Quality Care in Outpatient Chemotherapy. Design and Validation of the Novel Care Quality Ambulatory Instrument / Cuidado con calidad en quimioterapia ambulatoria. Diseño y validación del nuevo instrumento Care Quality Ambulatory / Cuidado com qualidade em quimioterapia ambulatória. Desenho e validação do novo instrumento Care Quality Ambulatory

Introduction: Neither validated scales nor scales translated into Spanish currently exist to evaluate the perception of quality care in people receiving outpatient chemotherapy, despite their usefulness in evaluating the care provided by nurses and in promoting changes in the delivery of these services. Objective: To design and validate the novel Care Quality Ambulatory-I (CQAMB-I) instrument in outpatient chemotherapy services. Materials and methods: This is an instrument validation study carried out in three stages: literature review, design, and validation of the instrument. Content validation was performed with 14 specialists with at least a master's degree and experience in chemotherapy or quality services; face validation was carried out through a pilot test with 31 participants diagnosed with cancer who received curative chemotherapy, and construct validation was carried out through an exploratory factor analysis with 436 users who received outpatient chemotherapy with curative intent. Results: A total of 15 items were removed in the content validation stage; none were removed in face validation. In construct validation, participants had a median age of 56 years, a median treatment time of 5 months, and breast cancer was the most commonly diagnosed form of cancer. Eighteen models were run, 30 items were removed, 6 factors emerged, and a KMO of 0.80 and a Cronbach's alpha of 0.82 were obtained. Conclusion: The CQAMB-I proved to be valid and reliable for the evaluation of quality care in outpatient chemotherapy services. Additionally, it enabled expanding the conception of such care beyond the attributes of structure, process, and outcome.

Introducción: no existen escalas validadas, ni traducidas al español para evaluar la percepción del cuidado con calidad en personas que reciben quimioterapia ambulatoria, a pesar de su utilidad para evaluar la prestación de servicios enfermeros y generar cambios en la entrega de estos. Objetivo: diseñar y validar el nuevo instrumento Care Quality Ambulatory-I (CQAMB-I) en servicios de quimioterapia ambulatoria. Materiales y métodos: estudio de validación de instrumentos en tres fases: revisión de la literatura, diseño y validación del instrumento. Se realizó validación de contenido con 14 expertos con formación mínima de maestría y experiencia en servicios de quimioterapia o calidad; validación facial a través de prueba piloto con 31 participantes con diagnóstico de cáncer que recibían quimioterapia curativa; y validación de constructo por medio de un análisis factorial exploratorio con 436 usuarios que recibían quimioterapia ambulatoria con intención curativa. Resultados: en la validación de contenido se eliminaron 15 ítems; en la validación facial no se eliminó ninguno; y en la validación de constructo los participantes tuvieron una mediana de edad de 56 años, mediana de tiempo de tratamiento de 5 meses y cáncer de mama como el más diagnosticado. Se ejecutaron 18 modelos, se eliminaron 30 ítems, emergieron 6 factores y se obtuvo un KMO de 0.80 y un alpha de Cronbach de 0.82. Conclusión: el instrumento CQAMB-I demostró ser válido y confiable para evaluar el cuidado con calidad en servicios de quimioterapia ambulatoria y, adicionalmente, permitió ampliar la concepción de este más allá de los atributos de estructura, proceso y resultado.

Introdução: não existem escalas validadas nem traduzidas ao espanhol para avaliar a percepção do cuidado com qualidade em pessoas que recebem quimioterapia ambulatória, apesar de sua utilidade para avaliar a prestação de serviços de enfermagem e gerar mudanças na entrega destes. Objetivo: desenhar e validar o novo instrumento Care Quality Ambulatory-I (CQAMB-I) em serviços de quimioterapia ambulatória. Materiais e método: estudo de validação de instrumentos em três fases: revisão da literatura, desenho e validação do instrumento. Foi realizada validação de conteúdo com 14 especialistas com formação mínima de mestrado e experiência em serviços de quimioterapia ou qualidade; validação facial por meio de teste-piloto com 31 participantes com diagnóstico de câncer que recebiam quimioterapia curativa e validação de constructo por meio de uma análise fatorial exploratória com 436 usuários que recebiam quimioterapia ambulatória com intenção curativa. Resultados: na validação de conteúdo, foram eliminados 15 itens; na validação facial, não foi eliminado nenhum; na validação de constructo, os participantes tiveram uma média de idade de 56 anos, média de tempo de tratamento de 5 meses e câncer de mama como o mais diagnosticado. Foram executados 18 modelos, foram eliminados 30 itens, emergidos 6 fatores e obtido um KMO de 0,80 e um alpha de Cronbach de 0,82. Conclusões: o instrumento CQAMB-I demonstrou ser válido e confiável para avaliar o cuidado com qualidade em serviços de quimioterapia ambulatória e, além disso, permitiu ampliar a concepção deste mais além dos atributos de estrutura, processo e resultado.

