Implementation of an environmental decision support system for controlling the pre-oxidation step at a full-scale drinking water treatment plant.

Drinking water treatment plants (DWTPs) face changes in raw water quality, and treatment needs to be adjusted to produce the best water quality at the minimum environmental cost. An environmental decision support system (EDSS) was developed for aiding DWTP operators in choosing the adequate permanganate dosing rate in the pre-oxidation step. To this end, multiple linear regression (MLR) and multi-layer perceptron (MLP) models are compared for choosing the best predictive model. Besides, a case-based reasoning (CBR) model was approached to provide the user with a distribution of solutions given similar operating conditions in the past. The predictive model consisted of an MLP and has been validated against historical data with sufficient good accuracy for the utility needs (R2 = 0.76 and RSE = 0.13 mg·L-1). The integration of the predictive and the CBR models in an EDSS gives the user an augmented decision-making capacity of the process and has great potential for both assisting experienced users and for training new personnel in deciding the operational set-point of the process.

Belief That Caffeine Ingestion Improves Performance in a 6-Minute Time Trial Test without Affecting Pacing Strategy.

This study aimed to analyze the placebo effect associated with caffeine ingestion on running performance. METHODS: Thirteen recreationally trained males in long-distance running (age: 38.5 ± 11.9 years, 11.0 ± 8.8 years of running experience) performed a 6 min time trial test in each experimental condition (caffeine-informed/placebo ingested (placebo) and non-ingested (control)) separated by 7 days. The total distance covered was measured, and partial times of each 400 m were used to analyze the pacing strategy. Heart rate and kinematic variables were recorded for each split. In addition, the rate of perceived exertion and prevalence of caffeine side effects was measured using questionnaires. RESULTS: Placebo ingestion improved running performance in the 6 min time trial test (1668 ± 139 m placebo vs. 1642 ± 158 m control, t = 2.49; p = 0.03; moderate ES = 0.69), while pacing, heart rate, RPE, and kinematic variables were similar between conditions (p > 0.05 in all cases). Minor side effects were reported. CONCLUSIONS: Beliefs of caffeine ingestion can improve running performance at speeds around maximal aerobic speed in recreationally trained runners without affecting pacing strategy so this "nutritional" strategy could be useful in competition scenarios. As a practical application, recreationally trained runners could improve ≈5 s in 1500 m or mile competitions.

[Management of the COVID-19 pandemic in Catalonian old people's homes]. / La gestión de la pandemia de COVID-19 en las residencias geriátricas de Cataluña.

The covid-19 pandemic has exposed the deficiencies in the provision of social and health services, especially in nursing homes in Catalonia. This fact has triggered the debate on the residential model that Catalonia needs for the 21st century has begun.The objective of this article is to describe the management of the COVID-19 pandemic, during the five epidemic waves that affected the nursing homes of Catalonia, from an initial stage of absolute lack of control, to a final stage of pandemic control thanks to the rapid vaccination rate against COVID-19 in this área.

NOM fractionation by HPSEC-DAD-OCD for predicting trihalomethane disinfection by-product formation potential in full-scale drinking water treatment plants.

Chlorination is a common method for water disinfection; however, it leads to the formation of disinfection by-products (DBPs), which are undesirable toxic pollutants. To prevent their formation, it is crucial to understand the reactivity of natural organic matter (NOM), which is considered a dominant precursor of DBPs. We propose a novel size exclusion chromatography (SEC) approach to evaluate NOM reactivity and the formation potential of total trihalomethanes-formation potentials (tTHMs-FP) and four regulated species (i.e. CHCl3, CHBrCl2, CHBr2Cl, and CHBr3). This method combines enhanced SEC separation with two analytical columns working in tandem and quantification of apparent molecular weight (AMW) NOM fractions using C content (organic carbon detector, OCD), 254-nm spectroscopic (diode-array detector, DAD) measurements, and spectral slopes at low (S206-240) and high (S350-380) wavelengths. Links between THMs-FP and NOM fractions from high performance size exclusion chromatography HPSEC-DAD-OCD were investigated using statistical modelling with multiple linear regressions for samples taken alongside conventional full-scale as well as full- and pilot-scale electrodialysis reversal and bench-scale ion exchange resins. The proposed models revealed promising correlations between the AMW NOM fractions and the THMs-FP. Methodological changes increased fractionated signal correlations relative to bulk regressions, especially in the proposed HPSEC-DAD-OCD method. Furthermore, spectroscopic models based on fractionated signals are presented, providing a promising approach to predict THMs-FP simultaneously considering the effect of the dominant THMs precursors, NOM and Br-.

