Clinical features and long-term outcomes of systemic lupus erythematosus: comparative data of childhood, adult and late-onset disease in a national register

Systemic lupus erythematosus (SLE) affects predominantly women at reproductive age but may present at any age. Age at disease onset has a modulating effect on presentation and course of disease, but controversies persist regarding its impact on long-term outcome. Our aims were to characterize clinical features, co-morbidities and cumulative damage in childhood-onset, adult-onset and late-onset SLE. Patients with childhood-onset SLE fulfilling ACR 1997 criteria were identified in a nationwide register-Reuma.pt/SLE (N = 89) and compared with adult-onset and late-onset counterparts matched 1:1:1 for disease duration. 267 SLE patients with mean disease duration of 11.9 ± 9.3 years were analyzed. Skin (62 %), kidney (58 %), neurological (11 %) and hematologic involvement (76 %) were significantly more common in childhood-onset SLE and disease activity was higher in this subset than in adult- and late-onset disease (SLEDAI-2K 3.4 ± 3.8 vs. 2.2 ± 2.7 vs. 1.6 ± 2.8, respectively; p = 0.004). Also, more childhood-onset patients received cyclophosphamide (10 %) and mycophenolate mofetil (34 %). A greater proportion of women (96 %), prevalence of arthritis (89 %) and anti-SSA antibodies (34 %) were noted in the adult-onset group. There was a significant delay in the diagnosis of SLE in older ages. Co-morbidities such as hypertension, diabetes and thyroid disease were significantly more frequent in late-onset SLE, as well as the presence of irreversible damage evaluated by the SLICC/ACR damage index (20 vs. 26 vs. 40 %; p < 0.001). Greater organ involvement as well as the frequent need for immunosuppressants supports the concept of childhood-onset being a more severe disease. In contrast, disease onset is more indolent but co-morbidity burden and irreversible damage are greater in late-onset SLE, which may have implications for patients' management.

A quality improvement intervention in geriatric psychiatry care: Results of a pre-post design study

Introduction

Innovative approaches are needed to respond to the increasing number of elderly subjects with complex psychiatric conditions who require flexible and rapid responses, avoiding unnecessary hospital admissions. A new organizational model was implemented in our psychogeriatric service in September 2011 consisting of:

– a comprehensive multidisciplinary geriatric assessment;

– a helpline for caregivers for management of acute behavioral problems;

– programmed visits to nursing homes.

Aims

To evaluate whether the implementation of this program was associated with a reduction in hospital admissions and emergency department visits.

Methods

This is a pre-post test design study, involving 1197 patients who attended the Old Age Psychiatric (OAP) Unit three years before and three years after the implementation of the organizational intervention (1.09.2008 to 1.10.2014). An index of patient × year was calculated considering the period during which the patient was followed in OAP Unit. Data was obtained from the medical files of all eligible patients regarding demographic variables, number and type of hospital admissions and emergency department visits.

Results

During the 3 years before the intervention 671.2 patients × years were included (mean age of 75.8 years) while after the intervention this reached 2010.1 patients × years (mean age of 77.8 years). The intervention was associated with a decrease of 44% in psychiatry emergency visits, 48% in general emergency visits, 44% in psychiatric ward admissions and 51% in geriatric ward admissions.

Conclusions

The implementation of this new model was associated with significant reduction of hospital-based service utilization. Future research should determine if this was coupled with increased health outcomes.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Influence of feeding differentiation on the age at onset of puberty in Brazilian Bergamasca dairy ewe lambs

