Linking functional composition moments of the sub-Mediterranean ecotone with environmental drivers.

Introduction: Functional trait-based approaches are extensively applied to the study of mechanisms governing community assembly along environmental gradients. These approaches have been classically based on studying differences in mean values among species, but there is increasing recognition that alternative metrics of trait distributions should be considered to decipher the mechanisms determining community assembly and species coexistence. Under this framework, the main aim of this study is to unravel the effects of environmental conditions as drivers of plant community assembly in sub-Mediterranean ecotones. Methods: We set 60 plots in six plant communities of a sub-Mediterranean forest in Central Spain, and measured key above- and belowground functional traits in 411 individuals belonging to 19 species, along with abiotic variables. We calculated community-weighted mean (CWM), skewness (CWS) and kurtosis (CWK) of three plant dimensions, and used maximum likelihood techniques to analyze how variation in these functional community traits was driven by abiotic factors. Additionally, we estimated the relative contribution of intraspecific trait variability and species turnover to variation in CWM. Results and discussion: The first three axes of variation of the principal component analyses were related to three main plant ecological dimensions: Leaf Economics Spectrum, Root Economics Spectrum and plant hydraulic architecture, respectively. Type of community was the most important factor determining differences in the functional structure among communities, as compared to the role of abiotic variables. We found strong differences among communities in their CWMs in line with their biogeographic origin (Eurosiberian vs Mediterranean), while differences in CWS and CWK indicate different trends in the functional structure among communities and the coexistence of different functional strategies, respectively. Moreover, changes in functional composition were primarily due to intraspecific variability. Conclusion: We observed a high number of strategies in the forest with the different communities spreading along the acquisitive-conservative axis of resource-use, partly matching their Eurosiberian-Mediterranean nature, respectively. Intraspecific trait variability, rather than species turnover, stood as the most relevant factor when analyzing functional changes and assembly patterns among communities. Altogether, our data support the notion that ecotones are ecosystems where relatively minor environmental shifts may result in changes in plant and functional composition.

Living at the edge: the functional niche occupation of woody plant communities in the submediterranean ecotone.

BACKGROUND AND AIMS: Submediterranean areas are rich ecotones, where slight modifications in environmental conditions can lead to substantial changes in the composition of plant communities. They thus offer an ideal scenario to examine plant community assembly. In this study, we followed a trait-based approach including intraspecific variability to elucidate (1) the relationship between niche occupancy components and species richness, (2) the processes governing the assembly of these communities and (3) the contribution of intraspecific trait variability in shaping the functional trait space. METHODS: We measured eight morphological and chemical traits in 405 individuals across 60 plots located in different forest communities (Mediterranean, Eurosiberian and Mixed) coexisting within a submediterranean ecosystem in central Spain. We calculated three niche occupancy components related to Hutchinson's n-dimensional hypervolumes: the total functional volume of the community, the functional overlap between species within the community and the average functional volume per species, and then used null models to explore the relative importance of habitat filtering, limiting similarity and intraspecific variability as assembly patterns. KEY RESULTS: Both habitat filtering and niche differentiation drive the community assembly of Mediterranean communities, whereas limiting similarity and hierarchical competition shape Eurosiberian communities. Intraspecific responses were mostly explained by shifts in species niches across the functional space (changes in the position of the centroids of hypervolumes). CONCLUSIONS: Different assembly mechanisms govern the structure of Mediterranean, Eurosiberian and Mixed plant communities. Combining niche occupancy components with a null model approach at different spatial scales offers new insights into the mechanisms driving plant community assembly. Consideration of intraspecific variability is key for understanding the mechanisms governing species coexistence in species-rich ecotones.

Economic Evaluation of Clinical, Nutritional and Rehabilitation Interventions on Oropharyngeal Dysphagia after Stroke: A Systematic Review.

