Karst aquifers and, especially, their caves and springs, are singular sites of the geoheritage due to their scientific, touristic and use (water resources) values. Besides, they are recognized as habitats of special protection by the Habitat Directive (92/43/CEE) and would be used for sustainable development in UNESCO Global Geoparks (UGGp). However, their management continues to be a challenge at the present day since karst aquifers and their associated springs and caves are vulnerable environments used by many actors and affected by land uses and changes in surface hydrology and groundwater. Our work aims to implement of a suitable management of aquifers and springs in the Courel Mountains UGGp based on hydrogeological studies. The studies include mainly the characterization of aquifers' functioning, the elaboration of the spring inventory, physicochemical analyses and geoconservation actions.

Las Loras UNESCO Global Geopark (UGGp) is located in the contact between the southernmost sector of the Basque-Cantabrian Basin and the North of the Cenozoic Duero basin. The bedrock is mainly made up of carbonate aquifers, mainly limestones, dolomites, and marls. Hydrogeologically, these aquifers are shared by the Ebro basin (Páramo de Sedano y Lora groundwater body, ES091MSBT002) and the Duero basin (Quintanilla-Peñahorada-Las Loras groundwater body, ES020MSBT00400004), being of the order of 80% of the UGGp drained towards the latter. This work aims to present a state-of-the-art overview of the regional hydrogeological knowledge and identifies the main lines of work for a detailed hydrogeological characterization of the Las Loras UGGp. The work methodology, includes a bibliographic review of the materials published in various sources, both official and sources from other non-profit entities, that have contributed to regional and local knowledge in the region. The capture of data from official sources, mainly Duero River Basin Authority (CHD) and the IGME-CSIC databases, and their treatment, allowed the obtaining of a snapshot of the state of the aquifers on a regional scale. The results lead to the need for a hydrogeological study that includes recent trends and the assessment of the impact of global change on groundwater resources. Some elements of hydrogeological interest are identified as Sites of Geological Interest, and are compiled on Las Loras UGGp website. Other, potential new points are commented in this work. These results are part of the IGCP-730 project funded by UNESCO’s International Geosciences Program.

OBJECTIVE:To analyze the variables associated with ICU refusal decisions as a life support treatment limitation measure.DESIGN:Prospective, multicentrico SCOPE: 62 ICU from Spain between February 2018 and March 2019.PATIENTS:Over 18 years of age who were denied entry into ICU as a life support treatment limitation measure.INTERVENTIONS:None.MAIN INTEREST VARIABLES:Patient comorities, functional situation as measured by the KNAUS and Karnosfky scale; predicted scales of Lee and Charlson; severity of the sick person measured by the APACHE II and SOFA scales, which justifies the decision-making, a person to whom the information is transmitted; date of discharge or in-hospital death, destination for hospital discharge.RESULTS:A total of 2312 non-income decisions were recorded as an LTSV measure of which 2284 were analyzed. The main reason for consultation was respiratory failure (1080 [47.29%]). The poor estimated quality of life of the sick (1417 [62.04%]), the presence of a severe chronic disease (1367 [59.85%]) and the prior functional limitation of patients (1270 [55.60%]) were the main reasons for denying admission. The in-hospital mortality rate was 60.33%. The futility of treatment was found as a risk factor associated with mortality (OR: 3.23; IC95%: 2.62-3.99).CONCLUSIONS:Decisions to limit ICU entry as an LTSV measure are based on the same reasons as decisions made within the ICU. The futility valued by the intensivist is adequately related to the final result of death.

