Migraine treatment consensus document of the Spanish Society of Neurology (SEN), Spanish Society of Family and Community Medicine (SEMFYC), Society of Primary Care Medicine (SEMERGEN) and Spanish Association of Migraine and Headache (AEMICE) on migraine treatment. / Documento de consenso de la Sociedad Española de Neurología (SEN), Sociedad Española de Medicina de Familia y Comunitaria (SEMFYC), Sociedad de Medicina de Atención Primaria (SEMERGEN) y Asociación Española de Migraña y Cefalea (AEMICE) sobre el tratamiento de la migraña.

Migraine is a disease with a high prevalence and incidence, in addition to being highly disabling, causing a great impact on the patient's quality of life at a personal, family and work level, but also social, given its high expense due to its direct (care) and indirect (presenteeism and work absenteeism) costs. The multiple and recent developments in its pathophysiological knowledge and in its therapy require updating and, therefore, in this article the Spanish scientific societies most involved in its study and treatment (SEN, SEMFYC and SEMERGEN), together with the Association Spanish Association for Patients with Migraine and other Headaches (AEMICE), we have developed these updated care recommendations. We reviewed the treatment of migraine attacks, which consisted mainly of the use of NSAIDs and triptans, to which ditans and gepants have been added. We also discuss preventive treatment consisting of oral preventive drugs, botulinum toxin, and treatments that block the action of calcitonin-related peptide (CGRP). Finally, we emphasize that pharmacological treatments must be complementary to carrying out general measures consisting of identifying and managing/deletion the precipitating factors of the attacks and the chronicizing factors, controlling the comorbidities of migraine and eliminating analgesic overuse.

Defining the maximum nitrogen surplus in water management plans to recover nitrate polluted aquifers in Spain.

Nitrate pollution in aquifers is a global concern. Spain has developed a national strategy to recover nitrate polluted aquifers aligned with the European Union (EU) policies, specifically through the water planning under the EU Water Framework Directive. River basin management plans use PATRICAL model results to define the maximum nitrogen surplus in each polluted aquifer for the first time. The maximum nitrogen surplus allows to reach the good status in each aquifer and the model provides the number of years required. Around 30% of the aquifers in Spain is currently heavily polluted by nitrates. Model results show that 90% of these aquifers can be recovered in next 6-12 years by increasing nitrogen use efficiency and reducing nitrogen losses around 50%, which is in line with the EU Farm to Fork Strategy. The remaining aquifers require additional reductions to achieve the good status. In Spain this increase in nitrogen efficiency can be obtained with different measures including 30% reduction of current fertilization.

Effect of climate change on the water quality of Mediterranean rivers and alternatives to improve its status.

Surface water (SW) quality is particularly vulnerable to increased concentrations of nutrients, and this issue may be exacerbated by climate change. Knowledge of the effects of temperature and rainfall on SW quality is required to take the necessary measures to achieve good SW status in the future. To address this, the aims of this study were threefold: (1) to assess how a changing climate may alter the nitrate, ammonium, phosphorus and biological oxygen demand status (BOD5) of SW; (2) assess the relationship between water quality and flow; and (3) simulate diffuse and point source pollution reduction scenarios in the Júcar River Basin District in the Mediterranean region. A regionalised long-term climate scenario was used following one Representative Concentration Pathway (RCP8.5) with the data incorporated into the coupling of hydrological and water quality models. According to these climate change scenarios, SW with poor nitrate, ammonium, phosphorus and BOD5 status are expected to increase in the future by factors of 1.3, 1.9, 4 and 4, respectively. Furthermore, median ammonium and phosphorus concentration may be doubled in months with low flows. Additional measures are required to maintain current status in the water bodies, and it is necessary to reduce at least 25% of diffuse nitrate pollution, and 50% of point loads of ammonium, phosphorus, and BOD5.

Fertigation to recover nitrate-polluted aquifer and improve a long time eutrophicated lake, Spain.

