Impact of Standard Versus Low Pneumoperitoneum Pressure on Peritoneal Environment in Laparoscopic Cholecystectomy. Randomized Clinical Trial

BACKGROUND

High CO 2 pneumoperitoneum pressure during laparoscopy adversely affects the peritoneal environment. This study hypothesized that low pneumoperitoneum pressure may be linked to less peritoneal damage and possibly to better clinical outcomes.

MATERIALS AND METHODS

One hundred patients undergoing scheduled laparoscopic cholecystectomy were randomized 1:1 to low or to standard pneumoperitoneum pressure. Peritoneal biopsies were performed at baseline time and 1 hour after peritoneum insufflation in all patients. The primary outcome was peritoneal remodeling biomarkers and apoptotic index. Secondary outcomes included biomarker differences at the studied times and some clinical variables such as length of hospital stay, and quality and safety issues related to the procedure.

RESULTS

Peritoneal IL6 after 1 hour of surgery was significantly higher in the standard than in the low-pressure group (4.26±1.34 vs. 3.24±1.21; P =0.001). On the contrary, levels of connective tissue growth factor and plasminogen activator inhibitor-I were higher in the low-pressure group (0.89±0.61 vs. 0.61±0.84; P =0.025, and 0.74±0.89 vs. 0.24±1.15; P =0.028, respectively). Regarding apoptotic index, similar levels were found in both groups and were 44.0±10.9 and 42.5±17.8 in low and standard pressure groups, respectively. None of the secondary outcomes showed differences between the 2 groups.

CONCLUSIONS

Peritoneal inflammation after laparoscopic cholecystectomy is higher when surgery is performed under standard pressure. Adhesion formation seems to be less in this group. The majority of patients undergoing surgery under low pressure were operated under optimal workspace conditions, regardless of the surgeon's expertise.

Safety of early oral ambulatory treatment of adult patients with bloodstream infections discharged from the emergency department

This study evaluates the safety of early oral ambulatory treatment of adult patients diagnosed with bacteremia after their discharge from the emergency department. A cohort of 206 febrile ambulatory patients was assessed. Bacteremic low-risk patients were recommended an oral treatment and were compared with matched febrile non-bacteremic outpatients. Rates of 14-day mortality and unplanned re-consultations were similar and below 5% in both cohorts, highlighting the safety of oral therapy of low-risk bacteremia, even from its onset.

Effect of Casein Phosphopeptide-Amorphous Calcium Phosphate Added to Milk, Chewing Gum, and Candy on Dental Caries: A Systematic Review

Casein is one of the most studied proteins with activity against dental caries. In particular, casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) has shown promising remineralizing properties. In vivo evidence on the anticaries potential of CPP-ACP added to foodstuffs is elusive, nonetheless. Hence, this systematic review aimed at determining whether the use of CPP-ACP added to foodstuffs has a remineralizing or inhibitory action on dental demineralization either in vivo or in situ. The review protocol followed the PRISMA-P criteria and was registered in PROSPERO. PubMed, Scopus, and Web of Science databases were searched using predefined criteria, based on the PICO question: Is there an effect on dental caries upon adding CPP-ACP to milk, chewing gums, or candies? No year or language limits were applied. Article selection and data extraction were carried out independently by 2 investigators. Two hundred ten titles were examined, 23 were selected for full-text review, and 16 studies were included (2 in vivo and 14 in situ). CPP-ACP was added to candy in 2 studies, to milk in 2 studies, and to chewing gum in 12 studies. The main outcomes included enamel remineralization and activity against dental biofilm. The overall quality of the evidence was classified as moderate. The available evidence suggests that CPP-ACP added to milk, chewing gum, or candy has a potential remineralizing activity on tooth enamel, with some additional antibacterial activity on the dental biofilm. Further clinical studies are needed to verify if this effect is clinically significant in reducing the caries lesion incidence or to revert the demineralizing process.

Duration of antibiotic treatment for Gram-negative bacteremia - Systematic review and individual participant data (IPD) meta-analysis

BACKGROUND

We aim to compare the effect of short versus long treatment duration in Gram-negative bacteremia on all-cause mortality in pre-specified sub-groups.

METHODS

Individual participant data meta-analysis of randomized controlled trials (RCTs) comparing short (≤7) versus longer (>7 days) antibiotic treatment for Gram-negative bacteremia. Participants were adults (≥18 years), with Gram-negative bacteremia during hospital stay. We searched PubMed, Cochrane Central Register of Controlled Trials, and Web of Science to identify trials conducted up to May 2022. Primary outcome was 90-day all-cause mortality. Secondary outcomes were 30-day mortality, relapse of bacteremia, length of hospital stay, readmission, local or distant infection complications, adverse events, and resistance emergence.Outcomes were assessed in pre-specified subgroups: women vs men; non-urinary vs urinary source; presence vs absence of hypotension on initial presentation; immunocompromised patients versus non-immunocompromised patients, and age (above/below 65). Fixed-effect meta-analysis model was used to estimate pooled odds ratio (OR) and 95% confidence interval (CI). All three trials had low risk of bias for allocation generation and concealment.

FINDINGS

Three RCTs (1186 patients) were included; 1121 with enterobacterales bacteremia. No significant difference in mortality was demonstrated between 7- and 14-days treatment (90-day mortality: OR 1.08, 95% CI 0.73-1.58; 30-day mortality: 1.08, 0.62-1.91). Relapse (1.00, 0.50-1.97); length of hospital stay (P = 0.78); readmission (0.96, 0.80-1.22); and infection complications (local: 1.62 0.76-3.47; distant: 2.00, 0.18-22.08), were without significant difference, and so were adverse events or resistance emergence.No significant difference in clinical outcomes between 7 and 14 days of antibiotics was demonstrated in the subgroups of gender, age, hemodynamic status, immune status, and source of infection.

