a barrier decreasing the inhibition.

Evolution of regional oxygen saturation in the peri-operative of thoracic surgery and its relationship with central venous saturation

OBJECTIVE

To study the relationship between the values of SvcO2 and SrcO2 in lung resection with one lung ventilation (OLV) and changes in these variables and mean arterial pressure (MAP) and arterial oxygen saturation (SpO2) during the perioperative period.

MATERIAL AND METHODS

Prospective, observational study of 25 patients in whom pulmonary resection was performed with OLV. The values of MAP, SpO2, SvO2, and SrcO2 were recorded at 6 different times: 1)baseline; 2)double-lung ventilation before the OLV (VBP1); 3)during OLV; 4)after double-lung ventilation (VBP2); 5)30minutes after surgery, and 6)6hours after surgery.

RESULTS

The SrcO2 showed a significant increase from baseline to starting ventilation (65.72±9.05% vs 70.44±7.24%; P<.01). There were no significant changes in their values at the different intraoperative times. Post-operatively, as in the case of the SvcO2, a significant decrease (P<.001) of its value compared with the previous value was observed.

CONCLUSIONS

SrcO2 showed a significant increase after induction of anaesthesia and initiation of mechanical ventilation compared to baseline, and a significant decrease at the end of surgery after extubation in the immediate postoperative period. Being a tissue monitoring, non-invasive technique and with continuous values it can alert the clinician of changes in the ratio of oxygen consumption (VO2) to oxygen delivery (DO2) at times of greatest risk, such as OLV, extubation, and the early postoperative period.

Removal of tetracyclines from swine manure at full-scale activated sludge treatment plants

The purpose of this study was to investigate the fate of three tetracyclines (TCs), namely oxytetracycline (OTC), chlortetracycline (CTC) and doxycycline (DC) at two different full-scale swine manure-activated sludge treatment plants. Throughout treatment, OTC, CTC and DC were removed by 71-76%, 75-80% and 95%, respectively. Removal of these TCs under physical treatment was deniable. On the contrary, the flocculation-coagulation and the secondary clarification resulted in a relevant reduction of the concentration of these TCs.

Influence of dissolved oxygen concentration on the start-up of the anammox-based process: ELAN®

The anammox-based process ELAN® was started-up in two different sequencing batch reactor (SBR) pilot plant reactors treating municipal anaerobic digester supernatant. The main difference in the operation of both reactors was the dissolved oxygen (DO) concentration in the bulk liquid. SBR-1 was started at a DO value of 0.4 mg O2/L whereas SBR-2 was started at DO values of 3.0 mg O2/L. Despite both reactors working at a nitrogen removal rate of around 0.6 g N/(L d), in SBR-1, granules represented only a small fraction of the total biomass and reached a diameter of 1.1 mm after 7 months of operation, while in SBR-2 the biomass was mainly composed of granules with an average diameter of 3.2 mm after the same operational period. Oxygen microelectrode profiling revealed that granules from SBR-2 where only fully penetrated by oxygen with DO concentrations of 8 mg O2/L while granules from SBR-1 were already oxygen penetrated at DO concentrations of 1 mg O2/L. In this way granules from SBR-2 performed better due to the thick layer of ammonia oxidizing bacteria, which accounted for up to 20% of all the microbial populations, which protected the anammox bacteria from non-suitable liquid media conditions.

Accessory gallbladder originating from the right hepatic duct

Major vascular injury during laparoscopic procedures is a rare but catastrophic complication. We report a pediatric case of aortic laceration during the setup phase of diagnostic laparoscopy in a 5-year-old girl with recurrent abdominal pain. The Veress needle inserted below the umbilicus confirmed the proper placement by use of a saline-filled syringe. The abdomen was insufflated without difficulty. The first trocar was inserted at the same point as Veress needle. The video laparoscope was introduced, and a small amount of blood was seen in the abdomen. We converted the procedure to laparotomy immediately. There was a large retroperitoneal hematoma. The vascular laceration was identified at the origin of the iliac arteries. It was sutured with prolene 5/0. The girl was discharged without further complication on the 10th postoperative day. The incidence of major vascular injuries is 0.03% to 0.07%. The vessels most frequently involved are the aorta, the iliac arteries, the mesenteric vessels, and the vena cava. More than 400 cases have been reported in the literature, but only four of these involve pediatric patients. In the vast majority of cases, the complication took place during the setup phase of laparoscopy (75%), and were related to the introduction of either the Veress needle (30%) or the first umbilical trocar (43%), although the rate is opposite this in some studies.

