Impact of outdoor air pollution on severity and mortality in COVID-19 pneumonia.

The relationship between exposure to air pollution and the severity of coronavirus disease 2019 (COVID-19) pneumonia and other outcomes is poorly understood. Beyond age and comorbidity, risk factors for adverse outcomes including death have been poorly studied. The main objective of our study was to examine the relationship between exposure to outdoor air pollution and the risk of death in patients with COVID-19 pneumonia using individual-level data. The secondary objective was to investigate the impact of air pollutants on gas exchange and systemic inflammation in this disease. This cohort study included 1548 patients hospitalised for COVID-19 pneumonia between February and May 2020 in one of four hospitals. Local agencies supplied daily data on environmental air pollutants (PM10, PM2.5, O3, NO2, NO and NOX) and meteorological conditions (temperature and humidity) in the year before hospital admission (from January 2019 to December 2019). Daily exposure to pollution and meteorological conditions by individual postcode of residence was estimated using geospatial Bayesian generalised additive models. The influence of air pollution on pneumonia severity was studied using generalised additive models which included: age, sex, Charlson comorbidity index, hospital, average income, air temperature and humidity, and exposure to each pollutant. Additionally, generalised additive models were generated for exploring the effect of air pollution on C-reactive protein (CRP) level and SpO2/FiO2 at admission. According to our results, both risk of COVID-19 death and CRP level increased significantly with median exposure to PM10, NO2, NO and NOX, while higher exposure to NO2, NO and NOX was associated with lower SpO2/FiO2 ratios. In conclusion, after controlling for socioeconomic, demographic and health-related variables, we found evidence of a significant positive relationship between air pollution and mortality in patients hospitalised for COVID-19 pneumonia. Additionally, inflammation (CRP) and gas exchange (SpO2/FiO2) in these patients were significantly related to exposure to air pollution.

The Burden and Impacts of Mealtime Insulin from the Perspective of People with Diabetes.

INTRODUCTION: While there have been continued advances in insulin treatment for diabetes since the discovery of insulin 100 years ago, some unmet needs still remain, including those related to mealtime insulin (MTI). The objective of this study was to explore the impacts related to MTI and the relative burden of the impacts on people with diabetes. METHODS: This study was conducted across two phases, namely, a qualitative and quantitative phase. People with type 1 and 2 diabetes using MTI in the USA and UK were recruited for the study. The qualitative phase involved 30 interviews to explore the impacts associated with MTI. Based on the results of the qualitative phase, a list of impacts was developed to evaluate the importance of MTI impacts using best-worst scaling. RESULTS: A total of 30 participants completed interviews, and 336 completed the quantitative phase. Participants described a range of impacts associated with MTI, including psychological (72.0%), social (63.0%), work/school (53.8%), and sleep (51.7%). Impacts for the quantitative phase were categorized under the following domains: diabetes distress, diabetes management, work productivity, and social. The three most burdensome impacts were related to diabetes distress, but the diabetes management domain contributed more than diabetes distress to the relative burden. There were minor differences in the relative importance of impacts by diabetes type, diabetes duration, and experience with continuous glucose monitoring. CONCLUSION: This study confirms that people with diabetes using MTI still have an array of unmet needs, including those related to the management of their diabetes and the emotional distress of having diabetes. These findings may be useful for healthcare provider (HCP)-patient interactions to ensure HCPs are allowing patients an opportunity to discuss their experiences with MTI.

A new perspective on diabetes distress using the type 2 diabetes distress assessment system (T2-DDAS): Prevalence and change over time.

AIMS: To establish cut-points and thresholds for elevated diabetes distress; document change over time; and define minimal clinically important differences (MCID) using the new Type 2 Diabetes Distress Assessment System (T2-DDAS). METHODS: A national sample of adults with type 2 diabetes completed the T2-DDAS CORE distress scale and the 7 T2-DDAS SOURCE distress scales at baseline and 6-months. Scores were computed separately for insulin- and non-insulin users. Spline regression models defined CORE cut-points and SEM formulas defined MCID. A rational "threshold" approach defined elevated SOURCE scores. RESULTS: 471 participants (205 insulin, 266 non-insulin) completed both assessments. Analyses yielded ≥2.0 as the cut-point for both elevated CORE and elevated SOURCE. Prevalence of elevated CORE was 61.8 % (69.9 % over 6 months). Elevated SOURCE scores varied from 30.6 % (Stigma/Shame) to 76.4 % (Management); 87.5 % indicated at least 1 elevated SOURCE score. Most (77.1 %) reported multiple elevated SOURCES. 81.8 % with elevated CORE distress at baseline remained elevated at 6 months. MCID analyses yielded +/- 0.25 as significant change. Few differences between insulin- and non-insulin users occurred. CONCLUSIONS: Elevated CORE distress is highly prevalent and persistent over time; most participants reported multiple SOURCES of distress. Findings highlight the need for comprehensive assessment of diabetes distress.