INTERPRETATION

For patients hemodynamically stable and afebrile at 48 h prior to discontinuation, seven days of antibiotic therapy for enterobacterales bacteremia result in similar outcomes as 14 days, in terms of mortality, relapse, length of hospital stay, complications of infection, resistance emergence, and adverse events. These results apply for any adult age group, gender, source of infection, immune status, and hemodynamic status on presentation.

FUNDING

There was no funding source for this study.

Study protocol for a randomized clinical trial to assess 7 versus 14-days of treatment for Pseudomonas aeruginosa bloodstream infections (SHORTEN-2 trial)

BACKGROUND

Research priorities in Antimicrobial Stewardship (AMS) have rapidly evolved in the last decade. The need for a more efficient use of antimicrobials have fueled plenty of studies to define the optimal duration for antibiotic treatments, and yet, there still are large areas of uncertainty in common clinical scenarios. Pseudomonas aeruginosa has been pointed as a priority for clinical research, but it has been unattended by most randomized trials tackling the effectiveness of short treatments. The study protocol of the SHORTEN-2 trial is presented as a practical example of new ways to approach common obstacles for clinical research in AMS.

OBJECTIVE

To determine whether a 7-day course of antibiotics is superior to 14-day schemes for treating bloodstream infections by P. aeruginosa (BSI-PA).

METHODS

A superiority, open-label, randomized controlled trial will be performed across 30 Spanish hospitals. Adult patients with uncomplicated BSI-PA will be randomized to receive a 7 versus 14-day course of any active antibiotic. The primary endpoint will be the probability for the 7-day group of achieving better outcomes than the control group, assessing altogether clinical effectiveness, severe adverse events, and antibiotic exposure through a DOOR/RADAR analysis. Main secondary endpoints include treatment failure, BSI-PA relapses, and mortality. A superiority design was set for the primary endpoint and non-inferiority for treatment failure, resulting in a sample size of 304 patients.

CONCLUSIONS

SHORTEN-2 trial aligns with some of the priorities for clinical research in AMS. The implementation of several methodological innovations allowed overcoming common obstacles, like feasible sample sizes or measuring the clinical impact and unintended effects.

TRIAL REGISTRATION

EudraCt: 2021-003847-10; ClinicalTrials.gov: NCT05210439.

Assessment of incidence and trends in cerebrovascular disease in the healthcare district of Lleida (Spain) in the period 2010-2014

OBJECTIVES

This study aimed to determine the incidence and trends of cerebrovascular disease (CVD) in the healthcare district of Lleida.

MATERIAL AND METHODS

We performed a population-based prospective cohort study including the entire population of the healthcare district of Lleida (440 000 people). Information was gathered from the minimum basic data set from the emergency department and hospital discharges for the period from January 2010 to December 2014. All types of stroke were included. We evaluated crude and age-standardised rates using the world population as a reference. Patients without neuroimaging confirmation of the diagnosis were excluded.

RESULTS

We identified 4397 patients: 1617 (36.8%) were aged 80 years or over; 3969 (90.3%) presented ischaemic stroke, and 1741 (39.6%) were women. The crude incidence rate ranged from 192 (95% confidence interval [CI], 179-205) to 211 (95% CI, 197-224) cases per 100 000 population, in 2012 and 2013, respectively. Age-standardised rates ranged from 93 (95% CI, 86-100) to 104 (95% CI, 96-111) cases per 100 000 population, in 2012 and 2013, respectively. For all years, incidence rates increased with age, and were significantly higher among men than among women.

CONCLUSION

The impact of CVD in Lleida is comparable to that observed in other European regions. However, population ageing induces a high crude incidence rate, which remained stable over the five-year study period.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Estradiol and Progesterone as key modulators of central systems implicated in schizophrenia

Introduction

It has been suggested that dysregulation of sex hormones is associated with schizophrenia. However, obesity and metabolic syndrome are very common between schizophrenic patients, and it can also dysregulate sex hormones so they could act as confounders.

Objectives

To determine if estradiol and progesterone are abnormally elevated regardless of obesity or metabolic syndrome in men with SCZ.

Methods

We measured serum levels of progesterone and estradiol in 56 schizophrenic male patients at treatment with a depot antipsychotic. Subsequently, we studied the association or independence of our results with obesity or metabolic syndrome by a Chi Square Test.

Results

66.07% of our patients elevated progesterone levels, 19.64% of our patients elevated estradiol levels, and 16.07% of our patients elevated both, progesterone and estradiol, simultaneously. We found no relationship between increased estradiol and / or progesterone with obesity and / or metabolic syndrome.

Conclusions

Estradiol and progesterone are abnormally elevated regardless of obesity and / or metabolic syndrome in male schizophrenic patients on depot treatment.

Disclosure

No significant relationships.

Economic consequences of the overuse of short-acting beta-adrenergic agonists (SABA) in the treatment of asthma in Spain

BACKGROUND

To determine the relationship between short-acting beta-adrenergic agonist (SABA) overuse and healthcare resource use and costs in asthma patients in routine clinical practice.

MATERIAL AND METHODS

A longitudinal retrospective study in Spanish primary and specialized care using the BIG-PAC® Medical Records Database was conducted. Asthma patients ≥12 years of age who attended ≥ 2 consultations during 2017 and had 1-year follow-up data available were included. Main outcomes were demographics, comorbidities, medication, clinical and healthcare resource use and costs. The relationship between SABA overuseand healthcare costs, and between asthma severity and healthcare costs was determined.