Implications of full-scale implementation of an anammox-based process as post-treatment of a municipal anaerobic sludge digester operated with co-digestion

The feasibility of treating the supernatant of a municipal sludge digester supplemented with co-substrates by means of an anammox-based process (ELAN(®)) was tested in Guillarei (NW of Spain). Ammonia concentration measured in the supernatant of the sludge digester varied in the range 800-1,500 g N/m(3) due to the fact that the sludge produced in the plant was co-digested with wastes coming from surrounding food industries. Treating this supernatant in the ELAN(®) reactor, nitrogen removal rates up to 1.1 kg N/(m(3) d) were reached in experiments run in a pilot plant reactor operated in batch mode. No nitrite oxidation was registered after several months of operation despite the average dissolved oxygen (DO) concentrations being 1.5 g O2/m(3) and the temperature reaching values as low as 18 °C. By keeping the DO set point at 1-2 g O2/m(3) and tuning the hydraulic retention time, the stability of the process was guaranteed and the presence of co-substrates in the anaerobic digester did not affect negatively the operation of the autotrophic nitrogen removal process. Due to the success of the pilot plant experiment, an upscale of the process to full scale is proposed. Mass balances applied to Guillarei wastewater treatment plant revealed that in the main stream line the average denitrification rate calculated with the data of year 2011 was 226 kg N/d. Since the nitrogen removal efficiency is limited by the amount of readily biodegradable organic matter available to carry out denitrification in the water line, the implementation of an anammox-based process to treat the supernatant seems the best option to improve the effluent quality in terms of nitrogen content. The nitrogen removal rate in the sludge line would be 30 times higher than the one in the water line. The implementation of the process would improve the energetic balance and the nitrogen removal performance of the plant.

Enhanced ammonia removal at room temperature by pH controlled partial nitrification and subsequent anaerobic ammonium oxidation

The Anammox-based processes are suitable for the treatment of wastewaters characterized by a low carbon to nitrogen (C/N) ratio. The application of the Anammox process requires the availability of an effluent with a NO2- -N/NH4+ -N ratio composition around 1 g g-1, which involves the necessity of a previous step where the partial nitrification is performed. In this step, the inhibition of the nitrite-oxidizing bacteria (NOB) is crucial. In the present work, a combined partial nitrification-ANaerobic AMmonia OXidation (Anammox) two-units system operated at room temperature (20 degreeC) has been tested for the nitrogen removal of pre-treated pig slurry. To achieve the successful partial nitrification and inhibit the NOB activity, different ammonium/inorganic carbon (NH4+/IC) ratios were assayed from 1.19 to 0.82g NH4+-Ng-1 HCO3-C. This procedure provoked a decrease of the pH value to 6.0 to regulate the inhibitory effect over ammonia-oxidizing bacteria caused by free ammonia. Simultaneously, the NOB experienced the inhibitory effect of free nitrous acid which avoided the presence of nitrate in the effluent. The NH4+/IC ratio which allowed the obtaining of the desired effluent composition (50% of both ammonium and nitrite) was 0.82 +/- 0.02 g NH4+-N g-1 HCO3- -C. The Anammox reactor was fed with the effluent of the partial nitrification unit containing a NO2 -N/NH4+ -N ratio of 1 g g-1' where a nitrogen loading rate of 0.1 g N L-1 d-1 was efficiently removed.

