Woodchip bioreactors for saline leachates denitrification can mitigate agricultural impacts in mediterranean areas: The Campo de Cartagena-Mar Menor environmental issue.

Leachates from intensive agriculture containing high nitrate have been identified as a major cause of the severe eutrophication crisis that impacts Mar Menor (SE Spain), the largest hypersaline coastal lagoon in the Mediterranean basin. A best management practice for removing NO3--N is denitrifying bioreactors. This is the first study to assess the efficiency of citrus woodchips bioreactors in treating agricultural leachates that flow to the Mar Menor via surface discharges. Denitrification capacity, woodchip degradation (by weight loss), formation of potentially harmful compounds, and greenhouse gas (GHG) emissions were assessed. Three bioreactors (6 m × 0.98 m x 1.2 m) filled with citrus woodchips (3 m3 d-1 per bioreactor) through which the untreated ditch water over 1.5 years. Bioreactors were operated at 8 h, 16 h, and 24 h hydraulic residence time respectively, in each bioreactor. The main characteristics of the ditch water were: pH ≈ 7.5-8.0, electrical conductivity ≈ 5-8 dS m-1, dissolved organic carbon ≈6-10 mg L-1, and NO3--N ≈ 22-45 mg L-1. Bioreactors were highly efficient in reducing NO3--N. The average RNO3 in effluents was for the complete experimental period 8 g N m-3 d-1, 10.9 g N m-3 d-1, and 12.6 g N m-3 d-1 for 8, 16 and 24 h residence time, respectively. Nitrate reduction efficiency was modulated by seasonal changes in temperature, with an increasing efficiency in warmer periods (maximum ≈ 85-90% for all hydraulic residence time) and decreasing in colder ones (minimum ≈ 12%, 23% and 41% for hydraulic residence time 8, 16 and 24 h respectively). Woodchips degradation was greatest during the first six months (average ≈ 29% weight loss) in the material above the water level, attributable to aerobic mineralization of the organic carbon, while weight loss was ≈11% in woodchip media continuously below the water level. Dissolved organic carbon, sulfide, ammonium, and soluble phosphorus concentrations in the effluents were mostly low, although some peaks in concentrations occurred. Design consideration must be taken to avoid environmental impacts due to the occasional presence of harmful compounds in the effluents.

Mentoring: what to expect from our surgical mentors in Colombia? A Latin American example.

OBJECTIVE: Identifying the scope of surgical mentoring at Pontificia Universidad Javeriana and compare the perceptions of teachers and students to recognize characteristics and competences of such practice and future needs. METHOD: Two surveys were designed to evaluate the existence and importance of mentoring and inquire about the characteristics, qualities and skills expected on mentors. RESULTS: Both groups agree on the importance of having a mentor. 84.2% of teachers consider themselves mentors, however, only 38.6% of students considered them as such. The most relevant quality of the mentor recognized by students was the willingness and ability to teach, while for teachers it was respect. For the students, the most important competence was the ability to explain and teach about the procedures to be performed, while for teachers it was the ability to provide confidence and security. CONCLUSIONS: There is a paradoxical behavior, most students consider they do not have a mentor while most teachers consider to be such. The need to expand the literature regarding mentoring in Colombia specifically in the surgical field was identified.

OBJETIVO: Identificar el alcance del mentoring quirúrgico en la Facultad de Medicina de la Pontificia Universidad Javeriana y comparar las percepciones de docentes y estudiantes, con el fin de reconocer características y competencias de dicha práctica y necesidades a futuro. MÉTODO: Se diseñaron dos encuestas para evaluar la existencia y la importancia del proceso de mentoring e indagar acerca de las características, las cualidades y las competencias esperadas de los mentores. RESULTADOS: Ambos grupos coinciden en la importancia de contar con un mentor. El 84.2% de los docentes consideran ser mentores, pero solo el 38.6% de los estudiantes los consideraron a ellos como tales. Las cualidad más relevantes del mentor reconocidas por los estudiantes fueron la disposición y la habilidad para enseñar, mientras que para los docentes fue el respeto. Para los estudiantes, la competencia más importante fue la capacidad de explicar y enseñar sobre los procedimientos a realizar, mientras que para los docentes fue la capacidad de brindar confianza y seguridad. CONCLUSIONES: Existe un comportamiento paradójico, pues los estudiantes no consideraron contar con un mentor mientras que los docentes sí estimaron serlo. Se identificó la necesidad de ampliar la literatura respecto al mentoring en Colombia, específicamente en el ámbito quirúrgico.