RESULTS

This SABA use IN Asthma (SABINA) study included 39,555 patients, mean (standard deviation, SD) age 49.8 (20.7) years; 64.2% were female. Charlson comorbidity index was 0.7 (1.0). SABA overuse (≥ 3 canisters/year) was 28.7% (95% CI: 27.7-29.7), with an overall mean number of 3.3 (3.6) canisters/year. Overall, 5.1% of patients were prescribed ≥12 canisters/year. SABA overuse was correlated with healthcare costs (ρ = 0.621; p < 0.001).The adjusted mean annual cost/patient, according to the Global Initiative for Asthma (GINA 2019) classification of asthma severity, was €2,231, €2,345, €2,735, €3,473, and €4,243,for GINA steps 1-5, respectively (p < 0.001). Regardless of asthma severity, SABA overuse yielded a significant increase in healthcare costs per patient and year (€5,702 vs. €1,917, p < 0.001) compared with recommended use (< 2 canisters/year).

CONCLUSIONS

SABA overuse yields greater costs for the Spanish National Health System. Costs increased according to asthma severity.

Seven-versus 14-day course of antibiotics for the treatment of bloodstream infections by Enterobacterales: a randomized, controlled trial

OBJECTIVE

To prove that 7-day courses of antibiotics for bloodstream infections caused by members of the Enterobacterales (eBSIs) allow a reduction in patients' exposure to antibiotics while achieving clinical outcomes similar to those of 14-day schemes.

METHODS

A randomized trial was performed. Adult patients developing eBSI with appropriate source control were assigned to 7 or 14 days of treatment, and followed 28 days after treatment cessation; treatments could be resumed whenever necessary. The primary endpoint was days of treatment at the end of follow-up. Clinical outcomes included clinical cure, relapse of eBSI and relapse of fever. A superiority margin of 3 days was set for the primary endpoint, and a non-inferiority margin of 10% was set for clinical outcomes. Efficacy and safety were assessed together with a DOOR/RADAR (desirability of outcome ranking and response adjusted for duration of antibiotic risk) analysis.

RESULTS

248 patients were assigned to 7 (n = 119) or 14 (n = 129) days of treatment. In the intention-to-treat analysis, median days of treatment at the end of follow-up were 7 and 14 days (difference 7, 95%CI 7-7). The non-inferiority margin was also met for clinical outcomes, except for relapse of fever (-0.2%, 95%CI -10.4 to 10.1). The DOOR/RADAR showed that 7-day schemes had a 77.7% probability of achieving better results than 14-day treatments.

CONCLUSIONS

7-day schemes allowed a reduction in antibiotic exposure of patients with eBSI while achieving outcomes similar to those of 14-day schemes. The possibility of relapsing fever in a limited number of patients, without relevance to final outcomes, may not be excluded, but was overcome by the benefits of shortening treatments.

Cosmic Ray Background Removal With Deep Neural Networks in SBND

In liquid argon time projection chambers exposed to neutrino beams and running on or near surface levels, cosmic muons, and other cosmic particles are incident on the detectors while a single neutrino-induced event is being recorded. In practice, this means that data from surface liquid argon time projection chambers will be dominated by cosmic particles, both as a source of event triggers and as the majority of the particle count in true neutrino-triggered events. In this work, we demonstrate a novel application of deep learning techniques to remove these background particles by applying deep learning on full detector images from the SBND detector, the near detector in the Fermilab Short-Baseline Neutrino Program. We use this technique to identify, on a pixel-by-pixel level, whether recorded activity originated from cosmic particles or neutrino interactions.

Odderon Exchange from Elastic Scattering Differences between pp and pp[over ¯] Data at 1.96 TeV and from pp Forward Scattering Measurements

We describe an analysis comparing the pp[over ¯] elastic cross section as measured by the D0 Collaboration at a center-of-mass energy of 1.96 TeV to that in pp collisions as measured by the TOTEM Collaboration at 2.76, 7, 8, and 13 TeV using a model-independent approach. The TOTEM cross sections, extrapolated to a center-of-mass energy of sqrt[s]=1.96  TeV, are compared with the D0 measurement in the region of the diffractive minimum and the second maximum of the pp cross section. The two data sets disagree at the 3.4σ level and thus provide evidence for the t-channel exchange of a colorless, C-odd gluonic compound, also known as the odderon. We combine these results with a TOTEM analysis of the same C-odd exchange based on the total cross section and the ratio of the real to imaginary parts of the forward elastic strong interaction scattering amplitude in pp scattering for which the significance is between 3.4σ and 4.6σ. The combined significance is larger than 5σ and is interpreted as the first observation of the exchange of a colorless, C-odd gluonic compound.

[Vaccination against community acquired pneumonia in adults. Update 2021 of the position paper by Neumoexpertos en Prevención Group]

Community-acquired pneumonia (CAP) continues to be an important cause of morbidity and mortality in adults. The aim of this study is to update the practical prevention guide for CAP through vaccination in Spain developed in 2016 and updated in 2018, based on available vaccines and evidence through bibliographic review and expert opinion. The arrival of COVID-19 as a new cause of CAP and the recent availability of safe and effective vaccines constitutes the most significant change. Vaccines against pneumococcus, influenza, pertussis and COVID-19 can help to reduce the burden of disease from CAP and its associated complications. The available evidence supports the priority indications established in this guide, and it would be advisable to try to achieve a widespread dissemination and implementation of these recommendations in routine clinical practice.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Long-Term Impact of an Educational Antimicrobial Stewardship Program on Management of Patients with Hematological Diseases

