ON ТНЕ QUANTIТAТIVE DEТERMINATION OF CONCREMENTS

In our previous report the results were presented of comparative studies of methods for quantitative determination of calcium, magnesium, oxalate and phosphate ions in model solutions of concrements. The experimental data obtained indicate that the following methods may bе considered the most appropriate:1. Complexometric determination of Са2+ with 0,002 М solution of complexon III with fluorexon - thymolphthalein as indicator.2. Simultaneous complexometric determination of Са2-+ аnd Mg2 + а separate determination of Са2+ and detection of the amount of Mg2+ through the existing difference. 3. Plumbometric determination of C2O42 - with 0,1 М solution of Рb(NО3)2.4. Direct complexometric determination of РO43 - with 0,01 M solution of MgSO4. The purpose of the prelimiпary work was to evaluate contemporary methods for the determination of Ca2+, Mg2+, С2O42 - and РO43 - first оn model solutions аnd then on native concrements. In the present work some results are reported of the quantitative study of concrements of renal or vesical origin. The materials are obtained at the Surgical Clinic and the Propedeutic Iпternal Clinic at the Higher Medical Institute in Varna. Data presented are compaired with data obtained bу means of other methods

ON ТНЕ QUANTIТAТIVE DEТERMINATION OF CONCREMENTS

The chemical composition of concrements has been of clinical interest for long. For that reason methods for its determination have already been devised. А method for the qualitative examination of concrements is proposed bу Halman. These methods are old in many respects and do not meet the present capacities of chemical analysis. А method for quantitative determination has been proposed also bу Schpet and Кeiser, but this method is neither contemporary.The interest shown in internal and urological practice toward the quantitative composition of concrements stimulated us to elaborate а method for quantitative analysis, primarily of renal and vesical concrements. We directed our attention mainly toward modern methods. Our definite experimental work consisted of the following: 1) comparative study of known methods on model solutions prepared bу us; 2) application of selected methods for definite analysis of concrements. We chose mainly complexometric methods which imvosed а necessity to specify the conditions for determination of Са +, Mg2+, C2O42-, РO43- in model solutions, resembling concrement solutions. The results are reported in the present work

Impact of renal impairment on atrial fibrillation: ESC-EHRA EORP-AF Long-Term General Registry

Background: Atrial fibrillation (AF) and renal impairment share a bidirectional relationship with important pathophysiological interactions. We evaluated the impact of renal impairment in a contemporary cohort of patients with AF. Methods: We utilised the ESC-EHRA EORP-AF Long-Term General Registry. Outcomes were analysed according to renal function by CKD-EPI equation. The primary endpoint was a composite of thromboembolism, major bleeding, acute coronary syndrome and all-cause death. Secondary endpoints were each of these separately including ischaemic stroke, haemorrhagic event, intracranial haemorrhage, cardiovascular death and hospital admission. Results: A total of 9306 patients were included. The distribution of patients with no, mild, moderate and severe renal impairment at baseline were 16.9%, 49.3%, 30% and 3.8%, respectively. AF patients with impaired renal function were older, more likely to be females, had worse cardiac imaging parameters and multiple comorbidities. Among patients with an indication for anticoagulation, prescription of these agents was reduced in those with severe renal impairment, p <.001. Over 24 months, impaired renal function was associated with significantly greater incidence of the primary composite outcome and all secondary outcomes. Multivariable Cox regression analysis demonstrated an inverse relationship between eGFR and the primary outcome (HR 1.07 [95% CI, 1.01–1.14] per 10 ml/min/1.73 m2 decrease), that was most notable in patients with eGFR <30 ml/min/1.73 m2 (HR 2.21 [95% CI, 1.23–3.99] compared to eGFR ≥90 ml/min/1.73 m2). Conclusion: A significant proportion of patients with AF suffer from concomitant renal impairment which impacts their overall management. Furthermore, renal impairment is an independent predictor of major adverse events including thromboembolism, major bleeding, acute coronary syndrome and all-cause death in patients with AF

Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry

Background: Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The ‘Atrial fibrillation Better Care’ (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients. Methods: From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses. Results: Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58–0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52–0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58–0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56–0.98) and composite outcome (aHR: 0.76, 95%CI 0.60–0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. Conclusions: An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients

Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients: a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry

Background: Epidemiological studies in atrial fibrillation (AF) illustrate that clinical complexity increase the risk of major adverse outcomes. We aimed to describe European AF patients\u2019 clinical phenotypes and analyse the differential clinical course. Methods: We performed a hierarchical cluster analysis based on Ward\u2019s Method and Squared Euclidean Distance using 22 clinical binary variables, identifying the optimal number of clusters. We investigated differences in clinical management, use of healthcare resources and outcomes in a cohort of European AF patients from a Europe-wide observational registry. Results: A total of 9363 were available for this analysis. We identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients and prevalent non-cardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients with low prevalence of comorbidities; Cluster 3 (n = 2955;31.6%) characterized by patients\u2019 prevalent cardiovascular risk factors/comorbidities. Over a mean follow-up of 22.5 months, Cluster 3 had the highest rate of cardiovascular events, all-cause death, and the composite outcome (combining the previous two) compared to Cluster 1 and Cluster 2 (all P <.001). An adjusted Cox regression showed that compared to Cluster 2, Cluster 3 (hazard ratio (HR) 2.87, 95% confidence interval (CI) 2.27\u20133.62; HR 3.42, 95%CI 2.72\u20134.31; HR 2.79, 95%CI 2.32\u20133.35), and Cluster 1 (HR 1.88, 95%CI 1.48\u20132.38; HR 2.50, 95%CI 1.98\u20133.15; HR 2.09, 95%CI 1.74\u20132.51) reported a higher risk for the three outcomes respectively. Conclusions: In European AF patients, three main clusters were identified, differentiated by differential presence of comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of major adverse outcomes