This study aimed to assess the efficacy of ceftazidime/avibactam (C/A) in the treatment of infections due to Gram-negative bacteria (GNB) in critically ill patients. A multicentre, retrospective, observational study was conducted in critically ill patients receiving C/A for GNB infections. We evaluated demographic data, localisation and severity of infection, clinical and microbiological outcomes, and mortality. A total of 68 patients received C/A for serious GNB infections. The main infections were respiratory (33.8%), intra-abdominal (22.1%) and urinary tract infections (10.3%); bacteraemia was found in 22 cases (32.4%). Most infections were complicated by septic shock (58.8%) or sepsis (36.8%) and most of them required life-supporting therapies. Enterobacterales (79.4%) and Pseudomonas aeruginosa (19.1%) were the most frequently isolated bacteria; 84.2% of isolates were carbapenem-resistant. Thirty-four patients (50.0%) received C/A in combination with other antimicrobials. Fifty patients (73.5%) presented a favourable clinical response. Microbiological eradication was documented in 25 cases (36.8%). No significant differences were found in clinical response between patients treated with monotherapy or combined therapy (79.4% vs. 67.6%; P = 0.27). Overall intensive care unit (ICU) mortality was 41.2%. Univariate analysis showed that 30-day all-cause mortality was significantly ( P < 0.05) associated with bacteraemia, previous corticosteroid use and the need of life-supporting therapies. C/A appears to be an effective therapy for severe infections due to GNB, including carbapenem-resistant isolates, in critically ill patients. C/A combination therapy was not associated with a higher clinical response. Mortality correlated significantly with the presence of bacteraemia, previous corticosteroid use and the need for life-supporting therapies.(c) 2022 Elsevier Ltd and International Society of Antimicrobial Chemotherapy. All rights reserved.

Forecasting coastal dynamics and sea cliff retreat under different sea level rise scenarios requires a good un-derstanding of the conditioning factors and their relative contribution to cliff stability. The so-called Jurassic Cantabrian Coast extends along 76 km of the coastline of the Asturias region (N Spain) and is well-known worldwide due to its paleontological heritage, in particular the presence of dinosaur remains and footprints. The abundance of stratigraphic, paleontological and tectonic studies contrasts with the scarcity of studies focused on the stability of this rocky coastline where cliffs predominate, sometimes exceeding 120 m in height. In fact, evidence of current and recent instability processes can be observed along the entire coastline. In this regard, continuous monitoring is crucial to understand ongoing instabilities in rocky coastlines, as in these settings some instabilities might initiate as slow movements that induce subtle topographic changes whose detection from either satellite or aerial imagery is problematic due to the spatial and temporal resolutions. This contribution presents a 4D evolution model of a key site, the Tazones Lighthouse landslide, located on the Cantabrian Coast of Asturias (N Spain), which affects subvertical rocky cliffs sculpted in the Jurassic bedrock made of alternating sandstone and marl. A high resolution multiapproach methodology was developed in order to understand its structure and kinematic characteristics, including: i) interpretation of aerial photographs and unmanned aerial photogrammetric surveys (UAV); ii) 22 monthly monitoring campaigns by total station; iii) 5 manual boreholes; iv) geomechanical characterization of the cliff bedrock; v) geomorphological evidence mapping; vi) analysis of landscape deformations obtained from UAV; and vii) precipitation, soil moisture and significant wave height (Hs) data analysis. The results show that the slope evolves by means of a complex-type mass movement, which combines translational and sliding mechanisms, and occupies tens of thousands of square meters. DTM and fieldwork analysis indicate that mass movement is mainly controlled by bedrock discontinuities (S0, 360/15-17; J1, 262/85; J2 166/75). The most important accelerations of slope movement correlate very well with rainfall, soil moisture and waves. Thus, the largest displacements occurring in January and October-November 2019, coincide with 2 periods of storms (maximum 24-h rainfall of 64.5 mm and 82.1 mm and maximum H-s of 6.54 and 9.09, respectively) and soil moisture values above 90%. Half of the markers moved more than 1 m and one of them exceeded 15 m. The 4D model obtained after the interpretation of the Tazones Lighthouse slope whole dataset, allows an understanding of how the surrounding cliffs have evolved in the past, fundamental to dicting their future behaviour.

From a post hoc analysis of the ADENI-UCI study (multicenter, observational, cohort, prospective study, with a follow-up period of 13 months, in 62 Intensive Medicine Services in Spain. geographical differences in the reason for denial of income in UCI as a LTSV measure are analyzed. A total of 2284 with an average age of 75.25 (12.45) years were included. 59.43% male. By means of multinominal regression adjusted by age, sex, APACHE and SOFA, was evident (by choosing the northern for reference) that age in the south was a less significantly exposed reason (OR: 0.48 (IC95%: 0.35-0.65). p.

