Infective Endocarditis in the Elderly: Challenges and Strategies

The specific management of infective endocarditis (IE) in elderly patients is not specifically addressed in recent guidelines despite its increasing incidence and high mortality in this population. The term "elderly" corresponds to different ages in the literature, but it is defined by considerable comorbidity and heterogeneity. Cancer incidence, specifically colorectal cancer, is increased in older patients with IE and impacts its outcome. Diagnosis of IE in elderly patients is challenging due to the atypical presentation of the disease and the lower performance of imaging studies. Enterococcal etiology is more frequent than in younger patients. Antibiotic treatment should prioritize diminishing adverse effects and drug interactions while maintaining the best efficacy, as surgical treatment is less commonly performed in this population due to the high surgical risk. The global assessment of elderly patients with IE, with particular attention to frailty and geriatric profiles, should be performed by multidisciplinary teams to improve disease management in this population.

AB0440 USE OF BELIMUMAB IN CLINICAL PRACTICE. CLINICAL AND SEROLOGICAL EFFECTIVENESS AND CORTICOSTEROID-SPARING ACTIVITY

Background

Since 2011, the use of Belimumab for the treatment of Systemic Lupus Erythematosus (SLE)

has demonstrated efficacy and safety in several randomised clinical trials. However, strict inclusion criteria may restrict those results limiting the interpretation of these results to routine clinical practice populations.

Objectives

The aim of this study was to analyse the profile of patients using Belimumab as well as the clinical, serological and corticosteroid-sparing outcomes that may result from it use.

Methods

Retrospective cohort study including patients diagnosed with SLE and treated with Belimumab. Epidemiological, clinical and analytical data were collected at 6, 12 and 24 months before and after starting treatment with Belimumab. To assess effectiveness, the SELENA-SLEDAI, SLICC, clinical changes, concomitant treatments, corticosteroid dose and ds-DNA and C3-C4 levels were used.

Safety was evaluated by assessing the need and cause for discontinuation of Belimumab.

Results

Thirty-one patients were included, mostly 28 (90.32%) women, with a mean age of 48.55 ± 1.95 years and a mean time of disease progression since diagnosis of 16.13 ± 1.77 years. The most prevalent affection before initiation of Belimumab were joint (83.87%), systemic (58.06%), skin (29.03%) and nephropathy (22.58%). The mean SELENA-SLEDAI score before Belimumab was 5.32 ± 0.46; 64.5% had elevated anti-dsDNA, 48.39% and 54.84% had low C3 and C4 levels, respectively.

Before starting Belimumab, the most used treatments were both antimalarials (72.4%) and corticosteroids (80.6%). The main reason for starting Belimumab was the ineffectiveness of previous treatments (67.7%). The vast majority of patients were treated subcutaneously (90.3%) and there were no major adverse events leading to drug withdrawal, with a median duration of use of 19.3 months (IQR: 9.75-35.55).

Conclusion

After starting Belimumab, a decrease in the SELENA-SLEDAI activity scale, an increase in C3 and C4 levels, and a significant decrease in anti-dsDNA levels at 6 months were observed.

At 12 and 24 months, continuity of this trend was observed, although statistical significance was not reached. As concerns corticosteroids, we observed a decrease in steroid use below 7.5mg/day and even 5mg/day after the introduction of Belimumab avoiding the undesirable effects of prolonged steroid use.

Table 1.BEFORE BELIMUMAB (n=31)6 MONTHS (n=28)12 MONTHS (n=22)24 MONTHS (n=9)ESLEDAI x̄ (SD)5,32 (0,46)2,28 (0,44)2,90 (0,72)3,44 (1,39)P<0,001P<0,005p>0,05High dsDNA - n (%)18 (58,06)14 (61,29)14 (45,16)4 (12,9)P<0,001P=0,036P=0,7Low C3 (<90mg/dl) - n (%)15 (48,39)11 (35,48)9 (29,03)3 (9,68)P=0,006P=0,193P=0,06Low C4 (<16mg/dl) - n (%)17 (54,84)14 (45,16)11 (35,48)5 (16,13)P<0,001P=0,003P=0,217)Figure 1.

