Brief windows with more favorable atmospheric conditions explain patterns of Polylepis reticulata tree water use in a high-altitude Andean forest

Polylepis trees occur throughout the Andean mountain region, and it is the tree genus that grows at the highest elevation worldwide. In the humid Andes where moisture is rarely limiting, Polylepis trees must adapt to extreme environmental conditions, especially rapid fluctuations in temperature, ultraviolet radiation and vapor pressure deficit (VPD). However, Polylepis' water-use patterns remain largely unknown despite the importance of understanding their response to microclimate variation to determine their capacity to maintain resilience under future environmental change. We conducted a study in a Polylepis reticulata Kunth forest in the Ecuadorian Andes to evaluate its tree water-use dynamics and to identify the main environmental drivers of transpiration. Tree sap flow was monitored simultaneously with soil volumetric water content (VWC) and microclimate during 2 years for trees growing in forest edge and interior locations. We found that sap flow was primarily controlled by VPD and that VWC exerted a secondary role in driving sap flow dynamics. The highest values for sap flow rates were found when VPD > 0.15 kPa and VCW < 0.73 cm3 cm-3, but these threshold conditions only occurred during brief periods of time and were only found in 11% of our measurements. Moreover, these brief windows of more favorable conditions occurred more frequently in forest edge compared with forest interior locations, resulting in edge trees maintaining 46% higher sap flow compared with interior trees. Our results also suggest that P. reticulata has a low stomatal control of transpiration, as the sap flow did not decline with increasing VPD. This research provides valuable information about the potential impacts of projected future increases in VPD due to climate change on P. reticulata water-use dynamics, which include higher sap flow rates leading to greater transpirational water loss due to this species' poor stomatal control.

Clinical impact of the suspension of the ERAS protocol on patients undergoing radical cystectomy during the COVID-19 pandemic

INTRODUCTION

During the beginning of the COVID-19 pandemic in our center, neither prehabilitation nor multimodal rehabilitation could be applied due to the excessive patient load on the health system and to reduce SARS-CoV-2 transmission. The objective of our study was to analyze the evolution, complications, and survival up to one year of patients who underwent radical cystectomy in our hospital from March 1st to May 31st, 2020 (period of the first wave COVID-19 pandemic in Spain). We also compared the results with cystectomized patients outside the pandemic period and with application of the ERAS (Enhanced Recovery After Surgery) protocol.

MATERIAL AND METHODS

Single-center, retrospective cohort study of patients scheduled for radical cystectomy from March 1st, 2020 to May 31st, 2020. They were matched with previously operated patients using a 1:2 propensity matching score. The matching variables were demographic data, preoperative and intraoperative clinical conditions.

RESULTS

A total of 23 radical cystectomies with urinary diversion were performed in the period described. In none of the cases the prehabilitation or the follow-up of our ERAS protocol could be applied, and this was the only difference we found between the 2 groups. Although the minimally invasive approach was more frequent in the pandemic group, the difference was not statistically significant. Three patients were diagnosed with COVID-19 during their admission, presenting severe respiratory complications and high in-hospital mortality. Apart from respiratory complications secondary to SARS-CoV-2, we also found statistically significant differences in other postoperative complications. The hospital stay increased by 3 days in the pandemic group.

CONCLUSIONS

Patients who underwent radical cystectomy at our center during the first wave of the COVID-19 pandemic had a higher number and severity of respiratory and non-respiratory complications. Discontinuation of the ERAS protocol was the main difference in treatment between groups.

[CLINICAL IMPACT OF THE SUSPENSION OF THE ERAS PROTOCOL ON PATIENTS UNDERGOING RADICAL CYSTECTOMY DURING THE COVID-19 PANDEMIC.]

INTRODUCTION

During the beginning of the COVID-19 pandemic in our center, neither prehabilitation nor multimodal rehabilitation could be applied due to the excessive patient load on the health system and to reduce SARS-CoV-2 transmission. The objective of our study was to analyze the evolution, complications, and survival up to one year of patients who underwent radical cystectomy in our hospital from March 1st to May 31st, 2020 (period of the first wave COVID-19 pandemic in Spain). We also compared the results with cystectomized patients outside the pandemic period and with application of the ERAS (Enhanced Recovery After Surgery) protocol.

MATERIAL AND METHODS

Single-center, retrospective cohort study of patients scheduled for radical cystectomy from March 1st,2020 to May 31st, 2020. They were matched with previously operated patients using a 1:2 propensity matching score. The matching variables were demographic data, preoperative and intraoperative clinical conditions.

RESULTS

A total of 23 radical cystectomies with urinary diversion were performed in the period described. In none of the cases the prehabilitation or the follow-up of our ERAS protocol could be applied, and this was the only difference we found between the 2 groups. Although the minimally invasive approach was more frequent in the pandemic group, the difference was not statistically significant. Three patients were diagnosed with COVID-19 during their admission, presenting severe respiratory complications and high in-hospital mortality. Apart from respiratory complications secondary to SARS-CoV-2, we also found statistically significant differences in other postoperative complications. The hospital stay increased by 3 days in the pandemic group.

CONCLUSIONS

Patients who underwent radical cystectomy at our center during the first wave of the COVID-19 pandemic had a higher number and severity of respiratory and non-respiratory complications. Discontinuation of the ERAS protocol was the main difference in treatment between groups.