INTRODUCTION:Decisions not to admit a patient to intensive care units (ICU) as a way of limiting life support treatment (LLST) is a practice that can affect the operation of the emergency services and the way in which patients die. METHODS:Post hoc analysis of the ADENI-UCI study. The main variable analysed was the reason for refusal of admission to the ICU as a measure of LLST. For the present post hoc analysis, the registered patients were divided into 2 groups: the patients assessed in the intensive medicine services from the emergency department and the patients assessed from the conventional hospitalization areas. Student t was used in the comparative statistics when the mean values of the patient sub-cohorts were compared. Categorical variables were compared with the χ2 tests. RESULTS:The ADENI-ICU study included 2,284 decisions not to admit to the ICU as a measure of LLST. Estimated poor quality of life (p=.0158), the presence of severe chronic disease (P=.0169) and futility of treatment (P=.0006) were percentage decisions with greater weight within the population of hospitalized patients. The percentage of disagreement between the consulting physician and the intensivist was significantly lower in patients assessed from the emergency services (P=.0021). CONCLUSIONS:There are appreciable differences in the reasons for consultation, as well as in those for refusal of admission to an ICU between the consultations made from an emergency department and a conventional hospitalization facility.

BACKGROUND:Information is lacking regarding long-term survival and predictive factors for mortality in patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19) and undergoing invasive mechanical ventilation. We aimed to estimate 180-day mortality of patients with COVID-19 requiring invasive ventilation, and to develop a predictive model for long-term mortality. METHODS:Retrospective, multicentre, national cohort study between March 8 and April 30, 2020 in 16 intensive care units (ICU) in Spain. Participants were consecutive adults who received invasive mechanical ventilation for COVID-19. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection detected in positive testing of a nasopharyngeal sample and confirmed by real time reverse-transcriptase polymerase chain reaction (rt-PCR). The primary outcomes was 180-day survival after hospital admission. Secondary outcomes were length of ICU and hospital stay, and ICU and in-hospital mortality. A predictive model was developed to estimate the probability of 180-day mortality. RESULTS:868 patients were included (median age, 64 years [interquartile range [IQR], 56-71 years]; 72% male). Severity at ICU admission, estimated by SAPS3, was 56 points [IQR 50-63]. Prior to intubation, 26% received some type of noninvasive respiratory support. The unadjusted overall 180-day survival rates was 59% (95% CI 56-62%). The predictive factors measured during ICU stay, and associated with 180-day mortality were: age [Odds Ratio [OR] per 1-year increase 1.051, 95% CI 1.033-1.068)), SAPS3 (OR per 1-point increase 1.027, 95% CI 1.011-1.044), diabetes (OR 1.546, 95% CI 1.085-2.204), neutrophils to lymphocytes ratio (OR per 1-unit increase 1.008, 95% CI 1.001-1.016), failed attempt of noninvasive positive pressure ventilation prior to orotracheal intubation (OR 1.878 (95% CI 1.124-3.140), use of selective digestive decontamination strategy during ICU stay (OR 0.590 (95% CI 0.358-0.972) and administration of low dosage of corticosteroids (methylprednisolone 1 mg/kg) (OR 2.042 (95% CI 1.205-3.460). CONCLUSION:The long-term survival of mechanically ventilated patients with severe COVID-19 reaches more than 50% and may help to provide individualized risk stratification and potential treatments. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT04379258. Registered 10 April 2020 (retrospectively registered).

Background: This study aimed to assess the efficacy of ceftolozane-tazobactam (C/T) for treating infections due to Pseudomonas aeruginosa ( P. aeruginosa) in critically ill patients. Patients and Methods: A multicenter, retrospective and observational study was conducted in critically ill patients receiving different C/T dosages and antibiotic combinations for P. aeruginosa infections. Demographic data, localisation and severity of infection, clinical and microbiological outcome, and mortality were evaluated. Results: Ninety-five patients received C/T for P. aeruginosa serious infections. The main infections were nosocomial pneumonia (56.2%), intra-abdominal infection (10.5%), tracheobronchitis (8.4%), and urinary tract infection (6.3%). Most infections were complicated with sepsis (49.5%) or septic shock (45.3%), and bacteraemia (10.5%). Forty-six episodes were treated with high-dose C/T (3 g every 8 hours) and 38 episodes were treated with standard dosage (1.5 g every 8 hours). Almost half (4 4.2%) of the patients were treated with C/T monotherapy, and the remaining group received combination therapy with other antibiotics. Sixty-eight (71.6%) patients presented a favourable clinical response. Microbiological eradication was documented in 42.1% (40/95) of the episodes. The global ICU mortality was 36.5%. Univariate analysis showed that 30-day mortality was significantly associated ( P < 0.05) with Charlson Index at ICU admission and the need of life-supporting therapies. Conclusions: C/T appeared to be an effective therapy for severe infections due to P. aeruginosa in critically ill patients. Mortality was mainly related to the severity of the infection. No benefit was observed with high-dose C/T or combination therapy with other antibiotics. (c) 2020 Published by Elsevier Ltd.