Screening of microplastics in water and sludge lines of a drinking water treatment plant in Catalonia, Spain.

Microplastics (MPs) are emerging pollutants detected everywhere in the environment, with the potential to harm living organisms. The present study investigated the concentration, morphology, and composition of MPs, between 20 µm and 5 mm, in a drinking water treatment plant (DWTP) located close to Barcelona (Catalonia, NE Spain). The sampling included different units of the DWTP, from influent to effluent as well as sludge line. Sampling strategy, filtration, allows sampling of large volumes of water avoiding sample contamination, and during 8 h in order to increase the representativeness of MPs collected. The pre-treatment of the samples consisted of advanced oxidation with Fenton's reagent and hydrogen peroxide, followed by density separation of the particles with zinc chloride solution. Visual identification was performed with an optical and stereoscopic microscope with final Fourier-transform infrared spectroscopic (FTIR) confirmation. MPs were found in all DWTP samples, with concentrations from 4.23 ± 1.26 MPs/L to 0.075 ± 0.019 MPs/L in the influent and effluent of the plant, respectively. The overall removal efficiency of the plant was 98.3%. The most dominant morphology was fibers followed by fragments and films. Twenty-two different polymer types were identified and synthetic cellulose, polyester, polyamide, polypropylene, polyethylene, polyurethane, and polyacrylonitrile were the most common. Although MPs could be incorporated from the distribution network, MPs intake from drinking water from this DWTP was not an important route compared to fish and seafood ingestion.

Protection against anti-citrullinated protein antibody-positive rheumatoid arthritis is predominantly associated with HLA-DRB1*1301: a meta-analysis of HLA-DRB1 associations with anti-citrullinated protein antibody-positive and anti-citrullinated protein antibody-negative rheumatoid arthritis in four European populations.

OBJECTIVE: The protective effect of HLA-DRB1 alleles on the development of rheumatoid arthritis (RA) is poorly understood. The aim of this study was to perform a meta-analysis of 4 European populations to investigate which HLA-DRB1 alleles are associated with protection in anti-citrullinated protein antibody (ACPA)-positive RA and ACPA-negative RA. METHODS: Data for >2,800 patients and >3,000 control subjects for whom information on HLA-DRB1 typing and ACPA status was available were collected from 4 European countries: Norway, Sweden, The Netherlands, and Spain. The odds ratios (ORs) and 95% confidence intervals (95% CIs) associated with the different HLA-DRB1 alleles were analyzed in a combined meta-analysis focused on protective alleles and classifications. The analysis of ACPA-positive RA was stratified for the shared epitope (SE) alleles, to correct for skewing due to this association. RESULTS: In ACPA-positive RA, the only alleles that conveyed protection after stratification for SE were HLA-DRB1*13 alleles (OR 0.54 [95% CI 0.38-0.77]). The protective effect of the allele classifications based on the DERAA and D70 sequences was no longer present after exclusion of DRB1*13 (for D70, OR 0.97 [95% CI 0.75-1.25]), indicating that DRB1*13, rather than the DERAA or D70 sequence as such, is associated with protection. Among the DRB1*13 alleles, only DRB1*1301 was associated with protection (OR 0.24 [95% CI 0.09-0.59]). Protection appeared to follow a north-to-south gradient, with the strongest association in northern European countries. In ACPA-negative RA, there were no robust associations with HLA-DRB1 alleles. CONCLUSION: Our data do not support any of the classifications of protective alleles and indicate that protection against ACPA-positive RA is predominantly associated with HLA-DRB1*1301.