Antimicrobial stewardship programs (ASPs) in hematological patients are especially relevant. However, information about ASPs in this population is scarce. For 11 years, we quarterly assessed antimicrobial consumption and incidence and death rates of multidrug-resistant (MDR) bloodstream infections (BSI) in the hematology Department. Healthcare activity indicators were also monitored yearly. We performed an interrupted time-series analysis. Antimicrobials showed a sustained reduction with a relative effect of −62.3% (95% CI −84.5 to −40.1) nine years after the inception of the ASP, being especially relevant for antifungals (relative effect −80.4%, −90.9 to −69.9), quinolones (relative effect −85.0%, −102.0 to −68.1), and carbapenems (relative effect −68.8%, −126.0 to −10.6). Incidence density of MDR BSI remained low and stable (mean 1.10 vs. 0.82 episodes per 1000 occupied bed days for the pre-intervention and the ASP period, respectively) with a quarterly percentage of change of −0.3% (95% CI −2.0 to 1.4). Early and late mortality of MDR BSI presented a steady trend (quarterly percentage of change −0.7%, 95% CI −1.7 to 0.3 and −0.6%, 95% CI −1.5 to 0.3, respectively). Volume and complexity of healthcare activity increased over the years. The ASP effectively achieved long-term reductions in antimicrobial consumption and improvements in the prescription profile, without increasing the mortality of MDR BSI.

Impact of the COVID-19 Pandemic on Antimicrobial Consumption and Hospital-Acquired Candidemia and Multidrug-Resistant Bloodstream Infections

During the COVID-19 pandemic, the implementation of antimicrobial stewardship strategies has been recommended. This study aimed to assess the impact of the COVID-19 pandemic in a tertiary care Spanish hospital with an active ongoing antimicrobial stewardship programme (ASP). For a 20-week period, we weekly assessed antimicrobial consumption, incidence density, and crude death rate per 1000 occupied bed days of candidemia and multidrug-resistant (MDR) bacterial bloodstream infections (BSI). We conducted a segmented regression analysis of time series. Antimicrobial consumption increased +3.5% per week (p = 0.016) for six weeks after the national lockdown, followed by a sustained weekly reduction of −6.4% (p = 0.001). The global trend for the whole period was stable. The frequency of empirical treatment of patients with COVID-19 was 33.7%. No change in the global trend of incidence of hospital-acquired candidemia and MDR bacterial BSI was observed (+0.5% weekly; p = 0.816), nor differences in 14 and 30-day crude death rates (p = 0.653 and p = 0.732, respectively). Our work provides quantitative data about the pandemic effect on antimicrobial consumption and clinical outcomes in a centre with an active ongoing institutional and education-based ASP. However, assessing the long-term impact of the COVID-19 pandemic on antimicrobial resistance is required.

FRI0295 ADALIMUMAB LEVELS ARE ASSOCIATED WITH DRUG RETENTION RATES IN AXIAL SPONDYLOARTHRITIS PATIENTS

Background:

Production of anti-drug antibodies (ADA) could cause low serum anti-TNF levels and low drug retention rates.

Objectives:

To assess the relationship between serum adalimumab (ADL) levels and drug retention rates in patients with axial SpA.

Methods:

Single-center prospective study in patients with axial SpA, according to ASAS criteria, being treated with ADL. In the first part of the study, from December 2010 to June 2016, data was collected and serum samples were taken. In a second part of the study, clinical records were reviewed to find out the dates and reasons of treatment discontinuation. Information was collected on age gender, body mass index (BMI), date of diagnosis of SpA, laboratory data, including HLAB27, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), prior biological treatment for SpA, concomitant conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs). SpA disease activity was assessed by BASDAI, ASDAS and PGA scores. A serum sample was taken from all patients just before the next adalimumab dose. ADL and ADA levels were analysed with ELISA Promonitor®, (Proteomika, Progénica, Griffols) and correlated with SpA activity using BASDAI and ASDAS scores. Cox proportional hazards model was performed in order to assess the relation of variables with drug interruption.

Results:

Up to January 2016, 51 consecutive patients were included. The mean (range) age was 46,9 (18–68) and 47.1% were women. HLAB27 was positive in 82,4% of patients. Mean disease duration was 122,9 months (2-408) and mean duration of treatment with adalimumab was 17,8 months (1-69). ADL was the first biological agent received in 36 patients (70.6%). Eleven patients (21.6%) were on concomitant treatment with receiving concomitant csDMARDs, mainly methotrexate (MTX) (15.7%) and sulfasalazine (5.9%). The mean (SD) activity scores were BASDAI 4,0 ± 2,3; ASDAS-PCR 2,1 ± 1,1 and ASDAS-VSG 2,1 ± 1,0.

ADA prevalence was 27.5%, with none detected in the 21.6% taking csDMARDs (p = 0.021). ADL level was normal (> 3 mg/l) in 36 patients (70.6%), all without ADA. Fifteen patients (29.4%) had subtherapeutic ADL levels (< 3 mg/l), with ADA in 14 (93%).

Total ADL treatment time was 241,16 patient/years, and mean ADL treatment time was 4,73 years. Cox model results were resumed in table 1. Multivariate study show that ADL level > 3 mg/L was a protective factor for ADL interruption (HR 0.01 (0.00-0.59, p=0.026), while previous etanercept treatment was a risk factor for ADL interruption 9.54 (1.23-74.08, p=0.031).

Table 1.

Cox model.