The objective of the study was to evaluate body growth and age at onset of puberty on lambs fed two specific diets for low and high growth rates. A herd of 20 Brazilian Bergamasca lambs was divided in two groups (n= 10) and kept confined throughout the experimental period, two animals of the same treatment/pen. Two phases were established: Phase 1, from 90 days of age until the onset of puberty; and Phase 2, from puberty onset up to 1 year old. For Phase 1, two distinct diets were formulated, being: Treatment A, which was formulated to obtain an average daily gain of approximately 150g; and Treatment B, for an average daily gain of about 250g. In Phase 2, a balanced, equal diet was provided to both groups. Every 14 days, the animals were weighed and given average daily gain, average daily dry matter intake and body condition score. From the 5th month of age on, in each group, a vasectomized male was used to detect estrus, establishing age at puberty onset and estrus interval for each lamb. Blood samples were collected every 28 days to determine plasma growth hormone concentration. Treatment B lambs gained more weight and had higher body condition score (P<0.05) and there was no difference for age at puberty onset and plasma growth hormone levels (P>0.05) between treatments. It was found that both treatments showed satisfactory performances. Thus, treatment A may be indicated as a reasonable feeding system to achieve positive responses on confined ewe lambs during growth phase.

Thoracoscopy in the management of pediatric empyemas

INTRODUCTION

Thoracoscopy is increasingly being used in the treatment of empyema. This study assesses feasibility, efficacy and safety in children.

MATERIAL AND METHODS

Clinical files of patients who underwent primary thoracoscopy for empyema between 2006 and 2014 were reviewed. Demographic, clinical and surgical data were analyzed and a comparison between the period before (period1) and after (period2) the learning curve was performed.

RESULTS

Ninety-one patients (53 males, 58%) were submitted to thoracoscopy at a median age of 4 years. There were 19 conversions to thoracotomy with a steady decrease of conversion rate until 2009 (period1) and no conversions thereafter (period2). There was no difference in any of the analyzed parameters between patients submitted to thoracoscopy alone and those requiring conversion in period1. Six cases (6.6%) needed redo-operation (five in period2) and thoracotomy was the elected approach in four. Necrotizing pneumonia was present in 60% of the reoperated cases; in other words, in period2 3 out of 9 cases with necrotizing pneumonia required reintervention (p=0.07). Thoracotomy was avoided in sixty-eight (75%) patients (62% in period1 versus 92% in period2, p=0.001).

DISCUSSION AND CONCLUSIONS

Thoracoscopic approach for empyema is feasible and safe avoiding a significant number of thoracotomies after a short learning curve. An increase of reintervention rate should be expected, but throracoscopy alone is effective in the great majority of the cases. Necrotizing pneumonia may be associated with a higher risk of reintervention, as it is a contra-indication to thoracoscopy and probably surgery.

Platelet Rich Plasma: What should the rheumatologist expect?

In the last few decades, thousands of patients have benefited from platelet rich plasma (PRP) therapies, emerging as a safe alternative in many different medical fields. Current evidence suggests that PRP may be of benefit over standard treatment in osteoarthritis patients and, in the musculoskeletal soft tissue injuries potential healing effects are waiting to be confirmed with robust evidence. Finally, in systemic rheumatic diseases PRP seems to have a role to play in the treatment of extra-articular symptoms.

Methamphetamine promotes α-tubulin deacetylation in endothelial cells: the protective role of acetyl-l-carnitine

Methamphetamine (METH) is a powerful psychostimulant drug used worldwide for its reinforcing properties. In addition to the classic long-lasting monoaminergic-disrupting effects extensively described in the literature, METH has been consistently reported to increase blood brain barrier (BBB) permeability, both in vivo and in vitro, as a result of tight junction and cytoskeleton disarrangement. Microtubules play a critical role in cell stability, which relies on post-translational modifications such as α-tubulin acetylation. As there is evidence that psychostimulants drugs modulate the expression of histone deacetylases (HDACs), we hypothesized that in endothelial cells METH-mediation of cytoplasmatic HDAC6 activity could affect tubulin acetylation and further contribute to BBB dysfunction. To validate our hypothesis, we exposed the bEnd.3 endothelial cells to increasing doses of METH and verified that it leads to an extensive α-tubulin deacetylation mediated by HDACs activation. Furthermore, since we recently reported that acetyl-l-carnitine (ALC), a natural occurring compound, prevents BBB structural loss in a context of METH exposure, we reasoned that ALC could also preserve the acetylation of microtubules under METH action. The present results confirm that ALC is able to prevent METH-induced deacetylation providing effective protection on microtubule acetylation. Although further investigation is still needed, HDACs regulation may become a new therapeutic target for ALC.