Normothermic regional perfusion (NRP) in controlled donation after circulatory death is becoming a popular method due to the favorable results of the grafts procured under this technique. This procedure requires experience, and, sometimes, the availability of extracorporeal membrane oxygenation (ECMO) machines to implement NRP is limited to tertiary hospitals. In order to provide support with NRP in controlled donation after circulatory death across the different hospitals of the Autonomous Community of Madrid, a mobile NRP team was created. In the first 18 months since its creation, the mobile NRP team participated in 33 procurements across nine different hospitals, representing 72% of all controlled donations after circulatory death in the Autonomous Community of Madrid. NRP was successfully performed in 29 (88%) cases, with a mean duration of 69 ± 27 minutes. A total of 39 kidneys, 12 livers, and 5 bilateral lungs were recovered and transplanted. None of the livers were discarded due to an elevation in transaminases during NRP. A mobile NRP team is a feasible option and, in our series, aided in the optimization and recovery of organs from donors after controlled circulatory death in centers where ECMO technology was not available.

Severe carbon monoxide (CO) poisoning causes fulminant deaths in common environment as well as neurological sequelae to survivors. Prevention of delayed neurological syndrome (DNS) after exposure to CO, the most important sequela, is based up to date on hyperbaric oxygen administration. Nevertheless, its use remains controversial due to the lack of evidence regarding its efficacy. The aim of this review is to report therapies under investigation for preventing or improving DNS, some of them with promising results in humans.

BACKGROUND:Acute myocardial infarction (AMI) with no evidence of relevant stenosis of the coronary artery, known as myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA), has a prevalence of up to 14%. The various causes of MINOCA lead to damage of the myocardium, and there are marked differences in diagnoses, prognoses, and treatments. Although the number of patients affected is considerable owing to the high prevalence of acute coronary syndrome (ACS), the causes of MINOCA have received little attention with the result that some patients may not receive appropriate treatment. Awareness of this disease among clinicians has started only to improve since the beginning of the current century. The aim of this study was to develop a score that enables patients with MINOCA to be distinguished from patients with MI with coronary artery disease (MI-CAD) and thus to facilitate appropriate diagnosis and therapy. PATIENTS AND METHODS:A multicenter observational cohort study was designed. All patients aged ≥18 years from the ARIAM-SEMICYUC (Analysis of Delay in AMI-Spanish Society of Intensive Care Medicine and Coronary Unit) registry, diagnosed with AMI, and admitted to critical care units or coronary care units (CCUs) were included. Patients were classified into two groups: MINOCA, comprising patients with no significant lesions on angiography, and MI-CAD, comprising patients with lesions of the coronary artery tree. RESULTS:A score based on standard variables to assess the probability of MINOCA on admission was designed, showing a maximum value corresponding to a 40% probability of MINOCA. The discriminative power of the model was 0.756 (P-value for the Hosmer-Lemeshow test was >0.05). At 30-day follow-up, the mortality rate was higher for MI-CAD patients. CONCLUSION:Patients with MINOCA constitute a population that differs from other patients with AMI. Their differential characteristics require a certain diagnostic effort to align therapy with the disease causing the ischemic event. This score could prove useful in establishing additional diagnostic procedures.