Disclosure of Interests

None declared

Study of nitrogen fluxes across conventional solid floor cubicle and compost-bedded pack housing systems in dairy cattle barns located in the Mediterranean area: Effects of seasonal variation

The aim of this study was to determine the effect of housing system (or manure management system) and season on manure N recovery and volatilization using an N mass balance. Dietary, milk, and manure N were monitored together with outside temperatures in 6 dairy barns. Three barns were designed as conventional freestalls (cubicle, CUB) with an automatic manure scraper system and concrete floor, in which the gutter in the middle was continuously scraped (every 2-4 h) and the slurry was conveyed toward an open-air concrete pool. The other 3 barns were designed as a loose housing system (HS) with a compost-bedded pack (CB) and conventional confinement housing provided with a feed alley that was cleaned mechanically (2-3 times per day). The farms under study were located near Lleida in the center of the Ebro valley, in northeastern Spain. Nitrogen recovery was measured twice under farm-like conditions either during spring-summer (3 mo of increasing temperatures) or fall-winter (3 mo of decreasing temperatures). The number of cows per barn ranged from 99 to 473, and average age, mean lactation, and parturition intervals were 4.1 yr, 2.43 lactations, and 426.6 d, respectively. In spring-summer, animals ate more [26.3 vs. 23.8 kg of dry matter (DM)/d] and produced more milk (34.6 vs. 31.3 kg/d ± 0.68). However, milk composition did not change. Stored manure from the CB system showed a higher DM concentration with respect to the CUB system (379.15 vs. 97.65 g/kg of fresh matter); however, N (31.45 vs. 40.2), NH₃-N (5.3 vs. 18.9) and its ratios with phosphorus (NH₃-N:P, 3.52 vs. 5.2) and potassium (NH₃-N:K, 0.615 vs. 2.69) showed the opposite trend. No differences were found in N intake (653 vs. 629.5 g/d) or milk N secretion (190 vs. 177.8 g/d for CUB and CB barns, respectively) although net N recovery of the excreted N (N_intake - N_Milk) was significantly lower in manure in CB barns than in CUB systems (193.8 vs. 389.3 g/d). The proportion of N irreversible loss in relation to the N intake was higher in CB than in CUB barns (42.3 vs. 11.0%). There was no clear association between season and irreversible N losses; however, the housing system was pivotal in the association between N recovery in manure and irreversible losses by volatilization.

Residential greenness is differentially associated with childhood allergic rhinitis and aeroallergen sensitization in seven birth cohorts

BACKGROUND

The prevalence of allergic rhinitis is high, but the role of environmental factors remains unclear. We examined cohort-specific and combined associations of residential greenness with allergic rhinitis and aeroallergen sensitization based on individual data from Swedish (BAMSE), Australian (MACS), Dutch (PIAMA), Canadian (CAPPS and SAGE), and German (GINIplus and LISAplus) birth cohorts (n = 13 016).

METHODS

Allergic rhinitis (doctor diagnosis/symptoms) and aeroallergen sensitization were assessed in children aged 6-8 years in six cohorts and 10-12 years in five cohorts. Residential greenness was defined as the mean Normalized Difference Vegetation Index (NDVI) in a 500-m buffer around the home address at the time of health assessment. Cohort-specific associations per 0.2 unit increase in NDVI were assessed using logistic regression models and combined in a random-effects meta-analysis.

RESULTS

Greenness in a 500-m buffer was positively associated with allergic rhinitis at 6-8 years in BAMSE (odds ratio = 1.42, 95% confidence interval [1.13, 1.79]) and GINI/LISA South (1.69 [1.19, 2.41]) but inversely associated in GINI/LISA North (0.61 [0.36, 1.01]) and PIAMA (0.67 [0.47, 0.95]). Effect estimates in CAPPS and SAGE were also conflicting but not significant (0.63 [0.32, 1.24] and 1.31 [0.81, 2.12], respectively). All meta-analyses were nonsignificant. Results were similar for aeroallergen sensitization at 6-8 years and both outcomes at 10-12 years. Stratification by NO2 concentrations, population density, an urban vs rural marker, and moving did not reveal consistent trends within subgroups.

CONCLUSION

Although residential greenness appears to be associated with childhood allergic rhinitis and aeroallergen sensitization, the effect direction varies by location.

Parental allergic disease before and after child birth poses similar risk for childhood allergies

Whether the strength of associations between parental and child allergic diseases differs by whether the first onset of the parental disease is before or after a child's birth has never been examined and is the aim of this study. Yearly childhood asthma, allergic rhinitis, and eczema diagnoses were longitudinally regressed against the effect of a parental disease (pre- vs post-child birth) of the same type separately for each parent using generalized estimation equations. Both a maternal and paternal history of asthma were associated with childhood asthma prevalence up to 15 years of age. Effect estimates were similar for parental asthma with first onset before and after the birth of the child. The results for allergic rhinitis and eczema were less consistent. Parental allergic diseases with first onsets before and after the birth of a child both pose risks to childhood allergic disease in the offspring, especially for asthma.