ContinueDiscon=tinueUnivariateHRMultivariateHRADL level<3 mg/L13 (86,7%)2 (13,3%)0.05 (0.00-0.65, p=0.022)0.01 (0.00-0.59, p=0.026)≥3 mg/L28 (77,8%)8 (22,2%)Concomitant DMARDYes8 (72,7%)3 (27,3%)0.56 (0.14-2.26, p=0.419)0.28 (0.05-1.65, p=0.159)No33 (82,5%)7 (17,5%)BMINormal13 (86,7%)2 (13,3%)2.56 (0.54-12.23, p=0.239)0.48 (0.02-9.75, p=0.634)Overweight/obese27 (77,1%)8 (22,9%)AgeMean (SD)46,4 (12,2)48,7 (11,6)0.93 (0.24-3.60, p=0.912)0.60 (0.10-3.84, p=0.594)GenderMen19 (70,4%)8 (29,6%)0.43 (0.09-2.03, p=0.283)0.58 (0.03-10.06, p=0.705)Women22 (91,7%)2 (8,3%)InfliximabpreviousYes4 (40,0%)6 (60,0%)3.31 (0.92-11.87, p=0.066)1.37 (0.23-8.24, p=0.731)No37(90,2%)4 (9,8%)EtanerceptpreviousYes2 (22,2%)7 (77,7%)8.17 (2.09-31.90, p=0.003)9.54 (1.23-74.08, p=0.031)No39 (92,9%)3 (7,1%)

ADL: adalimumab; BMI: body mass index; DMARD: disease modifying antirheumatic drug; SD: standard deviation.

Conclusion:

Adalimumab drug levels > 3 mg/L is a protective factor against treatment interruption.

Etanercept previous treatment was a risk factor for treatment interruption.

Acknowledgments:

The study was supported by a grant from “Asociación para la Investigación en Reumatología de la Marina Baixa” (AIRE-MB).

Disclosure of Interests:

None declared

Motor Dysfunction as a Prodrome of Parkinson's Disease

BACKGROUND

Recognition of motor signs in the prodromal stage could help identify those at risk of developing Parkinson's disease (PD).

OBJECTIVE

This study identified motor symptoms and signs in individuals suspected of having PD but who did not have a progressive reduction in the speed and amplitude of finger tapping or other physical signs indicative of bradykinesia.

METHODS

146 patients, who had symptoms or signs suggestive of PD, were serially evaluated by a movement disorder specialist, using the Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) Part III and video recordings. If the patients 'converted' to PD during follow-up, they were categorized as cases and compared with those who did not meet PD criteria during follow-up (non-cases).

RESULTS

The 82 cases were more likely to have action dystonia or postural/action/rest tremor of a limb (OR 2.8; 95% CI 1.1-7.1; p = 0.02), a reduced blink rate at rest (OR 2.3; 95% CI 1.2-4.6; p = 0.01), anxiety (OR 8.9; 95% CI 2.6-31.1; p < 0.001), depression (OR 7.0; 95% CI 2.9-17.2; p < 0.001), or a frozen shoulder (OR 3.1; 95% CI 1.6-6.2) than the 64 'non-cases'.A reduction of the fast blink rate was common in patients who met the criteria for PD (p < 0.001).

CONCLUSIONS

This study emphasizes that motor dysfunction is a component of the clinical prodrome seen in some patients with PD.

Efficacy and safety of a comprehensive educational antimicrobial stewardship program focused on antifungal use

OBJECTIVE

Few data exist regarding the impact of antimicrobial stewardship programs on antifungal use. We evaluated the efficacy and safety of a comprehensive long-term antimicrobial stewardship program (ASP) focused on antifungal use.

METHODS

During a 9-year period, we quarterly assessed antifungal consumption, incidence density of hospital-acquired candidemia, Candida spp. distribution, antifungal resistance, and crude death rate per 1000 occupied bed days (OBDs) of hospital-acquired candidemia. We performed segmented regression analysis of interrupted time series.

RESULTS

A significant change in trend was observed for antifungal consumption, with a sustained reduction of -0.87% per quarter (95% confidence interval [CI], -1.36 -0.38, p < 0.001), accounting for a final reduction of -38.4%. The main reduction was produced in fluconazole, with a sustained reduction of -1.37% per quarter (95%CI, -1.96 -0.68, p<0.001). The incidence density of hospital-acquired candidemia decreased, with a change in slope of -5.06% cases per 1000 OBDs per year (95%CI, -8.23 -1.77, p = 0.009). The 14-day crude death rate per 1000 OBDs dropped from 0.044 to 0.017 (-6.36% deaths per 1000 OBDs per year; 95%CI, -13.45 -1.31, p = 0.09).

CONCLUSIONS

This ASP has succeeded in optimizing the use of antifungal with a long-lasting reduction without increasing the incidence, neither the mortality, of hospital-acquired candidemia.

Dilemmas and New Paradigms in Asthma Management

Asthma is one of the most common inflammatory diseases in the world. The main goal of treatment is to achieve optimal control. Although every patient is different, clinical practice guidelines can help physicians to manage the disease. However, the recommendations made by guidelines are not always identical, and the continuous release of new data on the various management strategies can mislead both patients and physicians. We aim to summarize the main controversies in management and treatment recommendations in asthma guidelines, revise the most recent scientific evidence, and pinpoint possible solutions. We do not issue new recommendations or challenge evidence-based guidelines. We concluded that more tools are necessary to achieve and measure optimal asthma control and to better assess the impact of asthma on patients' lives. Also essential is a more accurate appraisal of the short-term and long-term effectiveness and safety of asthma therapies and the possibilities of successful immunomodulation.

Differences between diabetic and non-diabetic patients with community-acquired pneumonia in primary care in Spain

BACKGROUND

Diabetes is one of the underlying risk factors for developing community-acquired pneumonia (CAP). The high prevalence of diabetes among population and the rising incidence of this illness, converts it as an important disease to better control and manage, to prevent its secondary consequences as CAP. The objective of this research is to describe the characteristics of the patients with diabetes and the differences with the no diabetes who have had an episode of CAP in the context of the primary care field.