Reversible magnetic mercury extraction from water

Magnetic carbon-coated cobalt nanoparticles functionalized with polyethyleneimine proved to be highly effective and selective for the detoxification of mercury ions from aqueous solutions.

[X-linked agammaglobulinemia: experience in a Portuguese hospital]

INTRODUCTION

X-Linked agammaglobulinemia (XLA) is characterized by an arrest of B cell differentiation, leading to recurrent bacterial infections. Lifelong immunoglobulin replacement therapy (IRT) is indicated to prevent infections and their complications.

MATERIAL AND METHODS

A retrospective study of patients with XLA followed in a level three hospital was performed; data was collected retrospectively by review of clinical files.

RESULTS

XLA was diagnosed in 9 children. One (11%) had a positive family history with a prenatal diagnosis. Infection was the clinical presentation in all the others (89%), at an average age of 13 months; diagnosis was established at a mean age of 3.4 years. Acute otitis media (7/9) and pneumonia (5/9) were the most frequently observed. Seven (78%) presented serum immunoglobulin G (IgG) levels below 200mg/dL and all of them had CD19(+) B cells below 2%. Neutropenia was present at diagnosis in three patients (33%). Bruton tyrosine kinase (BTK) mutations were identified in all cases. Intravenous IRT was initiated, switched later to subcutaneous administration, in all. The mean time of follow-up was 10.7 years with cumulative time of 97 years. Eight children (89%) achieved IgG serum levels above 800 mg/dL. One presented lower values due to renal loss. No deaths occurred. After diagnosis the most frequent infections were acute otitis media (6/9). In spite of stable adequate IgG levels on IRT, two patients developed bronchiectasis.

CONCLUSIONS

XLA overall prognosis is good, as long as patients have an early and adequate treatment. However, bronchiectasis can occur even on adequate immunoglobulin replacement therapy.

Comparative In Vitro Effect of TiF4 to NaF and Potassium Oxalate on Reduction of Dentin Hydraulic Conductance

Dentin hypersensitivity (DH) is related to an increase in dentin permeability. This study tested the effect of titanium tetrafluoride (TiF4) compared with sodium fluoride (NaF) and potassium oxalate gel on reducing hydraulic conductance (Lp) from the perspective of diminishing dentin permeability. The Lp of the dentin disks (1.0 ± 0.2 mm) was evaluated using Flodec. The maximum Lp values of each disk were taken after phosphoric acid etching (15 seconds) and randomly allocated to seven groups (n=8) according to the treatments. The minimum (smear layer) and the maximum (after acid etching) Lp values were recorded. Treatments were performed for 4 minutes as follows: 1) NaF varnish 2) and solution (2.45% F, pH 5.0), 3) TiF4 varnish and 4) solution (2.45% F, pH 1.0), 5) 3% potassium oxalate gel, 6) free fluoride varnish (placebo, pH 5.0), 7) and no treatment (control). The Lp after each treatment was assessed. Samples were exposed to an erosive challenge (6% citric acid, pH 2.1, 1 minute), and the final Lp was recorded. The data were statistically analyzed using repeated measures two-way analysis of variance (p&lt;0.05). All treatments were effective in reducing dentin Lp compared with the control immediately after the application. However, only potassium oxalate and NaF varnish significantly differed from placebo varnish (p&lt;0.0001). The same results were found after the erosive challenge. Therefore, the TiF4 was less effective than the NaF varnish and potassium oxalate gel in reducing dentin permeability. Using this experimental model, both NaF varnish and potassium oxalate gel reduced the Lp similarly to the presence of smear layer.