TRAF2 Is a Novel Ubiquitin E3 Ligase for the Na,K-ATPase ß-Subunit That Drives Alveolar Epithelial Dysfunction in Hypercapnia.

Several acute and chronic lung diseases are associated with alveolar hypoventilation leading to accumulation of CO2 (hypercapnia). The ß-subunit of the Na,K-ATPase plays a pivotal role in maintaining epithelial integrity by functioning as a cell adhesion molecule and regulating cell surface stability of the catalytic α-subunit of the transporter, thereby, maintaining optimal alveolar fluid balance. Here, we identified the E3 ubiquitin ligase for the Na,K-ATPase ß-subunit, which promoted polyubiquitination, subsequent endocytosis and proteasomal degradation of the protein upon exposure of alveolar epithelial cells to elevated CO2 levels, thus impairing alveolar integrity. Ubiquitination of the Na,K-ATPase ß-subunit required lysine 5 and 7 and mutating these residues (but not other lysines) prevented trafficking of Na,K-ATPase from the plasma membrane and stabilized the protein upon hypercapnia. Furthermore, ubiquitination of the Na,K-ATPase ß-subunit was dependent on prior phosphorylation at serine 11 by protein kinase C (PKC)-ζ. Using a protein microarray, we identified the tumor necrosis factor receptor-associated factor 2 (TRAF2) as the E3 ligase driving ubiquitination of the Na,K-ATPase ß-subunit upon hypercapnia. Of note, prevention of Na,K-ATPase ß-subunit ubiquitination was necessary and sufficient to restore the formation of cell-cell junctions under hypercapnic conditions. These results suggest that a hypercapnic environment in the lung may lead to persistent epithelial dysfunction in affected patients. As such, the identification of the E3 ligase for the Na,K-ATPase may provide a novel therapeutic target, to be employed in patients with acute or chronic hypercapnic respiratory failure, aiming to restore alveolar epithelial integrity.

[Current evidence on virtual reality and its potential usefulness in post-stroke neurorehabilitation]. / Evidencias actuales sobre la realidad virtual y su utilidad potencial en la neurorrehabilitación postictus.

INTRODUCTION: Virtual reality therapy (VRT) constitutes a powerful and motivating tool for stroke patients to actively participate in the process of neurorehabilitation, providing augmented performance feedback, with the aim of achieving better therapeutic results owing to the enhancing of neuroplasticity mechanisms. AIM: To report the most relevant data about the applications of VRT in the post-stroke neurorehabilitation. DEVELOPMENT: We conducted a PubMed search for articles, latest books, leading clinical practice guidelines, and scientific societies, regarding such applications. CONCLUSIONS: Different performed randomized clinical trials (RCT) show that VRT safely facilitates in a statistically significant way motor and functional recovery of upper limb, gait, balance, quality of life related to health, and activities of daily living, together with conventional therapy, but have no clearly demonstrated overall superiority to conventional therapy. In this regard, underlying specific mechanisms remain elusive at this stage. Future RCT should define the good responder stroke patient profile based on the VRT used in conjunction with conventional therapy, allowing the generation of neurorehabilitation approaches that combine a customized immersive VRT with the clinical experience of the therapists, to maximize the results. It is necessary to carry out well-designed RCT, including larger samples of appropriately selected stroke subjects, to draft a consensus document that allows recommending, with a greater level of evidence and on a widespread basis, the implementation of VRT as add-on therapy in post-stroke neurorehabilitation. As well as to determine if the beneficial effects are maintained in the long term and to clarify the most suitable treatment schedule.