Factores asociados a falla terapéutica con maniobras de reposición canalicular en pacientes con diagnóstico de vértigo posicional paroxístico benigno en la Clínica de Otorrinolaringología de Antioquia, Medellín, Colombia / Factors associated with therapeutic failure with canalicular repositioning maneuvers in patients diagnosed with benign paroxysmal positional vertigo at Antioquia Otorhinolaryngology Clinic, Medellin, Colombia"

Introducción: múltiples factores se han relacionado con el desarrollo de la recurrencia del vértigo posicional paroxístico benigno (VPPB). Objetivo: determinar la asociación entre la falla terapéutica de las maniobras de reposición canalicular (MRC) y las variables sociodemográficas y clínicas en los pacientes con diagnóstico de VPPB. Diseño: estudio observacional de cohorte retrospectiva. Materiales y métodos: revisión de historias clínicas de la consulta de vértigo de la Clínica Orlant, Medellín, Colombia. Resultados: se incluyeron 41 pacientes con diagnóstico de VPPB a quienes se les realizó MRC y seguimiento clínico entre 1 y 8 semanas. El 90,2 % eran de sexo femenino, con una mediana de edad de 58 (±183) años; se encontró uso de vestibulosupresores en un 68,3 %, y es la betahistina el más consumido (43,9 %). El 51,2 % de pacientes presentaron falla terapéutica y se identificó una asociación con el número total de MRC realizadas y el uso de vibrador mastoideo (p < 0,001), teniendo en cuenta que los pacientes mejoraron clínicamente al final del seguimiento con una media de 77 % (p < 0,001). No se encontraron asociaciones estadísticamente significativas con el resto de variables. Conclusión: no hubo asociación entre la falla terapéutica y las variables estudiadas, excepto número de MRC, el uso del vibrador mastoideo y la mejoría clínica final, posiblemente porque el vibrador mastoideo se aplica a los pacientes en quienes hay persistencia de síntomas y signos con las maniobras desencadenantes, y por factores fisiopatológicos no esclarecidos; con esto finalmente se logra una mejoría clínica con más de dos MRC

Introduction: Multiple factors have been related to the development of recurrence of benign paroxysmal positional vertigo (BPPV). Objective: To determine the association between therapeutic failure of canalicular repositioning maneuvers (CRM) with sociodemographic and clinical variables in patients with a diagnosis of BPPV. Design: Observational retrospective cohort study. Materials and methods: Review of medical records of the vertigo clinic of the Orlant Clinic, Medellín - Colombia. Results: 41 patients with a diagnosis of BPPV who underwent CRM and clinical follow-up between 1 and 8 weeks were included. 90.2% were female, with a median age of 58 (± 18.3) years, use of vestibulosuppressants was found in 68.3%, betahistine being the most consumed (43.9%). 51.2% of patients presented therapeutic failure, identifying an association with the total number of CRMs performed and the use of a mastoid vibrator with (p < 0.001), taking into account that the patients improved clinically at the end of follow-up with a mean of 77% (p < 0.001). No statistically significant associations were found with the rest of the variables. Conclusion: There was no association between therapeutic failure and the variables studied except number of CRM, use of the mastoid vibrator and final clinical improvement, possibly because the mastoid vibrator is applied to patients in whom there are persistence of symptoms and signs with the triggering maneuvers for unclear pathophysiological factors, finally achieving clinical improvement with more than two CRMs.

Sampling optimization for blend monitoring of a low dose formulation in a tablet press feed frame using spatially resolved near-infrared spectroscopy.