Use of nitrogen and phosphorus in agriculture increases agricultural production but also generates important environmental problems around the world, such as high nitrate levels in aquifers and an increase in eutrophication of waters. A set of tools and models are used, ENVIRO-GRO and PATRICAL models, to analyse the effect of large irrigation system modernization, 13,700 ha, from traditional flood irrigation to modernized drip irrigation, in the aquifer nitrate levels and in the phosphorus inputs to a 50-years eutrophicated RAMSAR lake, Albufera lake. Based on data collected from end users, modernized irrigation system reduces the amount of nitrogen applied from 25 % to 45 % and phosphorus applied around 90-95 %, so phosphorus content on soil, phosphorus legacy, is reducing by time. Obtained results indicate that nitrogen leaching as nitrate is reduced by 70 % to 83 % and surface runoff during irrigation events disappear, hence phosphorus contributions to surface waters are eliminated. Nitrate polluted aquifer will be recovered in 5-6 years after complete implement of measures and phosphorus inputs to the lake are reduced around 20 % contributing to improve the status of the eutrophicated Albufera lake. Results show great agreement with the European Strategy to reduce the use of fertilizers and how the fertilizers technical management in fertigation can contribute to greater efficiency in it use and improvement of the environment.

Risk assessment of climate change impacts on Mediterranean coastal wetlands. Application in Júcar River Basin District (Spain).

Sea level rise (SLR) produced by climate change affects severely coastal ecosystems which are currently being impacted by sea level rise in many parts of the world. In relation with coastal wetlands, the most relevant induced effect will occur on water and soil's salt content, especially in areas below sea level. This could lead into a reduction of habitat for the wetlands' biota. In this context, this research assesses the SLR related risk in the Júcar River Basin District (JRBD). Hazard, exposure, impact, vulnerability, and risk maps have been elaborated. The design and application of measures is prioritized in those areas classified as Very High risk with the aim of improving coastal ecosystems' climate change adaptation. In Western Mediterranean coast, average sea level (ASL) will rise 0.16 m (2026-2045) and 0.79 m (2081-2100) referred to the reference period (1986-2005). High-end scenarios indicate that ASL will rise 1.35 m-1.92 m (2081-2100). The risk analysis results show that 90% of JRBD area affected by SLR, corresponds to coastal wetlands. Half of the affected area belongs to L'Albufera de Valencia wetland with 32.44 km2 below sea level, which represents a water volume of 42.64 hm3 (2026-2045) and a surface between 72.53 and 138.96 km2 representing from 118.36 to 289.70 hm3 (2081-2100). In the case of L'Albufera de Valencia the impact will be throughout the 21st century, the average rate of SLR will leap from 4 to 11 cm per decade, therefore MSL will reach the current wetland levels by 2040-2045. This makes necessary to modify the lake's management rules, which will lead to an increase of 40 hm3 in water storage and a reduction in water's renewal time compared to current rates (from 15 to 5 times a year).

Adapting water resources systems to climate change in tropical areas: Ecuadorian coast.

Climate change is expected to increase rainfall and temperature in the tropical areas of the Ecuadorian coast. The increase in temperature will also increase evapotranspiration therefore, future water balance on Ecuadorian coast will have a slight variation. Changes in precipitation patterns and evapotranspiration will produce an increase in the water requirements for current crops, so an imbalance in the water resources systems between natural resources and water demands is expected. This study presents water resources management as an adaptation measure to climate change for reducing vulnerability in tropical areas. Twelve bias-corrected climate projections are used, from: two AR5 General Circulation Models (GCMs), two Representative Concentration Pathways, 4.5-8.5 scenarios, and three time periods, short-term (2010-2039), medium-term (2040-2069) and long-term (2070-2099). These data were incorporated into the Lumped Témez Hydrological Model. Climate change scenarios predict for the long-term period both a mean rainfall and temperature increases up to 22%-2.8 °C, respectively. Besides, the potential evapotranspiration will increase until 12% by Penman-Monteith method and 60% by Thornthwaite method. Therefore, natural water resources will finally have an increase of 19% [8-30%]. Additionally, water requirements for crops will increase around 4% and 45%. As this research shows, in tropical regions, currently viable water resources systems could become unsustainable under climate change scenarios. To guarantee the water supply in the future additional measures are required as reservoir operation rules and irrigation efficiency improvement of system from 0.43 to 0.65, which it involves improving the distribution and application system. In study area future irrigation areas have been estimated for 13,268 ha, which under climate change scenarios is unsustainable, only 11,500 ha could be expanded with a very high irrigation efficiency of 0.73. Therefore, in tropical areas the effect of climate change on expansion projects for irrigated areas should be considered to ensure the functioning systems.