Immune escape of cancer cells with beta2-microglobulin loss over the course of metastatic melanoma

Cancer cells escape T-cell-mediated destruction by losing human leukocyte antigen (HLA) class I expression via various mechanisms, including loss of beta2-microglobulin (β2m). Our study illustrates the immune escape of HLA class I-negative tumor cells and chronological sequence of appearance of tumor β2m gene mutation in successive lesions obtained from a patient with metastatic melanoma. We observed a gradual decrease in HLA expression in consecutive lesions with few HLA-negative nodules in the primary tumor and the emergence of a totally negative lesion at later stages of the disease. We detected loss of β2m in β2m-negative nests of the primary tumor caused by a combination of two alterations: (i) a mutation (G to T substitution) in codon 67 in exon 2 of β2m gene, producing a stop codon and (ii) loss of the second gene copy by loss of heterozygosity (LOH) in chromosome 15. The same β2m mutation was found in a homogeneously β2m-negative metastasis 10 months later and in a cell line established from a biopsy of a postvaccination lymph node. Microsatellite analysis revealed the presence of LOH in chromosomes 6 and 15 in tumor samples, showing an accumulation of chromosomal loss at specific short tandem repeats in successive metastases during disease progression. HLA loss correlated with decreased tumor CD8+ T-cell infiltration. Early incidence of β2m defects can cause an immune selection and expansion of highly aggressive melanoma clones with irreversible genetic defects causing total loss of HLA class I expression and should be taken into consideration as a therapeutic target in the development of cancer immunotherapy protocols.

Effects of the cycle distribution on the performance of SBRs with aerobic granular biomass

The aerobic granular systems are mainly sequencing batch reactors where the biomass is submitted to feast-famine regimes to promote its aggregation in the form of granules. In these systems, different cycle distributions can be applied for the simultaneous removal of organic matter, nitrogen and phosphorus. In this work two strategies were followed in order to evaluate the effects of the cycle distribution. In the first experiment, the length of the operational cycle was decreased in order to maximize the treatment capacity and consequently the famine/feast ratio was also decreased. In the second experiment, an initial anoxic phase was implemented to improve nitrogen removal efficiency. The results obtained showed that to reduce the famine/feast ratio from 10 to 5 was possible by increasing the treated organic and nitrogen loading rates in the system to 33%, without affecting the removal efficiencies of organic matter (97%) and nitrogen (64%) and producing a slight detriment of the granules characteristics. On the other hand, the implementation of an anoxic phase of 30 min previous to the aerobic one with a pulse-fed mode increased the nitrogen removal of pig manure from 20 to 60%, while the cycle configuration comprising a continuous feeding simultaneous with an anoxic phase of 60 min did not enhance the nitrogen removal and even worsen the ammonia oxidation.

Autotrophic denitrification with sulphide in a sequencing batch reactor

In this study a sequencing batch reactor was used to simultaneously remove both sulphide and nitrate via an autotrophic denitrification process. The sulphide loading rates were gradually increased from 200 mg S(2-) L(-1) d(-1)-450 mg S(2-) L(-1)d(-1)while the nitrogen loading rates were kept at 450 mg NO(3)(-)-N L(-1)d(-1). The obtained results demonstrated that it was possible to carry out autotrophic denitrification in a Sequencing Batch Reactor with removal efficiencies of sulphide and nitrogen of 100% and 67%, respectively. The efficiency of the process was influenced by the pH value in the reactor. The operation at pH values higher than 9.0 decreased the efficiency of sulphide oxidation into sulphate to 11.3%. The main bacteria populations present in the sludge belonged to Thiobacillus genus.

Short- and long-term effects of ammonium and nitrite on the Anammox process

Autotrophic anaerobic ammonium oxidation (Anammox) is a biological process in which Planctomycete-type bacteria combine ammonium and nitrite to generate nitrogen gas. Both substrates can exert inhibitory effects on the process, causing the decrease of the specific activity of the biomass and the loss of the stable operation of reactors. The aim of the present work is to evaluate these effects in short- and long-term experiments. The short-term effects were carried out with two different types of Anammox biomass, biofilm on inorganic carriers and flocculent sludge. The effects of ammonium on both kinds of biomass were similar. A decrease of the Specific Anammox Activity (SAA) of 50% was observed at concentrations about 38 mg NH(3)-N·L(-1), while 100 mg NH(3)-N·L(-1) caused an inhibition of 80%. With regards to nitrite, the SAA was not affected at concentrations up to 6.6 μg HNO(2)-N·L(-1) but it suffered a decrease over 50% in the presence of 11 μg HNO(2)-N·L(-1) in the case of the biofilm. The flocculent biomass was much less resistant and its SAA sharply decreased up to 30% of its initial value in the presence of 4.4 μg HNO(2)-N·L(-1). The study of the long-term effects was carried out in lab-scale Sequencing Batch Reactors (SBR) inoculated with the biofilm biomass. Concentrations up to 20 mg NH(3)-N·L(-1) showed no effects on either reactor efficiency or biomass activity. However, when free ammonia concentrations reached values between 35 and 40 mg NH(3)-N·L(-1), the operation turned unstable and the efficiency was totally lost. Nitrous acid concentrations around 1.5 μg HNO(2)-N·L(-1) caused a loss of the efficiency of the treatment and a destabilization of the system. However, a total restoration of the SAA was observed after the stoichiometric feeding was applied to the SBR.

