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The current morbimortality of serious infections is unacceptable and there is a need to promote the increase in the efficacy of empirical and targeted antibiotherapy. This could be achieved by initiatives coming from ASP teams aimed at promoting increased efficacy of antibiotic therapy .In the optimization of the antibiotic therapy there are several critical points in which an adequate timing could achieve benefits in the survival of patients with severe infections: prompt initiation of empirical treatment; de-escalation performance, appropriate targeted treatment; and finally, curtail antibiotic duration.

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Rigid polyurethane foams were prepared by the one-step expandable foam method using casting molding followed by forming clay-based composites. Polyurethane/vermiculite foam composites (PU/VMT) were controlled based on adding the percentage of clay in the formulation. The effects of composite modifications were evaluated by X-ray diffraction (XRD), thermogravimetric analysis (TG/DTG), and scanning electron microscopy (SEM/EDS) applied to the flame retardancy explored by the vertical burn test. The results indicated that adding clay controlled the particle size concerning polyurethane (PU) foams. However, they exhibited spherical structures with closed cells with relatively uniform distribution. XRD analysis showed the peaks defined at 2θ = 18° and 2θ = 73° relative to the crystallinity in formation and interaction of rigid segments were identified, as well as the influence of crystallinity reduction in composites. In the flame test, the flame retardant surface was successful in all composites, given the success of the dispersibility and planar orientation of the clay layers and the existence of an ideal content of vermiculite (VMT) incorporated in the foam matrix.

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ABSTRACT: Current data on the frequency and efficacy of linezolid (LNZ) in infective endocarditis (IE) are based on small retrospective series. We used a national database to evaluate the effectiveness of LNZ in IE.This is a retrospective study of IE patients in the Spanish GAMES database who received LNZ. We defined 3 levels of therapeutic impact: LNZ < 7 days, LNZ high-impact (≥ 7 days, > 50% of the total treatment, and > 50% of the LNZ doses prescribed in the first weeks of treatment), and LNZ ≥ 7 days not fulfilling the high-impact criteria (LNZ-NHI). Effectiveness of LNZ was assessed using propensity score matching and multivariate analysis of high-impact cases in comparison to patients not treated with LNZ from the GAMES database matched for age-adjusted comorbidity Charlson index, heart failure, renal failure, prosthetic and intracardiac IE device, left-sided IE, and Staphylococcus aureus. Primary outcomes were in-hospital mortality and one-year mortality. Secondary outcomes included IE complications and relapses.From 3467 patients included in the GAMES database, 295 (8.5%) received LNZ. After excluding 3 patients, 292 were grouped as follows for the analyses: 99 (33.9%) patients in LNZ < 7 days, 11 (3.7%) in LNZ high-impact, and 178 (61%) in LNZ-NHI. In-hospital mortality was 51.5%, 54.4%, and 19.1% respectively. In the propensity analysis, LNZ high-impact group presented with respect to matched controls not treated with LNZ higher in-hospital mortality (54.5% vs 18.2%, P = .04). The multivariate analysis showed an independent relationship of LNZ use with in-hospital mortality (odds ratio 9.06, 95% confidence interval 1.15--71.08, P = .03).Treatment with LNZ is relatively frequent, but most cases do not fulfill our high-impact criteria. Our data suggest that the use of LNZ as definitive treatment in IE may be associated with higher in-hospital mortality.

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Coumarin-based lanthanide complexes of general formula [Ln(coum)3(phen)(H2O)x]·yH2O (Ln-phen, x = 0,1, 0 ≤ y ≤ 1.5; phen = 1,10-phenanthroline; coum = 3-acetyl-4-hydroxylato-coumarin; Ln = Eu, Tb, Dy, Tm) and [Ln(coum)3(batho)]·0.7EtOH (Ln-batho, batho = 4,7-diphenyl-1,10-phenanthroline; Ln = Eu, Tb, Dy, Tm) were synthesized. The magnetic relaxation and photoluminescence behavior of these complexes was compared with that of the related compounds [Ln(coum)3(EtOH)(H2O)]·EtOH (Ln-coum), so as to investigate the effects of incorporating a second chromophore, either the phen or batho ligand, to the original coordination scaffold, provided with three coumarin (coum) ligands. Slow relaxation of the magnetization under H = 0 with moderate activation energies was observed for the Dy-phen (U/kB = 99.1 K) and Dy-batho (U/kB = 67.1 K) compounds, whereas Tb analogues presented field-induced single molecule magnet (SMM) behavior, with U/kB = 11.7 K (16.6 K@3 kOe) for Tb-phen (Tb-batho), respectively. Luminescent emission in the visible range was observed for all the Ln-coumarin based compounds upon ligand sensitization, with high quantum yields of 45 (40%) for Eu-phen (Eu-batho) compounds and 65-76-58% for Tb-coum, phen, batho analogues. Sensitization is mainly provided by the coumarin ligand having the energy difference ΔE between its triplet state T1 and the lanthanide emitting level closest to the optimum, while the second ligand can play either a synergistic or competing sensitizing role. The Tb-phen/batho compounds presented simultaneously SMM and luminescent behavior, with excellent values of the bifunctional figure of merit (ηSMM-QY ∼ 1000% K). The reported compounds represent a new class of bifunctional materials with potential interesting application in various fields.