BACKGROUND: Post-stroke oropharyngeal dysphagia (PS-OD) and its complications increase healthcare costs, suggesting that its appropriate management is cost-effective. We aimed to assess the efficiency of healthcare interventions in PS-OD management. METHODS: A systematic review was conducted following PRISMA recommendations. Four databases were searched from inception through 30 June 2021. Outcome measures were cost-effectiveness and cost-savings of healthcare interventions. English and Spanish literature were included. Narrative and tables were used to present and synthesise evidence. Quality was evaluated using the CHEERS Statement. RESULTS: A total of 244 studies were identified, and 10 were included. Screening and diagnosis of PS-OD studies found: (1) adjusted reduction in hospitalisation costs when assessed during the first admission day; (2) non-significant reduction in hospitalisation costs with OD management after thrombolysis; and (3) videofluoroscopy as the most cost-effective screening method (compared to bedside evaluation and a combination of both). Two studies showed cost-effective rehabilitation programmes, including OD management. Pelczarska et al. showed an incremental cost-utility ratio of texture-modified diets using a gum-based thickener of 20,977 PLN (4660€) following a dynamic model, and Kotecki et al. commercially prepared thickened fluids that were 44% to 59% less expensive than in situ prepared fluids. Elia et al. showed home enteral nutrition was cost-effective (£12,817/QALY), and Beavan et al. showed higher nutrient intake and low increase in hospitalisation costs using looped-nasogastric tubes (£5.20 for every 1% increase). Heterogeneity between studies precluded a quantitative synthesis. CONCLUSIONS: Included studies suggest that healthcare interventions aiming to prevent OD complications are cost-effective. However, studies assessing novel strategies are needed.

The management of polypharmacy in people living with HIV.

Antiretroviral therapy (ART) has modified the prognosis of HIV which has evolved into a chronic condition. People living with HIV (PLWH) are living longer presenting an increased number of comorbidities leading to polypharmacy. Literature on the prevalence, associated factors, drug-drug interactions (DDIs), effects on ART-outcomes, geriatric conditions, and nutritional status together with health-interventions aimed to reduce it is presented in this review. A literature search was conducted on the MEDLINE database for all relevant English- and Spanish-language studies since 2006. Studies providing data of interest were identified and ordered in groups: (i) prevalence and associated factors (n = 37), (ii) DDIs (n = 19), (iii) Effects on ART-outcomes (n = 12), (iv) Effects on health conditions (n = 13), and (V) Health-interventions to assess and/or reduce it (n = 9). Polypharmacy occurs in 9-91% of PLWH (2.6-19.5% affected by severe polypharmacy). Main factors associated with polypharmacy are older age, a higher number of comorbidities, frailty, deteriorated renal function, and previous hospitalizations. DDIs were present in 19.15-84% of cases (1.3-12.2% for the most severe types). Mainly involved non-ART drugs were antihypertensives, statins, antithrombotic agents, corticosteroids, divalent cations, and antiacids. Polypharmacy can affect ART selection, adherence, and outcomes and has been related to some geriatric conditions such as falls, frailty, and poor nutritional status. Potentially prescribing issues are present in up to 87.9% of cases according to the STOPP-START and Beers criteria and some pharmacist-led interventions have been shown to reduce it. Considering these findings, polypharmacy should be considered a clinical concern in this population and treatment-optimization programs are needed to reduce its burden.

Successful long-term treatment of paediatric ulcerative colitis with vedolizumab: a case report.

Biologics are recommended to treat paediatric ulcerative colitis (UC) that is chronically active or steroid-dependent despite aminosalicylic acids (5-ASA) and thiopurine treatments. Anti-tumour necrosis factor inhibitors (Anti-TNF inhibitors) are the agents of choice and vedolizumab could be considered as second-line biologic therapy.In the current case, we aim to describe a successful long-term treatment with vedolizumab in a 9-year-old boy with severe UC and primary non-response to infliximab. Concomitant azathioprine was used, and steroid refractoriness was also detected. Drug and anti-drug antibody levels were negative after infliximab induction so a switch to a 6-week-induction vedolizumab regimen followed by a maintenance regimen as a monotherapy was decided. The clinical response and tolerability to vedolizumab allowed long-term disease remission. Vedolizumab is currently non-authorised to treat paediatric patients and there is limited data on long-term treatments to date. This case contributes to the literature by adding evidence on the long-term efficacy and safety of vedolizumab in paediatric UC.