Woodchip bioreactors provide sustained denitrification of brine from groundwater desalination plants.

Woodchip bioreactors are widely known as a best management practice to reduce excess nitrate loads that are discharged with agricultural leachates. The aim of this study was to evaluate the performance of citrus woodchip bioreactors for denitrification of brine (electrical conductivity ≈ 17 mS cm-1) from groundwater desalination plants with high nitrate content (NO3--N ≈ 48 mg L-1) in the Campo de Cartagena agricultural watershed, one of the main providers of horticultural products in Europe. The performance was evaluated relative to seasonal changes in temperature, dissolved organic carbon (DOC) provided by woodchips, hydraulic residence time (HRT) and woodchip aging. Bioreactors (capacity 1 m3) operated for 2.5 years (121 weeks) in batch mode (24 h HRT) with three batches per week. Denitrification efficiency was modulated by DOC concentration, temperature, hydraulic residence time and the drying-rewetting cycles. High salinity of brine did not prevent nitrate removal from occurring. The high DOC availability (>25 mg C L-1) during the first ≈48 weeks resulted in high nitrate removal rate (>75%) and nitrate removal efficiency (until ≈ 25 g N m-3 d-1) regardless of temperature. Moreover, the high DOC contents in the effluents during this period may present environmental drawbacks. Denitrification was still high after 2.5 years (reaching ≈9.3 g N m-3 d-1 in week 121), but dependence on warm temperature became more apparent with woodchips aging from week ≈49 onwards. Nitrate removal efficiency was highest on the first weekly batch, immediately after woodchips had been unsaturated for four days. It was attributable to a flush of DOC produced by aerobic microbial metabolism during drying that stimulated denitrification following re-saturation. Hence, alternance of drying-rewetting cycles is an operation practice that increase bioreactors nitrate removal performance.

Emergency department attendance and reasons for consultation after cryoballoon ablation for pulmonary vein isolation of atrial fibrillation.

INTRODUCTION AND OBJECTIVES: There are few data on emergency visits after cryoballoon-based pulmonary vein isolation. The aim of this study was to quantify emergency department visits during the first 3 months after the procedure and to identify the reasons for consultation, final diagnoses, and the therapeutic approach. METHODS: Observational, retrospective study of 330 consecutive patients undergoing a first cryoballoon-based ablation procedure. Patients were followed up for 90 days after the procedure. We recorded emergency visits, symptoms, electrocardiographic data, and the therapeutic approach. Final diagnoses were classified as rhythm disorder, confirmed complication, possible complication, and unrelated to the procedure or to the arrhythmic disorder. RESULTS: A total of 112 (34%) patients attended the emergency department, 50 (44.6%) for palpitations. Sustained atrial arrhythmias were documented in 44 (39.3%) patients. Among the 29 (25.9%) visits for complications potentially related to the procedure, 5 were confirmed inguinal puncture complications and 10 were classified as unconfirmed possible complications. Forty-one visits were unrelated to the procedure or to the arrhythmic disorder. A total of 21.4% of the visits were due to palpitations requiring no therapeutic action. CONCLUSIONS: A third of the patients attended the emergency department at least once, with the most frequent reason being arrhythmia-related symptoms. Late complications were rare and generally mild. Up to 20% of emergency visits could potentially be avoided by the availability of a teleconsulting system with remote electrocardiogram transmission.

[Healthcare for migrants on the high seas. The case of the operation EUNAVFOR MED "Sophia".] / El caso de la operación EUNAVFOR MED "Sophia".