Mother's body mass index and food intake in school-aged children: results of the GINIplus and the LISAplus studies

BACKGROUND/OBJECTIVES

Mother's body mass index (BMI) is a strong predictor of child BMI. Whether mother's BMI correlates with child's food intake is unclear. We investigated associations between mother's BMI/overweight and child's food intake using data from two German birth cohorts.

SUBJECTS/METHODS

Food intakes from 3230 participants were derived from parent-completed food frequency questionnaires. Intakes of 11 food groups were categorized into three levels using group- and sex-specific tertile cutoffs. Mother's BMI and overweight were calculated on the basis of questionnaire data. Multinomial regression models assessed associations between a child's food intake and mother's BMI/overweight. Linear regression models assessed associations between a child's total energy intake and mother's BMI. Models were adjusted for study region, maternal education, child's age, sex, pubertal status and energy intake and the BMIs of the child and father.

RESULTS

Mothers' BMI was associated with high meat intake in children (adjusted relative risk ratio (RRR (95% confidence interval))=1.06 (1.03; 1.09)). Mothers' overweight was associated with the meat intake (medium versus low RRR=1.30 (1.07; 1.59); high versus low RRR=1.50 (1.19; 1.89)) and egg intake (medium versus low RRR=1.24 (1.02; 1.50); high versus low RRR=1.30 (1.07; 1.60)) of children. There were no consistent associations for rest of the food groups. For every one-unit increase in mothers' BMI, the total energy intake in children increased by 9.2 kcal (3.7; 14.7). However, this effect was not significant after adjusting for children's BMI.

CONCLUSIONS

Our results suggest that mother's BMI and mother's overweight are important correlates of a child's intake of energy, meat and eggs.

Reconstrucción del aparato extensor de la mano a través de la cobertura cutánea. A propósito de un caso

Los traumatismos graves sobre el dorso de la mano suelen comprometer el aparato extensor y provocan adherencias cicatriciales entre las diferentes estructuras afectadas que se traducen en rigidez. Presentamos un caso de cobertura y reconstrucción tendinosa de la mano utilizando el tejido subcutáneo del colgajo transferido como superficie de deslizamiento de aparato extensor.

[Epidemiological study of attempted suicide managed at the hospital emergency department]

PURPOSE

The authors investigate psychiatric and sociodemographic characteristics of the patients attended at the emergency department in the General Hospital of Mostoles, after their suicidal intent, and of those who repeated a suicidal intent in the first year of follow-up.

METHODOLOGY

It is a prospective study, with a duration of one year, in a real sample with 119 patients randomized as a stratified sample from the population attended after their intent. Data recollection was made with a psychiatric semi-structured interview and Beck's letality and suicidal intent scales. Recruitment and follow-up periods were one year long for each of them. Statistical analysis was realized with the chi square test and Fischer's exact test to evaluate associations among cualitative variable and the variance analysis of the relations between qualitative and quantitative variable.

RESULTS

Suicide intent ratio was 82/100,000 inhabitants, being in 83% by medicament ingestion. 71% were women, 66% were between 15 and 30 years old, 50% were unmarried and 12% were separated. 33% suffered from a affective disorder, and 23% were alcohol abusers. 6% of them bad a psycotic disorder. 52% of the patients had previous psychiatric disorders and 43% had been in treatment. 46% of them had someone in their families with a psychiatric disorder. 29% were repeaters after a previous attempt. Concerning to a prior contact with the Mental Health Services in the preceding month Significant differences were observed by age, but no significant differences were observed by sex. 26% used alcohol prior to the intent, mainly men. EIB and ELB ratings were significatively higher in retired than in students. Among the patients who repeated their intent (14.5%) of the followed, 78% were women, with an age between 30 and 56 years old. 61% were diagnosed having an affective disorder and 10% had psycotic disorders. 88% of the repeaters were in psychiatric treatment for five years or more.

Pressure-induced contraction of the juxtamedullary afferent arterioles in spontaneously hypertensive rats

1. In the SHR juxtamedullary nephron preparation, the increase of the perfusion pressure from 80 to 160 mmHg increased the diameters of arcuate arteries but produced a pressure-dependent contraction of the afferent arterioles, a response that can account for renal autoregulation. 2. The pressure-induced contractions of the afferent arterioles were abolished by 1 microM nifedipine and by 10 microM furosemide, suggesting that the autoregulatory responses are mainly mediated by tubuloglomerular mechanisms and can be abolished by calcium antagonists.