Benchmarking empirical models for THMs formation in drinking water systems: An application for decision support in Barcelona, Spain.

Drinking water treatment plants (DWTPs) face changes in raw water quality, which affect the formation of disinfection by-products. Several empirical modelling approaches have been reported in the literature, but most of them have been developed with lab-scale data, which may not be representative of real water systems. Therefore, the application of these models for real-time operation of DWTPs might be limited. At the present study, multiple linear regression (MLR) and multi-layer perceptrons (MLP) were benchmarked using field-scale data for predicting the THMs formation in a case-study DWTP in Barcelona, Spain. After fitting the studied models, MLR exhibited good fit with the validation data set (R2 = 0.88 and MAE = 4.0 µg·L-1) and described the most plausible input-output relationships with field-scale data. The MLR predictive model was incorporated into an environmental decision support system (EDSS) for assessing the THMs formation at two critical points of the distribution network. A Monte Carlo scheme was applied for quantifying uncertainty of model predictions at these points, considering low and high water quality scenarios and different degrees of treatment by an electrodialysis reversal process. The results show that the use of the proposed EDSS can help in real operation of complex drinking water systems, which face important changes in water quality throughout the year.

Assessment of dead-end ultrafiltration for the detection and quantification of microbial indicators and pathogens in the drinking water treatment processes.

A safe water supply requires distinct treatments and monitoring to guarantee the absence of pathogens and substances potentially hazardous for human health. In this study we assessed the efficiency of the dead-end ultrafiltration (DEUF) method to concentrate faecal indicator organisms (FIO) and pathogens in water samples with different physicochemical characteristics. Water samples were collected at the treatment stages of two drinking water treatment plants to analyse the concentration of a variety of 7 FIO and 4 reference microbes which have some species that are pathogenic to humans: Campylobacter spp., enteroviruses, Cryptosporidium spp. and Giardia spp. The samples were analysed before and after concentration by DEUF, detecting FIO concentrations about 1 log10 higher in non-concentrated samples from both catchments. Percent recoveries were highly variable with a mean of 43.8 ± 17.5%, depending on the FIO and inherent sample characteristics. However, DEUF enabled FIO concentration in high volumes of water (100-500 l), allowing a reduction in the detection limit compared to the non-concentrated samples due to the high volume processing capabilities of the method. As a consequence, the detection of FIO removal from water in the drinking water treatment process was 1.0-1.5 logarithms greater in DEUF-treated water compared to unfiltered samples. The DEUF method improved the detection of target indicators and allowed for the detection of pathogens in low concentrations in water after the treatment stages, confirming the suitability of DEUF to concentrate high volumes of different types of water. This method could be useful for microbial analysis in water treatment monitoring and risk assessment, allowing the identification of critical points during the water treatment process and potential hazards in water destined for several uses.

[In search of the origin of municipal pharmacists]. / En busca del origen de los farmacéuticos titulares.

The evolution of public health in Spain during the 19th century can be divided into three stages. In the first stage (1812-1833), the reign of Fernando VII prevented the development of the liberal postulates: <>. The second stage (1833-1873), was characterized by the legislative development of sanitary organization in Spain. As a result of this new legislative framework, and in the context of social hygiene (<>), the figures of municipal health professionals appeared, engaged by the city councils to be in charge of the medical assistance of the poor (municipal physician), of the pharmaceutical assistance of the poor (municipal pharmacist), and of the health inspection of meat from the slaughterhouses (municipal veterinarian). The third stage (1873-1904), marked the beginning of a new age (microbiology) and the beginning of the scientific method. Microbiology prompted the creation of municipal laboratories throughout the state and laid the foundations for the creation of the Healthcare Services of Medicine, Pharmacy and Veterinary Science at the beginning of the xx century. These organizations would have a well-defined organizational structure with wider functions.