METHODS

A retrospective, observational study in adult patients (> 18 years-old) who suffer from CAP and attended at primary care in Spain between 2009 and 2013 was developed using the Computerized Database for Pharmacoepidemiological Studies in Primary Care (BIFAP). We carried out a descriptive analysis of the first episodes of CAP, in patients with or without diabetes as comorbidity. Other morbidity (CVA, Anaemia, Arthritis, Asthma, Heart disease, Dementia, Depression, Dysphagia, Multiple sclerosis, Epilepsy, COPD, Liver disease, Arthrosis, Parkinson's disease, Kidney disease, HIV) and life-style factors were also included in the study.

RESULTS

A total of 51,185 patients were included in the study as they suffer from the first episode of CAP. Of these, 8012 had diabetes as comorbidity. There were differences between sex and age in patients with diabetes. Patients without diabetes were younger, and had less comorbidities including those related to lifestyles such as smoking, alcoholism, social and dental problems than patients with diabetes.

CONCLUSIONS

Patients who developed an episode of CAP with diabetes have more risk factors which could be reduced with an appropriate intervention, including vaccination to prevent successive CAP episodes and hospitalization. The burden of associated factors in these patients can produce an accumulation of risk. Health care professional should know this for treating and control these patients in order to avoid complications. Diabetes and those other risk factors associated could be reduced with an appropriate intervention, including vaccination to prevent the first and successive CAP episodes and the subsequent hospitalization in severe cases.

Constraints on Light Dark Matter Particles Interacting with Electrons from DAMIC at SNOLAB

We report direct-detection constraints on light dark matter particles interacting with electrons. The results are based on a method that exploits the extremely low levels of leakage current of the DAMIC detector at SNOLAB of 2-6×10^{-22}  A cm^{-2}. We evaluate the charge distribution of pixels that collect <10e^{-} for contributions beyond the leakage current that may be attributed to dark matter interactions. Constraints are placed on so-far unexplored parameter space for dark matter masses between 0.6 and 100  MeV c^{-2}. We also present new constraints on hidden-photon dark matter with masses in the range 1.2-30  eV c^{-2}.

Combining case-finding methods for COPD in primary care: a large, two-stage design study

BACKGROUND

Underdiagnosis of chronic obstructive pulmonary disease (COPD) is common. We aimed to assess the effectiveness of using the Chronic Obstructive Pulmonary Disease-Population Screener (COPD-PS) questionnaire with pre-bronchodilator (BD) peak expiratory flow (PEF) measurements as a case-finding strategy for COPD in primary care.

METHODS

This was a two-stage, cross-sectional study comprising a population survey in a primary care population aged 35 years without previous COPD, followed by a validation study using COPD-PS 4 or PEF 2.2 l/s·m2, and confirmed by spirometry (post-BD forced expiratory volume in 1 s/forced vital capacity [FEV1/FVC] <0.70). The predictive capacity of the strategy was assessed in a case-control sub-study.

RESULTS

Of a total of 10 071 individuals, 6969 (69.2%) participants were included. Both tests were positive in 4.3% subjects, PEF only in 2.1% and COPD-PS only in 5.1%. Of the 802 with positive screening results, COPD was confirmed using spirometry in 130, accounting for 1.9% of all participants and 16.2% of those who tested positive on COPD-PS or PEF. Among the 130 true-positives, the mean score for the COPD-PS questionnaire was 5.1 l/s·m2 (± standard deviation [SD] 1.7) and 1.9 l/s·m2 (±SD 0.8) for pre-BD PEF, both significantly worse than in the 672 false-positives. The combined use of both screening tests had a sensitivity of 67.5%, a specificity of 71.3% and a diagnostic accuracy of 69.6%.

CONCLUSION

Case finding for COPD using COPD-PS + PEF led to a 90% reduction in the number of spirometry tests performed.

Clinical impact of an educational antimicrobial stewardship program associated with infectious diseases consultation targeting patients with cancer: Results of a 9-year quasi-experimental study with an interrupted time-series analysis

OBJECTIVES

Antibiotic stewardship programs (ASP) have already demonstrated clinical benefits. However, their effectiveness or safety in immunocompromised hosts needs to be proved.

METHODS

An ecologic quasi-experimental study was performed from January 2009 to June 2017 in the Oncology department of a tertiary-care hospital. A stable program of Infectious Diseases consultation (IDC) already existed at this unit, and an educational ASP was added in 2011. Its main intervention consisted of face-to-face educational interviews. Antibiotic consumption was assessed through quarterly Defined Daily Doses (DDD) per 100 occupied bed-days. Mortality was evaluated in patients with bloodstream infections through the quarterly incidence density per 1000 admissions, and the annual mortality rates at 7 and 30-days. Time-trends were analysed through segmented-regression analysis, and the impact of the ASP was assessed through before-after interrupted time-series analysis.

RESULTS

Mortality significantly decreased throughout the study period (-13.3% annual reduction for 7-day mortality rate, p < 0.01; -8.1% annual reduction for 30-day mortality, p = 0.03), parallel to a reduction in antibiotic consumption (quarterly reduction -0.4%, p = 0.01), especially for broader-spectrum antibiotics. The before-after study settled a significant inflexion point on the ASP implementation for the reduction of antibiotic consumption (change in level 0.95 DDD, p = 0.71; change in slope -1.98 DDD per quarter, p < 0.01). The decreasing trend for mortality before the ASP also continued after its implementation.

