Ecological impacts of atmospheric pollution and interactions with climate change in terrestrial ecosystems of the Mediterranean Basin:Current research and future directions

Mediterranean Basin ecosystems, their unique biodiversity, and the key services they provide are currently at risk due to air pollution and climate change, yet only a limited number of isolated and geographically-restricted studies have addressed this topic, often with contrasting results. Particularities of air pollution in this region include high O3 levels due to high air temperatures and solar radiation, the stability of air masses, and dominance of dry over wet nitrogen deposition. Moreover, the unique abiotic and biotic factors (e.g., climate, vegetation type, relevance of Saharan dust inputs) modulating the response of Mediterranean ecosystems at various spatiotemporal scales make it difficult to understand, and thus predict, the consequences of human activities that cause air pollution in the Mediterranean Basin. Therefore, there is an urgent need to implement coordinated research and experimental platforms along with wider environmental monitoring networks in the region. In particular, a robust deposition monitoring network in conjunction with modelling estimates is crucial, possibly including a set of common biomonitors (ideally cryptogams, an important component of the Mediterranean vegetation), to help refine pollutant deposition maps. Additionally, increased attention must be paid to functional diversity measures in future air pollution and climate change studies to establish the necessary link between biodiversity and the provision of ecosystem services in Mediterranean ecosystems. Through a coordinated effort, the Mediterranean scientific community can fill the above-mentioned gaps and reach a greater understanding of the mechanisms underlying the combined effects of air pollution and climate change in the Mediterranean Basin

Three-Layer Control for Active Wrists in Robotized Laparoscopic Surgery

Abstract-This paper is focused on the motion control problem for a laparoscopic surgery robot assistant with an actuated wrist. These assistants may apply non-desired efforts to the patient abdomen. Therefore, this article proposes a control methodology based on three feedback levels, which have been defined as layers. These layers control different aspects of the endoscope movement. A low level assures the dynamic of the robot assistant is performed accordingly. The mid level emulates a passive wrist behavior to avoid any efforts over the abdomen. An external high level deals with the global movement planning. This architecture also makes easier to analyze the stability of the whole system. Finally, a real in-vitro experiment has been implemented with an industrial robot in order to contrast the validity of this article procedure

Caracterización del desplazamiento generado en la raíz del conjunto menisco-sutura en el postoperatorio inmediato mediante video-fotogrametría

La reparación de la raíz meniscal mediante técnica de sutura transtibial es cada vez más frecuente, a medida que se producen avances en los métodos de diagnóstico de este tipo de lesión. Una complicación tras este tipo de intervenciones es el desarrollo de desplazamientos de la raíz reparada por acumulación de las contribuciones de los distintos componentes involucrados en el sistema de reparación: el material de sutura, la interacción menisco-sutura en los orificios de inserción y el método de cierre de las suturas. Estos desplazamientos pueden propiciar la cicatrización incompleta observada en diversos estudios clínicos sobre la efectividad de la reparación mediante técnicas de sutura transtibial. . Así mismo, pueden dar lugar a alteraciones importantes en el contacto de la articulación tibio-femoral, como se ha observado en un modelo porcino para desplazamientos de la raíz de 3 mm respecto a su posición anatómica. En este trabajo se propone un estudio biomecánico en modelo porcino del conjunto menisco-sutura aislado para analizar las contribuciones al desplazamiento de la raíz debidas a los alargamientos del hilo de sutura y de su orificio de inserción en el tejido meniscal bajo cargas de tracción. El trabajo concluye que: - La mayor aportación al desplazamiento de la raíz la produce el hilo de sutura para una longitud típica del túnel óseo de 40mm. - El inicio de la rotura del tejido meniscal se inicia a valores de carga muy próximos a la carga última en el ensayo de tracción. - En ausencia de monitorización, la fuerza del primer máximo local , de la curva del ensayo de rotura es una medida más representativa de la resistencia a la retención de la sutura del tejido meniscal que la carga última.Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tech

Validación del modelo porcino para el análisis comparativo del desplazamiento y la resistencia en la raíz meniscal reparada

Cuando se aplican técnicas de reinserción mediante sutura transtibial, el desplazamiento de la raíz se produce por acumulación de las contribuciones de los distintos componentes involucrados en el sistema de reparación: el material de sutura, la interacción menisco‐sutura en los orificios de inserción y el método de cierre de las suturas. Debido a la dificultad para disponer de especímenes de meniscos humanos de calidad similar a la dada en pacientes en los que habitualmente se prescribe la reparación (edad <55 años), en los estudios biomecánicos sobre técnicas de reparación meniscal es habitual el uso de especímenes animales y en particular de origen porcino. Con el objetivo de aportar datos acerca de la validez del uso de modelos porcinos en estudios comparativos de la eficacia de distintas técnicas de reparación de la raíz meniscal, se realiza un análisis comparando los resultados de un modelo porcino y un modelo humano. El estudio concluye que: - Las contribuciones porcentuales de las componentes estudiadas al desplazamiento de la raíz meniscal son similares en los modelos porcino y humano de edad avanzada utilizados, tanto tras el ensayo cíclico como al inicio del corte, lo que valida el uso del modelo porcino para estudios comparativos. - Fcut muestra valores muy cercanos a Fp y con una fuerte correlación positiva en modo humano y porcino. Mientras que Fult. no se correlaciona con Fcut en modelo humano, aunque si en modelo porcino El primer máximo local se propone como el valor más adecuado para analizar la resistencia a la retención de la sutura cuando no se monitoriza la entrefase menisco-sutura. -La resistencia a la retención de la sutura es significativamente mayor en modelo porcino que en modelo humano de edad avanzada.Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tech

