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Resumen Objetivo Validar un modelo sencillo de riesgo para predecir bacteriemia (5MPB-Toledo) en los pacientes atendidos en los servicios de urgencias hospitalarios (SUH) por un episodio de infeccion. Metodos Estudio observacional de cohortes prospectivo y multicentrico de los hemocultivos (HC) obtenidos en 74 SUH espanoles en los pacientes adultos (≥ 18 anos) atendidos por infeccion desde el 1 de octubre de 2019 hasta el 29 de febrero de 2020. Se analizo la capacidad predictiva del modelo con el area bajo la curva (ABC) de la caracteristica operativa del receptor (COR) y se calculo el rendimiento diagnostico de los puntos de corte (PC) del modelo elegidos con los calculos de la sensibilidad, la especificidad, el valor predictivo positivo y el valor predictivo negativo. Resultados Se incluyeron 3.843 episodios de HC extraidos. De ellos, se consideraron como bacteriemias verdaderas 839 (21,83%) y como HC negativos 3.004 (78,17%). Entre los negativos, 172 (4,47%) se consideraron contaminados. Se categorizo a los pacientes en bajo (0-2 puntos), moderado (3-5 puntos) y alto (6-8 puntos) riesgo, con una probabilidad de bacteriemia de 1,5, 16,8 y 81,6%, respectivamente. El ABC-COR del modelo tras remuestreo fue de 0,930 (IC 95%: 0,916-0,948). El rendimiento diagnostico del modelo con un PC ≥ 5 puntos consigue una sensibilidad del 94,76% (IC 95%: 92,97-96,12), especificidad del 81,56% (IC 95%: 80,11-82,92) y un valor predictivo negativo del 98,24% (IC 95%: 97,62-98,70). Conclusion El modelo 5MPB-Toledo es de utilidad para predecir bacteriemia en los pacientes atendidos en el SUH por un episodio de infeccion.

To validate a simple risk score to predict bacteremia (MPB5-Toledo) in patients seen in the emergency departments (ED) due to infections.Prospective and multicenter observational cohort study of the blood cultures (BC) ordered in 74 Spanish ED for adults (aged 18 or older) seen from from October 1, 2019, to February 29, 2020. The predictive ability of the model was analyzed with the area under the Receiver Operating Characteristic curve (AUC-ROC). The prognostic performance for true bacteremia was calculated with the cut-off values chosen for getting the sensitivity, specificity, positive predictive value and negative predictive value.A total of 3.843 blood samples wered cultured. True cases of bacteremia were confirmed in 839 (21.83%). The remaining 3.004 cultures (78.17%) were negative. Among the negative, 172 (4.47%) were judged to be contaminated. Low risk for bacteremia was indicated by a score of 0 to 2 points, intermediate risk by 3 to 5 points, and high risk by 6 to 8 points. Bacteremia in these 3 risk groups was predicted for 1.5%, 16.8%, and 81.6%, respectively. The model's area under the receiver operating characteristic curve was 0.930 (95% CI, 0.916-0.948). The prognostic performance with a model's cut-off value of ≥ 5 points achieved 94.76% (95% CI: 92.97-96.12) sensitivity, 81.56% (95% CI: 80.11-82.92) specificity, and negative predictive value of 98.24% (95% CI: 97.62-98.70).The 5MPB-Toledo score is useful for predicting bacteremia in patients attended in hospital emergency departments for infection.

Design a risk model to predict bacteraemia in patients attended in emergency departments (ED) for an episode of infection. This was a national, prospective, multicentre, observational cohort study of blood cultures (BC) collected from adult patients (≥ 18 years) attended in 71 Spanish EDs from October 1 2019 to March 31, 2020. Variables with a p value

14 Pág, Cytokines are small proteins that regulate innate and adaptive immune responses and are released by both immune and non-immune cell types. In the current study, the constitutive and induced gene expression profiles of a suite of proinflammatory and regulatory cytokines was examined comparatively in eight rainbow trout (Oncorhynchus mykiss) cell lines, in order to establish the cytokine repertoires of these different cell types, especially the understudied non-immune cells. They included three epithelial cell lines (RTgut, RTgill, and RTL), one endothelial cell line (RTH), one fibroblast cell line (RTG-2), two stromal cell lines (TSS and TPS-2) and one monocyte/macrophage-like cell line (RTS-11). Three types of primary leukocytes (derived from blood, spleen and head kidney) of trout were also included in the analysis, to allow comparison to the repertoires expressed in T cells, as a major source of cytokines in immune responses. The major findings are: 1) IL-2A, IL-2B, IL-4/13B1, IL-4/13B2, IL-10b, P40B1, P28B, IL-17A/F1b, TNF-α3, TNF-α4, IFNγ1, CCL20L2b and CCL20L3a are expressed mainly in leukocytes but IL-17 N, IL-17D, IL-20 and CCL20L1b2 are not expressed in these cells. Hence future studies in these cell lines will help establish their function in fish; 2) Some of the cytokines were differentially expressed in the cell lines, revealing the potential role of these cell types in aspects of trout mucosal and inflammatory immune responses, 3) Similar cell types grouped together in the cell cluster analysis, including the leukocyte cluster, stromal cell cluster, and epithelial and endothelial cell cluster. Taken together, this investigation of these trout cell lines forms a good database for studying the function of cytokines not expressed in isolated leukocytes or that are preferentially expressed in the cell lines. Furthermore, the cytokine expression analysis undertaken confirmed the phenotypic relationship of these cell types at the molecular level., Fuguo Liu was supported by a Newton International Fellowship funded by the Academy of Medical Sciences, UK (AMS, NIF004\1036).

