Burden and challenges of heart failure in patients with chronic kidney disease. A call to action.

Patients with the dual burden of chronic kidney disease (CKD) and chronic congestive heart failure (HF) experience unacceptably high rates of symptom load, hospitalization, and mortality. Currently, concerted efforts to identify, prevent and treat HF in CKD patients are lacking at the institutional level, with emphasis still being placed on individual specialty views on this topic. The authors of this review paper endorse the need for a dedicated cardiorenal interdisciplinary team that includes nephrologists and renal nurses and jointly manages appropriate clinical interventions across the inpatient and outpatient settings. There is a critical need for guidelines and best clinical practice models from major cardiology and nephrology professional societies, as well as for research funding in both specialties to focus on the needs of future therapies for HF in CKD patients. The implementation of cross-specialty educational programs across all levels in cardiology and nephrology will help train future specialists and nurses who have the ability to diagnose, treat, and prevent HF in CKD patients in a precise, clinically effective, and cost-favorable manner.

Integrative health risk assessment of air pollution in the northwest of Spain.

Levels, origins and potential risks due to different air pollutants (ozone, SO2 and particle-borne metals) in NW Spain were investigated in eight locations affected by different emission sources. All monitored locations suffered the influence of traffic and industrial emissions, being this influence more important in urban locations. Although average values of the estimated hazard index (HI) due to particle-borne metals showed values lower than one, maximum values of this parameter exceeded this safety limit in urban locations. In general, Ni and As were identified as those metals most contributing to the HI. Furthermore, the presence of industrial emission episodes produced a significant increase in the magnitude of the HI in two of the seven urban areas. Therefore, the frequency and intensity of these episodes should be further investigated. Finally, levels of airborne and particle-borne pollutants were integrated with the aim of providing a comprehensive assessment of health risk. According to an established indexing system, air quality can be classified from good to moderate, being the southern urban locations (the most densely populated and industrialised ones) presenting the worst values. However, either the high or the low influence of acute and chronic-effect pollutants on air quality depends on the location.

Assessment of intestinal microbiota modulation ability of Bifidobacterium strains in in vitro fecal batch cultures from preterm neonates.

Microbial colonization of the infant gut is essential for the development of the intestine and the immune system. The intestinal microbiota of full-term breast-fed infants is considered as the health standard for newborns. A culture medium containing formula milk was designed, which allowed a balanced growth of intestinal microorganisms and was used to perform fecal batch cultures from preterm babies. Sixteen Bifidobacterium strains and fructooligosaccharides (FOS) were tested for their ability to modulate in vitro the intestinal microbiota. The production of short chain fatty acids (SCFA) was measured by Gas Chromatography and the levels of some anaerobe (Bifidobacterium and Bacteroides groups) and facultative anaerobes (Enterobacteriaceae, Enterococcaceae, Weissella group, and Klebsiella pneumoniae) were determined by quantitative PCR. Results were referred to a fecal negative control culture without microorganisms or FOS added. Strains that in fecal cultures counteracted better the aberrancies previously found in feces of preterm babies, as compared with full-term breast-fed infants, were selected. The three Bifidobacterium bifidum strains tested in this work promoted the most suitable shifts in SCFA and in the ratio of variables facultative anaerobes to anaerobes. Two Bifidobacterium breve strains complied with the requirement for facultative anaerobes and anaerobes and one of them also promoted a suitable shift of SCFA. Bifidobacteria behaved similarly as FOS regarding the microbial profiles in fecal cultures but the production of lactic and acetic acid was much lower. B. breve and B. bifidum strains selected represent promising candidates for their assessment in more complex in vitro and in vivo models.

External validation and comparison of three scores to predict renal replacement therapy after cardiac surgery: a multicenter cohort.