CONCLUSIONS

The combination of an ASP with IDC improved antibiotic use among patients with cancer, and was accompanied by a reduction of mortality of bacteraemic infections. Implementation of the ASP was necessary to effectively change antibiotic use.

Gentamicin as Empirical Treatment in Hemodialysis Patients: Safety, Pharmacokinetics, and Pharmacodynamics

The aim of this study was to describe the safety profile and pharmacokinetic/pharmacodynamic parameters in end-stage renal disease patients who received gentamicin as empirical treatment in catheter-related bacteremia when they showed infection signs, regardless of the timing of the next HD. Patients received gentamicin 3 mg/kg before blood culture extraction when they showed infection signs and regardless of the timing of next hemodialysis session. Serum concentrations were collected after the gentamicin administration (peak level) and before the next HD (trough level). Toxicities and adverse drug events were registered. The main pharmacokinetic/pharmacodynamic goal for Gram-negative infections was peak:minimum inhibitory concentration (MIC) ≥10. Sixteen patients were included. Nephrotoxicity was not assessed in this population, and no ototoxicity was found. According to microbial isolation and gentamicin susceptibility, the value of peak:MIC was 5.4 ± 2.0. The administration of gentamicin in these conditions was safe. Estimated pharmacokinetic values were consistent with previous studies and appropriate according to peak:MIC goal for Gram-negative organisms with MIC ≤1 mg/L.

SMPDL3b modulates insulin receptor signaling in diabetic kidney disease

Sphingomyelin phosphodiesterase acid-like 3b (SMPDL3b) is a lipid raft enzyme that regulates plasma membrane (PM) fluidity. Here we report that SMPDL3b excess, as observed in podocytes in diabetic kidney disease (DKD), impairs insulin receptor isoform B-dependent pro-survival insulin signaling by interfering with insulin receptor isoforms binding to caveolin-1 in the PM. SMPDL3b excess affects the production of active sphingolipids resulting in decreased ceramide-1-phosphate (C1P) content as observed in human podocytes in vitro and in kidney cortexes of diabetic db/db mice in vivo. Podocyte-specific Smpdl3b deficiency in db/db mice is sufficient to restore kidney cortex C1P content and to protect from DKD. Exogenous administration of C1P restores IR signaling in vitro and prevents established DKD progression in vivo. Taken together, we identify SMPDL3b as a modulator of insulin signaling and demonstrate that supplementation with exogenous C1P may represent a lipid therapeutic strategy to treat diabetic complications such as DKD.

Longitudinal Associations between Dietary Patterns and Weight Status in Puerto Rican Infants and Toddlers' Participants of the WIC Program

OBJECTIVE

To explore the associations between feeding practices and diet quality with weight in Puerto Rican infants/toddlers.

METHODS

This was a longitudinal study done in a sample of 296 caregivers and their children aged 0-24 months from a WIC clinic in PR. A. Caregivers completed questionnaires on socio-demographics and feeding practices and infant's weight and length were measured at the baseline and follow-up (1 year later) visits. Diet quality was assessed using an adapted version of the Diet Quality Index Score (DQIS) for infants/toddlers.

RESULTS

A total of 77 participants completed the follow-up visit. At baseline, overweight/obesity was found in 5% while in the follow-up visit it increased to 16%. Exclusive breastfeeding for less than one month (RR 1.32, 95% C.I. 1.10, 1.59) and formula-based diets (RR 1.29; 95% C.I. 1.08, 1.54) increased the odds of overweight/ obesity at follow-up compared to longer breastfeeding and those never formula-fed. DQIS significantly decreased from the baseline to the follow-up visit. The overall DQIS was not significantly associated with weight; however, a trend was observed between a negative change in the breast-milk and 100% juices score with higher odds of overweight/obesity while a negative change in the vegetable score was associated with lower odds of overweight/obesity.

CONCLUSION

Diet quality significantly decreased over time in our sample. Breastfeeding for less than one month and formula-based diets significantly increased the odds of overweight/obesity at follow-up, but no significant associations were found with DQIS or its components.

Transitando hacia el ejercicio de autonomía y liderazgo: … «para el posicionamiento hay que luchar»

Introducción: En Chile, las enfermeras/os tienen respaldo legal para gestionar el cuidado, esto facilita el desarrollo de competencias para ejercer autonomía y liderazgo. Actualmente persisten barreras para transitar hacia un reconocimiento real de la independencia profesional. Objetivo: Develar la experiencia vivida de enfermeras con cargos en niveles de jefatura respecto al propio desarrollo para lograr el liderazgo y autonomía profesional. Metodología: Estudio cualitativo descriptivo-interpretativo, desde la trayectoria fenomenológica de Edmund Husserl. Muestreo selectivo de caso homogéneo de tres enfermeras que desempeñaban rol de jefatura en instituciones de salud, región Valparaíso, Chile. Participación consentida. Entrevista no estructurada. Análisis del discurso utilizando el modelo de liderazgo integral de Ken Wilber. Resultados: Categorías: Conciencia del líder «ser inquieta...intelectualmente». Construyendo competencias «el liderazgo se aprende». Transitando hacia el ejercicio de la autonomía y el liderazgo, “para el posicionamiento hay que luchar”. El peso de las estructuras organizacionales «tu rol es parte de un hospital». Interpretación: El eEjercicio del liderazgo y la autonomía se fundamenta en competencias actitudinales por sobre las cognitivas y técnicas. Existe mayor apoyo y reconocimiento a nivel institucional, que al interior del equipo de salud. Persisten limitaciones para lograr máxima expresión del liderazgo y autonomía, por persistencia de modelos institucionales hegemónicos, centrados en decisiones médicas y desconocimiento del rol integrado. Conclusión: El líder se mueve en un escenario dual, entre un menor reconocimiento del equipo y un creciente empoderamiento del rol autónomo y visibilidad a nivel directivo institucional.