To validate a previously described hospital emergency department risk model to predict mortality in patients with COVID-19.Prospective observational noninterventional study. Patients aged over 18 years diagnosed with COVID-19 were included between December 1, 2020, and February 28, 2021. We calculated a risk score for each patient based on age 50 years (2 points) plus 1 point each for the presence of the following predictors: Barthel index 90 points, altered level of consciousness, ratio of arterial oxygen saturation to fraction of inspired oxygen 400, abnormal breath sounds, platelet concentration 100 × 109/L, C reactive protein level 5 mg/dL, and glomerular filtration rate 45 mL/min. The dependent variable was 30-day mortality. We assessed the score's performance with the area under the receiver operating characteristic curve (AUC).The validation cohort included 1223 patients. After a median follow-up of 80 days, 143 patients had died; 901 patients were classified as having low risk (score, 4 points), 270 as intermediate risk (5-6 points), and 52 as high risk ( 7 points). Thirty-day mortality rates at each risk level were 2.8%, 22.5%, and 65.4%, respectively. The AUC for the score was 0.883; for risk categorization, the AUC was 0.818.The risk score described is useful for stratifying risk for mortality in patients with COVID-19 who come to a tertiary-care hospital emergency department.Validación de un indicador de mortalidad previamente descrito en pacientes con COVID-19 en un servicio de urgencias hospitalario (SUH).Estudio observacional prospectivo no intervencionista. Se incluyeron pacientes 18 años diagnosticados de COVID-19 (1 de diciembre de 2020 hasta 28 de febrero de 2021). Se calculó el indicador para cada paciente: edad 50 años (2 puntos), índice de Barthel 90 puntos (1 punto), alteración de consciencia (1 punto), índice de SaO2/ FIO2 400 (1 punto), auscultación respiratoria patológica (1 punto), plaquetas 100 x 109/L (1 punto), proteína C reactiva 5 mg/dL (1 punto) y filtrado glomerular 45 mL/min (1 punto). La variable dependiente fue la mortalidad observada a 30 días. El rendimiento del indicador se valoró con el análisis del área bajo la curva de la característica operativa del receptor (ABC-COR).La validación del indicador se realizó sobre una cohorte de 1.223 pacientes. Tras una mediana de seguimiento de 80 días, 143 pacientes habían fallecido. Un total de 901 pacientes fueron catalogados como riesgo bajo (indicador 4 puntos), 270 lo fueron como riesgo intermedio (5-6 puntos) y 52 como riesgo alto ( 7 puntos). La mortalidad a 30 días observada en cada categoría fue de 2,8%, 22,5% y 65,4%, respectivamente. El ABC-COR fue de 0,883 para el indicador utilizado cuantitativamente y de 0,818 cuando se usó cualitativamente en forma de categorías de riesgo.El indicador descrito es una herramienta útil para estratificar el riesgo de mortalidad de los pacientes con COVID-19 que consultan a un SUH de un centro de tercer nivel.

Altres ajuts: acords transformatius de la UAB Spring viremia of carp (SVC) remains as a vaccine orphan disease mostly affecting juvenile specimens. Young fish are especially difficult to vaccinate and oral administration of vaccine combined with food would be the election system to minimise stress and the vaccination costs associated to injection. However, administration of prophylactics with food pellets faces off several drawbacks mainly related with vaccine degradation and weak protection correlates of oral vaccines. Here we present a platform based on recombinant proteins (subunit vaccines) manufactured as highly resistant nanostructured materials, and providing excellent levels of protection against SVC virus in a preliminary i.p injection challenge. The G3 domain of SVCV glycoprotein G was overexpressed in E. coli together with IFNγ and the modular protein was purified from bacterial aggregates (inclusion bodies) as highly organised nanostructured biomaterial (nanopellets, NP). These SVCV-IFN were taken up by zebrafish cells leading to the enhanced expression of different antiviral and IFN markers (e.g vig1, mx, lmp2 or ifngr1 among others) in zebrafish liver cells (ZFL). To monitor if SVCV and SVCV-IFN can be taken up by intestinal epithelia and can induce antiviral response we performed experiments with SVCV and SVCV-IFN in 3 days post fertilization (dpf) zebrafish larvae. Both, SVCV and SVCV-IFN were taken up and accumulated in the intestine without signs of toxicity. The antiviral response in larvae showed a different induction pattern: SVCV-IFN did not induce an antiviral response while SVCV showed a good antiviral induction. Interestingly ZF4, an embryonic derived cell line, showed an antiviral response like ZFL cells, although the lmp2 and ifngr1 (markers of the IFNγ response) were not overexpressed. Experiments with adult zebrafish indicated an excellent level of protection against a SVCV model infection where SVCV-IFN vaccinated fish reached 20% cumulative mortality while control fish reached over 80% cumulative mortality.

BOOK REVIEWS - CRITICA DE LIBROS - CRITICA DE LIVROS Patrick Doyle: Civilising Rural Ireland: The Co-Operative Movement, Development and the Nation-State, 1889-1939 Tony Varley Ana Cristina Roque, Cristina Brito y Cecilia Veracini (Eds.): Peoples, Nature and Environments: Learning to Live Together Antonio Ortega Santos Sylvie Bépoix y Hervé Richard (Dirs.): La forêt au Moyen Âge Juan José Larrea Manuel González de Molina, David Soto, Gloria Guzmán Casado, Juan Infante, Eduardo Aguilera, Jaime Vila y Roberto García Ruíz: Historia de la Agricultura Española desde una perspectiva biofísica, 1900-2010 Ernesto Clar Enric Saguer (Ed.): Els cortals empordanesos, del segle xiii al xxi. Sis estudis Antònia Morey Tous Enric Vicedo (Ed.): Recs històrics: Pagesia, història i patrimonio Mar Ortega-Reig Francisco Acosta (Coord.): La aurora de rojos dedos: El Trienio Bolchevique desde el sur de España Antonio Herrera González de Molina Antonio Luis López Martínez: Las ferias de ganado en Andalucía Occidental y Extremadura, 1830-1958 José Antonio Mendizabal