Since 2015, the Spanish Navy participates in the Operation EUNAVFOR MED Sophia, a naval operation of the European Union against the trafficking of human beings in the Mediterranean in which our ships carry out an important humanitarian work in the rescue and assistance of migrants on the sea. The attention and health care of these migrants lies mainly in the military Health Group and it is based on a series of principles and procedures among which the application of a triage adapted to the special conditions of rescue and assistance on the sea and in the diagnosis and treatment of various pathologies present among migrants. In this context, a series of epidemiological data is provided, especially the most frequent pathologies attended by rescued migrants and emphasizing the importance of adopting a series of measures to prevent the transmission of infectious pathologies that are rare or already eradicated in our country.

Desde 2015, la Armada española participa en la operación EUNAVFOR MED Sophia, una operación naval de la Unión Europea contra el tráfico de seres humanos en el Mediterráneo, en la que nuestros buques realizan una importante labor humanitaria en el rescate y asistencia de migrantes en la mar. La atención y asistencia sanitaria de estos migrantes recae principalmente en el Grupo de Sanidad militar, y se basa en una serie de principios y procedimientos entre los que destacan la aplicación de un triaje adaptado a las especiales condiciones del rescate y asistencia en alta mar, así como en el diagnóstico y tratamiento de diversas patologías presentes entre los migrantes. En este sentido, este trabajo proporciona una serie de datos epidemiológicos, incidiendo en las patologías más frecuentes entre los migrantes rescatados, y destacando la importancia de la adopción de una serie de medidas para prevenir la transmisión de patologías infecciosas poco frecuentes o ya erradicadas en nuestro país.

Bioreactors for brine denitrification produced during polluted groundwater desalination in fertigation areas of SE Spain: batch assays for substrate selection.

Increasing knowledge of nitrate removal using denitrifying bioreactors has illustrated the usefulness of this management practice for treating discharge water from agricultural land uses. The objective of this study was to assess the viability of almond shell, chopped carob, olive bone, and citrus woodchip as carbon media for denitrification of brine with high nitrate load (EC ≈ 20 dS m-1, NO3--N concentration ≈ 65-80 mg NO3--N L-1) in bioreactors. To the authors' knowledge, this is the first test of denitrifying brine using organic wastes as the carbon substrate, and the first use of these carbon media for that purpose. Nitrate removal efficiency and efficiency:cost ratio were considered. The results indicated that the best removal efficiency and cheapest cost were provided by citrus woodchip (3.02 ± 0.15 mg NO3--N m-3 d-1) at a cost of ≈ 6€ m-3, followed by almond shell (1.54 ± 0.20 mg NO3--N m-3 d-1) at a cost of ≈ 19€ m-3. Chopped carob and olive bone showed negligible nitrate removal in the brine; chopped carob generated acidic leachate with extremely high dissolved organic carbon, and olive bone resulted in a highly saline leachate. Of the four media tested, the results of this study indicated that citrus woodchip was the most suitable media for denitrification of the brine.

Medium- and long-term outcome after a single second-generation cryoballoon ablation in patients with paroxysmal and persistent atrial fibrillation.

INTRODUCTION AND OBJECTIVES: To report medium- and long-term results following a single second-generation cryoballoon (CB2)-based ablation procedure in patients with paroxysmal (PAF) and persistent (PeAF) atrial fibrillation. METHODS: A retrospective study was performed of consecutive patients undergoing a first CB2-based ablation procedure in a tertiary center. Cryoenergy was applied for 3 min if a time to effect <60 s was documented or 4 min otherwise, with a bonus application in cases of late isolation or suboptimal temperature. Follow-up was obtained from the regional health electronic records system and by telephone or personal interviews. Recurrence was defined as any atrial arrhythmia >30 s beyond a three-month blanking period. The clinical impact of recurrences was classified using a severity score. RESULTS: A total of 172 patients (134 PAF and 38 PeAF) were included, of whom 25 (14.5%) had structural heart disease and 120 (69.7%) had a normal or mildly dilated left atrium. Acute success was achieved in 167 (97.1%). After a median follow-up of 27 (14-41) months, 100 patients (58.1%) remained free of atrial arrhythmias (64.2% for PAF and 36.8% for PeAF, p=0.006). Left atrial size (p=0.05) and clinical presentation as PeAF (p=0.006) were predictors of recurrence. Of patients with recurrences, 11.1% did not require further therapies and an additional 16.7% had good control with antiarrhythmic drugs. CONCLUSIONS: A single CB2 procedure resulted in 58.1% of patients remaining free of atrial arrhythmias at 27-month follow-up. Conservative management was useful in 27.8% of patients with recurrences.