Real-world effectiveness and durability of dual antiretroviral therapy in HIV-infected patients.

BACKGROUND AND OBJECTIVES: While randomised controlled trials in HIV-infected patients have shown that certain dual antiretroviral therapy (DAT) regimens are non-inferior in terms of efficacy compared with classical triple-drug regimens, few real clinical experiences have been described. The aim of the study was to investigate, in real clinical practice, DAT effectiveness, durability, and risk factors for treatment discontinuation. METHODS: This was a prospective cohort study that included HIV-infected patients treated with DAT (2015-2020). DAT was considered effective when patients achieved or maintained virological suppression and was assessed at 24 and 48 weeks. DAT durability was evaluated using the Kaplan-Meier method. Adherence and treatment cost were compared with patients' previous antiretroviral regimens. RESULTS: 51 patients were included, 27.5% with HIV-1 RNA ≥50 copies/mL at baseline, treated with a wide range of dual combinations. At 48 weeks follow-up, 83.8% and 50.0% of patients who started DAT with HIV-1 RNA <50 copies/mL and ≥50 copies/mL, respectively, were suppressed. 39 out of 51 patients (76.5%) maintained DAT for a mean treatment duration of 40.5±14.8 weeks. Full adherence was observed in 78.4% of patients compared with 70.2% in the previous regimen. Mean daily cost was €18.6±4.3 compared with €16.1±7.9 in the previous regimen (p=0.008). CONCLUSION: DAT effectiveness and durability were higher in patients who were virologically suppressed at baseline. DAT is a possible alternative for virologically non-suppressed patients who cannot be treated with a triple-drug regimen.

The Hydration Status of Adult Patients with Oropharyngeal Dysphagia and the Effect of Thickened Fluid Therapy on Fluid Intake and Hydration: Results of Two Parallel Systematic and Scoping Reviews.

BACKGROUND: The effect of oropharyngeal dysphagia (OD) and thickened fluid (TF) therapy on hydration status has not been well defined in the literature. We aimed to assess the hydration status in patients with OD and the effect TF therapy has on it. METHODS: Two literature reviews following PRISMA methodology (each one including a systematic and a scoping review) were performed: (R1) hydration status in adult patients with OD; (R2) effect of TF therapy on fluid intake and dehydration. Narrative and descriptive methods summarized both reviews. Quality assessment was assessed by Joanna Briggs Institute tools and GRADE. RESULTS: (R1) Five out of twenty-two studies using analytical parameters or bioimpedance showed poorer hydration status among OD and 19-100% prevalence of dehydration; (R2) two high quality studies (total of 724 participants) showed positive effects of TF on hydration status. Among the articles included, nine out of ten studies that evaluated fluid intake reported a reduced TF intake below basal water requirements. CONCLUSIONS: Dehydration is a highly prevalent complication in OD. There is scientific evidence on the positive effect of TF therapy on the hydration status of patients with OD. However, strict monitoring of fluid volume intake is essential due to the low consumption of TF in these patients.

Safety of Short-Term Treatments with Oral Chloroquine and Hydroxychloroquine in Patients with and without COVID-19: A Systematic Review.