OBJECTIVES To investigate whether the diagnosis of acute coronary syndrome (ACS) in coronary artery bypass grafting (CABG) patients with chest pain (CP) is more difficult based on the initial clinical and electrocardiogram (ECG) findings. METHODS We included consecutive CP patients attended at a single emergency department (ED) during a 10-year period. CABG status and the final diagnosis of ACS were considered as stated in the ED discharge report. We evaluated the frequency of 21 CP characteristics (CPC) and four ECG signatures, their individual and collective association with ACS, and ED length of stay (LOS) in CABG and non-CABG patients. RESULTS We included 34 429 patients [median age: 61 years; female: 41.8%; CABG: 2204 patients (6.4%)], and ACS was diagnosed in 6727 (19.5%; CABG/non-CABG 37.2%/18.3%; P < 0.001). CABG patients more frequently had CPC and ECG findings typically associated with ACS, but their final association with ACS was weaker than in non-CABG patients (only significant after adjustment for attendant diaphoresis, throat irradiation, ST-segment elevation and T-wave inversion). The collective discriminative capacity was significantly lower in CABG patients (area under the curve 0.710 vs. 0.793; P < 0.001), even after adjustment (0.708 vs. 0.790; P < 0.001). ED LOS was longer for CABG patients, overall (P < 0.001) and for patients diagnosed with ACS (P = 0.008) and non-ACS (P < 0.001), but these differences disappeared after adjustment. CONCLUSION CABG substantially reduces the diagnostic performance of CPC and ECG findings to suggest ACS. A longer LOS in the ED in CABG patients is more related to their baseline characteristics than to CABG itself.

espanolObjetivo. Analizar la adecuacion de las prescripciones de antibioticos de categoria especial (ATB de CE) en el Servicio de Urgencias Hospitalario (SUH) de un centro urbano de tercer nivel. Material y metodos. Se selecciono una muestra aleatoria de 100 pacientes diferentes a los que se les inicio un ATB de CE en Urgencias durante el ano 2018. El equipo investigador reviso la historia clinica del episodio de urgencias y de ingreso. Se determino mediante regresion logistica los factores independientes asociados con el grado de adecuacion del tratamiento. Resultados. Se analizaron 97 prescripciones de las cuales 66 (68%) cumplian los criterios de prescripcion adecuada. El grado de adecuacion fue del 70% si la infeccion estaba relacionada con la asistencia sanitaria y del 75% si el paciente tenia factores de riesgo de infeccion por microorganismos multirresistentes (MMR). El porcentaje de adecuacion fue mayor en los casos en los que se especifico el foco de la infeccion (72%) y la gravedad del episodio (73%). Las variables independientes que se asociaron a una prescripcion adecuada fueron: la presencia de factores de riesgo de infeccion por MMR (OR: 2,35 IC 95%: 1,65 – 3,17 p: 0,01), el especificar el foco de la infeccion (OR: 3,79 IC 95%: 1,72 – 4,22 p: 0,02) y senalar la gravedad del episodio (OR: 3,09 IC 95%: 1,12 – 3,09 p: 0,03). Conclusiones. La prescripcion de los ATB de CE en el SUH es adecuada en la medida que se tenga en cuenta el ambito de adquisicion de la infeccion, los factores de riesgo de MMR, el foco de infeccion y la gravedad del cuadro clinico. EnglishObjective. The aim of the study was to analyze the adequacy of the special category antibiotics prescriptions in the Emergency Department (ED) of a third level urban Hospital. Material and methods. A random sample of 100 different patients who were started with a special category antibiotic along 2018 in the ED was selected. The research team reviewed the medical history of the emergency and admission episode. The independent factors associated with the degree of adequacy of the treatment were determined by logistic regression. Results. A total of 97 prescriptions were analyzed of which 66 (68%) met the criteria of adequate prescription, 23 (24%) adequate prescription, but with equally recommended alternatives and 8 (8%) were inappropriate prescriptions. The degree of adequacy was 70% if the infection was related to healthcare and 75% if the patient had risk factors for multiresistant (MR) microorganisms’ infection. The percentage of adequacy was higher in the cases in which the focus of the infection (72%) and the severity of the episode (73%) were specified. The independent variables that were associated with an adequate prescription were: the presence of risk factors for MR microorganisms’ infection (OR: 2.35 95% CI: 1.65 - 3.17 p: 0.01), if the focus of the infection (OR: 3.79 95% CI: 1.72 - 4.22 p: 0.02) and the severity of the episode (OR: 3.09 95% CI: 1.12 - 3.09 p: 0.03) were specified. Conclusions. The prescription of special category antibiotics in ED is appropriate if the clinical guidelines are followed and if the setting of infection acquisition, the risk factors of MR microorganisms, the focus and the severity of infection are taken into account in clinical picture.

The adaptation to the multiple facets of climate/global change challenges the conventional means of water system planning. Numerous demand and supply management options are often available, from which a portfolio of adaptation measures needs to be selected in a context of high uncertainty about future conditions. A framework is developed to integrate inputs from the two main approaches commonly used to plan for adaptation. The proposed “top–down meets bottom–up” approach provides a systematic and practical method for supporting the selection of adaptation measures at river basin level by comprehensively integrating the goals of economic efficiency, social acceptability, environmental sustainability, and adaptation robustness. The top-down approach relies on the use of a chain of models to assess the impact of global change on water resources and its adaptive management over a range of climate projections. Future demand scenarios and locally prioritized adaptation measures are identified following a bottom-up approach through a participatory process with the relevant stakeholders and experts. Cost-effective combinations of adaptation measures are then selected using a hydro-economic model at basin scale. The resulting adaptation portfolios are climate checked to define a robust program of measures based on trade-offs between adaptation costs and reliability. Valuable insights are obtained on the use of uncertain climate information for selecting robust, reliable, and resilient water management portfolios. Finally, cost allocation and equity implications are analyzed through the comparison of economically rational results (cooperative game theory) and the application of social justice principles.