In-line measurements of low dose blends in the feed frame of a tablet press were performed for API concentration levels as low as 0.10% w/w. The proposed methodology utilizes the advanced sampling capabilities of a Spatially Resolved Near-Infrared (SR-NIR) probe to develop Partial Least-Squares calibration models. The fast acquisition speed of multipoint spectra allowed the evaluation of different numbers of co-adds and feed frame paddle speeds to establish the optimum conditions of data collection to predict low potency blends. The interaction of the feed frame paddles with the SR-NIR probe was captured with high resolution and allowed the implementation of a spectral data selection criterion to remove the effect of the paddles from the calibration and testing process. The method demonstrated accuracy and robustness when predicting drug concentrations across different feed frame paddle speeds.

Una reflexión sobre las actitudes hacia la Enfermedad de Alzheimer / A A reflection about attitudes towards Alzheimer's disease

Introducción: La enfermedad de Alzheimer (EA) se considera como una afección crónica con alta prevalencia a nivel mundial. Su sintomatología, el impacto que genera en el funcionamiento de la persona y los cambios que causa en su red de apoyo social, han llevado a que sea un tema de amplio interés para la investigación. La idea de desarrollar la EA y convivir con ella genera diversas actitudes, es decir la tendencia a asumir una posición en favor o en contra. Objetivos: reflexionar sobre las actitudes hacia la EA, a partir de los hallazgos obtenidos en una revisión de la literatura publicada entre 2000 y 2020. Resultados: se encontraron diversas creencias hacia la EA en relación con su etiología, curso y tratamiento, así como el predominio de sentimientos y emociones negativos hacia ella. Llama la atención las conductas dirigidas a buscar la prevención de esta enfermedad. Conclusiones: se reflexiona sobre la relevancia y la pertinencia de considerar la evaluación de las actitudes en los contextos de salud.

Introduction: Alzheimer ́s disease (AD) is considered a chronic condition with high prevalence worldwide. Its symptomatology, the impact it causes on patient ́s ability to function and the negative changes in his or her social support network have made it a very interesting topic for research. The idea of developing AD and living with it give rise to diverse attitudes, that is, the tendency to take a stance in favor of or against AD. This article aims to make a reflection on the attitudes towards AD, based on the findings obtained in a review of the literature published between 2000 and 2020. Results: we found various beliefs regarding AD, related with its etiology, course and treatment, as well as the predominance of negative feelings and emotions towards it. Our attention is caught by the behaviors aimed at seeking developments in its prevention. Conclusions: we reflect on the relevance and pertinence of considering the evaluation of attitudes in the contexts of health.

Biodegradabilidad de lixiviados procedentes de un relleno sanitario utilizando un sistema de lodos activados flujo pistón / The biodegradability of leachates from a landfill using an activated sludge processes plug flow reactor system / Biodegradabilidade de lixiviados de um aterro usando um sistema de lodos ativados de fluxo de pistão

Resumen En esta investigación se desarrolló un Reactor Flujo Pistón (RFP) de lodos activados, que fue empleado para determinar el Tiempo de Retención Celular (TRC) óptimo para tratar cargas altas de lixiviado y estimar el comportamiento cinético del sistema con el fin que sirva de base para proyecciones de escalamiento y diseño de reactor de este tipo a escala real. Para ello se realizó el diseño, la construcción y puesta en marcha del RFP a nivel de laboratorio (capacidad de 50L) en condiciones de operación continua con recirculación de lodo y se utilizó como sustrato lixiviado procedente del relleno sanitario El Guayabal de la ciudad de Cúcuta. Se determinó como parámetros de control cuatro TRC diferentes entre 5 y 20 días diferenciada por etapas. Se evaluaron las variables de pH, Temperatura, Oxígeno disuelto y Sólidos Suspendidos Volátiles en el Licor Mixto (SSVLM). En cuanto al control y monitoreo de la eficiencia de remoción se escogió la Demanda Química de Oxígeno (DQO) como parámetro para medir la degradación de materia orgánica, dado que este parámetro a diferencia de la Demanda Bioquímica de Oxígeno (DBO5) puede ser calculado en un menor tiempo. El sistema biológico RFP alcanzó estabilizarse en un período de operación entre 20 y 25 días con remociones promedio mayores a 92% para TRC de 15 y 20 días mientras que TRC menores reportaron remociones promedio por debajo del 86%. Así mismo TRC de 15 permitió un Factor de carga (F/M) óptima promedio de 1.1 KgDQO/KgSSV.d. Las constantes cinéticas obtenidas en esta investigación, representativas para un sistema de RFP operado a escala laboratorio para remoción de materia orgánica carbonacea en lixiviados fueron: KS= 836.5 mg/L DQO, k=4.8123 d1, Y= 0.089 mg SSVLM/mg DQO y kd= 0.018 d-1, ajustados por regresión al modelo matemático de Lawrence y McCarty al poseer una correlación de 0.97 entre los datos experimentales obtenidos y el modelo y amplia aplicación en el campo de diseño de reactores de lodos activados.