Chloroquine (CQ) and hydroxychloroquine (HCQ) have recently become the focus of global attention as possible treatments for Coronavirus Disease 2019 (COVID-19). The current systematic review aims to assess their safety in short treatments (≤14 days), whether used alone or in combination with other drugs. Following the PRISMA and SWiM recommendations, a search was conducted using four health databases for all relevant English-, Chinese-, and Spanish-language studies from inception through 30 July 2021. Patients treated for any condition and with any comparator were included. The outcomes of interest were early drug adverse effects and their frequency. A total of 254 articles met the inclusion criteria, including case and case-control reports as well as cross-sectional, cohort, and randomised studies. The results were summarised either qualitatively in table or narrative form or, when possible (99 studies), quantitatively in terms of adverse event frequencies. Quality evaluation was conducted using the CARE, STROBE, and JADAD tools. This systematic review showed that safety depended on drug indication. In COVID-19 patients, cardiac adverse effects, such as corrected QT interval prolongation, were relatively frequent (0-27.3% and up to 33% if combined with azithromycin), though the risk of torsade de pointes was low. Compared to non-COVID-19 patients, COVID-19 patients experienced a higher frequency of cardiac adverse effects regardless of the regimen used. Dermatological adverse effects affected 0-10% of patients with autoimmune diseases and COVID-19. A broad spectrum of neuropsychiatric adverse effects affected patients treated with CQ for malaria with variable frequencies and some cases were reported in COVID-19 patients. Gastrointestinal adverse effects occurred regardless of drug indication affecting 0-50% of patients. In conclusion, CQ and HCQ are two safe drugs widely used in the treatment of malaria and autoimmune diseases. However, recent findings on their cardiac and neuropsychiatric adverse effects should be considered if these drugs were to be proposed as antivirals again.

Economic evaluations of health care interventions in oropharyngeal dysphagia after stroke: protocol for a systematic review.

BACKGROUND AND PURPOSE: Oropharyngeal dysphagia (OD) affects 40-81% of patients after stroke. A recent systematic review on the costs of OD and its main complications showed higher acute and long-term costs for those patients who developed OD, malnutrition and pneumonia after stroke. These results suggest that appropriate management of post-stroke OD could reduce clinical complications and costs. The purpose of this systematic review is to assess the available literature for healthcare interventions that are efficient or cost-effective in the management of OD. METHODS: A systematic review on economic evaluations of health care interventions will be performed on post-stroke patients with OD following PRISMA recommendations. Four bibliographic databases will be searched and a subsequent reference check will be done. English and Spanish literature will be included without date restrictions. Studies will be included if they refer to economic evaluations or in which cost savings were reported in post-stroke patients suffering OD. Studies will be excluded if they are partial economic evaluation studies, if they refer to esophageal dysphagia, or if OD is caused by causes different from stroke. Evidence will be presented and synthetised with a narrative method and using tables. Quality evaluation will be done using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. DISCUSSION: The protocol for this systematic review is the first step to assess the cost-effectiveness of the healthcare interventions that have been described as potential treatments for post-stroke OD. This systematic review will summarise the current evidence on the relation between cost and benefits associated with the appropriate management of OD in post-stroke patients. TRIAL REGISTRATION: PROSPERO CRD42020136245.

Risk factors for nosocomial bloodstream infections in COVID-19 affected patients: protocol for a case-control study.

BACKGROUND: Nosocomial bloodstream infection (nBSI) is an important clinical concern among COVID-19 hospitalised patients. It can cause sepsis and septic shock leading to high morbidity, mortality, and the emergence of antibiotic resistance. The aim of this case-control study is to identify the risk factors associated with the nBSI development in COVID-19 hospitalised patients and its incidence. METHODS AND ANALYSIS: A retrospective case-control study will be performed. Cases will include nBSI episodes of adult patients (≥18 years) admitted to Hospital Universitari Germans Trias i Pujol, Barcelona, Spain, from April to December 2020 with a diagnosis of SARS-CoV-2 pneumonia. Patients transferred from other hospitals will be excluded. Controls will include hospitalisation episodes of COVID-19 patients without nBSI. We will recruit a minimum of 74 nBSI episodes (cases) and 74 controls (according to sample size calculation). We will collect data on sociodemographics, clinical status at admission, hospital admission, in-hospital mortality, and exposure data (use of antivirals, glucocorticoids or immunomodulatory agents, length of hospitalisation, and use of medical devices such as intravenous catheters). A bivariate and a subsequent multivariate regression analysis will be performed to assess the independent effect of the associated risk factors after adjusting for confounders. The nBSI incidence rate will be estimated according to the number of nBSI episodes in admitted COVID-19 patients among the total person-month of follow-up. ETHICS AND DISSEMINATION: The protocol of this study was approved by the Ethical Committee for Drug Investigation of the Hospital Universitari Germans Trias i Pujol. The results of this case-control study will be published in a peer reviewed journal.