To develop a risk model to predict 30-day mortality after emergency department treatment for COVID-19.Observational retrospective cohort study including 2511 patients with COVID-19 who came to our emergency department between March 1 and April 30, 2020. We analyzed variables with Kaplan Meier survival and Cox regression analyses.All-cause mortality was 8% at 30 days. Independent variables associated with higher risk of mortality were age over 50 years, a Barthel index score less than 90, altered mental status, the ratio of arterial oxygen saturation to the fraction of inspired oxygen (SaO2/FIO2), abnormal lung sounds, platelet concentration less than 100 000/mm3, a C-reactive protein concentration of 5 mg/dL or higher, and a glomerular filtration rate less than 45 mL/min. Each independent predictor was assigned 1 point in the score except age, which was assigned 2 points. Risk was distributed in 3 levels: low risk (score of 4 points or less), intermediate risk (5 to 6 points), and high risk (7 points or above). Thirty-day risk of mortality was 1.7% for patients who scored in the low-risk category, 28.2% for patients with an intermediate risk score, and 67.3% for those with a high risk score.This mortality risk stratification tool for patients with COVID-19 could be useful for managing the course of disease and assigning health care resources in the emergency department.Derivar un modelo de riesgo para estimar la probabilidad de mortalidad a los 30 días de la visita a urgencias de pacientes con COVID-19.Estudio observacional de cohortes retrospectivo de 2.511 pacientes con COVID-19 atendidos en el servicio de urgencias hospitalario (SUH) del 1 de marzo al 30 de abril de 2020. Se realizó análisis de supervivencia mediante Kaplan Meier y regresión de Cox.La mortalidad por cualquier causa a los 30 días fue de un 8%. Los factores asociados de forma independiente a mayor mortalidad fueron: edad 50 años, índice de Barthel 90 puntos, alteración del nivel de consciencia, índice de SaO2/FIO2 400, auscultación respiratoria anómala, cifra de plaquetas 100.000/mm3, PCR 5 mg/dL y filtrado glomerular 45 mL/min. A estos factores se les asignó una puntuación de 1, excepto a la edad, que se le asignó un valor de 2 puntos. Se dividió el modelo de riesgo en 3 categorías: riesgo bajo (menor o igual a 4 puntos), riesgo intermedio (5-6 puntos) y riesgo alto (igual o superior a 7 puntos). Para los pacientes clasificados como de bajo riesgo la probabilidad de mortalidad a los 30 días fue del 1,7%, en los casos de riesgo intermedio fue del 28,2% y para los de alto riesgo fue del 67,3%.Disponer de una herramienta para estratificar el riesgo de mortalidad de los pacientes con COVID-19 que consultan a un SUH podría ser de utilidad para la gestión de los recursos sanitarios disponibles.

The aim was to develop a predictive model of infection by multidrug-resistant microorganisms (MDRO). A national, retrospective cohort study was carried out including all patients attended for an infectious disease in 54 Spanish Emergency Departments (ED), in whom a microbiological isolation was available from a culture obtained during their attention in the ED. A MDRO infection prediction model was created in a derivation cohort using backward logistic regression. Those variables significant at p 21 points). Findings were similar in the validation cohort. Several patient-specific factors were independently associated with MDRO infection risk. When integrated into a clinical prediction rule, higher risk scores and risk classes were related to an increased risk for MDRO infection. This clinical prediction rule could be used by providers to identify patients at high risk and help to guide antibiotic strategy decisions, while accounting for clinical judgment.

Fish viral diseases represent a constant threat to aquaculture production. Thus, a better understanding of the cellular mechanisms involved in establishing an antiviral state associated with protection against virus replication and pathogenesis is paramount for a sustainable aquaculture industry. This review summarizes the current state of knowledge on five selected host innate immune-related genes in response to the most relevant viral pathogens in fish farming. Viruses have been classified as ssRNA, dsRNA, and dsDNA according to their genomes, in order to shed light on what those viruses may share in common and what response may be virus-specific, both in vitro (cell culture) as well as in vivo. Special emphasis has been put on trying to identify markers of resistance to viral pathogenesis. That is, those genes more often associated with protection against viral disease, a key issue bearing in mind potential applications into the aquaculture industry.

[EN] During the last three decades, like many other Mediterranean states, Spain has intensively promoted the modernization of irrigation, focusing mainly on the introduction of pressurized irrigation systems. Following 30 years of investment, a shift in irrigation policies is needed to solve some of the deficiencies in this modernization process and to incorporate new measures to cope with upcoming challenges generated by international markets, climate change and other social and economic processes. This paper describes and analyses the results of participatory research carried out with the water user associations in the autonomous region of Valencia, in order to define post-modernization irrigation policies. A survey and 24 local workshops involving 304 water user associations were conducted during the irrigation season of 2018 in order to form an assessment of the sector and design new irrigation policies. The results show that after 30 years of important investment, the obsolescence of the infrastructure has become the current main priority, making farmers dependent on public subsidies. New necessities have also emerged, such as renewable energies and nonconventional water resources, which farmers consider indispensable in order to reduce operating costs and guarantee water supply., This work has been developed under the framework of the research agreement "Estudio para la modernizacion del regadio en la Comunidad Valenciana", between the Universitat Politecnica de Valencia and the Generalitat Valenciana, and conducted as part of the research project "Design and evaluation of strategies to adapt to global climate change in Mediterranean watersheds by using irrigation water intensively (ADAPTAMED)" (RTI2018-101483-B-I00), funded by the Ministerio de Economia y Competitividad (MINECO) of Spain and with EU FEDER funds.

Simple Summary In aquatic biological models, the communication between cells from the immune system remains poorly characterized. In this work, to determine the gene expression of master transcriptional factors that coordinate the polarization of T cells, co-cultures of rainbow trout splenocytes are analyzed after stimulation with Interferon-gamma and/or Piscirickettsia salmonis. The results showed an upregulation of foxp3 compared to the other transcriptional factors, suggesting a potential communication between cells in the spleen, which may induce a Treg phenotype. Abstract In fish, the spleen is one of the major immune organs in the animal, and the splenocytes could play a key role in the activation and modulation of the immune response, both innate and adaptive. However, the crosstalk between different types of immune cells in the spleen has been poorly understood. In this work, an in vitro strategy is carried out to obtain and characterize mononuclear splenocytes from rainbow trout, using biomarkers associated with lymphocytes (CD4 and IgM) and antigen-presenting cells (CD83 and MHC II). Using these splenocytes, co-cultures of 24 and 48 h are used to determine the gene expression of master transcriptional factors that coordinate the polarization of T cells (t-bet, gata3, and foxp3). The results show a proportional upregulation of foxp3 (compared to t-bet and gata3) in co-cultures (at 24 h) of IFNγ-induced splenocytes with and without stimulation of Piscirickettsia salmonis proteins. In addition, foxp3 upregulation was established in co-cultures with IFNγ-induced cells and in cells only stimulated previously with P. salmonis proteins at 48 h of co-culture. These results show a potential communication between antigen-presenting-like cells and lymphocyte in the spleen, which could be induced towards a Treg phenotype.