TITLE: Evidencias actuales sobre la realidad virtual y su utilidad potencial en la neurorrehabilitación postictus.Introducción. La terapia con realidad virtual (TRV) constituye una herramienta poderosa que motiva a los pacientes con ictus a participar activamente en su neurorrehabilitación, y proporciona retroalimentación aumentada del rendimiento, con objeto de obtener mejores resultados terapéuticos gracias a la potenciación de los mecanismos de neuroplasticidad. Objetivo. Exponer los datos más relevantes sobre las aplicaciones de la TRV en la neurorrehabilitación postictus. Desarrollo. Búsqueda de artículos en PubMed, últimos libros y principales guías de práctica clínica y sociedades científicas publicados con respecto a dichas aplicaciones. Conclusiones. Los diferentes ensayos clínicos aleatorizados (ECA) realizados demuestran que la TRV facilita, de forma segura y estadísticamente significativa, la recuperación motora y funcional del miembro superior, la marcha, el equilibrio, la calidad de vida relacionada con la salud y las actividades de la vida diaria, junto con la terapia convencional, sin ser globalmente superior a la terapia convencional. Aún no se conocen los mecanismos específicos subyacentes. Los ECA futuros deberán definir el perfil de paciente respondedor según la TRV empleada, permitiendo generar enfoques de neurorrehabilitación que conjuguen una TRV personalizada inmersiva y la experiencia clínica de los terapeutas para maximizar los resultados. Son precisos ECA bien diseñados, incluyendo muestras amplias de pacientes adecuadamente seleccionados, para redactar un documento de consenso que permita recomendar, con un mayor nivel de evidencia y de forma generalizada, la implementación de la TRV como terapia complementaria en la neurorrehabilitación postictus, determinar si los efectos beneficiosos se mantienen a largo plazo y clarificar qué esquema de tratamiento es el más apropiado.

Evidencias actuales sobre la realidad virtual y su utilidad potencial en la neurorrehabilitación postictus / Current evidence on virtual reality and its potential usefulness in post-stroke neurorehabilitation

Introducción: La terapia con realidad virtual (TRV) constituye una herramienta poderosa que motiva a los pacientes con ictus a participar activamente en su neurorrehabilitación, y proporciona retroalimentación aumentada del rendimiento, con objeto de obtener mejores resultados terapéuticos gracias a la potenciación de los mecanismos de neuroplasticidad. Objetivo: Exponer los datos más relevantes sobre las aplicaciones de la TRV en la neurorrehabilitación postictus. Desarrollo: Búsqueda de artículos en PubMed, últimos libros y principales guías de práctica clínica y sociedades científicas publicados con respecto a dichas aplicaciones. Conclusiones: Los diferentes ensayos clínicos aleatorizados (ECA) realizados demuestran que la TRV facilita, de forma segura y estadísticamente significativa, la recuperación motora y funcional del miembro superior, la marcha, el equilibrio, la calidad de vida relacionada con la salud y las actividades de la vida diaria, junto con la terapia convencional, sin ser globalmente superior a la terapia convencional. Aún no se conocen los mecanismos específicos subyacentes. Los ECA futuros deberán definir el perfil de paciente respondedor según la TRV empleada, permitiendo generar enfoques de neurorrehabilitación que conjuguen una TRV personalizada inmersiva y la experiencia clínica de los terapeutas para maximizar los resultados. Son precisos ECA bien diseñados, incluyendo muestras amplias de pacientes adecuadamente seleccionados, para redactar un documento de consenso que permita recomendar, con un mayor nivel de evidencia y de forma generalizada, la implementación de la TRV como terapia complementaria en la neurorrehabilitación postictus, determinar si los efectos beneficiosos se mantienen a largo plazo y clarificar qué esquema de tratamiento es el más apropiado

Introduction: Virtual reality therapy (VRT) constitutes a powerful and motivating tool for stroke patients to actively participate in the process of neurorehabilitation, providing augmented performance feedback, with the aim of achieving better therapeutic results owing to the enhancing of neuroplasticity mechanisms. Aim: To report the most relevant data about the applications of VRT in the post-stroke neurorehabilitation. DEVELOPMENT. We conducted a PubMed search for articles, latest books, leading clinical practice guidelines, and scientific societies, regarding such applications. Conclusions: Different performed randomized clinical trials (RCT) show that VRT safely facilitates in a statistically significant way motor and functional recovery of upper limb, gait, balance, quality of life related to health, and activities of daily living, together with conventional therapy, but have no clearly demonstrated overall superiority to conventional therapy. In this regard, underlying specific mechanisms remain elusive at this stage. Future RCT should define the good responder stroke patient profile based on the VRT used in conjunction with conventional therapy, allowing the generation of neurorehabilitation approaches that combine a customized immersive VRT with the clinical experience of the therapists, to maximize the results. It is necessary to carry out well-designed RCT, including larger samples of appropriately selected stroke subjects, to draft a consensus document that allows recommending, with a greater level of evidence and on a widespread basis, the implementation of VRT as add-on therapy in post-stroke neurorehabilitation. As well as to determine if the beneficial effects are maintained in the long term and to clarify the most suitable treatment Schedule

Flexural vibration systems with gyroscopic spinners.