Chemical characterization and relative toxicity assessment of disinfection byproduct mixtures in a large drinking water supply network.

In order to reduce the formation of disinfection by-products (DBPs) during potabilization of water it is necessary to explore the potential of the source water and the applied treatment to generate these chemicals. This is actually more challenging in large drinking water networks that use different source waters to satisfy drinking water demand. In this regard, this work investigated the formation of DBPs in water matrices that are commonly supplied to the city of Barcelona and its metropolitan area. The regulated trihalomethanes and haloacetic acids were the most abundant DBP classes in these waters, followed by haloacetamides and haloacetonitriles or trihalogenated acetaldehydes (THALs). On the contrary, the formation potential of iodo-DBPs was minor. Mixing of drinking water treatment plant finished waters with desalinated water decreased the overall DBP formation potential of the water but resulted in the increased formation of brominated DBPs after long chlorine contact time. The formation of most DBPs was enhanced at high water temperatures (except for Br-THALs) and increasing residence times. Potential cytotoxicity and genotoxicity of the DBP mixtures were mainly attributed to the presence of nitrogen-containing DBPs and HAAs.

N-acetylcysteine exerts protective effects and prevents lung redox imbalance and peroxynitrite generation in endotoxemic rats.

The aim of this study was to determine in endotoxemic rats the effects of N-acetylcysteine on lung redox imbalance and plasma peroxynitrite generation. Eighty male Wistar rats were divided in two sets of five experimental groups. Six hours after vehicle (Control group: isotonic NaCl sterile solution i.p.; n=7), lipopolysaccharide (LPS group: 1 mg/Kg i.p.; n=8), N-acetylcysteine plus LPS (NAC+LPS group, n=8), NAC plus the nitric oxide synthesis inhibitor N(w)-nitro-L-arginine methyl ester plus LPS (NAC+NAME+LPS group; n=8), or NAME plus LPS (NAME+LPS group; n=9), arterial blood and lung samples were taken from each animal under sodium pentobarbital anesthesia. In five additional groups treated as described above, in vivo plasma oxidation of dihydrorhodamine (DRH) 123 to rhodamine (RH)123 was measured as index of peroxynitrite formation. LPS treated rats presented increased plasma lactate, thrombocytopenia and both, decreased reduced thiols and increased lipid peroxidation in lung tissue. Moreover, LPS produced increments in plasma concentration of nitrites/nitrates and DRH 123 oxidation. Pretreatment with NAC prevented all these changes induced by LPS except the increment in plasma concentration of nitrites/nitrates. The protective effects seen in LPS rats pretreated with NAC were not observed in the NAC+NAME+LPS group. In conclusion, the results of this study show that in endotoxemia induced by LPS in rats, NAC produces protective effects on lung redox balance and prevents peroxynitrite anion generation.

[Study of refrigeration towers associated with community outbreaks of legionellosis]. / Estudio de las torres de refrigeración asociadas a brotes comunitarios de legionelosis.

OBJECTIVE: To evaluate the factors of risk of the risk cooling towers associated to a community outbreak of legionellosis according to its characteristics of maintenance and the quality of the water with the purpose of improving the systems of prevention of this one disease. METHOD: To compare the piece of information gathered between the 4 types of cooling towers: control 1, control 2, probable and confirmed. A total of 184 cooling towers have been studied associated to 17 community outbreak of legionellosis of the province of Barcelona (Spain) during the year 2004, of which 112 are control 1, 54 control 2, 8 probable and 10 confirmed. RESULTS: The confirmed towers are characterized by: high levels of conductivity, total aerobes, calcic hardness, total solids in dissolution, temperature and turbidity; low levels of chlorine (< 2 ppm); of use hypochlorite as disinfectant in a 10%; greater degree of breach of the revision program and cleaning of the internal elements of the tower (tray, stuffed and separating of drops); degree of performance of the periodic disinfections and the cleaning of deposits of the 100%. A 47% of the investigated towers do not use the previous treatments of the water in spite of diminishing the parametric values of the quantitatives variables. CONCLUSIONS: Measures of prevention of the legionellosis would be due to guarantee: a good quality of the water and the pursuit of its quantitatives variables; chlorine levels superior to 2 ppm; the evaluation of the individual risk for each installation; the performance of the 100% of the program of revision of the internal elements of the towers.