Resumen: El artículo comienza con un debate sobre el concepto de “contracción” y sus orígenes, fuera del ámbito del desarrollo rural. A partir de ahí, se muestra la distribución de las zonas rurales en contracción en toda Europa. A continuación, se describen los procesos socioeconómicos que impulsan el declive demográfico en las zonas rurales, utilizando tanto la revisión bibliográfica del proyecto ESCAPE como los resultados de sus ocho estudios de caso. Seguidamente, se describe de forma breve la evolución de las intervenciones de la UE para paliar los efectos del declive demográfico, y se hacen algunas observaciones sobre el panorama político/de gobernanza actual. Concluimos considerando cómo una mejor comprensión del problema y del proceso de reducción puede conducir a intervenciones más eficaces, en el contexto de una visión renovada a largo plazo para el medio rural europeo. Este último debe reconocer plenamente el creciente abanico de oportunidades a las que se enfrentan las zonas rurales, a medida que la COVID-19 cambia estas y se aceleran las transformaciones en el comportamiento laboral y en la geografía de la actividad económica, y se cumplen los anteriores cambios graduales en la tecnología y los mercados. Palabras clave: Espacios rurales, declive demográfico, enfoque neo-endógeno, crecimiento inclusivo. Abstract: The paper begins with a discussion of the concept of “shrinking”, and its origins, outside the realm of rural development. Building on this, the paper shows the distribution of shrinking rural areas across Europe. Using both the project’s literature review and findings from its eight case studies the socio-economic processes which drive demographic decline in rural areas are then described. A brief account of the evolution of EU interventions to alleviate the effects of shrinking, and some remarks about the current policy/governance landscape follow. We conclude by considering how a better understanding of the problem and process of shrinking may lead to more effective interventions, within the context of a refreshed long-term vision for Rural Europe. The latter needs to fully acknowledge the expanding repertoire of opportunities confronting rural areas as COVID-19 changes in working behaviour, and the geography of economic activity, accelerate, and fulfil, previously incremental shifts in technology and markets. Key words: Rural areas, demographic decline, neo-endogenous approach, inclusive growth.

To analyze emergency department (ED) revisits from patients discharged with possible coronavirus disease 2019 (COVID-19).Retrospective observational study of consecutive patients who came to the ED over a period of 2 months and were diagnosed with possible COVID-19. We analyzed clinical and epidemiologic variables, treatments given in the ED, discharge destination, need to revisit, and reasons for revisits. Patients who did or did not revisit were compared, and factors associated with revisits were explored.The 2378 patients included had a mean age of 57 years; 49% were women. Of the 925 patients (39%) discharged, 170 (20.5%) revisited the ED, mainly for persistence or progression of symptoms. Sixty-six (38.8%) were hospitalized. Odds ratios (ORs) for the following factors showed an association with revisits: history of rheumatologic disease (OR, 2.97; 95% CI, 1.10-7.99; P = .03), digestive symptoms (OR, 1.73; 95% CI, 1.14-2.63; P = .01), respiratory rate over 20 breaths per minute (OR, 1.03; 95% CI, 1.0-1.06; P = .05), and corticosteroid therapy given in the ED (OR, 7.78; 95% CI, 1.77-14.21, P = .01). Factors associated with hospitalization after revisits were age over 48 years (OR, 2.57; 95% CI, 1 42-4.67; P = .002) and fever (OR, 4.73; 95% CI, 1.99-11.27; P = .001).Patients under the age of 48 years without comorbidity and with normal vitals can be discharged from the ED without fear of complications. A history of rheumatologic disease, fever, digestive symptoms, and a respiratory rate over 20 breaths per minute, or a need for corticosteroid therapy were independently associated with revisits. Fever and age over 48 years were associated with a need for hospitalization.Analizar las revisitas y los factores asociados a la misma en pacientes con diagnóstico de posible COVID-19 dados de alta de un servicio de urgencias hospitalario (SUH).Estudio observacional, retrospectivo que incluyó pacientes consecutivos que consultaron al SUH en un periodo de 2 meses y fueron diagnosticados de posible de COVID-19. Se analizaron variables clínico-epidemiológicas, tratamiento administrado en urgencias, destino final, revisita al SUH y motivo de esta. Se hizo un análisis comparativo entre ambos grupos (revisita sí/no) y se identificaron factores asociados a la revisita.Se incluyeron 2.378 pacientes (edad media 57 años; 49% mujeres). De los pacientes dados de alta (39% del total; n = 925), 170 (20,5%) reconsultaron al SUH, principalmente por persistencia o progresión de síntomas, y 66 (38,8%) precisaron ingreso. Los factores relacionados con la revisita fueron: antecedentes de enfermedad reumatológica [OR: 2,97 (IC 95%: 1,10-7,99, p = 0,03)], síntomas digestivos [OR: 1,73 (IC 95%: 1,14-2,63, p = 0,01)], frecuencia respiratoria $ 20 [OR: 1,03 (IC 95%: 1,0-1,06, p = 0,05)] y haber recibido tratamiento con esteroides en urgencias [OR: 7,78 (IC 95%: 1,77-14,21, p = 0,01)]. Los factores asociados al ingreso en la revisita fueron la edad $ 48 años [OR: 2,57 (IC 95%: 1,42-4,67, p = 0,002)] y presentar fiebre [OR: 4,73 (IC 95%: 1,99-11,27, p = 0,001)].Los pacientes con posible COVID-19 menores de 48 años, sin comorbilidad y con signos vitales normales podrían ser dados de alta desde urgencias sin temor a sufrir complicaciones. Los antecedentes de enfermedad reumatológica, fiebre, sintomas digestivos, frecuencia respiratoria $ 20/min o necesidad de tratamiento con esteroides fueron factores independientes de revisita, y la fiebre y edad $ 48 años de necesidad de ingreso.