The Economics Spectrum Drives Root Trait Strategies in Mediterranean Vegetation.

Extensive research efforts are devoted to understand fine root trait variation and to confirm the existence of a belowground root economics spectrum (RES) from acquisitive to conservative root strategies that is analogous to the leaf economics spectrum (LES). The economics spectrum implies a trade-off between maximizing resource acquisition and productivity or maximizing resource conservation and longevity; however, this theoretical framework still remains controversial for roots. We compiled a database of 320 Mediterranean woody and herbaceous species to critically assess if the classic economics spectrum theory can be broadly extended to roots. Fine roots displayed a wide diversity of forms and properties in Mediterranean vegetation, resulting in a multidimensional trait space. The main trend of variation in this multidimensional root space is analogous to the main axis of LES, while the second trend of variation is partially determined by an anatomical trade-off between tissue density and diameter. Specific root area (SRA) is the main trait explaining species distribution along the RES, regardless of the selected traits. We advocate for the need to unify and standardize the criteria and approaches used within the economics framework between leaves and roots, for the sake of theoretical consistency.

Comparison of Two Protocols for the Assessment of Maximal Respiratory Pressures: Spanish Society of Pulmonology and Thoracic Surgery Versus American Thoracic Society/European Respiratory Society.

Background The measurement of maximal respiratory pressures (MRPs) is commonly used to assess respiratory muscle strength. However, in Spain, there is no consensus on which is the most adequate measurement protocol, as theSpanish Society of Pneumology and Thoracic Surgery (SEPAR) protocol differs from the one endorsed by the American Thoracic Society/European Respiratory Society(ATS/ERS). This study compared the absolute and predictive values of maximal expiratory and inspiratory pressures (MEP and MIP) in healthy adults obtained with the two protocols. Methods A cross-sectional study with a sample of healthy adults was conducted. Lung function and MRPs were assessed. MEP and MIP were measured using a digital manometer according to the SEPAR and ATS/ERS. Protocols were applied in random order by the same trained physiotherapist. The comfort experienced with each protocol was assessed through a short questionnaire. Paired t-tests were used to compare the results from both protocols. Results A total of 31 subjects (mean age 35.7±12.4 years; 14 females; FEV1=108.3±10.5%; FVC=103.7±10%) were included. There was a significant difference between MRPs favouring the SEPAR protocol, with the mean difference being 34.9±28.1 cmH2O (p˂0.001) for MEP and 8±11.6 cmH2O (p=0.001) for MIP. ATS/ERS protocol was, however, considered more comfortable than SEPAR (p<0.005). Conclusions This study shows that, in healthy adults, higher MRPs are obtained using the SEPAR protocol. Yet, the ATS/ERS protocol is experienced as more comfortable. Future studies are needed to analyse the application of both protocols in other populations and their associated comfort.

Cost-minimisation analysis of rectal cancer neoadjuvant chemoradiotherapy based on fluoropyrimidines (capecitabine versus 5-fluorouracil).