Aerobic granular SBR systems applied to the treatment of industrial effluents

Four lab scale sequencing batch reactors (SBRs) were operated to remove organic matter and nitrogen from four different industrial wastewaters. The biomass grew in the reactors in the form of aerobic granules characterized by good settling properties. The high biomass concentrations achieved inside the reactors allowed reducing the solids concentration in the effluent down to 0.2 g VSS L(-1). The organic loading rates (OLR) applied to reactors ranged between 0.7 and 5.0 g CODL(-1)d(-1) with removal efficiencies of 60-95%. The nitrogen loading rates (NLR) applied varied between 0.15 and 0.65 g NH(4)(+)-NL(-1)d(-1) with variable removal efficiencies in the four systems (between 15% and 76%).

Protein disorder in the centrosome correlates with complexity in cell types number

Here we study the properties and the evolution of proteins that constitute the Centrosome, the complex molecular assembly that regulates the division and differentiation of animal cells. We found that centrosomal proteins are predicted to be significantly enriched in disordered and coiled-coil regions, more phosphorylated and longer than control proteins of the same organism. Interestingly, the ratio of these properties in centrosomal and control proteins tends to increase with the number of cell-types. We reconstructed indels evolution, finding that indels significantly increase disorder in both centrosomal and control proteins, at a rate that is typically larger along branches associated with a large growth in cell-types number, and larger for centrosomal than for control proteins. Substitutions show a similar trend for coiled-coil, but they contribute less to the evolution of disorder. Our results suggest that the increase in cell-types number in animal evolution is correlated with the gain of disordered and coiled-coil regions in centrosomal proteins, establishing a connection between organism and molecular complexity. We argue that the structural plasticity conferred to the Centrosome by disordered regions and phosphorylation plays an important role in its mechanical properties and its regulation in space and time.

Kinetics and cellular sources of cathelicidin during the course of experimental latent tuberculous infection and progressive pulmonary tuberculosis

In spite of advances in immunology on mycobacterial infection, there are few studies on the role of anti-microbial peptides in tuberculosis. The cathelin-related anti-microbial peptide (CRAMP) is the only cathelicidin isolated from mice. In this work we investigated the cellular sources and the production kinetics of this molecule during experimental tuberculosis, using two well-characterized models of latent or chronic infection and progressive disease. The lung of non-infected control mice expressed CRAMP at very low levels. In both models of experimental tuberculosis the main cells immunolabelled for CRAMP were bronchial epithelial cells, macrophages and pneumocytes types II and I. After intratracheal infection with a high bacilli dose (H37Rv strain) in Balb/c mice to produce progressive disease, a high CRAMP gene expression was induced showing three peaks: very early after 1 day of infection, at day 21 when the peak of protective immunity in this model is raised, and at day 28 when the progressive phase starts and the immunoelectronmicroscopy study showed intense immunolabelling in the cell wall and cytoplasm of intracellular bacilli, as well as in cytoplasmic vacuoles. Interestingly, at day 60 post-infection, when advanced progressive disease is well established, characterized by high bacillary loads and extensive tissue damage, CRAMP gene expression decreased but strong CRAMP immunostaining was detected in vacuolated macrophages filled with bacilli. Thus, cathelicidin is highly produced during experimental pulmonary tuberculosis from diverse cellular sources and could have significant participation in its pathogenesis.