To identify predictors of mortality after implementation of a treatment protocol in the first 3 hours for patients who come to our emergency department with sepsis scored 2 or 3 on the Quick Sequential Organ Failure Assessment (qSOFA) scale.Our team identified adult emergency department patients with a diagnosis of sepsis on starting the morning shift between September 2018 and March 2019. We selected patients whose qSOFA score on arrival was 2 or 3. Variables were explored statistically to identify factors associated with mortality.A total of 90 patients with a mean (SD) age of 72 (16) years were included. Thirty-three (37%) died. Univariate analysis detected that the only qSOFA indicator that was significantly associated with mortality was altered mentation (level of consciousness), which was noted in 79% of patients who died versus 54% of survivors (P=.02). Other variables associated with higher mortality were age 70 years or older, an order to limit therapeutic interventions in emergencies, and lactic acid levels on first and second extractions. The treatment protocol was completed in 42% of the cases and compliance was associated with a lower mortality rate of 21% versus 54% when the protocol was not fully implemented (P=.003). Multivariate Cox regression analysis showed that risk for death was higher when the full protocol was not implemented within 3 hours of arrival (hazard ratio, 2.67; 95% CI, 1.15-6.21; P=.02).Full implementation of the protocol within 3 hours of hospital arrival favors survival in patients with sepsis and qSOFA scores of 2 or 3 on arrival. We recommend that emergency departments organize ways to train staff in the use of a sepsis treatment protocol and improve compliance.Determinar los factores predictivos de mortalidad de los pacientes que acuden a urgencias con sepsis y tiene un qSOFA de 2 o 3 puntos tras la implementación de un paquete de medidas a cumplimentar en las primeras 3 horas.De septiembre de 2018 a marzo de 2019 el equipo investigador identificó a los pacientes adultos que se encontraban en urgencias en el inicio del turno de mañana con el diagnóstico de sepsis. De estos pacientes se seleccionaron los que en el momento de su llegada tenían un qSOFA de 2 o 3 puntos. Se realizó análisis estadístico para establecer los factores relacionados con mortalidad.Se incluyeron 90 pacientes con una edad media de 72 (DE 16) años. La mortalidad global fue de 33 pacientes (37%). En el análisis univariado de mortalidad, el único indicador del qSOFA con significación estadística fue el nivel de consciencia (79% vs 54%, p = 0,02). Otras variables relacionadas con mayor mortalidad fueron: edad igual o mayor de 70 años, orden de limitación del esfuerzo terapéutico en urgencias y valor de la primera y de la segunda determinación de lactato. El cumplimiento del paquete de medidas fue del 42% y se asoció a una menor mortalidad (21% vs 54%, p = 0,003). En el análisis multivariado mediante regresión de Cox, los pacientes en los que no se cumplimentó el paquete de medidas en las primeras 3 horas tuvieron mayor riesgo de mortalidad al final del episodio (HR = 2,67; IC95% = 1,15-6,21; p = 0,02).En los pacientes con sepsis y un qSOFA de 2-3 puntos a su llegada a urgencias el cumplimiento del paquete de medidas en las primeras 3 horas mejora la supervivencia. Es recomendable hacer los esfuerzos organizativos y docentes necesarios para mejorar el cumplimiento.

Background We aimed to externally validate an emergency department triage algorithm including five hierarchical clinical variables developed to identify chest pain patients at low risk of having an acute coronary syndrome justifying delayed rather than immediate evaluation. Methods In a single-centre cohort enrolling 29,269 consecutive patients presenting with chest pain, the performance of the algorithm was compared against the emergency department discharge diagnosis. In an international multicentre study enrolling 4069 patients, central adjudication by two independent cardiologists using all data derived from cardiac work-up including follow-up served as the reference. Triage towards ‘low-risk’ required absence of all five clinical ‘high-risk’ variables: history of coronary artery disease, diabetes, pressure-like chest pain, retrosternal chest pain and age above 40 years. Safety (sensitivity and negative predictive value (NPV)) and efficacy (percentage of patients classified as low risk) was tested in this initial proposal (Model A) and in two additional models: omitting age criteria (Model B) and allowing up to one (any) of the five high-risk variables (Model C). Results The prevalence of acute coronary syndrome was 9.4% in the single-centre and 28.4% in the multicentre study. The triage algorithm had very high sensitivity/NPV in both cohorts (99.4%/99.1% and 99.9%/99.1%, respectively), but very low efficacy (6.2% and 2.7%, respectively). Model B resulted in sensitivity/NPV of 97.5%/98.3% and 96.1%/89.4%, while efficacy increased to 14.2% and 10.4%, respectively. Model C resulted in sensitivity/NPV of 96.7%/98.6% and 95.2%/91.3%, with a further increase in efficacy to 23.1% and 15.5%, respectively. Conclusion A triage algorithm for the identification of low-risk chest pain patients exclusively based on simple clinical variables provided reasonable performance characteristics possibly justifying delayed rather than immediate evaluation in the emergency department.

During the last decades, several regions of the world have experienced an increasingly forceful penetration by commercial service companies into irrigation water management, altering the institutional structures and procedures of common-pool resources management. In many cases, private-sector penetration takes place when water user organizations require a company to implement high-tech water control such as pressurized irrigation systems, as part of ‘modernization policies’. This study focuses on four representative cases of these processes with differing degrees of private-enterprise penetration in the Valencia Region (Spain). The research analyzes the strategies of collective-private confrontation and collaboration that are emerging in irrigator communities, and characterize how they affect the management of these irrigation systems. Results show how private enterprise intrusion has unequally affected the interactions between the different components of these irrigation systems. This has created different hybrids between private and common pool-resources management institutions, as well as different autonomies, dependencies and socio-political subjects. Users’ capacity to guide this coproduction process and maintain local control over their irrigation systems is essential to ensure the stability and preserve the robustness of each irrigation system. The quality of human capital and the recognition of collective water management values makes irrigation entities more robust vis-a-vis external pressures and disturbances, which in some of the cases analyzed have generated major social conflicts.