Heterogeneous Phenotype of Long QT Syndrome Caused by the KCNH2-H562R Mutation: Importance of Familial Genetic Testing.

INTRODUCTION AND OBJECTIVES: Long QT syndrome is an inherited ion channelopathy that leads to syncope and sudden death. Because of the heterogeneous phenotype of this disease, genetic testing is fundamental to detect individuals with concealed long QT syndrome. In this study, we determined the features of a family with 13 carriers of the KCNH2-H562R missense mutation, which affects the pore region of the HERG channel. METHODS: We identified the KCNH2-H562R mutation in a 65-year-old man with a prolonged QTc interval who had experienced an episode of torsade de pointes. Subsequently, a total of 13 mutation carriers were identified in the family. Carriers (age 48 [26] years; 46% males) underwent clinical evaluation, electrocardiography and echocardiography. RESULTS: The mean (standard deviation) QTc in carriers was 493 (42) ms (3 [23%] showed normal QTc); 6 (46%) had symptoms (4, syncope; 1, sudden death; 1, aborted sudden death [proband]). While under treatment with beta-blockers, 11 of 12 carriers (92%) remained asymptomatic at 5 years of follow-up (1 patient required left cardiac sympathectomy). The QTc shortening with beta-blockers was 50 (37) ms. There was 1 sudden death in a patient who refused treatment. CONCLUSIONS: Family study is essential in the interpretation of a genetic testing result. This article describes the heterogeneous and variable phenotype of a large family with the KCNH2-H562R mutation and highlights the role of genetic study for the appropriate identification of at-risk individuals who would benefit from treatment.

Psychological intervention in the Spanish military deployed on international operations.

BACKGROUND: Spain was one of the first countries to recognize the importance of psychological aspects in the planning and development of international military operations, and also to include military psychologists in contingents deployed abroad. METHOD: This paper describes the psychological intervention model used by Spanish military psychologists involved in military operations abroad. RESULTS: This model is comprised of a systematic set of interventions and actions carried out in the different phases of any military operation (concentration, deployment and post-mission). It also contemplates the intervention not only in personnel who integrate the military contingents, but also with their families and, at certain times of the mission, with the local population of the area in which the operation is carried out. CONCLUSIONS: The model presented has a preventive orientation, based on the selection and psychological preparation of contingents before deployment, and supplemented by support in the area of operations for personnel who need it, and the psychological care of their families in Spain. Whereas this model has been effective so far, in this work, we present a series of measures aimed at improving the psychological well-being of our troops deployed outside our country.

Darbepoetin inhibits proliferation of hepatic cancer cells in the presence of TGF-ß.

Darbepoetin (DPO), an erythropoietin (EPO) derivative, was licensed in 2002 to treat patients with solid tumors suffering from chemotherapy-dependent anemia, although various tumors express EPO to improve vascularization, thus favoring tumor growth and spreading. Therefore, we wanted to investigate direct effects of DPO on the liver tumor cell lines HepG2, SkHep1, Huh-7, AKN1, HCC-T and HCC-M, as well as on primary human hepatocytes (hHeps). DPO (0-40 ng/ml) did not affect viability of hHeps, HepG2, SkHep1, AKN1, HCC-T and HCC-M cells, as determined by Resazurin conversion. However, Huh-7 cells' viability dose-dependently decreased from 5 ng/ml DPO on. Lack of LDH release into culture medium and negative DNA laddering excluded apoptosis or necrosis as the cause for the reduced Resazurin conversion. In Huh-7 cells, DPO increased the expression of p53. Interestingly, Huh-7 cells showed the highest basal TGF-ß1 expression as compared to the other cell lines. Upon inhibition of TGF-ß1 signaling, DPO no longer reduced viability in Huh-7 cells. On the contrary, co-incubation with TGF-ß1 made the other cell lines responsive to DPO. Summarizing our data, we show that DPO reduces the growth of Huh-7 cells by up-regulation of the tumor-suppressor gene p53. This mechanism seems to be dependent on a strong TGF-ß expression and corresponding signaling in these cells, as other cell lines became responsive to DPO with TGF-ß1 supplementation. The knowledge of this mechanism offers great perspectives for the understanding and treatment of solid liver tumors.

