Continuous renal replacement therapy (CRRT) is increasingly used for the management of critically ill patients. As a consequence, the incidence of complications that accompany CRRT is also rising. However, a standardized approach for preventing or minimizing these adverse events is lacking. Dialytrauma is a newly proposed concept that encompasses all harmful adverse events related to CRRT while providing a framework for prevention or, at the least, early recognition of these events in order to attenuate the consequences. A mainstay of this approach is the utilization of a dedicated checklist for improving CRRT quality and patient safety. In this context, we discuss the most important adverse effects of CRRT and review current strategies to minimize them.

Since fish show daily rhythms in most physiological functions, it should not be 27 surprising that stressors may have different effects depending on the timing of exposure. 28Here we investigated the influence of time of day on the stress responses, at both 29 physiological and cellular levels, in gilthead sea bream (Sparus aurata L.) submitted to 30 air exposure for 30 s and then returned to their tank. One hour after air exposure, blood, 31 hypothalamus and liver samples were taken. Six fish per experimental group (control 32 and stressed) were sampled every 4 h during a 24-h cycle. Fish were fed in the middle 33 of the light cycle (ML) and locomotor activity rhythms were recorded using infrared 34 photocells to determine their daily activity pattern of behavior, which showed a peak 35 around feeding time in all fish. In the control group cortisol levels did not show daily 36 rhythmicity whereas in the stressed fish a daily rhythm of plasma cortisol was observed, 37 being the average values higher than in the control group, with increased differences 38 during the dark phase. Blood glucose showed daily rhythmicity in the control group but 39 not in the stressed one which also showed higher values at all sampling points. In the 40 hypothalamus of control fish a daily rhythm of corticotropin-releasing hormone (crh) 41 gene expression was observed, with the acrophase at the beginning of the light phase. 42However, in the stressed fish, this rhythm was abolished. The expression of 43 corticotropin-releasing hormone binding protein (crhbp) showed a peak at the end of 44 the dark phase in the control group, whereas in the stressed sea bream this peak was 45 found at ML. Regarding hepatic gene expression of oxidative stress biomarkers: i) 46 cytochrome c oxidase 4 (coxIV) showed daily rhythmicity in both control and stressed 47 fish, with the acrophases located around ML, ii) peroxiredoxin 3 (prdx3) and 5 (prdx5) 48 only presented daily rhythmicity of expression in the stressed fish, with the acrophase 49 located at the beginning of the light cycle, and iii) uncoupling protein 1 (ucp1) showed 50 3 significant differences between sampling points only in the control group, with 51 significantly higher expression at the beginning of the dark phase. Taken Fish in the wild and in aquaculture facilities face a variety of challenges, such as 77 attacks from predators, food competition, disturbance and exposure to poor water 78 quality, which seriously compromise fish welfare (Huntingford et al., 2006). The 79 specimens react to these adverse conditions through cellular, neuroendocrine and 80 behavioral adjustments, although the circadian mechanisms controlling these responses 81are not fully understood (Kulkckzykowska & Sánchez-Vázquez, 2010). 82The primary physiological response to stress in fish involves two major 83 neuroendocrine pathways: i) the hypothalamic sympathetic chromaffin cells (HSC) axis, 84and ii) the hypothalamic-pituitary-interrenal (HPI) axis (Wendelaar Bonga, 1997). In 85 the HPI cascade, corticotropin-...

Inappropriate antibiotic use in primary care, such as in respiratory tract infections (RTIs), is an important cause of bacterial resistance. This study aimed at describing the current pattern of outpatient antibiotic use in acute RTIs in Spain and evaluating adherence to national recommendations. A retrospective observational study was performed including all the episodes of RTIs registered during a 1-year period in a north-eastern Spanish region. Data related to patient demography, diagnoses and antibiotic prescriptions were collected from the electronic medical history database in the region, and adherence to recommendations for antibiotic prescribing was assessed. One third of patients with a RTI were prescribed an antibiotic, with young adults (aged 15-64 years) being the most treated. High prescribing rates were observed in patients with acute otitis, sinusitis and acute tonsillitis (about 70%), whereas low rates were found in acute bronchitis (50%) and non-specific upper RTIs (24%) episodes. A high prescription of broad-spectrum agents and antibiotics not recommended as first choice was observed. In accordance with Spanish guidelines, there exists a potential over-prescribing of antibiotics for all the diagnoses studied, especially in the adult population. Moreover, the choice of antibiotics is frequently based on agents with a high risk of increasing antimicrobial resistance. Multifaceted strategies should be implemented to improve the quality of antibiotic prescribing in primary care.Antimicrobial resistance is a major concern to the public health and may result from indiscriminate or poor use of antibiotics [1].Infectious diseases are the most frequent reason for encounter in primary care, and respiratory tract infections (RTIs) account for about two-thirds of all infections seen by the general practitioner (GP) [2]. Despite the fact that the benefit of antimicrobial treatment is rather low [3,4], a substantial number of patients with RTI are treated with antibiotics [5,6]. Diagnostic uncertainty characterizes the management of RTIs and doubt about the diagnosis and the aetiology may lead to antibiotic over-prescribing. Other factors such as patient preferences, fears of getting sued and fear of serious complications may influence the GP's prescribing decision [7].Studies have found a substantial gap between recommendations in evidence-based practice guidelines and doctors' actual prescribing behaviour [8].Compared with other European countries, Spain has historically displayed a high outpatient antibiotic use. The majority of antibiotics prescribed are broad-spectrum agents, and there are remarkable seasonal fluctuations reflecting an inappropriate prescribing of antibiotic for RTIs caused by viruses [9]. Consequently, resistance rates of the main respiratory pathogens remain high in Spain, although a decreasing trend has been observed in the last years [10].According to the disease-specific quality indicators for outpatient antibiotic prescribing developed by the European Surveillance Antimi...

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