Objective: To assess the correlation between left ventricular outflow tract velocity time integral (LVOT VTI) and stroke volume index (SVI) calculated by thermodilution methods in ventilated critically ill patients. Design: A prospective, descriptive, multicenter study was performed. Setting: Five intensive care units from university hospitals. Patients: Patients older than 17 years needing mechanical ventilation and invasive hemody-namic monitoring were included. Interventions: LVOT VTI was measured by pulsatile Doppler echocardiography. Calculations of SVI were performed through a floating pulmonary artery catheter (PAC) or a Pulse index Contour Cardiac Output (PiCCO (R)) thermodilution methods. Main variables: The relation between LVOT VTI and SVI was tested by linear regression analysis. Results: One hundred and fifty-six paired measurements were compared. Mean LVOT VTI was 20.83 +/- 4.86 cm and mean SVI was 41.55 +/- 9.55 mL/m(2). Pearson correlation index for these variables was r= 0.644, p< 0.001; ICC was 0.52 (CI 95% 0.4-0.63). When maximum LVOT VTI was correlated with SVI, Pearson correlation index was r = 0.62, p <0.001. Correlation worsened for extreme values, especially for those with higher LVOT VTI. Conclusions: LVOT VTI could be a complementary hemodynamic evaluation in selected patients, but does not eliminate the need for invasive monitoring at the present time. The weak correlation between LVOT VTI and invasive monitoring deserves additional assessment to identify the factors affecting this disagreement. (C) 2018 Elsevier Espana, S.L.U. y SEMICYUC. All rights reserved.

Analizar las variables asociadas a las decisiones de rechazo al ingreso en una Unidad de Cuidados Intensivos (UCI) como medida de limitación de tratamiento de soporte vital.Prospectivo, multicéntrico.Sesenta y dos UCI de España entre febrero de 2018 y marzo de 2019.Mayores de 18 años a los que se les negó el ingreso a una UCI como medida de limitación de tratamiento de soporte vital.Ninguna.Comorbilidades de los pacientes, situación funcional previa medida por la escala KNAUS y Karnosfky; escalas pronósticas de Lee y Charlson; gravedad del enfermo medida por las escalas APACHE II y SOFA, motivo que justifica la toma de la decisión, persona a la cual es trasmitida la información; fecha de alta o fallecimiento intrahospitalario, destino al alta hospitalaria.Se registraron un total de 2.312 decisiones de no ingreso como medida de limitación del tratamiento de soporte vital (LTSV), de las cuales se analizaron 2.284. El principal motivo de consulta fue la insuficiencia respiratoria (1.080 [47,29%]). La pobre calidad de vida estimada de los enfermos (1.417 [62,04%]), la presencia de una enfermedad crónica grave (1.367 [59,85%]) y la limitación funcional previa de los pacientes (1.270 [55,60%]) fueron los principales motivos esgrimidos para denegar el ingreso. La tasa de mortalidad intrahospitalaria fue del 60,33%. La futilidad del tratamiento se constató como factor de riesgo asociado a mortalidad (OR: 3,23; IC 95%: 2,62-3,99).Las decisiones para limitar el ingreso en UCI como medida de LTSV se basan en los mismos motivos que las decisiones tomadas dentro de la UCI. La futilidad valorada por el intensivista se relaciona adecuadamente con el resultado final de muerte.To analyze the variables associated with ICU refusal decisions as a life support treatment limitation measure.Prospective, multicentrico62 ICU from Spain between February 2018 and March 2019.Over 18 years of age who were denied entry into ICU as a life support treatment limitation measure.None.Patient comorities, functional situation as measured by the KNAUS and Karnosfky scale; predicted scales of Lee and Charlson; severity of the sick person measured by the APACHE II and SOFA scales, which justifies the decision-making, a person to whom the information is transmitted; date of discharge or in-hospital death, destination for hospital discharge.A total of 2312 non-income decisions were recorded as an LTSV measure of which 2284 were analyzed. The main reason for consultation was respiratory failure (1080 [47.29%]). The poor estimated quality of life of the sick (1417 [62.04%]), the presence of a severe chronic disease (1367 [59.85%]) and the prior functional limitation of patients (1270 [55.60%]) were the main reasons for denying admission. The in-hospital mortality rate was 60.33%. The futility of treatment was found as a risk factor associated with mortality (OR: 3.23; IC95%: 2.62-3.99).Decisions to limit ICU entry as an LTSV measure are based on the same reasons as decisions made within the ICU. The futility valued by the intensivist is adequately related to the final result of death.