Long-term culture of primary hepatocytes: new matrices and microfluidic devices.

Prediction of in vivo drug-induced hepatotoxicity by in vitro cell culture systems is still one of the main challenges in drug development. To date, most in vitro approaches are based on monolayer cultures of primary hepatocytes, although it is known that they rapidly lose their morphology and liver-specific functions, such as activities of drug-metabolizing enzymes and transporters. Hepatocyte dedifferentiation can be delayed by culturing cells in a 3D environment. Combination with continuous medium flow, which creates a more physiological situation, further improves the maintenance of hepatic functions. Here, we present recently developed hydrogels and scaffolds for 3D culture of hepatocytes, which aim at preserving hepatic morphology and functionality for up to 4 weeks in culture. Furthermore, major benefits and drawbacks of microfluidic devices for in vitro hepatotoxicity screening are discussed. Although promising advances have been made regarding the preservation of hepatic functions in 3D flow culture, major issues, such as expensive equipment, large cell numbers and low throughput, are still hampering their use in drug toxicity screening. For these devices to be applied and accepted in the drug-developing industry, it is necessary to combine easily accessible matrices that highly preserve the activities of drug-metabolizing enzymes with a user-friendly microfluidic platform, thereby finding the right balance between reflecting the in vivo situation and enabling satisfying throughput for drug candidate screening.

The right choice of antihypertensives protects primary human hepatocytes from ethanol- and recombinant human TGF-ß1-induced cellular damage.

BACKGROUND: Patients with alcoholic liver disease (ALD) often suffer from high blood pressure and rely on antihypertensive treatment. Certain antihypertensives may influence progression of chronic liver disease. Therefore, the aim of this study is to investigate the impact of the commonly used antihypertensives amlodipine, captopril, furosemide, metoprolol, propranolol, and spironolactone on alcohol-induced damage toward human hepatocytes (hHeps). METHODS: hHeps were isolated by collagenase perfusion. Reactive oxygen species (ROS) were measured by fluorescence-based assays. Cellular damage was determined by lactate-dehydrogenase (LDH)-leakage. Expression analysis was performed by reverse-transcription polymerase chain reaction and Western blot. Transforming growth factor (TGF)-ß signaling was investigated by a Smad3/4-responsive luciferase-reporter assay. RESULTS: Ethanol and TGF-ß1 rapidly increased ROS in hHeps, causing a release of 40%-60% of total LDH after 72 hours. All antihypertensives dose dependently reduced ethanol-mediated oxidative stress and cellular damage. Similar results were observed for TGF-ß1-dependent damage, except for furosemide, which had no effect. As a common mechanism, all antihypertensives increased heme-oxygenase-1 (HO-1) expression, and inhibition of HO-1 activity reversed the protective effect of the drugs. Interestingly, Smad3/4 signaling was reduced by all compounds except furosemide, which even enhanced this profibrotic signaling. This effect was mediated by expressional changes of Smad3 and/or Smad4. CONCLUSIONS: Our results suggest that antihypertensives may both positively and negatively influence chronic liver disease progression. Therefore, we propose that in future patients with ALD and high blood pressure, they could benefit from an adjusted antihypertensive therapy with additional antifibrotic effects.

Narrow irregular QRS tachycardia with AV dissociation: what is the mechanism?

A 39-year-old woman with no structural heart disease and frequent episodes of sudden onset palpitations was referred for the electrophysiological study. During the study, a slightly irregular narrow QRS tachycardia with AV dissociation was repeatedly induced and spontaneously terminated. Apparently, irregular cycles and termination of the tachycardia were related to the dissociated sinus rhythm: atrial depolarizations timed when the AV junction was refractory were able to reset the tachycardia, while early atrial depolarizations caused its termination. This observation was enough to diagnose the tachycardia mechanism in our case.