Accuracy, realism and general applicability of European forest models

Forest models are instrumental for understanding and projecting the impact of climate change on forests. A considerable number of forest models have been developed in the last decades. However, few systematic and comprehensive model comparisons have been performed in Europe that combine an evaluation of modelled carbon and water fluxes and forest structure. We evaluate 13 widely used, state-of-the-art, stand-scale forest models against field measurements of forest structure and eddy-covariance data of carbon and water fluxes over multiple decades across an environmental gradient at nine typical European forest stands. We test the models' performance in three dimensions: accuracy of local predictions (agreement of modelled and observed annual data), realism of environmental responses (agreement of modelled and observed responses of daily gross primary productivity to temperature, radiation and vapour pressure deficit) and general applicability (proportion of European tree species covered). We find that multiple models are available that excel according to our three dimensions of model performance. For the accuracy of local predictions, variables related to forest structure have lower random and systematic errors than annual carbon and water flux variables. Moreover, the multi-model ensemble mean provided overall more realistic daily productivity responses to environmental drivers across all sites than any single individual model. The general applicability of the models is high, as almost all models are currently able to cover Europe's common tree species. We show that forest models complement each other in their response to environmental drivers and that there are several cases in which individual models outperform the model ensemble. Our framework provides a first step to capturing essential differences between forest models that go beyond the most commonly used accuracy of predictions. Overall, this study provides a point of reference for future model work aimed at predicting climate impacts and supporting climate mitigation and adaptation measures in forests.

Recommendations for the evaluation and management of the anticipated and non-anticipated difficult airway of the Societat Catalana d'Anestesiologia, Reanimació i Terapèutica del Dolor, based on the adaptation of clinical practice guidelines and expert consensus

The Airway Division of the Catalan Society of Anaesthesiology, Intensive Care and Pain Management (SCARTD) presents its latest guidelines for the evaluation and management of the difficult airway. This update includes the technical advances and changes observed in clinical practice since publication of the first edition of the guidelines in 2008. The recommendations were defined by a consensus of experts from the 19 participating hospitals, and were adapted from 5 recently published international guidelines following an in-depth analysis and systematic comparison of their recommendations. The final document was sent to the members of SCARTD for evaluation, and was reviewed by 11 independent experts. The recommendations, therefore, are supported by the latest scientific evidence and endorsed by professionals in the field. This edition develops the definition of the difficult airway, including all airway management techniques, and places emphasis on evaluating and classifying the airway into 3 categories according to the anticipated degree of difficulty and additional safety considerations in order to plan the management strategy. Pre-management planning, in terms of preparing patients and resources and optimising communication and interaction between all professionals involved, plays a pivotal role in all the scenarios addressed. The guidelines reflect the increased presence of video laryngoscopes and second-generation devices in our setting, and promotes their routine use in intubation and their prompt use in cases of unanticipated difficult airway. They also address the increased use of ultrasound imaging as an aid to evaluation and decision-making. New scenarios have also been included, such as the risk of bronchoaspiration and difficult extubation Finally, the document outlines the training and continuing professional development programmes required to guarantee effective and safe implementation of the guidelines.

Modelling the seasonal impacts of a wastewater treatment plant on water quality in a Mediterranean stream using microbial indicators

Faecal pollution modelling is a valuable tool to evaluate and improve water management strategies, especially in a context of water scarcity. The reduction dynamics of five faecal indicator organisms (E. coli, spores of sulphite-reducing clostridia, somatic coliphages, GA17 bacteriophages and a human-specific Bifidobacterium molecular marker) were assessed in an intermittent Mediterranean stream affected by a wastewater treatment plant (WWTP). Using Bayesian inverse modelling, the decay rates of each indicator were correlated with two environmental drivers (temperature and streamflow downstream of the WWTP) and the generated model was used to evaluate the self-depuration distance (SDD) of the stream. A consistent increase of 1-2 log₁₀ in the concentration of all indicators was detected after the discharge of the WWTP effluent. The decay rates showed seasonal variation, reaching a maximum in the dry season, when SDDs were also shorter and the stream had a higher capacity to self-depurate. High seasonality was observed for all faecal indicators except for the spores of sulphite-reducing clostridia. The maximum SDD ranged from 3 km for the spores of sulphite-reducing clostridia during the dry season and 15 km for the human-specific Bifidobacterium molecular marker during the wet season. The SDD provides a single standardized metric that integrates and compares different contamination indicators. It could be extended to other Mediterranean drainage basins and has the potential to integrate changes in land use and catchment water balance, a feature that will be especially useful in the transient climate conditions expected in the coming years.

Norovirus detection in environmental samples in norovirus outbreaks in closed and semi-closed settings

BACKGROUND

Environmental surfaces are a potential vehicle for the transmission of norovirus outbreaks in closed and semi-closed settings. Testing of environmental samples may help control outbreaks.

AIM

To assess the level of environmental contamination by norovirus in acute gastroenteritis outbreaks in closed or semi-closed settings (nursing homes, schools, kindergartens, youth accommodations, hospitals and social health centres) in the Barcelona region between January 2017 and March 2019.

METHODS

A prospective surveillance study was carried out. Environmental samples (529) were collected in 46 of the 50 outbreaks of acute norovirus gastroenteritis from environmental surfaces of common areas, bathrooms and kitchens in closed and semi-closed settings when the outbreak was notified and 10 days later. Instructions for taking environmental samples were distributed to public health inspectors. Norovirus was detected by reverse transcription polymerase chain reaction.

FINDINGS

Environmental samples were positive for norovirus in 31 (67.4%) outbreaks. Norovirus was most frequently detected on elevator buttons (4/17, 24%), toilet handles (16/66, 24%) and handrail bars (7/34, 21%). Positive samples from the first sampling were mainly found in bathrooms and greater viral persistence in the second sampling was found on elevator buttons and TV remote controls. Nursing homes were the setting with the most types of environmental surfaces contaminated (82% in first samples and 55% in second samples).

CONCLUSION

The probability of virus detection is independent of the time between notification of the outbreak or symptom onset and sample collection. Our results suggest possible defects in cleaning protocols and disinfection in closed and semi-closed settings.

Towards a New Generation of Trait-Flexible Vegetation Models

Plant trait variability, emerging from eco-evolutionary dynamics that range from alleles to macroecological scales, is one of the most elusive, but possibly most consequential, aspects of biodiversity. Plasticity, epigenetics, and genetic diversity are major determinants of how plants will respond to climate change, yet these processes are rarely represented in current vegetation models. Here, we provide an overview of the challenges associated with understanding the causes and consequences of plant trait variability, and review current developments to include plasticity and evolutionary mechanisms in vegetation models. We also present a roadmap of research priorities to develop a next generation of vegetation models with flexible traits. Including trait variability in vegetation models is necessary to better represent biosphere responses to global change.