OBJECTIVES: The current standard treatment for patients with rectal cancer stage II-III is neoadjuvant chemoradiotherapy followed by surgery. Neoadjuvant chemoradiotherapy can be performed with 5-fluorouracil (5-FU) or capecitabine (CPC) considered to be equivalent therapies. Medication cost is higher for CPC than for 5-FU, however, the administration of continuous 5-FU intravenous infusion is related to other costs such as those associated with outpatient facilities or central venous catheter insertion. METHODS: This retrospective study analysed the direct sanitary costs associated with the treatments and their complications from a hospital perspective. Costs in patients treated with 5-FU or CPC were measured between January 2010 and July 2018 at Mataró Hospital. The aim of this study was to perform a cost-minimisation analysis between the two treatments. We aimed to assess the cost associated with the complications related to each drug and the economic impact of applying the most efficient option. RESULTS: Ninety-eight patients were analysed: 32 were treated with CPC and 66 with 5-FU. Treatment cost was significantly higher for 5-FU than for CPC (2560.86±99.17 and 563.10±9.52 respectively, P=0.0001). No significant differences were found in the costs associated with treatment complications between groups (148.21±934.91 and 41.41±102.50 euros respectively, P=0.322). CONCLUSIONS: Considering the clinical equivalence shown in the available trials and previous reviews, the most efficient treatment is neoadjuvant chemoradiotherapy with CPC. Complications associated with the treatments did not significantly modify these results. Other studies gave similar results both in the neoadjuvant and adjuvant context, reaffirmed in this study.

A Systematic and a Scoping Review on the Psychometrics and Clinical Utility of the Volume-Viscosity Swallow Test (V-VST) in the Clinical Screening and Assessment of Oropharyngeal Dysphagia.

(1) Background: The volume-viscosity swallow test (V-VST) is a clinical tool for screening and diagnosis of oropharyngeal dysphagia (OD). Our aims were to examine the clinical utility of the V-VST against videofluoroscopy (VFS) or fiberoptic endoscopic evaluation of swallow (FEES) and to map the V-VST usage with patients at risk of OD across the years since it was described for the first time, carrying a systematic and a scoping review. (2) Methods: We performed both a systematic review (SR) including studies that look at the diagnostic test accuracy, and a scoping review (ScR) with articles published from September 2008 to May 2020. Searches were done in different databases, including PubMed and EMBASE from September 2008 until May 2020, and no language restrictions were applied. A meta-analysis was done in the SR to assess the psychometric properties of the V-VST. Quality of studies was assessed by Dutch Cochrane, QUADAS, GRADE (SR), and STROBE (ScR) criteria. The SR protocol was registered on PROSPERO (registration: CRD42020136252). (3) Results: For the diagnostic accuracy SR: four studies were included. V-VST had a diagnostic sensitivity for OD of 93.17%, 81.39% specificity, and an inter-rater reliability Kappa = 0.77. Likelihood ratios (LHR) for OD were 0.08 (LHR-) and 5.01 (LHR+), and the diagnostic odds ratio for OD was 51.18. Quality of studies in SR was graded as high with low risk of bias. In the ScR: 34 studies were retrieved. They indicated that V-VST has been used internationally to assess OD's prevalence and complications. (4) Conclusions: The V-VST has strong psychometric properties and valid endpoints for OD in different phenotypes of patients. Our results support its utility in the screening and clinical diagnosis and management of OD.

Expectations and Perceptions of Healthcare Professionals for Robot Deployment in Hospital Environments During the COVID-19 Pandemic.

Several challenges to guarantee medical care have been exposed during the current COVID-19 pandemic. Although the literature has shown some robotics applications to overcome the potential hazards and risks in hospital environments, the implementation of those developments is limited, and few studies measure the perception and the acceptance of clinicians. This work presents the design and implementation of several perception questionnaires to assess healthcare provider's level of acceptance and education toward robotics for COVID-19 control in clinic scenarios. Specifically, 41 healthcare professionals satisfactorily accomplished the surveys, exhibiting a low level of knowledge about robotics applications in this scenario. Likewise, the surveys revealed that the fear of being replaced by robots remains in the medical community. In the Colombian context, 82.9% of participants indicated a positive perception concerning the development and implementation of robotics in clinic environments. Finally, in general terms, the participants exhibited a positive attitude toward using robots and recommended them to be used in the current panorama.

Healthcare costs of post-stroke oropharyngeal dysphagia and its complications: malnutrition and respiratory infections.