Autotrophic nitrogen removal at low temperature

In this work the autotrophic nitrogen removal was carried out at moderately low temperatures using two configurations: a) two-units one comprising a SHARON reactor coupled to an Anammox SBR and b) single-unit one consisting of a granular SBR performing the CANON process. At 20°C the two-units system was limited by the Anammox step and its nitrogen removal capacity was around ten times lower than the CANON system (0.08 g N/(L d) versus 1 g N/(L d)). When the CANON system was operated at 15°C the average removed nitrogen loading rate decreased to 0.2 g N/(L d). The CANON system was operated in order to limit the ammonia oxidation rate to avoid nitrite inhibition of Anammox bacteria. Since both, temperature and dissolved oxygen (DO) concentration regulate ammonia oxidizing bacteria activity, once the temperature of the reactor is decreased the DO concentration must be decreased to avoid the deeper oxygen penetration inside the granule which could cause inhibition of Anammox bacteria by oxygen and/or nitrite.

Aerobic granulation in a mechanical stirred SBR: treatment of low organic loads

Aerobic granular sludge was produced in a sequencing batch reactor (SBR) characterized by a height to diameter ratio of 2.5 and the use of mechanical stirring. Compact and regular aerobic granules of up to 1.75 mm of average diameter were formed in the reactor with an organic loading rate of 1.75 kg COD/(m3 d). Settling properties of the obtained aggregates were: sludge volumetric index of 30-40 mL/g VSS and settling velocity higher than 8 m/h. The effects of different carbon to nitrogen ratios (TOC/N) in the feeding on the organic matter oxidation and nitrification process were studied. The concentration of organic matter in the feeding was stepwise reduced (from 190.0 to 37.5 mg TOC/L) and ammonium increased (from 25 to 50 mg NH4+ -N/L). TOC/N ratios of 7.50, 3.00, 1.50 and 0.75 g/g in the feeding were tested. The TOC removal percentage was around 80-95% during the whole operational period and the N removal percentages obtained in the reactor were up to 40%, however, physical properties of the granules were not maintained.

Application of biofilm reactors to improve ammonia oxidation in low nitrogen loaded wastewater

An airlift reactor using zeolite particles as carrier material was used for the nitrification of effluents from the aquaculture industry. During the start-up the nitrogen concentration was kept around 100 mg NH4(+)-N/L to develop the nitrifying population. Later it was decreased down to around 3 mg NH4(+)-N/L and the dilution rate was increased up to 4.8 d(-1) in order to simulate the conditions in a an aquaculture waster treatment system. A nitrogen loading rate (NLR) of 535 mg NH(+)-N/m2 d was fully oxidized to nitrate. Higher values of NLRs caused nitrite accumulation. A second biofilm reactor was fed with a synthetic medium containing 50 mg NH4(+)-N/L which simulated the effluents from anaerobic units treating domestic wastewater. A nitrogen loading rate of 400 mg NH4(+)-N/L d was oxidized into nitrate with an efficiency of 60% at a dilution rate of 8 d(-1). Both biofilm systems allowed the development of a nitrifying population to treat the studied types of wastewaters.

Treatment of high loaded swine slurry in an aerobic granular reactor

Aerobic granular sludge grown in a sequential batch reactor was proposed as an alternative to anaerobic processes for organic matter and nitrogen removal from swine slurry. Aerobic granulation was achieved with this wastewater after few days from start-up. On day 140 of operation, the granular properties were: 5 mm of average diameter, SVI of 32 mL (g VSS)(-1) and density around 55 g VSS (L(granule))(-1). Organic matter removal efficiencies up to 87% and nitrogen removal efficiencies up to 70% were achieved during the treatment of organic and nitrogen loading rates (OLR and NLR) of 4.4 kg COD m(-3) d(-1) and of 0.83 kg N m(-3) d(-1), respectively. However, nitrogen removal processes were negatively affected when applied OLR was 7.0 kg COD m(-3) d(-1) and NLR was 1.26 kg N m(-3) d(-1). The operational cycle of the reactor was modified by reducing the volumetric exchange ratio from 50 to 6% in order to be able to treat the raw slurry without dilution.