Responses of photosynthesis and component processes to drought and temperature stress: are Mediterranean trees fit for climate change?

Global warming is raising concerns about the acclimatory capacity of trees and forests, especially in Mediterranean-type ecosystems. The sensitivity of photosynthesis to temperature is a key uncertainty for projecting the magnitude of terrestrial feedbacks on future climate change. While boreal, temperate and tropical species have been comparatively well investigated, our study provides the first comprehensive overview of the seasonal acclimatory responses of photosynthesis and its component processes to temperature in four Mediterranean climax species under natural conditions. We quantified seasonal changes in the responses of net photosynthesis (Anet), stomatal conductance (gs), mesophyllic conductance (gm) and electron-transport rate (Jcf), and investigated their sensitivity to drought and temperature stress in sunlit and shaded leaves of four Mediterranean tree species (Quercus ilex L., Pinus halepensis Mill., Arbutus unedo L. and Quercus pubescens Willd.). Sunlit leaves, but not shaded leaves, showed a pronounced seasonality in the temperature responses of Anet, gs, gm and Jcf. All four species and variables showed a remarkably dynamic and consistent acclimation of the thermal optimum (Topt), reaching peaks in summer ~29-32 °C. Changes in the shape of the response curves were, however, highly species-specific. Under severe drought, Topt of all variables were on average 22-29% lower. This was accompanied by narrower response curves above all in P. halepensis, reducing the optimal range for photosynthesis to the cooler morning or evening periods. Wider temperature-response curves and less strict stomatal control under severe drought were accompanied by wilting and drought-induced leaf shedding in Q. ilex and Q. pubescens and by additional branch dieback in A. unedo. Mild winter conditions led to a high Topt (~19.1-22.2 °C), benefitting the evergreen species, especially P. halepensis. Seasonal acclimation of Anet was explained better by gs and gm being less pronounced in Jcf. Drought was thus a key factor, in addition to growth temperature, to explain seasonal acclimation of photosynthesis. Severe drought periods may exceed more frequently the high acclimatory capacity of Mediterranean trees to high ambient temperatures, which could lead to reduced growth, increased leaf shedding and, for some species such as A. unedo, increased mortality risk.

Effect of aspirin in vascular surgery in patients from a randomized clinical trial (POISE-2)

BACKGROUND

In the POISE-2 (PeriOperative ISchemic Evaluation 2) trial, perioperative aspirin did not reduce cardiovascular events, but increased major bleeding. There remains uncertainty regarding the effect of perioperative aspirin in patients undergoing vascular surgery. The aim of this substudy was to determine whether there is a subgroup effect of initiating or continuing aspirin in patients undergoing vascular surgery.

METHODS

POISE-2 was a blinded, randomized trial of patients having non-cardiac surgery. Patients were assigned to perioperative aspirin or placebo. The primary outcome was a composite of death or myocardial infarction at 30 days. Secondary outcomes included: vascular occlusive complications (a composite of amputation and peripheral arterial thrombosis) and major or life-threatening bleeding.

RESULTS

Of 10 010 patients in POISE-2, 603 underwent vascular surgery, 319 in the continuation and 284 in the initiation stratum. Some 272 patients had vascular surgery for occlusive disease and 265 had aneurysm surgery. The primary outcome occurred in 13·7 per cent of patients having aneurysm repair allocated to aspirin and 9·0 per cent who had placebo (hazard ratio (HR) 1·48, 95 per cent c.i. 0·71 to 3·09). Among patients who had surgery for occlusive vascular disease, 15·8 per cent allocated to aspirin and 13·6 per cent on placebo had the primary outcome (HR 1·16, 0·62 to 2·17). There was no interaction with the primary outcome for type of surgery (P = 0·294) or aspirin stratum (P = 0·623). There was no interaction for vascular occlusive complications (P = 0·413) or bleeding (P = 0·900) for vascular compared with non-vascular surgery.

CONCLUSION

This study suggests that the overall POISE-2 results apply to vascular surgery. Perioperative withdrawal of chronic aspirin therapy did not increase cardiovascular or vascular occlusive complications. Registration number: NCT01082874 ( http://www.clinicaltrials.gov).

Are forest disturbances amplifying or canceling out climate change-induced productivity changes in European forests?

Recent studies projecting future climate change impacts on forests mainly consider either the effects of climate change on productivity or on disturbances. However, productivity and disturbances are intrinsically linked because 1) disturbances directly affect forest productivity (e.g. via a reduction in leaf area, growing stock or resource-use efficiency), and 2) disturbance susceptibility is often coupled to a certain development phase of the forest with productivity determining the time a forest is in this specific phase of susceptibility. The objective of this paper is to provide an overview of forest productivity changes in different forest regions in Europe under climate change, and partition these changes into effects induced by climate change alone and by climate change and disturbances. We present projections of climate change impacts on forest productivity from state-of-the-art forest models that dynamically simulate forest productivity and the effects of the main European disturbance agents (fire, storm, insects), driven by the same climate scenario in seven forest case studies along a large climatic gradient throughout Europe. Our study shows that, in most cases, including disturbances in the simulations exaggerate ongoing productivity declines or cancel out productivity gains in response to climate change. In fewer cases, disturbances also increase productivity or buffer climate-change induced productivity losses, e.g. because low severity fires can alleviate resource competition and increase fertilization. Even though our results cannot simply be extrapolated to other types of forests and disturbances, we argue that it is necessary to interpret climate change-induced productivity and disturbance changes jointly to capture the full range of climate change impacts on forests and to plan adaptation measures.