In this paper, we study the spectral properties of a finite system of flexural elements connected by gyroscopic spinners. We determine how the eigenfrequencies and eigenmodes of the system depend on the gyricity of the spinners. In addition, we present a transient numerical simulation that shows how a gyroscopic spinner attached to the end of a hinged beam can be used as a 'stabilizer', reducing the displacements of the beam. We also discuss the dispersive properties of an infinite periodic system of beams with gyroscopic spinners at the junctions. In particular, we investigate how the band-gaps of the structure can be tuned by varying the gyricity of the spinners. This article is part of the theme issue 'Modelling of dynamic phenomena and localization in structured media (part 1)'.

Dynamic characterization of a periodic microstructured flexural system with rotational inertia.

We consider the propagation of waves in a flexural medium composed of massless beams joining a periodic array of elements, elastically supported and possessing mass and rotational inertia. The dispersion properties of the system are determined and the influence and interplay between the dynamic parameters on the structure of the pass and stop bands are analysed in detail. We highlight the existence of three special dynamic regimes corresponding to a low stiffness in the supports and/or low rotational inertia of the masses; to a high stiffness and/or high rotational inertia regime; and to a transition one where dispersion degeneracies are encountered. In the low-frequency regime, a rigorous asymptotic analysis shows that the structure approximates a continuous Rayleigh beam on an elastic foundation. This article is part of the theme issue 'Modelling of dynamic phenomena and localization in structured media (part 1)'.

Beneficial Effects of Inspiratory Muscle Training Combined With Multicomponent Training in Elderly Active Women.

Purpose: This study aims to analyze changes in Maximum Inspiratory Pressure (MIP), lung function, cardiorespiratory fitness, and blood pressure, in 10 healthy active elderly women, following 7 weeks of inspiratory muscle training (IMT) combined with a multicomponent training program (MCTP). The association among these health parameters, their changes after training (deltas), and the influence of MIP at baseline (MIPpre) are also considered. Methods: IMT involved 30 inspirations at 50% of the MIP, twice daily, 7 days a week, while MCTP was 1 hr, twice a week. MIP, lung function (FVC, FEV1, FEV1/FVC, FEF25-75%, PEF), 6MWT, and blood pressure (SBP, DBP), jointly with body composition, were assessed before and after the intervention. Results: Seven weeks were enough to improved MIP (p = .019; d = 1.397), 6MWT (p = .012; d = .832), SBP (p = .003; d = 1.035) and DBP (p = .024; d = .848). Despite the high physical fitness (VO2 peak: M = 23.38, SD = 3.39 ml·min·Kg-1), MIPpre was low (M = 39.00, SD = 7.63 cmH2O) and displayed a significant negative correlation with ΔMIPpre-post (r = -.821; p < .004), showing that women who started the intervention with lower MIP achieved higher improvements in inspiratory muscle strength after training. Conclusions: No significant changes in spirometric parameters may signal that lung function is independent of early improvements in inspiratory muscles and cardiorespiratory fitness. Absence of correlation between physical fitness and respiratory outcomes suggests that being fit does not ensure cardiorespiratory health in active elderly women, so IMT might be beneficial and should supplement the MCTP in this population.

Clinical efficacy of fosfomycin combinations against a variety of gram-positive cocci / Eficacia clínica de las combinaciones de fosfomicina contra una variedad de cocos grampositivos