Recommendations for the Diagnosis and Management of Asbestos-Related Pleural and Pulmonary Disease. / Recomendaciones sobre el diagnóstico y manejo de la enfermedad pleural y pulmonar por asbesto.

Asbestos is the term used for a set of mineral silicates that tend to break up into fibers. Its use has been associated with numerous diseases affecting the lung and pleura in particular, all of which are characterized by their long period of latency. Asbestos, moreover, has been recognized by the WHO as a Group IA carcinogen since 1987 and its use was banned in Spain in 2002. The publication in 2013 of the 3rd edition of the specific asbestos health monitoring protocol, together with the development of new diagnostic techniques, prompted the SEPAR EROM group to sponsor publication of guidelines, which review the clinical, radiological and functional aspects of the different asbestos-related diseases. Recommendations have also been made for the diagnosis and follow-up of exposed patients. These recommendations were drawn up in accordance with the GRADE classification system.

Seasonal variability in clinical care of COPD outpatients: results from the Andalusian COPD audit.

OBJECTIVES: Clinical practice in chronic obstructive pulmonary disease (COPD) can be influenced by weather variability throughout the year. To explore the hypothesis of seasonal variability in clinical practice, the present study analyzes the results of the 2013-2014 Andalusian COPD audit with regard to changes in clinical practice according to the different seasons. METHODS: The Andalusian COPD audit was a pilot clinical project conducted from October 2013 to September 2014 in outpatient respiratory clinics of hospitals in Andalusia, Spain (8 provinces with more than 8 million inhabitants) with retrospective data gathering. For the present analysis, astronomical seasons in the Northern Hemisphere were used as reference. Bivariate associations between the different COPD guidelines and the clinical practice changes over the seasons were explored by using binomial multivariate logistic regression analysis with age, sex, Charlson comorbidity index, type of hospital, and COPD severity by forced expiratory volume in 1 second as covariates, and were expressed as odds ratio (OR) with 95% confidence intervals (CIs). RESULTS: The Andalusian COPD audit included 621 clinical records from 9 hospitals. After adjusting for covariates, only inhaler device satisfaction evaluation was found to significantly differ according to the seasons with an increase in winter (OR, 3.460; 95% CI, 1.469-8.151), spring (OR, 4.215; 95% CI, 1.814-9.793), and summer (OR, 3.371; 95% CI, 1.391-8.169) compared to that in autumn. The rest of the observed differences were not significant after adjusting for covariates. However, compliance with evaluating inhaler satisfaction was low. CONCLUSION: The various aspects of clinical practice for COPD care were found to be quite homogeneous throughout the year for the variables evaluated. Inhaler satisfaction evaluation, however, presented some significant variation during the year. Inhaler device satisfaction should be evaluated during all clinical visits throughout the year for improved COPD management.

Determinants for changing the treatment of COPD: a regression analysis from a clinical audit.