Characterization of Shiga Toxin-Producing Escherichia coli O157 Isolates from Bovine Carcasses

The main purpose of this study was to determine the prevalence of Escherichia coli O157 on bovine carcasses before and after chilling at a large slaughterhouse located in the city of Barcelona, Spain, to assess the effectiveness of dry chilling on reducing E. coli O157 contamination of carcasses. In addition, the study characterized the E. coli O157 strains isolated in terms of virulence factors, antibiotic susceptibility, and their genetic diversity. Individual bovine carcasses were sampled before (n = 300) and after (n = 300) chilling over an 8-month period. Positive samples for E. coli O157 were subjected to virulence screening by PCR (stx1, stx2, and eaeA genes and the fliCH7 gene), antimicrobial susceptibility testing, and molecular typing by pulsed-field gel electrophoresis. A total of 9.7% (29 of 300) of the nonrefrigerated carcasses examined and 2.3% (7 of 300) of the refrigerated carcasses were positive for E. coli O157. All the isolates were serotype O157:H7, 92% (33 of 36) carried the stx1, stx2, and eaeA genes, and 8% (3 of 36) carried the stx2 and eaeA genes. Antimicrobial susceptibility testing showed a high degree of resistance: 29 strains (81%) were resistant to at least 1 antimicrobial of the 12 antimicrobials tested; 69% (25 of 36) were resistant to 4 or more antimicrobials. Molecular typing by pulsed-field gel electrophoresis found a high diversity of genetic types, implying little cross-contamination in the slaughterhouse. This study confirms that E. coli O157:H7 is present on the carcasses slaughtered in Spain, although its prevalence is reduced by the dry chilling process used. The recovered isolates showed potential pathogenesis and a high degree of multidrug resistance, confirming the importance of bovine meat monitoring.

Balance between carbon gain and loss under long-term drought: impacts on foliar respiration and photosynthesis in Quercus ilex L

Terrestrial carbon exchange is a key process of the global carbon cycle consisting of a delicate balance between photosynthetic carbon uptake and respiratory release. We have, however, a limited understanding how long-term decreases in precipitation induced by climate change affect the boundaries and mechanisms of photosynthesis and respiration. We examined the seasonality of photosynthetic and respiratory traits and evaluated the adaptive mechanism of the foliar carbon balance of Quercus ilex L. experiencing a long-term rainfall-exclusion experiment. Day respiration (Rd) but not night respiration (Rn) was generally higher in the drought treatment leading to an increased Rd/Rn ratio. The limitation of mesophyll conductance (gm) on photosynthesis was generally stronger than stomatal limitation (gs) in the drought treatment, reflected in a lower gm/gs ratio. The peak photosynthetic activity in the drought treatment occurred in an atypical favourable summer in parallel with lower Rd/Rn and higher gm/gs ratios. The plant carbon balance was thus strongly improved through: (i) higher photosynthetic rates induced by gm; and (ii) decreased carbon losses mediated by Rd. Interestingly, photosynthetic potentials (Vc,max, Jmax, and TPU) were not affected by the drought treatment, suggesting a dampening effect on the biochemical level in the long term. In summary, the trees experiencing a 14-year-long drought treatment adapted through higher plasticity in photosynthetic and respiratory traits, so that eventually the atypical favourable growth period was exploited more efficiently.

Seasonal variability of foliar photosynthetic and morphological traits and drought impacts in a Mediterranean mixed forest

The Mediterranean region is a hot spot of climate change vulnerable to increased droughts and heat waves. Scaling carbon fluxes from leaf to landscape levels is particularly challenging under drought conditions. We aimed to improve the mechanistic understanding of the seasonal acclimation of photosynthesis and morphology in sunlit and shaded leaves of four Mediterranean trees (Quercus ilex L., Pinus halepensis Mill., Arbutus unedo L. and Quercus pubescens Willd.) under natural conditions. Vc,max and Jmax were not constant, and mesophyll conductance was not infinite, as assumed in most terrestrial biosphere models, but varied significantly between seasons, tree species and leaf position. Favourable conditions in winter led to photosynthetic recovery and growth in the evergreens. Under moderate drought, adjustments in the photo/biochemistry and stomatal/mesophyllic diffusion behaviour effectively protected the photosynthetic machineries. Severe drought, however, induced early leaf senescence mostly in A. unedo and Q. pubescens, and significantly increased leaf mass per area in Q. ilex and P. halepensis. Shaded leaves had lower photosynthetic potentials but cushioned negative effects during stress periods. Species-specificity, seasonal variations and leaf position are key factors to explain vegetation responses to abiotic stress and hold great potential to reduce uncertainties in terrestrial biosphere models especially under drought conditions.

Short-term water stress impacts on stomatal, mesophyll and biochemical limitations to photosynthesis differ consistently among tree species from contrasting climates

Predicting the large-scale consequences of drought in contrasting environments requires that we understand how drought effects differ among species originating from those environments. A previous meta-analysis of published experiments suggested that the effects of drought on both stomatal and non-stomatal limitations to photosynthesis may vary consistently among species from different hydroclimates. Here, we explicitly tested this hypothesis with two short-term water stress experiments on congeneric mesic and xeric species. One experiment was run in Australia using Eucalyptus species and the second was run in Spain using Quercus species as well as two more mesic species. In each experiment, plants were grown under moist conditions in a glasshouse, then deprived of water, and gas exchange was monitored. The stomatal response was analysed with a recently developed stomatal model, whose single parameter g1 represents the slope of the relationship between stomatal conductance and photosynthesis. The non-stomatal response was partitioned into effects on mesophyll conductance (gm), the maximum Rubisco activity (Vcmax) and the maximum electron transport rate (Jmax). We found consistency among the drought responses of g1, gm, Vcmax and Jmax, suggesting that drought imposes limitations on Rubisco activity and RuBP regeneration capacity concurrently with declines in stomatal and mesophyll conductance. Within each experiment, the more xeric species showed relatively high g1 under moist conditions, low drought sensitivity of g1, gm, Vcmax and Jmax, and more negative values of the critical pre-dawn water potential at which Vcmax declines most steeply, compared with the more mesic species. These results indicate adaptive interspecific differences in drought responses that allow xeric tree species to continue transpiration and photosynthesis for longer during periods without rain.