Introduction: Over recent years we have witnessed an increase in the resistance of microorganisms to the available antimicrobials and a decrease in the number of new antimicrobials. Fosfomycin is a safe and cheap broad-spectrum antibiotic which has shown very promising results in combination therapy, mainly against gram-negative microorganisms. Little is known, however, about its clinical efficacy against gram-positive microorganisms. Methods: We performed a retrospective review of all patients with severe gram-positive infections who received fosfomycin as part of their treatment from 2011 to 2017. We also performed in vitro time-kill assays to study the behaviour of fosfomycin with different antimicrobials against two strains of methicillin-resistant Staphylococcus aureus (MRSA) and two strains of methicillin-susceptible S. aureus (MSSA). Results: Seventy-five patients were treated with different fosfomycin combinations. Among them, 61 (81%) were successfully treated. Daptomycin plus fosfomycin was the most effective combination. Overall, the treatment with fosfomycin was safe, and side effects were minor. There was only one major side effect that resolved after discontinuation of therapy. Time-kill studies demonstrated increased activity of fosfomycin combinations, with daptomycin-fosfomycin being the most active combination against both MRSA and MSSA strains. Conclusions: Our results suggest that antimicrobial combinations including fosfomycin are an alternative and effective approach for gram-positive infections

Introducción: En los últimos años se ha ido produciendo un aumento de la resistencia de los microorganismos a los antimicrobianos disponibles, y una disminución en el número de nuevos antimicrobianos. La fosfomicina es un antibiótico seguro y barato con un amplio espectro de actividad, que ha mostrado resultados muy prometedores en terapia de combinación, principalmente contra microorganismos gramnegativos. Sin embargo, poco se conoce sobre su eficacia clínica frente a microorganismos grampositivos. Métodos: Revisión retrospectiva de todos los pacientes con infecciones graves por microorganismos grampositivos que recibieron fosfomicina como parte de su tratamiento, entre los años 2011 y 2017. También se realizaron curvas de letalidad in vitro para estudiar el comportamiento de la fosfomicina con diferentes antimicrobianos, frente a 2 cepas de Staphylococcus aureus resistentes a meticilina (SARM) y 2 cepas de S. aureus sensible a la meticilina (SASM). Resultados: Setenta y cinco pacientes recibieron tratamiento con diferentes combinaciones de fosfomicina. De ellos, 61 (81%) fueron tratados con éxito. Daptomicina más fosfomicina fue la combinación más efectiva. En general, el tratamiento con fosfomicina fue seguro, con efectos secundarios menores. Hubo solo un efecto secundario importante que se resolvió tras la suspensión del tratamiento. Las curvas de letalidad demostraron buena actividad de las combinaciones de fosfomicina, siendo la combinación daptomicina-fosfomicina la más activa, tanto frente a las cepas de SARM como de SASM. Conclusiones: Nuestros resultados sugieren que combinaciones con fosfomicina, pueden ser un tratamiento alternativo y efectivo en infecciones por grampositivos

Guidelines for seizure management in palliative care: Proposal for an updated clinical practice model based on a systematic literature review. / Guía para el manejo de las crisis epilépticas en cuidados paliativos: propuesta de un modelo actualizado de práctica clínica basado en una revisión sistemática de la literatura.

INTRODUCTION: Very little has been written on seizure management in palliative care (PC). Given this situation, and considering the forthcoming setting up of the Palliative Care Unit at our neurorehabilitation centre, the Clínica San Vicente, we decided to establish a series of guidelines on the use of antiepileptic drugs (AEDs) for handling seizures in PC. METHODS: We conducted a literature search in PubMed to identify articles, recent manuals, and clinical practice guidelines on seizure management in PC published by the most relevant scientific societies. RESULTS: Clinical practice guidelines are essential to identify patients eligible for PC, manage seizures adequately, and avoid unnecessary distress to these patients and their families. Given the profile of these patients, we recommend choosing AEDs with a low interaction potential and which can be administered by the parenteral route, preferably intravenously. Diazepam and midazolam appear to be the most suitable AEDs during the acute phase whereas levetiracetam, valproic acid, and lacosamide are recommended for refractory cases and long-term treatment. CONCLUSIONS: These guidelines provide general recommendations that must be adapted to each particular clinical case. Nevertheless, we will require further well-designed randomised controlled clinical trials including large samples of patients eligible for PC to draft a consensus document recommending adequate, rational, and effective use of AEDs, based on a high level of evidence, in this highly complex area of medical care.

Clinical efficacy of fosfomycin combinations against a variety of gram-positive cocci.