INTRODUCTION: This study is an analysis of a pilot COPD clinical audit that evaluated adherence to guidelines for patients with COPD in a stable disease phase during a routine visit in specialized secondary care outpatient clinics in order to identify the variables associated with the decision to step-up or step-down pharmacological treatment. METHODS: This study was a pilot clinical audit performed at hospital outpatient respiratory clinics in the region of Andalusia, Spain (eight provinces with over eight million inhabitants), in which 20% of centers in the area (catchment population 3,143,086 inhabitants) were invited to participate. Treatment changes were evaluated in terms of the number of prescribed medications and were classified as step-up, step-down, or no change. Three backward stepwise binominal multivariate logistic regression analyses were conducted to evaluate variables associated with stepping up, stepping down, and inhaled corticosteroids discontinuation. RESULTS: The present analysis evaluated 565 clinical records (91%) of the complete audit. Of those records, 366 (64.8%) cases saw no change in pharmacological treatment, while 99 patients (17.5%) had an increase in the number of drugs, 55 (9.7%) had a decrease in the number of drugs, and 45 (8.0%) noted a change to other medication for a similar therapeutic scheme. Exacerbations were the main factor in stepping up treatment, as were the symptoms themselves. In contrast, rather than symptoms, doctors used forced expiratory volume in 1 second and previous treatment with long-term antibiotics or inhaled corticosteroids as the key determinants to stepping down treatment. CONCLUSION: The majority of doctors did not change the prescription. When changes were made, a number of related factors were noted. Future trials must evaluate whether these therapeutic changes impact clinically relevant outcomes at follow-up.

Guideline Adherence in Outpatient Clinics for Chronic Obstructive Pulmonary Disease: Results from a Clinical Audit.

OBJECTIVES: Previous clinical audits of COPD have provided relevant information about medical intervention in exacerbation admissions. The present study aims to evaluate adherence to current guidelines in COPD through a clinical audit. METHODS: This is a pilot clinical audit performed in hospital outpatient respiratory clinics in Andalusia, Spain (eight provinces with more than 8 million inhabitants), including 9 centers (20% of the public centers in the area) between 2013 and 2014. Cases with an established diagnosis of COPD based on risk factors, clinical symptoms, and a post-bronchodilator FEV1/FVC ratio of less than 0.70 were deemed eligible. The performance of the outpatient clinics was benchmarked against three guidance documents available at the time of the audit. The appropriateness of the performance was categorized as excellent (>80%), good (60-80%), adequate (40-59%), inadequate (20-39%), and highly inadequate (<20%). RESULTS: During the audit, 621 clinical records were audited. Adherence to the different guidelines presented a considerable variability among the different participating hospitals, with an excellent or good adherence for symptom recording, MRC or CAT use, smoking status evaluation, spirometry, or bronchodilation therapy. The most outstanding areas for improvement were the use of the BODE index, the monitoring of treatments, the determination of alpha1-antitrypsin, the performance of exercise testing, and vaccination recommendations. CONCLUSIONS: The present study reflects the situation of clinical care for COPD patients in specialized secondary care outpatient clinics. Adherence to clinical guidelines shows considerable variability in outpatient clinics managing COPD patients, and some aspects of the clinical care can clearly be improved.

Hip arthroscopy after previous acetabular osteotomy for developmental dysplasia of the hip.

PURPOSE: The purpose of this study was to examine the arthroscopic findings in the hips of patients with long-term follow-up of Chiari osteotomies. TYPE OF STUDY: Prospective consecutive series of patients. METHODS: Seven consecutive patients (1 male, 6 female; average age, 23 years) having a Chiari osteotomy performed in 1 hip during childhood or adolescence for developmental dysplasia of the hip were studied. They presented mechanical hip symptoms and had adequate head coverage as a result of the osteotomy with preservation of joint space. Hip arthroscopy was performed in all cases. RESULTS: A massive labral tear dislocated in the midportion of the joint was found in all cases with varying degrees of cartilage damage in the acetabulum or femoral head. The labral tear was resected, cartilage lesions were repaired, and microfracturing of the exposed subchondral bone was performed. Mechanical symptoms improved after surgery and all of the patients were able to go back to activities of daily living. CONCLUSIONS: In the Chiari osteotomy, medial displacement of the acetabulum leaves the labrum in the center of the load-bearing area of the resulting acetabulum. Over time this can produce a tear of the labrum, which may be the cause of the mechanical symptoms in our series. It has been documented that labral tears can lead to early degenerative hip disease and, combined with the cartilage lesions, may explain in part the long-term bad results of the Chiari osteotomy. LEVEL OF EVIDENCE: Level IV.

Internal snapping hip syndrome: treatment by endoscopic release of the iliopsoas tendon.