Preoperative estimated glomerular filtration rate and the risk of major adverse cardiovascular and cerebrovascular events in non-cardiac surgery

BACKGROUND

Chronic kidney disease is an independent predictor of perioperative cardiovascular morbidity and mortality. We analysed the preoperative estimated glomerular filtration rate (eGFR) as a risk factor for perioperative major adverse cardiovascular and cerebrovascular events (MACCE) in non-cardiac surgery.

METHODS

In a post hoc analysis of the ANESCARDIOCAT database, patients were classified into six stages of eGFR calculated with the abbreviated Modification of Diet in Renal Disease Study and the Chronic Kidney Disease Epidemiology Collaboration equations: >90 (1), 60-89.9 (2), 45-59.9 (3a), 30-44.9 (3b), 15-29.9 (4), and <15 (5) ml min(-1) 1.73 m(-2). We analysed differences in MACCE, length of hospital stay, and all-cause mortality between eGFR stages.

RESULTS

The eGFR was available in 2323 patients. Perioperative MACCE occurred in 4.5% of patients and cardiac-related mortality was 0.5%. Five hundred and forty-three (23.4%) patients had an eGFR of <60 ml min(-1) 1.73 m(-2) and 127 (5.4%) had an eGFR below 45 ml min(-1) 1.73 m(-2). Logistic regression analysis showed that MACCE increased with eGFR impairment (P<0.001), with a marked increase from stage 3b onwards (odds ratio 1.8 vs 3.9 in 3a and 3b, respectively, P=0.047). All-cause mortality was not related to eGFR (P=0.071), but increased substantially between stages 3b and 4. The length of stay correlated with eGFR (P<0.001).

CONCLUSIONS

Perioperative MACCE increase with declining eGFR, primarily when <45 ml min(-1) 1.73 m(-2). We recommend the use of preoperative eGFR for cardiovascular risk assessment.

[Perioperative management of atrial fibrillation]

Atrial fibrillation is a frequent complication in the perioperative period. When it appears there is an increased risk of perioperative morbidity due to stroke, thromboembolism, cardiac arrest, myocardial infarction, anticoagulation haemorrhage, and hospital readmissions. The current article focuses on the recommendations for the management of perioperative atrial fibrillation based on the latest Clinical Practice Guidelines on atrial fibrillation by the European Society of Cardiology and the Spanish Society of Cardiology. This article pays special attention to the preoperative management, as well as to the acute perioperative episode. For this reason, the latest recommendations for the control of cardiac frequency, antiarrhythmic treatment and anticoagulation are included.

Is response to fire influenced by dietary specialization and mobility? A comparative study with multiple animal assemblages

Fire is a major agent involved in landscape transformation and an indirect cause of changes in species composition. Responses to fire may vary greatly depending on life histories and functional traits of species. We have examined the taxonomic and functional responses to fire of eight taxonomic animal groups displaying a gradient of dietary and mobility patterns: Gastropoda, Heteroptera, Formicidae, Coleoptera, Araneae, Orthoptera, Reptilia and Aves. The fieldwork was conducted in a Mediterranean protected area on 3 sites (one unburnt and two burnt with different postfire management practices) with five replicates per site. We collected information from 4606 specimens from 274 animal species. Similarity in species composition and abundance between areas was measured by the Bray-Curtis index and ANOSIM, and comparisons between animal and plant responses by Mantel tests. We analyze whether groups with the highest percentage of omnivorous species, these species being more generalist in their dietary habits, show weak responses to fire (i.e. more similarity between burnt and unburnt areas), and independent responses to changes in vegetation. We also explore how mobility, i.e. dispersal ability, influences responses to fire. Our results demonstrate that differences in species composition and abundance between burnt and unburnt areas differed among groups. We found a tendency towards presenting lower differences between areas for groups with higher percentages of omnivorous species. Moreover, taxa with a higher percentage of omnivorous species had significantly more independent responses of changes in vegetation. High- (e.g. Aves) and low-mobility (e.g. Gastropoda) groups had the strongest responses to fire (higher R scores of the ANOSIM); however, we failed to find a significant general pattern with all the groups according to their mobility. Our results partially support the idea that functional traits underlie the response of organisms to environmental changes caused by fire.

Effects of intraoperative colloid administration on outcome in a population-based general surgical cohort: a propensity score analysis

BACKGROUND

Many studies on colloids have recently been retracted, leaving us with uncertain evidence of their safety. We aimed to analyze whether intraoperative colloid administration is associated with postoperative complications.

METHODS

The prospectively compiled database of the ARISCAT study of a large, representative cohort of general surgical patients was reanalyzed to compare outcomes according to whether intraoperative colloids were administered or not; a propensity score was used to adjust for potential confounders. The primary outcomes were major postoperative complications. Secondary outcomes were postoperative hospital-free days within 90 days and mortality at 30 and 90 days. In a retrospective survey we asked each center's data collectors to estimate the proportions of the different colloids administered during the study period.

RESULTS

Of 2462 patients analyzed, 556 (22.6%) received some type of colloid intraoperatively. The median (25th-75th percentile) of total fluids administered was significantly higher in patients receiving colloids (10.0 [6.9-14.1] mL·kg-1·h-1 vs. 8.8 [6.0-12.8] mL·kg-1·h-1 for patients not receiving colloids; P<0.01). The median volume of colloids administered was 7.5 (6.3-10.4) mL·kg-1. An estimated 75.7% of the patients received third-generation hydroxyethyl starches (130/0.4). Significantly associated complications, after propensity score adjustment, were atelectasis, respiratory infection, bronchospasm, arrhythmia, sepsis, paralytic ileum, and hyperglycemia. Patients receiving colloids had 1.9 fewer postoperative hospital-free days (P<0.006). There were no significant differences in 30- and 90-day mortality.

CONCLUSION

Our study suggests an association of intraoperative colloid administration, mainly of 130/0.4 hydroxyethyl starches, with diverse major postoperative complications and longer hospital stay. Controlled studies are urgently needed to assess the safety profile of colloid use in surgical patients.