Investigation of pesticides and their transformation products in the Júcar River Hydrographical Basin (Spain) by wide-scope high-resolution mass spectrometry screening.

The Water Framework Directive 2000/60/EC implemented by the European Union established as the main objectives to achieve a "good ecological and chemical status" of the surface water and a "good quantitative and chemical status" of groundwater bodies. One of the major pressures affecting water bodies comes from the use of pesticides and their potential presence in the water ecosystems. For this purpose, the reliable determination of pesticides and their transformation products (TPs) in natural waters (both surface and groundwater) is required. The high number of compounds potentially reaching the aquatic environment makes extraordinary difficult, if not impossible, to investigate all these compounds even using the most powerful analytical techniques. Among these, liquid chromatography coupled to high-resolution mass spectrometry is emphasized due to its strong potential for detection and identification of many organic contaminants thanks to the accurate-mass full spectrum acquisition data. This work focuses on wide-scope screening of many pesticides and their TPs in surface water and groundwater samples, collected between March and May 2017, in the Júcar River Hydrographical Basin, Spain. For this purpose, a home-made database containing more than 500 pesticides and TPs was employed. Analyses performed by liquid chromatography coupled to quadrupole-time of flight mass spectrometry (LC-QTOF MS) allowed the identification of up to 27 pesticides and 6 TPs. The most detected compounds in groundwater were the herbicides atrazine, simazine, terbuthylazine, and their TPs (atrazine-desethyl, terbumeton-desethyl and terbuthylazine-desethyl). Regarding surface water, the fungicides carbendazim, thiabendazole and imazalil, the herbicide terbutryn and the TP terbumeton-desethyl were also detected. These results illustrate the wide use of these compounds (in the present or in the recent past) in the area under study and the vulnerability of the water bodies, and are in accordance with previous findings in other water bodies of the different Spanish Hydrographic systems.

Linking El Niño Southern Oscillation for early drought detection in tropical climates: The Ecuadorian coast.

El Niño Southern Oscillation (ENSO) is the most determining climate pattern in the tropics of the Pacific coast of America that regulate flood and drought periods. Over the last decades, Ecuador has incurred in significant economic losses due to drought events, around 4% of the GDP, mainly in the agricultural and livestock sectors and the hydropower generation. The use of Drought Indicators and the Early Drought Detection can contribute to reduce the impacts of these events. A drought forecasting system, based on ENSO and Drought Indicators, is presented to determine the possibility of appearance of drought events in Manabí River Basin District (MRBD). This system can help to the decision makers, in December (short-term drought, seasonal) and in May (long-term drought, annual), to activate the drought measures in the following months. Six climate indices are used for ENSO: Oceanic Niño Index (ONI), Southern Oscillation Index (SOI), and Sea Surface Temperature (SST) for Niño regions: 4, 3.4, 3 and 1 + 2. On the other hand, two drought indices are used: spatially distributed Standardized Precipitation Index (SPI) -1, 3, 6 and 12 months-, and a modified Palmer Drought Severity Index (PDSI), derived from a calibrated water balance model. This system allows early drought detection, assessing SST 1 + 2 (lag -7), 3 (lag -9) and 3.4 (lag -9) anomalies and drought indices, in December for a season drought and May for an annual drought. These analyses demonstrates that, drought may forecasting up to 7-9 months before their occurrence, through SST regions observations, based on strong relationship between ENSO and droughts occurrence.