Multiple interatrial electrical connection after heart transplantation.

A 62-year-old woman who underwent heart transplantation 6 years later presented a regular atrial tachycardia. Electrophysiologic evaluation showed an atrial arrhythmia in the recipient atrium with 2:1 conduction to the donor atrium, with a confusing electroanatomical map. With the suspect of alternant conduction through two different breakthroughs, the map was split in two concordant maps, corresponding to two connections that were successfully ablated. Later on, a third connection was detected and therefore ablated.

Ablation of Premature Ventricular Complexes Triggering Ventricular Fibrillation in a Patient with Long QT Syndrome.

We describe the case of a patient with long QT syndrome and recurrent ventricular fibrillation, triggered by premature ventricular complexes (PVCs) with a left bundle branch block pattern and inferior axis of the QRS. Activation mapping demonstrated the origin of the PVCs to be in the right ventricular outflow tract. Ventricular fibrillation (VF) was successfully treated by catheter ablation of the triggering PVCs and there has been no recurrence of VF during a follow-up period of 14 months.

Premature ventricular complexes as a trigger for ventricular fibrillation.

INTRODUCTION AND OBJECTIVES: The mechanisms that trigger ventricular fibrillation (VF) are poorly understood. The aim of this study was to analyze the initiation of VF in electrograms stored in implantable cardioverter-defibrillators (ICDs). METHODS: We analyzed ICD electrograms from patients who had suffered at least one episode of VF. RESULTS: Of 250 patients with ICDs, 13 (10 male and 3 female, age 49+/-22 years) had at least one episode of VF. The diagnoses were Brugada syndrome (n=4), ischemic heart disease (n=3), dilated cardiomyopathy (n=2), hypertrophic cardiomyopathy (n=1), short-coupled variant of torsades de pointes (n=1), endocardial fibroelastosis (n=1) and idiopathic VF (n=1). In 7 patients, VF was the reason for ICD implantation. Overall, 31 episodes of VF were recorded, including three episodes of arrhythmic storm. In the 7 patients who had more than one episode of VF (within minutes or up to 3 years apart), all episodes started with premature ventricular complexes (PVCs) that had the same morphology and similar coupling intervals. A short-long-short cycle was observed in 2 patients. In 21 episodes, PVCs that did not trigger VF were observed during sinus rhythm. There was no significant difference between them and PVCs that did trigger VF in terms of morphology, coupling interval (409+/-121 ms vs. 411+/-123 ms) or the preceding sinus rhythm RR interval (801+/-233 ms vs. 793+/-230 ms). CONCLUSIONS: Spontaneous VF in the form of an arrhythmic storm or an isolated episode were triggered by PVCs. On occasions, PVCs preceded VF without triggering it.

Same morphology of ventricular premature complexes triggering repeated ventricular fibrillation.

BACKGROUND: Episodes ventricular fibrillation (VF) initiated by ventricular premature complexes (VPCs) of a single morphology have been reported. However, the characteristics of the VPCs over long periods of time are unknown. OBJECTIVES: To compare the morphologies and coupling intervals of VPCs that initiate episodes of VF that occur at different time periods. METHODS: The database of the follow-up of the International Classification of Diseases (ICD) unit was reviewed and patients having at least two spontaneous VF episodes with available recorded EGMs in unipolar and bipolar configuration were included in the study. The coupling interval and morphology of the initiating beat were analyzed. RESULTS: Nine out of 300 patients with ICD had two or more spontaneous VF episodes. The time interval between episodes ranged from seconds (arrhythmic storm) to 3 years. The fibrillatory VPCs presented the same morphology in both recordings in all episodes of each patient. The coupling intervals of VPCs initiating VF were close for the episodes that occurred during a single arrhythmic storm and were more variable when the time intervals between episodes of VF were longer. CONCLUSION: VPCs triggering VF that occur at different times in the same patient have similar morphologies suggesting similar sites of origin for the initial VPC of VF in each patient.