INTRODUCTION: Over recent years we have witnessed an increase in the resistance of microorganisms to the available antimicrobials and a decrease in the number of new antimicrobials. Fosfomycin is a safe and cheap broad-spectrum antibiotic which has shown very promising results in combination therapy, mainly against gram-negative microorganisms. Little is known, however, about its clinical efficacy against gram-positive microorganisms. METHODS: We performed a retrospective review of all patients with severe gram-positive infections who received fosfomycin as part of their treatment from 2011 to 2017. We also performed in vitro time-kill assays to study the behaviour of fosfomycin with different antimicrobials against two strains of methicillin-resistant Staphylococcus aureus (MRSA) and two strains of methicillin-susceptible S. aureus (MSSA). RESULTS: Seventy-five patients were treated with different fosfomycin combinations. Among them, 61 (81%) were successfully treated. Daptomycin plus fosfomycin was the most effective combination. Overall, the treatment with fosfomycin was safe, and side effects were minor. There was only one major side effect that resolved after discontinuation of therapy. Time-kill studies demonstrated increased activity of fosfomycin combinations, with daptomycin-fosfomycin being the most active combination against both MRSA and MSSA strains. CONCLUSIONS: Our results suggest that antimicrobial combinations including fosfomycin are an alternative and effective approach for gram-positive infections.

Influencia de las intervenciones realizadas durante el parto en la duración de la lactancia materna / Influence of the interventions during labour on breastfeeding duration

Objetivo: Analizar la influencia de diferentes intervenciones clínicas realizadas durante el parto sobre el inicio y mantenimiento de la lactancia materna (LM) a los 4, 6 y 12 meses. Método: Estudio observacional prospectivo. Se llevó a cabo en el Hospital do Salnés de Vilagarcía de Arousa (Pontevedra). La población de estudio fueron mujeres que dieron a luz entre marzo y diciembre de 2016 con intención de amamantar. Se realizó seguimiento de la muestra durante 12 meses o hasta abandonar la LM. La variable de resultado fue la duración total de la LM. Las variables independientes fueron una serie de intervenciones frecuentes en el proceso perinatal. También se analizó el efecto acumulativo negativo de dichas intervenciones sobre la LM. Resultados: Se obtuvo una muestra de 189 mujeres. El tiempo de LM mediano fue de 12 meses en el grupo sin intervenciones, de 10 meses en el grupo de 1-3 intervenciones y de 5 en el grupo de 4 o más intervenciones, siendo las diferencias estadísticamente significativas (p= 0,014). Los eventuales factores de confusión o ajuste se estudiaron mediante análisis multivariante. Cabe destacar el efecto positivo de no utilizar la epidural para conseguir una LM que se mantenga hasta los 12 meses ( odds ratio 2,1; p= 0,03). Conclusiones: Es necesario un mayor esfuerzo por parte de las instituciones para capacitar y sensibilizar al personal sanitario en cuanto a las normas y prácticas relacionadas con la atención amigable a la madre, así como dar a conocer el efecto acumulativo negativo de las intervenciones realizadas en el parto. Las mujeres que necesiten múltiples intervenciones durante el parto podrían precisar ayuda suplementaria para mejorar sus resultados en la LM

Objective: To evaluate the influence of different clinical procedures (operations) during labour on the beginning and maintenance of breastfeeding at 4, 6 and 12 months. Method: An observational-prospective study was carried out at the Salnés Hospital (Vilagarcía de Arousa, Pontevedra). The study population were women who had given birth between March and December 2016 and had the intention of breastfeeding their babies. The sample of 189 women were followed for 12 months or until breastfeeding was ceased. The result variable was the total length of breastfeeding. Independent variables were a series of frequent procedures during labour. The negative accumulative effect on breastfeeding was also analysed. Results: The average breastfeeding time was 12 months in the group undergoing no procedures, 10 months in the group undergoing 1-3 procedures and 5 months in the group undergoing 4 or more procedures. The statistical differences are significant (p= 0.014). The potential confusion or adjustment factors were analysed by means of multivariate analysis. It is worth highlighting the positive effect of not using the epidural to achieve an LM that is maintained until 12 months (odds ratio 2.1; p= 0.03). Conclusions: A greater effort is necessary on behalf of the institutions to not only train and sensitize their staff about the guidelines and practice related to offering kind care to the mother, but also making them aware of the negative accumulative effect of the procedures carried out during labour. Women who undergo several procedures during labour may need extra support in order to improve their breastfeeding results

Clinical predictors of candidemia in medical non-neutropenic, non-ICU patients. The CaMed score.