BACKGROUND AND PURPOSE: The healthcare economic costs of post-stroke oropharyngeal dysphagia (OD) are not fully understood. The purpose of this study was to assess the acute, subacute and long-term costs related to post-stroke OD and its main complications (malnutrition and respiratory infections). METHODS: A cost of illness study of patients admitted to Mataró Hospital (Catalonia, Spain) from May 2010 to September 2014 with a stroke diagnosis was performed. OD, malnutrition and respiratory infections were assessed during hospitalization and follow-up (3 and 12 months). Hospitalization and long-term costs were measured from hospital and healthcare system perspectives. Multivariate linear regression analysis was performed to assess the independent effect of OD, malnutrition and respiratory infections on healthcare costs during hospitalization, and at 3 and 12 months' follow-up. RESULTS: In all, 395 patients were included of whom 178 had OD at admission. Patients with OD incurred major total in-hospital costs (€5357.67 ± €3391.62 vs. €3976.30 ± €1992.58, p < 0.0001), 3-month costs (€8242.0 ± €5376.0 vs. €5320.0 ± €4053.0, p < 0.0001) and 12-month costs (€11,617.58 ± €12,033.58 vs. €7242.78 ± €7402.55, p < 0.0001). OD was independently associated with a cost increase of €789.68 (p = 0.011) during hospitalization and of €873.5 (p = 0.084) at 3 months but not at 12 months. However, patients with OD who were at risk of malnutrition or malnourished and suffered respiratory infections incurred major mean costs compared with those patients without OD (€19,817.58 ± €13,724.83 vs. €7242.8 ± €7402.6, p < 0.0004) at 12 months' follow-up. CONCLUSION: Oropharyngeal dysphagia causes significant high economic costs during hospitalization that strongly and significantly increase with the development of malnutrition and respiratory infections at long-term follow-up.

A Dimensional Comparison between Evolutionary Algorithm and Deep Reinforcement Learning Methodologies for Autonomous Surface Vehicles with Water Quality Sensors.

The monitoring of water resources using Autonomous Surface Vehicles with water-quality sensors has been a recent approach due to the advances in unmanned transportation technology. The Ypacaraí Lake, the biggest water resource in Paraguay, suffers from a major contamination problem because of cyanobacteria blooms. In order to supervise the blooms using these on-board sensor modules, a Non-Homogeneous Patrolling Problem (a NP-hard problem) must be solved in a feasible amount of time. A dimensionality study is addressed to compare the most common methodologies, Evolutionary Algorithm and Deep Reinforcement Learning, in different map scales and fleet sizes with changes in the environmental conditions. The results determined that Deep Q-Learning overcomes the evolutionary method in terms of sample-efficiency by 50-70% in higher resolutions. Furthermore, it reacts better than the Evolutionary Algorithm in high space-state actions. In contrast, the evolutionary approach shows a better efficiency in lower resolutions and needs fewer parameters to synthesize robust solutions. This study reveals that Deep Q-learning approaches exceed in efficiency for the Non-Homogeneous Patrolling Problem but with many hyper-parameters involved in the stability and convergence.

Pharmaceutical interventions in the emergency department: cost-effectiveness and cost-benefit analysis.