Abstract An activated sludge processes (ASP) plug flow reactor (PFR) was developed in this research and used for determining optimal cell residence time (CRT) for treating high leachate loads and estimating the system's kinetic behaviour as a basis for scaling projections and this type of reactor design at full-scale. The RFP was designed, built and put into operation in the laboratory (50L capacity) involving continuous operation conditions with sludge recirculation; leached substrate from the city of Cúcuta's El Guayabal landfill was used. Four 5-day CRTs (ranging from 5 to 20 days) were used as control parameters. Variables were evaluated regarding pH, temperature, dissolved oxygen and mixed liquor volatile suspended solids (MLVSS). Regarding removal efficiency control and monitoring, chemical oxygen demand (COD) was chosen as a parameter for measuring organic matter degradation since COD (unlike biochemical oxygen demand (BOD5)) can be calculated in a shorter time. The RFP biological system became stabilised in a 20- to 25-day operating period, having greater than 92% average removal for 15- and 20-day CRTs, whilst lower CRTs reported lower than 86% average removal. A 15-day TRC gave an average 0.26 kgDQO/kgSSV.d optimal load factor (F/M). The representative kinetic constants obtained in this research for a laboratory-scale PFR system for the removal of carbonaceous organic matter in leachates were KS = 836mg COD / l, k = 4.8123 d1, Y = 0.089 mg SSVLM / mg COD and kd = 0.018 d-1, adjusted by regression using Lawrence and McCarty's mathematical model (having 0.97 correlation between the experimental data and the model). Such model should have broad application in the field of ASP-type PFRs.

Resumo Nesta pesquisa, um Reator de lodo ativado de Fluxo de Pistão (RFP) foi desenvolvido para determinar o Tempo de Retenção Celular (CRT) ideal para tratar altas cargas de lixiviado e estimar o comportamento cinético do sistema, a fim de servir de base para projetar o reator em escala real. Para isso, foram realizados RFP em nível de laboratório (capacidade de 50L) em condições de operação contínua com recirculação de lodo e foi utilizada como substrato lixiviado do aterro El Guayabal na cidade de Cúcuta. Usando quatro diferentes CRTs entre 5 e 20 dias como fatores de bloqueio. Foram avaliadas as variáveis ​​pH, Temperatura, Oxigênio Dissolvido e Sólidos Suspensos Voláteis no Licor Misto (SSVLM). Em relação ao controle e monitoramento da eficiência de remoção, a Demanda Química de Oxigênio (DQO) foi escolhida como parâmetro para medir a degradação da matéria orgânica, uma vez que este parâmetro, ao contrário da Demanda Bioquímica de Oxigênio (DBO5), pode ser calculado em um tempo mais curto. O sistema biológico da RFP se estabilizou em um período de operação entre 20 e 25 dias com remoções médias superiores a 92% para TRC de 15 e 20 dias, enquanto TRC menores mostraram remoções médias abaixo de 86%. Da mesma forma, TRC de 15 dias permitiu um fator de carga ideal médio (F / M) de 0,26 KgDQO / d. As constantes cinéticas obtidas nesta pesquisa, representativas de um sistema RFP operado em escala de laboratório para remoção de matéria orgânica carbonácea em lixiviados foram: KS = 836mg COD / l, k = 4,8123 d1, Y = 0,089 mg SSVLM / mg COD e kd = 0,018 d-1, ajustado por regressão ao modelo matemático de Lawrence e McCarty, tendo uma correlação de 0,97 entre os dados experimentais obtidos e o modelo e ampla aplicação na área de projeto de reatores de lodo ativado.

[A case report of Noonan syndrome diagnosed in primary healthcare]. / Reporte de un caso de síndrome de Noonan diagnosticado en atención primaria.

Noonan syndrome is an autosomal dominant inherited disorder with variable phenotypic expression. It belongs to the group of diseases known as RASopathies, which are characterized by mutations in the RAS genes. Patients develop symptoms such as facial dysmorphism, short stature, congenital heart disease, musculoskeletal disorders and mental retardation. In this article, we report a case of Noonan syndrome in a 14-year-old patient, diagnosed in a primary health center in Ecuador. The syndrome was identified through clinical diagnosis, after which the patient was referred to the secondary and tertiary levels for specialized care.