[EN] This work focuses on the transformation occurred with the shift from surface to drip irrigation, looking at three collective irrigation systems in Valencia (Spain). The extension of drip irrigation over areas previously irrigated by systems of gravity channels entails a process of change and transformation ofinstitutions and organizations managing irrigation. We analyze the main management changes occurred and how farmers adapt to the new technology. In order to assess these changes, interviews were conducted with farmers and managers of Water User Associations. Drip irrigation implementation policies result in unforeseen consequences, paradoxes and challenges for collective drip irrigation management. In the three cases, drip irrigation and automation has contributed to the centralization of decision-making. Besides, farmers and managers have also developed irrigation and fertigation strategies to adapt to the new technology. When some ofthese new operating procedures are applied, farmers obtain results closer to their own goals, but not necessarily linked to the virtues frequently attributed to drip systems., The authors wish to gratefully acknowledge the financial support from IWRMnet-SCP to the project ICARUS - IWRM for Climate Change Adaptation in Rural socio-ecosystem in Southern Europe, and also to the IMPADAPT project (CGL2013-48424-C2-1-R) with Spanish MINECO (Ministerio de Economia y Competitividad) funds.

To analyze changes in the characteristics of consecutively treated patients attended in the chest pain unit of a hospital emergency department over a 10-year period.All patients presenting with nontraumatic chest pain (NTCP) were included. We analyzed changes over time in epidemiologic characteristics, initial diagnostic classification (on clinical and electrocardiographic evaluation), final diagnosis (on discharge), and time until these diagnoses.A total of 34 552 consecutive patients with a mean (SD) age of 59 (13) years were included; 42% were women. The annual number of visits rose over time. Visits were fewer in summer and more numerous on workdays and between the hours of 8 AM and 4 PM (P.001, both comparisons). The number of women increased over time (up 0.29% annually, P.05) as did the number of patients under the age of 50 years (up 0.92% annually, P.001). With time, patients had fewer cardiovascular risk factors and less often had a history of ischemic heart disease. Fewer cases of NTCP had signs suggestive of acute coronary syndrome (ACS). ACS was ruled out at the time of initial and final diagnoses in 52.2% and 80.4%, respectively, and these percentages which rose over the 10-year period by 1.86% (P.001) and 0.56% (P=.04). Time to initial diagnosis did not change. However, time to final diagnosis did increase (P.001), and the delay was longer in patients diagnosed with ACS (P.001).The chest pain unit was more active at the end of the period, in keeping with the increase in patients with NTCP whose characteristics were not typical of coronary disease. The percentages of patients initially and finally diagnosed with ACS decreased with time.Analizar la evolución de las características epidemiológicas de las visitas atendidas de forma consecutiva en una unidad de dolor torácico (UDT) de un servicio de urgencias hospitalario (SUH) durante un periodo de 10 años.Se incluyeron todas las visitas por dolor torácico no traumático (DTNT), analizándose la evolución temporal de las características epidemiológicas, de la clasificación diagnóstica inicial (evaluación clínica inicial y electrocardiograma) y final (al alta de la UDT), y los tiempos necesarios para alcanzar las mismas.Se incluyeron 34.552 pacientes consecutivos con una edad media 59 (DE 13) años, el 42% mujeres. Se observó un incrementó en el número anual de visitas a la UDT (p0,001), menor afluencia los meses de verano (p0,001), y mayor los días laborables (p0,001) y de 8-16 horas (p0,001). Se comprobó que progresivamente más pacientes eran mujeres (+0,29% anual, p0,05), menores de 50 años (+0,92%, p0,001), con más factores de riesgo cardiovascular, menos antecedentes de cardiopatía isquémica y con DTNT menos sugestivo de síndrome coronario agudo (SCA). La clasificación diagnóstica inicial y final descartó SCA en un 52,2% y un 80,4% de pacientes, respectivamente, hecho que aumentó progresivamente durante el periodo evaluado (+1,86%, p0,001; y +0,56%, p = 0,04; respectivamente). El tiempo de clasificación inicial no se modificó, pero se incrementó el necesario para la clasificación final (p0,001), que resultó superior en pacientes con diagnóstico final de SCA (p0,001).Se observa un mayor uso de la UDT tras su creación, causado por un incremento de pacientes con DTNT de características no típicamente coronarias, disminuyendo el porcentaje de clasificados inicial y finalmente como debidos a SCA.

One of the most important challenges that agriculture faces is sustainable water management and its adaptation to climate change. This adaptation is more important in regions where recurrent draughts and overexploitation of water resources happen. However, historical irrigation systems, such as the Real Acequia de Moncada (RAM) in Valencia, have found innovative approaches to deal with this phenomenon. This paper analyzes the case of Massamagrell and Pu&ccedil, ol, which reused the treated waste-water of the closest waste-water treatment plant (WWTP). The study focused from a circular economy perspective on the technological, agronomical, and social implications of this decision. Results show that there are clear benefits for both farmers and WWTP managers. On the one hand, additional nutrients and regularity in their water supply benefit farmers. On the other, WWTP managers can reuse the treated effluent in the system, contributing to the closure of the water cycle and avoiding pumping the treated water into the sea. However, more detailed information and coordination is needed among the different stakeholders. Questions regarding the illegal connection of waste pipes with the traditional irrigation or the payment of pumping costs for reuse have gone unanswered, and there is a need for better reflection from all stakeholders.