DataSheet2_Age influence on resistance and deformation of the human sutured meniscal horn in the immediate postoperative period.pdf

Introduction: To preserve knee function, surgical repair is indicated when a meniscal root disinsertion occurs. However, this surgery has not yet achieved complete recovery of the joint´s natural biomechanics, with the meniscus-suture interface identified as a potentially determining factor. Knowing the deformation and resistance behavior of the sutured meniscal horn and whether these properties are preserved as the patient ages could greatly contribute to improving repair outcomes.Methods: A cadaveric experimental study was conducted on human sutured menisci classified into three n = 22 age groups (young ≤55; 55 Results: At the tissue level, the resistance in terms of Sc decrease with age (young: 47.2 MPa; middle-aged: 44.7 MPa; old: 33.8 MPa) being significantly different between the young and the old group (p = 0.015). Mean meniscal thickness increased with age (young: 2.50 mm; middle-aged: 2.92 mm; old: 3.38 mm; p = 0.001). Probably due to thickening, no differences in resistance were found at the specimen level, i.e., in Fc (overall mean 58.2 N) and Fu (overall mean 73.6 N). As for elasticity, ms was lower in the old group than in the young group (57.5 MPa vs. 113.6 MPa, p = 0.02) and the middle-aged one (57.5 MPa vs. 108.0 MPa, p = 0.04).Conclusion: Regarding the influence of age on the sutured meniscal horn tissue, in vitro experimentation revealed that meniscal horn specimens older than 75 years old had a more elastic tissue which was less resistant to cut-out than younger menisci at the suture hole area. However, a thickening of the meniscal horns with age, which was also found, leveled out the difference in the force that initiated the tear, as well as in the maximum force borne by the meniscus in the load-to-failure test.</p

DataSheet1_Age influence on resistance and deformation of the human sutured meniscal horn in the immediate postoperative period.pdf

Introduction: To preserve knee function, surgical repair is indicated when a meniscal root disinsertion occurs. However, this surgery has not yet achieved complete recovery of the joint´s natural biomechanics, with the meniscus-suture interface identified as a potentially determining factor. Knowing the deformation and resistance behavior of the sutured meniscal horn and whether these properties are preserved as the patient ages could greatly contribute to improving repair outcomes.Methods: A cadaveric experimental study was conducted on human sutured menisci classified into three n = 22 age groups (young ≤55; 55 Results: At the tissue level, the resistance in terms of Sc decrease with age (young: 47.2 MPa; middle-aged: 44.7 MPa; old: 33.8 MPa) being significantly different between the young and the old group (p = 0.015). Mean meniscal thickness increased with age (young: 2.50 mm; middle-aged: 2.92 mm; old: 3.38 mm; p = 0.001). Probably due to thickening, no differences in resistance were found at the specimen level, i.e., in Fc (overall mean 58.2 N) and Fu (overall mean 73.6 N). As for elasticity, ms was lower in the old group than in the young group (57.5 MPa vs. 113.6 MPa, p = 0.02) and the middle-aged one (57.5 MPa vs. 108.0 MPa, p = 0.04).Conclusion: Regarding the influence of age on the sutured meniscal horn tissue, in vitro experimentation revealed that meniscal horn specimens older than 75 years old had a more elastic tissue which was less resistant to cut-out than younger menisci at the suture hole area. However, a thickening of the meniscal horns with age, which was also found, leveled out the difference in the force that initiated the tear, as well as in the maximum force borne by the meniscus in the load-to-failure test.</p

Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016

Importance: End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time. Objective: To determine the changes in end-of-life practices in European ICUs after 16 years. Design, Setting, and Participants: Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision. Exposures: Comparison between the 1999-2000 cohort vs 2015-2016 cohort. Main Outcomes and Measures: End-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation [CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists. Results: Of 13 625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n = 2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years [interquartile range {IQR}, 59-79] vs 67 years [IQR, 54-75]; P < .001) and the proportion of female patients was similar (39.6% vs 38.7%; P = .58). Significantly more treatment limitations occurred in the 2015-2016 cohort compared with the 1999-2000 cohort (1601 [89.7%] vs 1918 [68.3%]; difference, 21.4% [95% CI, 19.2% to 23.6%]; P < .001), with more withholding of life-prolonging therapy (892 [50.0%] vs 1143 [40.7%]; difference, 9.3% [95% CI, 6.4% to 12.3%]; P < .001), more withdrawing of life-prolonging therapy (692 [38.8%] vs 695 [24.8%]; difference, 14.0% [95% CI, 11.2% to 16.8%]; P < .001), less failed CPR (110 [6.2%] vs 628 [22.4%]; difference, -16.2% [95% CI, -18.1% to -14.3%]; P < .001), less brain death (74 [4.1%] vs 261 [9.3%]; difference, -5.2% [95% CI, -6.6% to -3.8%]; P < .001) and less active shortening of the dying process (17 [1.0%] vs 80 [2.9%]; difference, -1.9% [95% CI, -2.7% to -1.1%]; P < .001). Conclusions and Relevance: Among patients who had treatment limitations or died in 22 European ICUs in 2015-2016, compared with data reported from the same ICUs in 1999-2000, limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently. These findings suggest a shift in end-of-life practices in European ICUs, but the study is limited in that it excluded patients who survived ICU hospitalization without treatment limitations.status: publishe

Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016

Key PointsQuestionHave end-of-life practices in European intensive care units (ICUs) changed from 1999-2000 to 2015-2016? FindingsIn this prospective observational study of 1785 patients who had limitations in life-prolonging therapies or died in 22 European ICUs in 2015-2016, compared with data previously reported from the same ICUs in 1999-2000 (2807 patients), treatment limitations (withholding or withdrawing life-sustaining treatment or active shortening of the dying process) occurred significantly more frequently (89.7\% vs 68.3\%), whereas death without any limitations in life-prolonging therapies occurred significantly less frequently (10.3\% vs 31.7\%). MeaningThese findings suggest that end-of-life care practices in European ICUs changed from 1999-2000 to 2015-2016 with more limitations in life-prolonging therapies and fewer deaths without treatment limitations. ImportanceEnd-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time. ObjectiveTo determine the changes in end-of-life practices in European ICUs after 16 years. Design, Setting, and ParticipantsEthicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision. ExposuresComparison between the 1999-2000 cohort vs 2015-2016 cohort. Main Outcomes and MeasuresEnd-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation {[}CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists. ResultsOf 13625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1\%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n=2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years {[}interquartile range \{IQR\}, 59-79] vs 67 years {[}IQR, 54-75]; P&lt;.001) and the proportion of female patients was similar (39.6\% vs 38.7\%; P=.58). Significantly more treatment limitations occurred in the 2015-2016 cohort compared with the 1999-2000 cohort (1601 {[}89.7\%] vs 1918 {[}68.3\%]; difference, 21.4\% {[}95\% CI, 19.2\% to 23.6\%]; P&lt;.001), with more withholding of life-prolonging therapy (892 {[}50.0\%] vs 1143 {[}40.7\%]; difference, 9.3\% {[}95\% CI, 6.4\% to 12.3\%]; P&lt;.001), more withdrawing of life-prolonging therapy (692 {[}38.8\%] vs 695 {[}24.8\%]; difference, 14.0\% {[}95\% CI, 11.2\% to 16.8\%]; P&lt;.001), less failed CPR (110 {[}6.2\%] vs 628 {[}22.4\%]; difference, -16.2\% {[}95\% CI, -18.1\% to -14.3\%]; P&lt;.001), less brain death (74 {[}4.1\%] vs 261 {[}9.3\%]; difference, -5.2\% {[}95\% CI, -6.6\% to -3.8\%]; P&lt;.001) and less active shortening of the dying process (17 {[}1.0\%] vs 80 {[}2.9\%]; difference, -1.9\% {[}95\% CI, -2.7\% to -1.1\%]; P&lt;.001). Conclusions and RelevanceAmong patients who had treatment limitations or died in 22 European ICUs in 2015-2016, compared with data reported from the same ICUs in 1999-2000, limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently. These findings suggest a shift in end-of-life practices in European ICUs, but the study is limited in that it excluded patients who survived ICU hospitalization without treatment limitations. This study compares changes in end-of-life practices (withholding or withdrawing of life-prolonging therapy, active shortening of the dying process, failed CPR, documentation of brain death) in 22 European ICUs between 1999-2000 and 2015-2016

Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study

Background End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices. Methods In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision. Findings Of 87 951 patients admitted to ICU, 12 850 (14middot6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p&lt;0middot001). Limitation of life-sustaining treatment occurred in 10 401 patients (11middot8% of 87 951 ICU admissions and 80middot9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44middot1%]), followed by withdrawing life-sustaining treatment (4680 [36middot4%]). More treatment withdrawing was observed in Northern Europe (1217 [52middot8%] of 2305) and Australia/New Zealand (247 [45middot7%] of 541) than in Latin America (33 [5middot8%] of 571) and Africa (21 [13middot0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0middot5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5middot1%). Failure of CPR occurred less frequently in Northern Europe (85 [3middot7%] of 2305), Australia/New Zealand (23 [4middot3%] of 541), and North America (78 [8middot5%] of 918) than in Africa (106 [65middot4%] of 162), Latin America (160 [28middot0%] of 571), and Southern Europe (590 [22middot5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation. Interpretation Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide. Funding None. Copyright (c) 2021 Elsevier Ltd. All rights reserved