[Evaluation of the efficiency of pharmacological antiemetic prophylaxis in different risk groups after general anaesthesia in the surgical population of Catalonia]

OBJECTIVE

To assess the efficiency of pharmacological antiemetic prophylaxis in patients subjected to surgery under general anaesthetic in different postoperative nausea and vomiting (NVPO) risk groups.

MATERIAL AND METHODS

A randomised, observational, prospective and multicentre cohort study was conducted. The study included 1239 patients from 26 hospitals who were subjected to elective surgery under general anaesthesia. The data collected included, demographic characteristics, the NVPO risk factors, anaesthetic technique, type of surgery, the duration, fluid therapy, antiemetic prophylaxis administered, and the incidence of NVPO in the first 24h after surgery. A stratified analysis (low, moderate and high risk) was performed with the intention of evaluating the relationship between prophylaxis and NVPO using a logistic regression model adjusted for propensity score. The number of patients needed to treat (NNT) to prevent an NVPO episode was then calculated for each of the strata.

RESULTS

The incidence of NVPO in the low risk stratum was 21.6% without prophylaxis and 8.6% with prophylaxis, 31.3% compared to 17.7% in the moderate risk, and 46.5% compared to 32.7% in the high risk group. There was a significant protective effect in the three strata (odds ratio between treated and untreated patients) and in the NNT (95% CI) was 7 (5-11) in the low risk stratum, 7 (5-13) in that of the moderate risk, and 6 (4-16) in the high risk.

CONCLUSIONS

The efficiency of pharmacological antiemetic prophylaxis in patients subjected to surgery under general anaesthesia was similar in all risk groups. Not providing antiemetic prophylaxis in low risk patients may not be justified due to the cost-effectiveness criteria. Future clinical guidelines to improve the quality of health care of patients operated on under general anaesthesia should consider the advantages of a universal NVPO prophylaxis.

[Risk factors for postoperative acute kidney injury in a cohort of 2378 patients from 59 hospitals]

OBJECTIVES

To assess risk factors for postoperative acute kidney injury (AKI) in adults with normal renal function hospitalized for major surgery. To analyze mortality and length of hospital stay in patients who develop postoperative AKI.

PATIENTS AND METHODS

Data for analysis were drawn from the 2006 ARISCAT study. The dependent variable was postoperative AKI defined as a decline in renal function demonstrated by a rise in plasma creatinine level to twice the baseline measurement or a 50% reduction in the glomerular filtration rate. Bivariate and multivariate analyses were used to identify preoperative and intraoperative risk factors.

RESULTS

We analyzed 2378 of the ARISCAT cases, which had been enrolled from 59 participating hospitals; 25 patients (1.1%) developed AKI. Analysis identified 5 risk factors: age, peripheral arterial disease, type of surgical incision, blood loss, and infusion of colloids. The area under the receiver operating characteristic curve was 0.88% (95% confidence interval, 0.79%-0.69%). Duration of hospital stay was longer for patients with postoperative AKI (21.8 days, vs 5.5 days for other patients; P=.007). Mortality was higher in patients with AKI at 30 days (36% vs 0.9%) and at 3 months (48% vs 1.7%).

CONCLUSIONS

The incidence of postoperative AKI was slightly over 1%. Knowledge of postoperative AKI risk factors can facilitate the planning of surgical interventions and anesthesia to reduce subsequent morbidity and mortality and length of hospital stay.

[Neuromuscular block management during general anesthesia in a cohort of 1545 patients: a multicenter study]

BACKGROUND AND OBJECTIVE

Neuromuscular blockers (NMBs) have traditionally been thought to increase the risk of respiratory complications, although drawing conclusions in this respect would require complex studies in large patient samples. The aim of this study was to analyze data from the ARISCAT study to obtain an overall picture of how NMBs are being used and blocks are reversed in Catalonia, Spain.

MATERIAL AND METHODS

NMB use as reflected in data from the ARISCAT study was analyzed. Case information from the database was organized into 4 groups: for patients not receiving a NMB (No-NMB), patients whose NMB block was performed with succinylcholine alone (SC), patients who received a single dose of a nondepolarizing NMB (SD-NMB), and patients who received additional doses of a nondepolarizing NMB or a continuous perfusion (AD-NMB). We analyzed patient characteristics, clinical and surgical characteristics, and complications during and after surgery in each of the groups. Variables were also analyzed according to whether the NMB effect had to be reversed.

RESULTS

Of the 2991 patients included in the ARISCAT study, 1545 received general or combined anesthesia. Of the 1545 patients, 1267 (89%) received a NMB and the block was reversed with an anticholinesterase agent in 54%. The group distribution was as follows: No-NMB, 103 patients; SC, 31; SD-NMB, 527; and AD-NMB, 709. The highest rate of comorbidity, longest duration of surgery, highest rate of complications during and after surgery, and the longest hospital stays were observed in the last of the 4 groups (AD-NMB). Reversion was required significantly more often after cardiothoracic and upper abdominal surgical procedures; the complication rates after those 2 types of surgery were statistically similar.

CONCLUSIONS

Nondepolarizing NMBs are used in combination with general anesthesia often in Catalonia; their use is associated with duration and type of surgery. A reversal drug is administered relatively more often in Catalonia than in other geographic areas.

[Radical cystectomy in patients with non-muscle invasive bladder cancer who fail BCG therapy]

OBJECTIVE

To assess the characteristics and outcomes of patients with non-muscle invasive bladder cancer (NMIBC) undergoing radical cystectomy (RC) due to BCG failure.

MATERIALS AND METHODS

Ninety-five (11%) of the 864 patients undergoing radical cystectomy (RC) at our center from 1989 to 2002 had received prior treatment with BCG. Of these, 62 (65.2%) underwent RC due to relapsing, high-risk NMIBC or CIS despite BCG therapy. A stage >or= pT2 tumor was reported in the cystectomy specimen in 17 (27%) of these patients, who were considered to have been understaged. RC was performed for clinical progression in 33 patients (34.7%). Their last transurethral resection before RC showed invasive disease. A retrospective analysis was made of the outcomes of patients who underwent RC for BCG failure and the clinical and pathological differences between understaged patients and those with clinical progression.