The aim was to develop a predictive model of infection by multidrug-resistant microorganisms (MDRO). A national, retrospective cohort study was carried out including all patients attended for an infectious disease in 54 Spanish Emergency Departments (ED), in whom a microbiological isolation was available from a culture obtained during their attention in the ED. A MDRO infection prediction model was created in a derivation cohort using backward logistic regression. Those variables significant at p0.05 assigned an integer score proportional to the regression coefficient. The model was then internally validated by k-fold cross-validation and in the validation cohort. A total of 5460 patients were included; 1345 (24.6%) were considered to have a MDRO infection. Twelve independent risk factors were identified in the derivation cohort and were combined into an overall score, the ATM (assessment of threat for MDRO) score. The model achieved an area under the curve-receiver operating curve of 0.76 (CI 95% 0.74-0.78) in the derivation cohort and 0.72 (CI 95% 0.70-0.75) in the validation cohort (p = 0.0584). Patients were then split into 6 risk categories and had the following rates of risk: 7% (0-2 points), 16% (3-5 points), 24% (6-9 points), 33% (10-14 points), 47% (15-21 points), and 71% (21 points). Findings were similar in the validation cohort. Several patient-specific factors were independently associated with MDRO infection risk. When integrated into a clinical prediction rule, higher risk scores and risk classes were related to an increased risk for MDRO infection. This clinical prediction rule could be used by providers to identify patients at high risk and help to guide antibiotic strategy decisions, while accounting for clinical judgment.

In recent years, fish nucleated red blood cells (RBCs) have been implicated in the response against viral infections. We have demonstrated that rainbow trout RBCs can express the antigen encoded by a DNA vaccine against viral hemorrhagic septicemia virus (VHSV) and mount an immune response to the antigen in vitro. In this manuscript, we show, for the first time, the role of RBCs in the immune response triggered by DNA immunization of rainbow trout with glycoprotein G of VHSV (GVHSV). Transcriptomic and proteomic profiles of RBCs revealed genes and proteins involved in antigen processing and presentation of exogenous peptide antigen via MHC class I, the Fc receptor signaling pathway, the autophagy pathway, and the activation of the innate immune response, among others. On the other hand, GVHSV-transfected RBCs induce specific antibodies against VHSV in the serum of rainbow trout which shows that RBCs expressing a DNA vaccine are able to elicit a humoral response. These results open a new direction in the research of vaccination strategies for fish since rainbow trout RBCs actively participate in the innate and adaptive immune response in DNA vaccination. Based on our findings, we suggest the use of RBCs as target cells or carriers for the future design of novel vaccine strategies., This research was funded by the European Research Council, grant number GA639249 (ERC Starting Grant).

It has recently come to light that nucleated red blood cells (RBCs) of fish, amphibians, reptiles and birds are multifunctional cells, because in addition to being involved in gas exchange and transport, it has also been reported that they respond to pathogens by means of (i) phagocytosis, (ii) antigen presentation, (iii) production of cytokines and antimicrobial peptides, (iv) regulation of complement system, and (v) exerting paracrine molecular communication with other immune cells and modulating their functions. Similarly, human cord blood nucleated RBCs have been shown to exert a regulatory function in the innate immune response, by means of the suppression of the production of inflammatory cytokines. This chapter comprises the study of the implications of nucleated RBCs as mediators of both branches of immune system (innate and adaptive immune responses). This work was supported by the European Research Council (ERC Starting Grant GA639249)

To compare the usefulness of the Quick Sepsis-related Organ Dysfunction (qSOFA) score and the Andorran Triage Model in a hospital emergency department.Patients who came to emergency department of a tertiary-eme hospital during the first hour of the morning shift over a 6-month period were included in the study if severity was assessed as level 2 or 3 according to the Andorran model. The qSOFA score was also assessed on arrival. The patients were then followed prospectively in the department and if they were admitted, follow-up continued on the ward. Thirty-day mortality was analyzed with Kaplan-Meier curves and the Cox multiple-variable regression model.A total of 322 patients with a mean age of 61 years were included. The qSOFA scores on arrival in the department were 0-1 points in 294 patients (91%) and 2-3 points in 28 (9%). Fourteen patients died as a consequence of the emergency. The 30-day probability of survival was calculated to be 97%. Factors related to mortality were level-2 triage classification, a qSOFA score of 2-3 points, age 70 years or older, and an abbreviated Charlson index of 4 points or higher. A qSOFA score of 2-3 points was the only independent variable associated with mortality in the Cox model.The qSOFA score is a useful triage indicator in patients who come to a hospital emergency department. It identifies patients with a worse prognosis.Comparar la utilidad pronóstica del ‘quick SOFA’ (qSOFA) con respecto al nivel de triaje asignado por el Modelo Andorrano de Triaje (MAT) en un servicio de urgencias hospitalario (SUH).Durante seis meses se incluyó a los pacientes que en la primera hora del turno de mañana consultaron en urgencias de un hospital terciario y fueron clasificados como nivel 2 o nivel 3 según el MAT. Se realizó seguimiento prospectivo del episodio de urgencias y del episodio de ingreso de aquellos pacientes que lo requirieron. Se analizó la mortalidad a 30 días mediante curvas de Kaplan-Meier y análisis multivariante mediante regresión de Cox.Se incluyeron 322 pacientes (edad media de 61 años). El valor del qSOFA a la llegada a urgencias fue de 0-1 puntos en 294 (91%) y de 2-3 puntos en 28 pacientes (9%). Un total de 14 pacientes fallecieron como consecuencia del episodio que motivó su asistencia en urgencias, y la probabilidad de supervivencia a los 30 días fue del 97%. Los factores relacionados con mayor mortalidad fueron el nivel 2 de triaje, el valor de qSOFA 2-3 puntos, la edad igual o mayor de 70 años y un índice Charlson abreviado de comorbilidad 4 puntos. En el análisis de regresión de Cox, un valor de qSOFA 2-3 fue el único factor asociado de forma independiente a mayor mortalidad.El qSOFA es un indicador útil en el triaje de los pacientes que acuden a un SUH, puesto que identifica de forma independiente a los que tienen un peor pronóstico.