Existing monitoring of Mediterranean sea: a gap analysis

The Marine Strategy Framework Directive (2008/56/EC) of the European Parliament and of the Council (17th June 2008) establishes a framework for community action in the field of marine environmental policy. A crucial issue will be to improve the existing marine monitoring programs to cover the MSFD requirements. The comparison and identification of gaps in the existent national monitoring is a first step to include new parameters and frequencies of observation according to all relevant Directives and specially to MSFD. Our report is a first, integrated, cross-state assessment of the present state of Mediterranean monitoring networks. Data on monitoring stations have been provided from all member states of IRIS-SES + Croatia and joint in a unique georeferenced dataset. We used the cross-classification to build contingency tables of the counts at each combination of factor levels. Distances from coastline, densities of sampling stations, spatial overlap across descriptors, were also reported. As main results, we observed a large heterogeneity across MS on the parameters measured for each descriptors, on the density of sampling stations and on the frequency of sampling. Larger gaps have been identified for the descriptors Mammals, Birds, Reptiles (D1, D4, D6), Litter (D10), Energy & Noise (D11). The outputs from this work will be included into a GIS planning tool (Activity 3) including many scales and levels on which the MSFD Directive has been built on, such as the characteristics level (e.g. biological features, physicochemical features), pressure and impact, indicator/threshold, spatial (location of monitoring stations) and temporal (frequency-periodicity) across regions-subregions-countries

Spatial and temporal extent of monitoring water column and seabed habitats indicators, based on their scales of natural variation

The Marine Framework Strategy Directive (MFSD, 2008/56/EC) aims for clean, healthy and productive marine ecosystems within all the EU Members states. The MFSD promotes an holistic, ecosystem based approach to marine conservation and monitoring (Art. 13) Monitoring strategies should: 1) focus on the potential of scale dependence in the observed dynamics and 2) be able to integrate the effect of mediating factors operating at different scale levels. However, present knowledge on spatial and temporal fluctuations in marine ecosystems is scarce. The boundaries of natural variation of several important marine ecosystem processes are still undefined. A major source of complexity is the fact that ecosystem processes are occurred across different spatial as well as temporal scales. The present knowledge gap results in uncertainty on the selection of measured parameters and the definition of sampling frequency and sites. Hereby, we discuss theoretical and applied issues related to definition of optimal cross-scale monitoring strategies. Literature data and existing databases were analyzed, to define the connectivity across nested scales of principal D1 (Biodiversity), D5 (Eutrophication), D6 (Seabed habitat integrity) MFSD descriptors. We conclude that present monitoring strategy does not completely fulfil the scaling issues due to lack of theoretical knowledge on cross-scale processes and poor coordination across monitoring operators. A stronger cooperation among member states and regional environmental agencies is needed to implement efficient cross-scale environmental monitoring. This research was developed by partners of the Integrated Regional monitoring Implementation Strategy in the South European Seas (IRIS-SES, http://iris-ses.eu) Project, a pilot project on new knowledge for an integrated management of human activities in the sea (PP/ENV D2/SEA 2012), funded by the European Union

Implementation of Marine Framework Directive for descriptors D1, D5, D6: milestones to cope monitoring plans with natural variability. Spatial and temporal extent of monitoring water column and seabed habitats indicators, based on their scales of natural variation

A major source of complexity in marine ecosystem monitoring is represented by the fact that ecosystem processes occurring across different spatial and temporal scales. The implementation of the monitoring strategies applied in accordance to Marine Framework Strategy Directive (MFSD, 2008/56/EC) is a step-by-step process, which should be focus on the potential of scale dependence in the observed dynamics and should be able to integrate the effect of mediating factors operating at different scale levels. Nevertheless, the correct definition of monitoring efforts for each indicator needs to reach a well-defined knowledge on the actual assessment of the “object” of monitoring including ranges of natural variability in terms of spatial and temporal natural fluctuations. Unluckily natural fluctuations are not yet well defined in marine environments for all of the MSFD indicators. For these reasons the achievement of MSFD goals could be severely affected by the lack of knowledge which led to the lack of clear and rationale criteria on the basis of which to align and cope the scale of the assessment with the ecosystem natural fluctuations. Hereby we address the design of monitoring programmes concerning water column and seabed habitats integrity indicators (Descriptors D1, D5, D6) by discussing spatial and temporal extent of monitoring based on their scales of natural variation. The multiple layer approach developed on mesoscales could allow reducing mistakes due to sampling and methodological limits and could allow reducing problems ranging within the comprehension of mechanisms to the anticipation of consequences. The opportune mesoscale is dependent on the indicator considered and range within 0.5 – 100 km for the spatial scale and from 0.2 to 12 months for the temporal scale