El síndrome de Noonan es un trastorno genético de herencia autosómica dominante, de expresión fenotípica variable. Pertenece al grupo de las enfermedades conocidas como rasopatías, trastornos producido por las mutaciones en los genes RAS. Los pacientes desarrollan síntomas como dismorfismo facial, talla baja, enfermedad cardíaca congénita, alteraciones músculos esqueléticas y discapacidad intelectual. En el presente reporte, se describe un caso de diagnóstico del síndrome de Noonan en un paciente de 14 años, realizado a nivel de atención primaria en Ecuador. El síndrome se identificó mediante diagnóstico clínico, permitiendo su derivación al segundo y tercer nivel de salud para una atención especializada.

Reporte de un caso de síndrome de Noonan diagnosticado en atención primaria / A case report of Noonan syndrome diagnosed in primary healthcare

El síndrome de Noonan es un trastorno genético de herencia autosómica dominante, de expresión fenotípica variable. Pertenece al grupo de las enfermedades conocidas como rasopatías, trastornos producido por las mutaciones en los genes RAS. Los pacientes desarrollan síntomas como dismorfismo facial, talla baja, enfermedad cardíaca congénita, alteraciones músculos esqueléticas y discapacidad intelectual. En el presente reporte, se describe un caso de diagnóstico del síndrome de Noonan en un paciente de 14 años, realizado a nivel de atención primaria en Ecuador. El síndrome se identificó mediante diagnóstico clínico, permitiendo su derivación al segundo y tercer nivel de salud para una atención especializada.

Noonan syndrome is an autosomal dominant inherited disorder with variable phenotypic expression. It belongs to the group of diseases known as RASopathies, which are characterized by mutations in the RAS genes. Patients develop symptoms such as facial dysmorphism, short stature, congenital heart disease, musculoskeletal disorders and mental retardation. In this article, we report a case of Noonan syndrome in a 14-year-old patient, diagnosed in a primary health center in Ecuador. The syndrome was identified through clinical diagnosis, after which the patient was referred to the secondary and tertiary levels for specialized care.

Communication of Career Pathways Through Associate Degree Program Web Sites: A Baseline Assessment.

BACKGROUND: The American Association for Respiratory Care sponsored a series of conferences that addressed the competency of the future workforce of respiratory therapists (RTs). Based upon the findings from those conferences, several initiatives emerged that support RTs earning a baccalaureate (or bachelor's) degree. The objective of this study was to identify the ways that associate degree programs communicate career pathways toward a baccalaureate degree through their Web sites. METHODS: This cross-sectional observational study used a random sample of 100 of the 362 associate degree programs approved by the Commission on Accreditation for Respiratory Care. Data were collected from 3 specific categories: demographic data, baccalaureate completion information, and the Web page location for the program. The presence of statements related to any pathway toward a bachelor's degree, transfer credits, articulation agreements, and links for baccalaureate completion were recorded. The descriptive statistics in this study were reported as total numbers and percentages. RESULTS: Of the 100 programs in the random sample, only 89 were included in the study. Only 39 (44%) programs had links on their program Web site that had any content related to bachelor's degrees, 16 (18%) identified college transfer courses toward a bachelor's degree, and 26 (29%) programs included baccalaureate articulation agreements on their Web site. CONCLUSIONS: A minority of associate degree programs communicated career pathway information to their prospective and current students through program Web sites. An informative Web site would make the path more transparent for entry-level students to meet their future educational needs as their careers progress.

Carboplatin Dosing Accuracy by Estimation of Glomerular Filtration versus Creatinuria in Cancer Patients.

BACKGROUND: The glomerular filtration rate (GFR) is essential for calculating the dose and the monitoring of carboplatin. Although GFR measurement (mGFR) by external markers is ideal, in most cases these are not employed; the most used method is GFR estimation (eGFR) by formulae, hence the need to identify the formula with the best performance. METHODS: Patients admitted between 2011 and 2017 and diagnosed with ovarian, endometrial, lung, esophageal, or testicular cancer were assessed retrospectively. The accuracy of the carboplatin dose calculated by creatinine concordance and by the Cockroft-Gault (CG), CKD-EPI, MDRD, Wright, and Jelliffe formulae was assessed using the intraclass correlation coefficient. RESULTS: Fifty-six medical histories were analyzed. The best accuracy was observed between the Wright formula (i.e., 0.71) and the dose calculated based on the 24-h creatinine clearance. Stratification by CKD was made in depurations < 60 mL/min, where the Jelliffe value was excellent (i.e., 0.75). In depurations ≥60 mL/min, CKD-EPI was the best formula, with an accuracy of 0.65. CG was the formula with the worst performance in calculating the dose and glomerular filtration, losing its usefulness with very low filtrations. CONCLUSIONS: GFR formulae and calculation of the carboplatin dose have good accuracy with the GFR obtained based on the 24-h creatinine clearance, with the Wright formula being the one with best performance and CG the one with worst performance.