OBJECTIVE: It has been shown that pharmacists, as members of multidisciplinary patient care teams, can decrease the number of medicine errors. The objective of the present study was to analyse pharmaceutical interventions (PI) in emergency departments, to assess their clinical relevance, the cost-effectiveness and the potential economic benefits. METHODS: We designed a 5-month observational prospective study of PI in the emergency department (ED) of a 330-bed hospital in Spain. We analysed PI made by a pharmacist during a period of 3 hours a day from Monday to Friday in the ED, and classified detected medication errors according to their relevance and severity using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) severity index, and whether or not the drug involved was on the High-Alert Medications Institute for Safe Medication Practices (ISMP) list. We used statistical analysis to study the relationship between the relevance of PI and age, gender, the number of interventions per patient, and whether or not the drug was on the High-Alert Medications ISMP list. We also estimated the incremental cost incurred for each PI (cost-effectiveness) and the potential economic benefits (cost-benefit). RESULTS: A total of 529 interventions for 390 patients (median age 72.7±8.6 years, 53.1% women) were performed during the study period, representing 1.4 interventions per patient with an acceptance rate of 84.9%. Of all potential medication errors, 112 (21.2%) were related to drugs on the High-Alert Medications ISMP list, and using the NCC MERP severity index, we found that 150 (28.3%) of those errors could cause harm. We also found a relationship between patients on high-risk medications according to the ISMP and the relevance of PI. Finally, this study showed an incremental cost for each PI of 20.23 Euros and a cost-benefit ratio of 3.46 Euros per intervention. CONCLUSION: These results show that clinical pharmacist can positively identify and reduce medication errors and costs associated, considering the number of interventions observed and those of clinical relevance. Based on these results, drug safety therapy in the ED can be improved by the revision of prescriptions by a clinical pharmacist.

Healthcare-related cost of oropharyngeal dysphagia and its complications pneumonia and malnutrition after stroke: a systematic review.

OBJECTIVES: To assess the healthcare costs associated with poststroke oropharyngeal dysphagia (OD) and its complications (malnutrition, dehydration, pneumonia and death). DESIGN: Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. DATA SOURCES: MEDLINE, Embase and the National Health Service Economic Evaluation Database were searched up to 31 December 2019. PARTICIPANTS: Patients with poststroke. PRIMARY OUTCOME MEASURES: The costs associated to poststroke OD and its complications. DATA ANALYSIS: Data were synthetised narratively, quality evaluation was done using an adaptation of Drummond's checklist and Grading of Recommendations Assessment, Development and Evaluation recommendations were used to assess strength of evidence. RESULTS: A total of 166 articles were identified, of which 10 studies were included. The cost of OD during the hospitalisation was assessed in four studies. One prospective study showed an increase of US$6589 for patients requiring tube feeding. Two retrospective studies found higher costs for those patients who developed OD, (US$7329 vs US$5939) among patients with haemorrhagic stroke transferred to inpatient rehabilitation and an increase of €3000 (US$3950) and SFr14 000 (US$15 300) in hospitalisation costs. One study did not found OD as a predictor for total medical costs in the multivariate analysis. One retrospective study showed an increase of US$4510 during the first year after stroke for those patients with OD. For pneumonia, five retrospective studies showed an increase in hospitalisation costs after stroke of between US$1456 and US$27 633. One prospective study showed an increase in hospitalisation costs during 6 months after stroke in patients at high malnutrition risk. Strength of evidence was considered moderate for OD and pneumonia and low for malnutrition. CONCLUSIONS: This systematic review shows moderate evidence towards higher costs for those patients who developed OD after stroke. The available literature is heterogeneous, and some important aspects have not been studied yet. Further studies are needed to define the specific cost of poststroke OD. PROSPERO REGISTRATION NUMBER: CRD42018099977.

Micro-needle implantable electrochemical oxygen sensor: ex-vivo and in-vivo studies.

Oxygen is vital for energy metabolism in mammals and the variability of the concentration is considered a clinical alert for a wide range of metabolic malfunctions in medicine. In this article, we describe the development and application of a micro-needle implantable platinum-based electrochemical sensor for measuring partial pressure of oxygen in intramuscular tissue (in-vivo) and vascular blood (ex-vivo). The Pt-Nafion® sensor was characterized morphological and electrochemically showing a higher sensitivity of -2.496 nA/mmHg (-1.495 nA/µM) when comparing with its bare counterpart. Our sensor was able to discriminate states with different oxygen partial pressures (pO2) for ex-vivo (blood) following the same trend of the commercial gas analyzer used as standard. For in-vivo (intramuscular) experiments, since there is not a gold standard for measuring pO2 in tissue, it was not possible to correlate the obtained currents with the pO2 in tissue. However, our sensor was able to detect clear statistical differences of O2 between hyperoxia and hypoxia states in tissue.