Improvement of the drought indicators system in the Júcar River Basin, Spain.

Droughts are one of the gravest natural threats currently existing in the world and their occurrence and intensity might be exacerbated in the coming years due to climate change. The severe impacts that droughts cause to inland water resources and to the associated socio-economic activities justify the continuous monitoring of the drought. The case study presented shows a practical application of a distributed drought monitoring system implemented in a real river basin district, the Júcar River Basin District (43,000km2), where drought periods of marked intensity have occurred historically and the climate ranges from humid in the north to semiarid in the south. Five drought indices have been applied: Standardised Precipitation Index (SPI) for meteorological drought; Palmer Drought Severity Index (PDSI) and a new soil moisture index (HI), for edaphic drought; Normalised Difference Vegetation Index (NDVI) for the vegetation activity; and Spanish Status Index (SI), for the operational drought. All indices are standardised to compare them. The relationship between the standardised operational drought index SI and the long-term meteorological indices, SPI-12 or SPI-24, show that in a medium size basin the concept of "prolonged drought" required by the European Commission under the Water Framework Directive could be defined by the use of accumulated precipitation indices. The number of months to be accumulated depends on the size of the basin and the water management system properties. In large basins, such as the Júcar river basin (22,000km2), there are significant deviations due to the spatial distribution of the drought. The use of a unique aggregated indicator could hide a significant drought in a specific area, or on the other hand show a non-real drought. Evolution of drought indices for each water management system must be accompanied by spatially distributed drought maps to better understand the drought status and its evolution.

GIS-based models for water quantity and quality assessment in the Júcar River Basin, Spain, including climate change effects.

This paper describes two different GIS models - one stationary (GeoImpress) and the other non-stationary (Patrical) - that assess water quantity and quality in the Júcar River Basin District, a large river basin district (43,000km(2)) located in Spain. It aims to analyze the status of surface water (SW) and groundwater (GW) bodies in relation to the European Water Framework Directive (WFD) and to support measures to achieve the WFD objectives. The non-stationary model is used for quantitative analysis of water resources, including long-term water resource assessment; estimation of available GW resources; and evaluation of climate change impact on water resources. The main results obtained are the following: recent water resources have been reduced by approximately 18% compared to the reference period 1961-1990; the GW environmental volume required to accomplish the WFD objectives is approximately 30% of the GW annual resources; and the climate change impact on water resources for the short-term (2010-2040), based on a dynamic downscaling A1B scenario, implies a reduction in water resources by approximately 19% compared to 1990-2000 and a reduction of approximately 40-50% for the long-term (2070-2100), based on dynamic downscaling A2 and B2 scenarios. The model also assesses the impact of various fertilizer application scenarios on the status of future GW quality (nitrate) and if these future statuses will meet the WFD requirements. The stationary model generates data on the actual and future chemical status of SW bodies in the river basin according to the modeled scenarios and reflects the implementation of different types of measures to accomplish the Urban Waste Water Treatment Directive and the WFD. Finally, the selection and prioritization of additional measures to accomplish the WFD are based on cost-effectiveness analysis.

Histopathology of cutaneous amebiasis.

Cutaneous amebiasis (CA) is the manifestation in the skin and underlying soft tissues of the pathogenic properties of Entamoeba histolytica, which may be the only expression of the infection or may be associated with disease in other organs. So far, there have been only isolated case reports on this disease. We herein report the histopathologic findings on a series of seven cases, six adults and one child, of CA. The most common findings include ulcers, areas of necrosis, mixed inflammatory infiltrates, and the presence of trophozoites, the invasive form of the parasite. CA is a very rare and severe disease, it is progressive and destructive; erythrophagocytosis, a microscopic sign of pathogenicity, is always seen in CA.