PURPOSE: The internal snapping hip syndrome is caused by slippage of the iliopsoas tendon over the iliopectineal eminence or the femoral head. Open surgical techniques have been successfully used to treat this condition. More recently, endoscopic techniques have become available to address this problem. The purpose of this study was to investigate an endoscopic technique for release of the iliopsoas tendon and its short-term results. TYPE OF STUDY: Consecutive case series. METHODS: Six patients (7 hips) with an average age of 38.5 years had an endoscopic release of the iliopsoas tendon for internal snapping hip syndrome. Hip arthroscopy was performed in every patient. Special inferior portals were used for psoas bursoscopy. The iliopsoas tendon was identified and released at the level of the lesser trochanter in all cases. RESULTS: Intra-articular concomitant injuries were identified and treated in 4 cases. No snapping symptoms were present in any patient after surgery nor at the last follow-up at, on average, 21 months. Significant loss of flexion strength was present after surgery but had improved by 8 weeks. CONCLUSIONS: In our hands, the endoscopic technique for iliopsoas tendon release was effective and reproducible and our results compare well with results of open procedures in the short term. LEVEL OF EVIDENCE: Level IV.

Clinical Audits in Outpatient Clinics for Chronic Obstructive Pulmonary Disease: Methodological Considerations and Workflow.

OBJECTIVES: Previous clinical audits for chronic obstructive pulmonary disease (COPD) have provided valuable information on the clinical care delivered to patients admitted to medical wards because of COPD exacerbations. However, clinical audits of COPD in an outpatient setting are scarce and no methodological guidelines are currently available. Based on our previous experience, herein we describe a clinical audit for COPD patients in specialized outpatient clinics with the overall goal of establishing a potential methodological workflow. METHODS: A pilot clinical audit of COPD patients referred to respiratory outpatient clinics in the region of Andalusia, Spain (over 8 million inhabitants), was performed. The audit took place between October 2013 and September 2014, and 10 centers (20% of all public hospitals) were invited to participate. Cases with an established diagnosis of COPD based on risk factors, clinical symptoms, and a post-bronchodilator FEV1/FVC ratio of less than 0.70 were deemed eligible. The usefulness of formally scheduled regular follow-up visits was assessed. Two different databases (resources and clinical database) were constructed. Assessments were planned over a year divided by 4 three-month periods, with the goal of determining seasonal-related changes. Exacerbations and survival served as the main endpoints. CONCLUSIONS: This paper describes a methodological framework for conducting a clinical audit of COPD patients in an outpatient setting. Results from such audits can guide health information systems development and implementation in real-world settings.

Assessment of drinking water quality using indicator bacteria and bacteriophages.

Bacterial indicators and bacteriophages suggested as potential indicators of water quality were determined by public laboratories in water from springs, household water wells, and rural and metropolitan water supplies in north-eastern Spain. Indicator bacteria were detected more frequently than bacteriophages in springs, household water wells and rural water supplies. In contrast, positive bacteriophage detections were more numerous than those of bacteria in metropolitan water supplies. Most of the metropolitan water supply samples containing indicators had concentrations of chlorine below 0.1 mg l(-1), their indicator loads resembling more closely those of rural water supplies than any other samples taken from metropolitan water supplies. The number of samples from metropolitan water supplies containing more than 0.1 mg l(-1) of chlorine that contained phages clearly outnumbered those containing indicator bacteria. Some association was observed between rainfall and the presence of indicators. Sediments from service reservoirs and water from dead ends in the distribution network of one of the metropolitan water supplies were also tested. Bacterial indicators and phages were detected in a higher percentage than in samples of tap water from the same network. Additionally, indicator bacteria were detected more frequently than bacteriophages in sediments of service reservoirs and water from dead end samples. We conclude that naturally occurring indicator bacteria and bacteriophages respond differently to chlorination and behave differently in drinking water distribution networks. Moreover, this study has shown that testing for the three groups of phages in routine laboratories is easy to implement and feasible without the requirement for additional material resources for the laboratories.