PURPOSE: Cardiac surgery-associated acute kidney injury requiring renal replacement therapy (RRT) is independently associated with mortality. Several risk scores have been developed to predict the need for RRT after cardiac surgery. We have compared and verified the external validity of the three main available scores for RRT prediction after cardiac surgery: the Thakar score, the Mehta tool, and the Simplified Renal Index. METHODS: The risk scores were calculated in a cohort of 1084 adult patients, 248 of whom required RRT, who underwent open-heart surgery in 24 Spanish hospitals in 2007. The performance of the systems was determined by examining their discrimination (areas under the receiver operating characteristic curves (aROC) and calibration (Lemeshow-Hosmer chi-square goodness-of-fit statistics). RESULTS: The aROCs in the Thakar score, the Mehta tool, and the Simplified Renal Index were 0.82, 0.76 and 0.79, respectively. The three scoring systems were poorly calibrated and tended to underestimate the actual need for RRT. CONCLUSIONS: The Thakar score and the Simplified Renal Index discriminated well between low - and high-risk patients in our cohort, and Thakar outperformed the Mehta tool. These best-performing scores may aid in the selection of optimal therapy, facilitate the planning of hospital resource utilization, improve preoperative counseling, select participants for clinical trials of renal-protective therapies and enable an accurate comparison between different institutions or surgeons.

Assessment of the addition of Thiobacillus denitrificans and Thiomicrospira denitrificans to chemolithoautotrophic denitrifying bioreactors.

The aim of the present study was to assess the impact of adding cultures of Thiobacillus denitrificans and Thiomicrospira denitrificans to two upflow anaerobic sludge bed (UASB) reactors: one inoculated with granular sludge and the other filled only with activated carbon (AC). The performances of the bioreactors and the changes in biomass were compared with a non-bioaugmented control UASB reactor inoculated with granular sludge. The reactors inoculated with granular sludge achieved efficiencies close to 90% in nitrate and thiosulfate removal for loading rates as high as 107 mmol-NO3 -/l per day and 68 mmol-S2O3 2-/l per day. Bioaugmentation with Tb. denitrificans and Tm. denitrificans did not enhance the efficiency compared to that achieved with non-bioaugmented granular sludge. The loading rates and efficiencies were 30-40% lower in the AC reactor. In all the reactors tested, Tb. denitrificans became the predominant species. The results strongly suggest that this bacterium was responsible for denitrification and sulfoxidation within the reactors. We additionally observed that granules partially lost their integrity during operation under chemolithoautotrophic conditions, suggesting limitations for long-term operation if bioaugmentation is applied in practice.

Integrative assessment of coastal pollution in a Ría coastal system (Galicia, NW Spain): correspondence between sediment chemistry and toxicity.

Elutriate embryo-larval bioassays with sea-urchins (Paracentrotus lividus) and ascidians (Ciona intestinalis) were conducted concurrently with trace metal analyses as part of an integrative assessment of sediment pollution at Ría de Pontevedra (Galicia, NW Spain). High metal contents in sediments were found in localised areas from the inner part of the estuary indicating a clear anthropogenic influence. In particular, very high Cu, Zn and Pb levels were found at sites P2 and P3, which were also the most toxic to the embryo-larval bioassays. Sediment quality guidelines were used to help in the ecological interpretation of sediment chemistry data and to identify pollutants of concern. Cu and Zn in P3 were consistently above the effects range median (ERM) values, which seem to be good predictors of toxicity to sea-urchin and ascidian embryos. A toxic unit approach, based on published EC(50) values and metal levels in elutriates, was used to assess the harmful ecological effects associated to sediment chemistry. Toxicity detected in P3 may be explained on the basis of the toxic unit model; however, the high toxicity detected at P2 may be attributable not only to the metals quantified in the analyses but also to unmeasured organic pollutants. Multidimensional scaling applied independently to the toxicology and chemistry data resulted in a good agreement between both types of configurations. Moreover, the Mantel test revealed a significant correlation (r(M)=0.481; p=0.019) between metal concentrations and toxicity data profiles, supporting the correspondence between configurations.

Toxicity assessment of crude and partially purified extracts of marine Synechocystis and Synechococcus cyanobacterial strains in marine invertebrates.