INTRODUCTION: Candida species are the leading cause of invasive fungal infections in hospitalised patients and are the fourth most common isolates recovered from patients with bloodstream infection. Few data exist on risk factors for candidemia in non-ICU patients. We performed a population-based case-control study to evaluate the main predictors for candidemia in non-ICU patients. METHODS AND FINDINGS: We included all non-neutropenic, non-critically ill and non-surgical adult patients with candidemia between January 2010 and June 2014. Patients with positive, non-candidal blood culture obtained at the same day (±2 days) were selected as controls. Cases and controls were matched according to hospital ward and clinical characteristics. Risk factors for candidemia were identified through a logistic regression. We included 56 candidemic and 512 bacteriemic non-candidemic patients. Most of candidemic patients (52) had received antibiotics prior to candidemia. Among them, the 30-day mortality rate was 34% (19/56). Multivariate analysis identified male sex, prior use of steroids, prior use of antibiotics, total parenteral nutrition and urinary catheterisation as independent predictors of candidemia. To develop the CaMed score, we rounded up weights of different risk factors as follows; total parenteral nutrition (+2), prior antibiotic therapy (+5), each of the other risk factors (+1). A score ≥ 7 identified patients at high risk of candidemia (P < 0.001; RR 29.805; CI 95% 10.652-83.397; sensitivity 79.2, specificity 82.6%, Youden index 0,62). CONCLUSIONS: Our set of easy independent predictors of candidemia in non-neutropenic, non-ICU, non-surgical patients provide a rationale for early initiation of antifungals and could reduce candidemia-related mortality.

Interfacial waveforms in chiral lattices with gyroscopic spinners.

We demonstrate a new method of achieving topologically protected states in an elastic hexagonal system of trusses by attaching gyroscopic spinners, which bring chirality to the system. Dispersive features of this medium are investigated in detail, and it is shown that one can manipulate the locations of stop-bands and Dirac points by tuning the parameters of the spinners. We show that, in the proximity of such points, uni-directional interfacial waveforms can be created in an inhomogeneous lattice and the direction of such waveforms can be controlled. The effect of inserting additional soft internal links into the system, which is thus transformed into a heterogeneous triangular lattice, is also investigated, as the hexagonal lattice represents the limit case of the heterogeneous triangular lattice with soft links. This work introduces a new perspective in the design of periodic media possessing non-trivial topological features.

Análisis cepstral de la voz normal y patológica en adultos españoles. Medida de la prominencia del pico cepstral suavizado en vocales sostenidas versus habla conectada / Cepstral analysis of normal and pathological voice in Spanish adults. Smoothed cepstral peak prominence in sustained vowels versus connected speech

INTRODUCCIÓN Y OBJETIVOS: En los últimos años se ha incrementado el uso de medidas cepstrales para la evaluación acústica de la voz. Uno de los parámetros más investigados es la prominencia del pico cepstral suavizado (CPPs). Los objetivos de este trabajo son conocer la utilidad de esta medida acústica en la evaluación objetiva de las alteraciones de la voz en español y determinar qué tipo de muestra de voz (vocales sostenidas o habla conectada) es la más sensible para evaluar la severidad de la disfonía. MÉTODO: En este estudio participaron 40 sujetos, 20 normofónicos y 20 con disfonía. Se grabaron 2 muestras de voz para cada sujeto (una/a/sostenida y 4 frases fonéticamente balanceadas) y se calculó la CPPs con el programa Praat. Tres expertos valoraron perceptivamente la voz de la muestra con el parámetro grado de la escala GRABS. RESULTADOS: Se encontraron valores significativamente menores en las voces disfónicas, tanto para la/a/(t[38] = 4,85, p < 0,000) como para las frases (t[38] = 5,75, p < 0,000). En relación con el tipo de muestra de voz más indicado para evaluar la severidad de las alteraciones de la voz se encontró una fuerte correlación con la escala acústico-perceptiva de la CPPs calculada a partir del habla conectada (rs = -0,73) y moderada con la calculada a partir de la vocal sostenida (rs= -0,56). CONCLUSIÓN: Los resultados de este estudio preliminar apuntan a que la CPPs es una buena medida para detectar la disfonía y para evaluar objetivamente el grado de severidad de las alteraciones en la voz