RESULTS

Five-year CSS was 90% in 45 patients with clinical and pathological NMIBC and 50.6% in 50 patients with progression to muscle-infiltrating disease (clinical progression and understaged) (p < 0,05). There were no differences in survival in patients with clinical progression as compared to understaged patients. Median time from tumor diagnosis to tumor progression was 24 months (10th-90th percentile, 6-98 months). Patients with clinical progression had significantly more T1 tumors (p = 0.015) in TUR before progression and more pT3 tumors (p < 0.01) in the RC specimen. Understaged patients more often had pathological pT4 stages (p < 0.02).

CONCLUSION

In patients with high-risk NMIBCs who fail BCG therapy, RC should be performed before progression because survival is decreased when the RC specimen shows muscle-invasive disease. High-grade T1 tumors are responsible for most early clinical progressions. Patients with NMIBC may have subclinical progression, mainly within the prostate.

[Hypertension and anesthesia: consensus statement of the Catalan Associations of Anesthesiology and Hypertension]

The prevalence of hypertension is high in the surgical population. Differing practices and the absence of consensus among physicians involved in caring for hypertensive patients has made it one of the most frequent reasons for cancelling scheduled surgery. The aim of this consensus statement is to outline a practical approach to managing the hypertensive surgical patient. Hypertension is associated with increased risk of perioperative complications, particularly those related to systemic effects and notable fluctuations in blood pressure during surgery. Preoperative assessment should center on a search for signs and symptoms of target organ damage. The anesthesiologist should seek to reduce perioperative fluctuations in arterial pressure, particularly guarding against sustained hypotension. After surgery, antihypertensive medication should be resumed as soon as possible.

[Survey of anesthetic techniques used in Catalonia: results of the analysis of 23,136 anesthesias (2003 ANESCAT study)]

OBJECTIVE

To examine anesthesia practice in Catalonia in 2003 and to describe the specific characteristics and distribution of the anesthesia techniques used and the patient profiles.

PATIENTS AND METHODS

We used the data from the ANESCAT epidemiological study that gathered information in questionnaire form on all anesthesias performed in Catalonia on 14 randomly selected days representative of practice in 2003.

RESULTS

All 131 hospitals authorized to perform anesthesia participated in the study. We collected 23136 questionnaires, from which we extrapolated to estimate 603189 anesthesias for the year and a rate of 9.0 anesthesias per 100 inhabitants per year. Fifty-eight percent of the patients were women and the mean age was 52 years. The physical status of the patients was as follows: ASA 1 or 2, 73.3%; ASA 3, 213%; ASA 4 or 5, 5.4%. The mean duration of anesthesia was 60 minutes. The most common form of anesthesia was a regional block (41.4%) and spinal block was the one performed most often. General anesthesia was used in 33.5% of the cases, combined anesthesia in 3.5%, and sedation in 21.6%. In descending order, orthopedics/trauma, ophthalmology, general surgery, obstetrics, cataract surgery, vaginal delivery, inguinal hernia repair, and colonoscopy were the procedures for which anesthesia was most commonly administered.

CONCLUSIONS

Almost 1 in 10 persons in Catalonia are given anesthesia each year and most of the procedures involve locoregional anesthesia or sedation. These data provide a picture of the current situation of anesthesiology and make it possible to forecast future anesthesia requirements.

[Incidence in Catalonia of spinal cord compression due to spinal hematoma secondary to neuraxial anesthesia]

OBJECTIVE

To study the incidence in Catalonia of spinal cord compression due to spinal hematoma secondary to neuraxial anesthesia.

METHODS

The incidence of hematoma was based on published cases (MEDLINE, the Spanish Medical Index [Indice Medico Español], and Google) or cases reported at medical meetings or conferences by anesthesiologists from Catalan hospitals from 1996 to 2005, inclusive. The annual number of neuraxial anesthesias (spinal, epidural, and combined) was estimated based on the ANESCAT 2003 survey and the total number of anesthesias was calculated using the ANESCAT 2003 survey in conjunction with the surgical reports of Catalan hospitals.

RESULTS

A total of 11 cases of spinal hematoma after neuraxial anesthesia (7 after spinal anesthesia and 4 after epidural anesthesia) were reported or published from 1996 to 2005, inclusive. A total of 194 154 neuraxial anesthesias were performed in 2003 (126 560 spinal anesthesias and 5926 combined spinal-epidural anesthesias) and it was estimated that somewhat over 1 700 000 neuraxial anesthesias were performed over the 10 years reviewed. The incidence (95% confidence interval [CI]) of hematoma was 0.6 (95% CI, 0.3-1.2) per 100 000 neuraxial anesthesias, 0.6 (95% CI, 0.3-1.3) per 100 000 spinal anesthesias, and 0.7 (95% CI, 0.2-1.9) per 100 000 epidural anesthesias.

CONCLUSIONS

The incidence of spinal hematoma after neuraxial anesthesia is slightly more than 1 per 150 000 anesthesias-a similar finding to that of other epidemiological studies. The incidence is slightly higher in epidural anesthesia. These data imply a risk of approximately 1 spinal hematoma per year in Catalonia.

Endourological management is better in early-onset ureteral stenosis in kidney transplantation

INTRODUCTION

The incidence of ureteral stenosis in kidney transplant recipients is 3%-8%. The treatment of ureteral stenosis has been traditionally operative reconstruction, although such intervention is associated with high rates of serious complications, including graft loss and even perioperative mortality. More recently, endourological treatment has been proposed due to its low morbidity.

OBJECTIVE

The objective of this study was to assess the usefulness of balloon percutaneous dilatation as a treatment technique for ureteral stenosis in kidney transplant recipients.