Among the Cyanoprokaryota, the genera Synechocystis and Synechococcus have rarely been studied with respect to potential toxicity. This is particularly true with marine environments where studies about the toxicity of cyanobacteria are restricted to filamentous forms at the warmer temperate and tropical regions and also to filamentous forms at cold seas such as the Baltic Sea. In this study, we describe the effects of cyanobacterial strains of the Synechocystis and Synechococcus genera isolated from the marine coast of Portugal, on marine invertebrates. Crude and partially purified extracts at a concentration of 100 mg/ml of freeze-dried material of the marine strains were tested for acute toxicity in nauplii of the brine shrimp Artemia salina, in the rotifer Brachionus plicatillis and in embryos of the sea urchin Paracentrotus lividus and the mussel Mytilus galloprovincialis. The cyanobacterial extracts, especially the crude extract, had an impact on A. salina nauplii. No significant toxic effects were registered against the rotifer. A negative impact of all strains was recorded on the embryonic development of the sea urchin, with toxic effects resulting in an inhibition of embryogenesis or development of smaller larvae. To the mussel embryos, the effects of cyanobacterial extracts resulted in a complete inhibition of embryogenesis. The results of all assays indicate that Synechocystis and Synechococcus marine strains contained toxic compounds to marine invertebrates.

Assessment of haemostatic risk factors in patients with acute renal failure associated with severe systemic inflammatory response syndrome. Development of a prognostic index.

BACKGROUND/AIM: The prognosis of acute renal failure (ARF) in the Intensive Care Unit (ICU) is variable and depends mainly on the underlying disease. Consequently, the outcome prediction is difficult. The majority of the prognostic measures used include clinical parameters and routine laboratory tests but not no study has considered the prognostic value of haemostatic disturbances. These disturbances play a key role in the evolution of multiple organ dysfunction syndrome (MODS) in patients with ARF, which occurs as part of systemic inflammatory response syndrome (SIRS). The aim of the present study was to search for early significant predictive factors among a group of haemostatic parameters in these patients. METHODS: Forty patients (age: 60.1 +/- 14.1 years) with ARF (requiring renal replacement therapy) associated with SIRS and haemodynamic instability (systolic blood pressure <90 mm Hg and/or vasopressor drugs) were included. The plasmatic levels of the following haemostatic factors were measured within the first 6 h of the SIRS evolution: von Willebrand Factor (vWF), thrombomodulin, plasminogen activity inhibitor type 1 (PAI-1 antigen), tissue type plasminogen activator (t-PA antigen), prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin complexes (TAT) and D-dimer. Age, sex, medical or surgical disease, septic status or not, type of ARF (prerenal or acute tubular necrosis, oliguric or nonoliguric), and requirement for inotropics and mechanical ventilation were also considered. Univariate and multivariate logistic regressions were used to identify the risk factors for death and to develop a possible mortality prediction model on this basis. RESULTS: By univariate analysis, high levels of PAI-1 antigen (>or=60 ng/ml) and F1 + 2 (>2.5 nmol/l) at early phases of ARF-severe SIRS were found to be independent risk factors for death (odds ratio (OR) = 6.37, p = 0.0181 and OR = 5.49, p = 0.0238, respectively). Age over 61 years and requirement of mechanical ventilation were independent death risk factors (OR = 4.33, p = 0.0251 and OR = 2.4, p = 0.0078, respectively). A possible mortality prediction model was obtained including the age and the PAI-1 antigen and F1 + 2 variables. CONCLUSION: In patients with ARF associated with severe SIRS, the independent risk factors from the early phases of the process are not only the known variables such as advanced age, but also high levels of PAI-1 antigen and F1 + 2. In the future, the individual probability of death could be calculated by a prediction model which includes these variables.

La evaluación del desempeño para la educación permanente del equipo local de salud: prueba de campo metodológica en el Canton de Pérez Zeledon, Costa Rica / Performance evaluation for continuing education of health staff

El PASCAP propuso en 1990 una metodología para evaluar el desempeño del equipo local de salud, con el propósito de ofrecer insumos para identificar necesidades de capacitación en los procesos de educación permanente. El diseño se sustentó en la reflexión del equipo local de salud sobre la equidad, la eficiencia y la eficacia del trabajo en salud en un área geográfica determinada y en relación con las necesidades de salud de los grupos humanos de mayor riesgo relativo de enfrentar y morir. Esta propuesta metodológica tuvo una prueba de campo en 1991 en un cantón de la República de Costa Rica, Centro América. Ella es el tema del presente artículo