Semi-Synthesis of Triterpene A-ring Derivatives from Oleanolic and Maslinic Acids. Theoretical and experimental 13C chemical shifts

Oleanolic and maslinic acids were isolated from solid waste from olive oil and several derivatives were semi-synthesised using typical reaction procedures. Experimental and theoretical (GIAO, B3LYP/6-31G*//MM+) 13C NMR chemical shifts for 21 compounds are given.

Semi-synthesis of triterpene A-ring derivatives from oleanolic and maslinic acids. Part II. Theoretical and experimental 13C chemical shifts†

Maslinic acid was obtained from olive-pressing residues, and several derivatives were formed. Rearrangements of 2-tosyloxy-derivatives of methyl maslinate made out by acetolysis. The main product of these rearrangements contained a cyclopentanic A-ring as a result of a concerted 2(3) → 4-abeo rearrangement process. Experimental and theoretical (GIAO, B3LYP/6-31G*//MM+) 13C NMR chemical shifts for 20 compounds are given.

Impact of De-escalation on Prognosis of Patients With Bacteremia due to Enterobacteriaceae: A Post Hoc Analysis From a Multicenter Prospective Cohort

Background

More data are needed about the safety of antibiotic de-escalation in specific clinical situations as a strategy to reduce exposure to broad-spectrum antibiotics. The aims of this study were to investigate predictors of de-escalation and its impact on the outcome of patients with bloodstream infection due to Enterobacteriaceae (BSI-E).

Methods

A post hoc analysis was performed on a prospective, multicenter cohort of patients with BSI-E initially treated with ertapenem or antipseudomonal β-lactams. Logistic regression was used to analyze factors associated with early de-escalation (EDE) and Cox regression for the impact of EDE and late de-escalation (LDE) on 30-day all-cause mortality. A propensity score (PS) for EDE vs no de-escalation (NDE) was calculated. Failure at end of treatment and length of hospital stay were also analyzed.

Results

Overall, 516 patients were included. EDE was performed in 241 patients (46%), LDE in 95 (18%), and NDE in 180 (35%). Variables independently associated with a lower probability of EDE were multidrug-resistant isolates (odds ratio [OR], 0.50 [95% confidence interval {CI}, .30–.83]) and nosocomial infection empirically treated with imipenem or meropenem (OR, 0.35 [95% CI, .14–.87]). After controlling for confounders, EDE was not associated with increased risk of mortality; hazard ratios (HR) (95% CIs) were as follows: general model, 0.58 (.25–1.31); model with PS, 0.69 (.29–1.65); and PS-based matched pairs, 0.98 (.76–1.26). LDE was not associated with mortality. De-escalation was not associated with clinical failure or length of hospital stay.

Conclusions

De-escalation in patients with monomicrobial bacteremia due to Enterobacteriaceae was not associated with a detrimental impact on clinical outcome.

Emergency contraception and risk habits in a university population

OBJECTIVE

The aim of our study was to determine the self-reported prevalence of use of emergency contraception (EC), identify factors associated with EC use, and measure the prevalence in university students of pregnancy and abortion among users and non-users of EC.

METHODS

A cross-sectional descriptive study of university students using a self-administered questionnaire was carried out in 2016. The main dependent variable was EC use at any time. Independent variables included sociodemographic factors and factors related to harmful habits and sexual behaviour.

RESULTS

The study sample consisted of 1309 students (median age 20 years). Forty per cent of participants reported using EC; condom failure was given as the main reason. Variables associated with EC use in both men and women were illegal drug consumption and having had more than 10 sexual partners. In women, other factors associated with EC use were age at first coitus and non-centrist political views. The prevalence of pregnancy was 6.5% and the prevalence of voluntary abortion was 2.9%. This prevalence was similar for men and women and for EC users and non-users.

CONCLUSION

EC use in university students was more likely in those who experienced contraceptive failure or used no contraception. There were differences between men and women. Those at higher risk of unplanned pregnancy were more likely to report EC use, which may explain why there was no difference in the rates of unwanted pregnancies between EC users and non-users.

Models for the propensity score that contemplate the positivity assumption and their application to missing data and causality

Generalized linear models are often assumed to fit propensity scores, which are used to compute inverse probability weighted (IPW) estimators. To derive the asymptotic properties of IPW estimators, the propensity score is supposed to be bounded away from zero. This condition is known in the literature as strict positivity (or positivity assumption), and, in practice, when it does not hold, IPW estimators are very unstable and have a large variability. Although strict positivity is often assumed, it is not upheld when some of the covariates are unbounded. In real data sets, a data-generating process that violates the positivity assumption may lead to wrong inference because of the inaccuracy in the estimations. In this work, we attempt to conciliate between the strict positivity condition and the theory of generalized linear models by incorporating an extra parameter, which results in an explicit lower bound for the propensity score. An additional parameter is added to fulfil the overlap assumption in the causal framework.

[Adult community acquired pneumonia vaccination: 2018 Update of the positioning of the Pneumonia Prevention Expert Group]

Community-acquired pneumonia (CAP) continues to be an important cause of morbidity and mortality in adults. The aim of this study is to update the 2016 practical prevention guidelines for CAP through vaccination in Spain, based on the available vaccines, as well as the evidence using a literature review and expert opinion. Vaccines against pneumococcus and influenza continue to be the main prevention tools available against CAP, and can contribute to reduce the burden of disease due to CAP and its associated complications. The available evidence supports the priority indications established in these guidelines, and it would be advisable to try to achieve a widespread dissemination and implementation of these recommendations in routine clinical practice.