PATIENTS AND METHODS

Among 1000 kidney transplantations performed between 1980 and 2004, the coexistence of high creatinine values and urinary tract dilatation in the postoperative period, after discarding concomitant causes, was managed with a percutaneous nephrostomy. Once renal function recovered, antegrade pyelography was performed to confirm the presence and determine the location of ureteral stenosis. Ureteral dilatation was performed using a 5-French balloon-fitted angioplasty catheter.

RESULTS

Fifty-six patients were diagnosed with ureteral stenosis during follow-up, an incidence of 5.6%. Transluminal balloon dilatation was the first therapeutic option in 45 cases, whereas surgery was performed directly on 11 patients. Disappearance of the stenosis as well as maintenance of an improved creatinine level was verified in 45% of cases (20 patients). Two patients experienced graft loss. Both a short time to diagnosis after transplantation (P = .06) and the presence of a previous acute rejection episode (P < .05) were good prognosis factors for the endourologic solution of a ureteral stricture.

CONCLUSIONS

Balloon dilatation may be considered the definitive procedure for treatment of ureteral stenosis in selected cases. Percutaneous nephrostomy should be used for initial diagnosis and improvement in the renal function before attempting an open procedure.

Cystectomy in patients with high risk superficial bladder tumors who fail intravesical BCG therapy: pre-cystectomy prostate involvement as a prognostic factor

PURPOSE

To review understaging and outcome of patients who underwent radical cystectomy (RC) for high risk superficial bladder cancer after bacillus Calmette-Guérin (BCG) failure.

PATIENTS AND METHODS

We carried out a retrospective study of 62 cases in which RC was indicated for clinical stage Tis, Ta, T1 transitional cell bladder tumors that failed transurethral resection (TUR) and BCG treatment. We used BCG (81 mg/Connaught BCG) in patients with superficial grade 3 tumors and CIS. We considered BCG failure a high-grade recurrence at 3 months of the first BCG course or after 2 courses. RC indications, correlation between their clinical and pathological stage and the ensuing progress were analyzed. We assessed the existence of any pre-cystectomy clinical or pathological factor related to understaging and survival.

RESULTS

RC was performed in 22 patients with carcinoma in situ (CIS) (35%), 7 with Ta (11,2%), 31 with T1 (50%), and 2 with Tx tumors (3%). All 62 but one were high-grade tumors (grade 3 and/or CIS). Tumor was clinically understaged with stages pT2 or greater on the RC specimen in 17 patients (27%). The presence of tumor in the prostatic urethra at the moment of endoscopic staging before RC was the only factor associated with clinical understaging (p=0.003) and shorter survival (p<0.0002). Five-year disease-specific survival rate was significantly lower in understaged (38%) as compared with not-understaged patients (90%) after a median follow-up of 40-months (range 1-142) (p=0.006). Overall five-year disease-specific survival was 79%.

CONCLUSIONS

RC should be performed prior to progression in high risk superficial tumors that fail after TUR and BCG. In patients with clinical and pathological nonmuscle invasive disease, RC provides an excellent disease-free survival. One third of patients with HRSBT who underwent RC after BCG failure were understaged and had a shorter survival. Tumor in the prostatic urethra at endoscopic staging was the only factor associated to understaging and shorter survival.

Vertical distribution of fine root density, length density, area index and mean diameter in a Quercus ilex forest

We used minirhizotrons to determine the vertical distribution of fine roots in a holm oak (Quercus ilex L.) forest in a typical Mediterranean area over a 3-year period (June 1994-March 1997). We measured fine root density (number of roots per unit area), fine root length density (length of roots per unit area), fine root area index (area of roots per unit area) and fine root mean diameter. Variables were pooled for each 10-cm depth interval to a depth of 60 cm. Fine roots tended to decrease with increasing depth except between 0 and 10 cm, where the values of all fine root variables were less than in the 10-cm stratum below. Fine root vertical distribution was compared with soil water content and soil temperature at different depths in the soil profile.

Fine roots dynamics in a Mediterranean forest: effects of drought and stem density

Summer drought is a characteristic trait of Mediterranean climates and can limit primary production. The holm oak (Quercus ilex L.) forest at the Prades Experimental Complex of Catchments (PECC, NE Spain) was managed by clearcutting until the 1950s. As a result of this practice, the forest has a high density (13000 stems ha(-1)) that is causing growth stagnation and intense competition for water. A thinning experiment was conducted to release resources, reduce stem competition and improve forest productivity. Minirhizotrons were installed in two plots in each of the thinned and control stands and fine root dynamics quantified to a soil depth of 60 cm over a 2-year period (June 1994-May 1996). Soil water content was higher and soil water penetrated deeper in the soil (30-50 cm) in the thinned plots than in the control plots. In the control plots, soil temperature did not vary substantially with depth (mean = 11.65 degrees C), whereas soil temperature was higher in shallow horizons compared with deep horizons in the thinned plots. Mean soil temperature was one degree higher in the thinned plots than in the control plots (12.9 versus 11.9 degrees C). There were always more roots in the top 20 cm of soil in thinned plots than in control plots. In the thinned plots, more than 50% of root density (root no. cm(-2)) was located in the top 20 cm of soil, whereas root density never reached 50% in the 0-20 cm soil layer of the control plots. Roots longevity varied from 35 to 471 days, and there were significant differences between soil depths. Root longevity was greater in the control plots than in the thinned plots.

[Anesthesia in Kearns-Sayre syndrome (mitochondrial myopathy)]

We report the case of a 27-year-old woman with a history of Kearns-Sayre syndrome and a double mitral lesion who underwent surgery without complications. Anesthetic induction was achieved with propofol and fentanyl, and maintenance was with nitrous oxide and oxygen through a face mask. There were no instances of O2 desaturation or hemodynamic alterations. The postoperative period transpired without adverse events and the patient was released 24 h after surgery. The management of anesthesia in this rare mitochondrial disease is described, and anesthetic alternatives are discussed as depending on clinical findings that can occur in the context of these syndromes.