INTRODUCTION AND OBJECTIVES: In recent years, the use of cepstral measures for acoustic evaluation of voice has increased. One of the most investigated parameters is smoothed cepstral peak prominence (CPPs). The objectives of this paper are to establish the usefulness of this acoustic measure in the objective evaluation of alterations of the voice in Spanish and to determine what type of voice sample (sustained vowels or connected speech) is the most sensitive in evaluating the severity of dysphonia. METHOD: Forty subjects participated in this study 40, 20 controls and 20 with dysphonia. Two voice samples were recorded for each subject (one sustained vowel/a/and four phonetically balanced sentences) and the CPPs was calculated using the Praat programme. Three raters perceptually evaluated the voice sample with the Grade parameter of GRABS scale. RESULTS: Significantly lower values were found in the dysphonic voices, both for/a/(t[38] = 4.85, P < .000) and for phrases (t[38] = 5,75, P < .000). In relation to the type of voice sample most suitable for evaluating the severity of voice alterations, a strong correlation was found with the acoustic-perceptual scale of CPPs calculated from connected speech (rs = -0.73) and moderate correlation with that calculated from the sustained vowel (rs = -0,56). CONCLUSION: The results of this preliminary study suggest that CPPs is a good measure to detect dysphonia and to objectively assess the severity of alterations in the voice

Validation of the Acoustic Voice Quality Index Version 03.01 and the Acoustic Breathiness Index in the Spanish language.

OBJECTIVE: The aim of this study was to validate the Acoustic Voice Quality Index 03.01 (AVQIv3) and the Acoustic Breathiness Index (ABI) in the Spanish language. METHOD: Concatenated voice samples of continuous speech (cs) and sustained vowel (sv) from 136 subjects with dysphonia and 47 vocally healthy subjects were perceptually judged for overall voice quality and breathiness severity. First, to reach a higher level of ecological validity, the proportions of cs and sv were equalized regarding the time length of 3 seconds sv part and voiced cs part, respectively. Second, concurrent validity and diagnostic accuracy were verified. RESULTS: A moderate reliability of overall voice quality and breathiness severity from 5 experts was used. It was found that 33 syllables as standardization of the cs part, which represents 3 seconds of voiced cs, allows the equalization of both speech tasks. A strong correlation was revealed between AVQIv3 and overall voice quality and ABI and perceived breathiness severity. Additionally, the best diagnostic outcome was identified at a threshold of 2.28 and 3.40 for AVQIv3 and ABI, respectively. CONCLUSIONS: The AVQIv3 and ABI showed in the Spanish language valid and robust results to quantify abnormal voice qualities regarding overall voice quality and breathiness severity.

Cepstral analysis of normal and pathological voice in Spanish adults. Smoothed cepstral peak prominence in sustained vowels versus connected speech. / Análisis cepstral de la voz normal y patológica en adultos españoles. Medida de la prominencia del pico cepstral suavizado en vocales sostenidas versus habla conectada.

INTRODUCTION AND OBJECTIVES: In recent years, the use of cepstral measures for acoustic evaluation of voice has increased. One of the most investigated parameters is smoothed cepstral peak prominence (CPPs). The objectives of this paper are to establish the usefulness of this acoustic measure in the objective evaluation of alterations of the voice in Spanish and to determine what type of voice sample (sustained vowels or connected speech) is the most sensitive in evaluating the severity of dysphonia. METHOD: Forty subjects participated in this study 40, 20 controls and 20 with dysphonia. Two voice samples were recorded for each subject (one sustained vowel/a/and four phonetically balanced sentences) and the CPPs was calculated using the Praat programme. Three raters perceptually evaluated the voice sample with the Grade parameter of GRABS scale. RESULTS: Significantly lower values were found in the dysphonic voices, both for/a/(t[38]= 4.85, P<.000) and for phrases (t[38] = 5,75, P<.000). In relation to the type of voice sample most suitable for evaluating the severity of voice alterations, a strong correlation was found with the acoustic-perceptual scale of CPPs calculated from connected speech (rs = -0.73) and moderate correlation with that calculated from the sustained vowel (rs = -0,56). CONCLUSION: The results of this preliminary study suggest that CPPs is a good measure to detect dysphonia and to objectively assess the severity of alterations in the voice.

Gyro-elastic beams for the vibration reduction of long flexural systems.

The paper presents a model of a chiral multi-structure incorporating gyro-elastic beams. Floquet-Bloch waves in periodic chiral systems are investigated in detail, with the emphasis on localization and the formation of standing waves. It is found that gyricity leads to low-frequency standing modes and generation of stop-bands. A design of an earthquake protection system is offered here, as an interesting application of vibration isolation. Theoretical results are accompanied by numerical simulations in the time-harmonic regime.