Process analytical technology in continuous manufacturing of a commercial pharmaceutical product.

The implementation of process analytical technology and continuous manufacturing at an FDA approved commercial manufacturing site is described. In this direct compaction process the blends produced were monitored with a Near Infrared (NIR) spectroscopic calibration model developed with partial least squares (PLS) regression. The authors understand that this is the first study where the continuous manufacturing (CM) equipment was used as a gravimetric reference method for the calibration model. A principal component analysis (PCA) model was also developed to identify the powder blend, and determine whether it was similar to the calibration blends. An air diagnostic test was developed to assure that powder was present within the interface when the NIR spectra were obtained. The air diagnostic test as well the PCA and PLS calibration model were integrated into an industrial software platform that collects the real time NIR spectra and applies the calibration models. The PCA test successfully detected an equipment malfunction. Variographic analysis was also performed to estimate the sampling analytical errors that affect the results from the NIR spectroscopic method during commercial production. The system was used to monitor and control a 28 h continuous manufacturing run, where the average drug concentration determined by the NIR method was 101.17% of label claim with a standard deviation of 2.17%, based on 12,633 spectra collected. The average drug concentration for the tablets produced from these blends was 100.86% of label claim with a standard deviation of 0.4%, for 500 tablets analyzed by Fourier Transform Near Infrared (FT-NIR) transmission spectroscopy. The excellent agreement between the mean drug concentration values in the blends and tablets produced provides further evidence of the suitability of the validation strategy that was followed.

Intra-articular, bursa, and tendon sheath injections: a survey of practice patterns among members of the American College of Rheumatology.

OBJECTIVE: The objective of this study was to survey members of the American College of Rheumatology (ACR) regarding intra-articular and soft tissue (musculoskeletal [MSK]) injections and to determine if injection techniques vary depending on type of practice and years of experience. METHODS: A survey was e-mailed to the members of the ACR to obtain demographics of the respondents, MSK injection practices, and adverse events seen. RESULTS: The most common indications for MSK injections were rheumatoid arthritis, osteoarthritis, and bursitis. Written consent and time-out procedures were more common in academic/government practices when compared with private practice. There was variation in the type of corticosteroid used. The most common preparations were methylprednisolone actetate (45.0%), triamcinolone acetonide (26.1%), triamcinolone hexacetonide (22.1%). This survey showed good agreement on the dosage of corticosteroid for MSK injections; however, as years of experience increased, clinicians were more likely to prescribe lower doses for shoulder and knee injections. CONCLUSIONS: In this survey of ACR members, we found self-reported differences in the type of corticosteroid used for MSK injections. There was general agreement on frequency of injections, but more experienced practitioners reported using lower doses of corticosteroid.

Trends in nitrate concentrations and determination of its origin using stable isotopes (18O and 15N) in groundwater of the Western Central Valley, Costa Rica.

A study was conducted to evaluate long-term trends in nitrate concentrations and to try to identify the origin of nitrate using stable isotopes (15N(NO3-) and 18O(NO3-)) in the aquifers of the western Central Valley, Costa Rica, where more than 1 million people depend on groundwater to satisfy their daily needs. Data from 20 sites periodically sampled for 4 to 17 years indicate an increasing trend in nitrate concentrations at five sites, which in a period ranging from 10 to 40 years, will exceed recommended maximum concentrations. Results of isotopic analysis indicate a correspondence between land use patterns and the isotopic signature of nitrate in groundwater and suggest that urbanization processes without adequate waste disposal systems, followed by coffee fertilization practices, are threatening water quality in the region. We conclude that groundwater management in this area is not sustainable, and that land use substitution processes from agricultural activity to residential occupation that do not have proper sewage disposal systems may cause a significant increment in the nitrate contaminant load.