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OBJECTIVES: To analyze the efficacy and safety of dolutegravir/rilpivirine (DTG/RPV) in HIV-infected patients who switched from any other antiretroviral therapy (ART). METHODS: Open-label, multicenter study including patients who switched to DTG/RPV between February 2015 and February 2016. Efficacy (HIV RNA <50 copies/mL), adverse events, and metabolic changes at 24 weeks were analyzed. RESULTS: A total of 104 participants were included, who switched for the following reasons: toxicity/intolerance (42.3%), convenience (27.8%), and drug interactions (17.3%). Prior regimens are protease inhibitor (56.7%), integrase strand transfer inhibitor (26.9%), and non-nucleoside reverse transcriptase inhibitor (16.3%). Efficacy at 24 weeks was 88.4% (intention to treat) and 96.8% (per protocol). Triglyceride levels were reduced, on average, by 12.7% and a mean decrease of 9.0% in the glomerular filtration rate was observed as well ( P values of .003 and .002, respectively), whereas total cholesterol, HDL cholesterol, LDL cholesterol, creatinine, and glutamic-pyruvic transaminase remained unchanged. No patient discontinued due to adverse events. CONCLUSIONS: Dolutegravir/RPV is effective and safe in long-term HIV-infected patients under any prior ART. Toxicity, convenience, and interactions were the main reasons for changing. At 24 weeks, the lipid profile improved with a decrease in triglycerides.

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OBJECTIVE: To simplify and optimize the ability of EuroSCORE I and II to predict early mortality after surgery for infective endocarditis (IE). METHODS: Multicentre retrospective study (n = 775). Simplified scores, eliminating irrelevant variables, and new specific scores, adding specific IE variables, were created. The performance of the original, recalibrated and specific EuroSCOREs was assessed by Brier score, C-statistic and calibration plot in bootstrap samples. The Net Reclassification Index was quantified. RESULTS: Recalibrated scores including age, previous cardiac surgery, critical preoperative state, New York Heart Association >I, and emergent surgery (EuroSCORE I and II); renal failure and pulmonary hypertension (EuroSCORE I); and urgent surgery (EuroSCORE II) performed better than the original EuroSCOREs (Brier original and recalibrated: EuroSCORE I: 0.1770 and 0.1667; EuroSCORE II: 0.2307 and 0.1680). Performance improved with the addition of fistula, staphylococci and mitral location (EuroSCORE I and II) (Brier specific: EuroSCORE I 0.1587, EuroSCORE II 0.1592). Discrimination improved in specific models (C-statistic original, recalibrated and specific: EuroSCORE I: 0.7340, 0.7471 and 0.7728; EuroSCORE II: 0.7442, 0.7423 and 0.7700). Calibration improved in both EuroSCORE I models (intercept 0.295, slope 0.829 (original); intercept -0.094, slope 0.888 (recalibrated); intercept -0.059, slope 0.925 (specific)) but only in specific EuroSCORE II model (intercept 2.554, slope 1.114 (original); intercept -0.260, slope 0.703 (recalibrated); intercept -0.053, slope 0.930 (specific)). Net Reclassification Index was 5.1% and 20.3% for the specific EuroSCORE I and II. CONCLUSIONS: The use of simplified EuroSCORE I and EuroSCORE II models in IE with the addition of specific variables may lead to simpler and more accurate models.

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BACKGROUND: Infective endocarditis (IE) caused by anaerobic bacteria is a rare and poorly characterized disease. Most data reported in the literature are from case reports [1-3]. Therefore, we assessed the situation of anaerobic IE (AIE) in Spain using the database of the Spanish Collaboration on Endocarditis (GAMES). METHODS: We performed a prospective study from 2008 to 2016 in 26 Spanish centers. We included 2491 consecutive cases of definite IE (Duke criteria). RESULTS: Anaerobic bacteria caused 22 cases (0.9%) of definite IE. Median age was 66 years (IQR, 56-73), and 19 (86.4%) patients were men. Most patients (14 [63.6%]) had prosthetic valve IE and all episodes were left-sided: aortic valves, 12 (54.5%); and mitral valves, 8 (36.4%). The most common pathogens were Propionibacterium acnes (14 [63.6%]), Lactobacillus spp (3 [13.63%]), and Clostridium spp. (2 [9.0%]), and the infection was mainly odontogenic. Fifteen of the 22 patients (68.2%) underwent cardiac surgery. Mortality was 18.2% during admission and 5.5% after 1 year of follow-up. When patients with AIE were compared with the rest of the cohort, we found that although those with AIE had a similar age and Charlson comorbidity index, they were more likely to have community-acquired IE (86.4% vs. 60.9%, p = 0.01), have undergone cardiac surgery (68.2% vs 48.7% p = 0.06), and have had lower mortality rates during admission (18.2% vs. 27.3%). CONCLUSION: IE due to anaerobic bacteria is an uncommon disease that affects mainly prosthetic valves and frequently requires surgery. Otherwise, there are no major differences between AIE and IE caused by other microorganisms.

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Hemophagocytic lymphohistiocytosis (HLH) is a very rare syndrome with a mortality up to 95% of cases if not treated. It is characterised by an excessive activation of the immune system that leads to a disproportionate and destructive inflammatory response. The high mortality rates are in part due to a delay in the diagnosis, and therefore clinicians must maintain a high index of suspicion. When the treatment is started early, the survival rate reaches around 55% of cases. HLH usually presents with persistent fever, pancytopenia, and organomegaly and is associated with very high levels of serum ferritin. In this manuscript, we present the case of a patient with primary Sjögren's syndrome who developed HLH after an acute infection by Cytomegalovirus. We will describe and discuss the pathogenesis, differential diagnosis and a pragmatic approach to the treatment for this critically important and, when diagnosed early, potentially curable syndrome.

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In order to improve infection prognosis and reduce the existing microbial resistance problem (a challenge similar to that of climate change), a higher implication of the Administration, an increased level of social awareness and the development of specific corporate networks, including the pharmaceutical industry, is needed. However, we must first consolidate Antimicrobial Stewardship Programmes with experts who seek to improve antibiotic therapy effectivity in severe infections and to reduce global antibiotic exposure.

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OBJECTIVE: To evaluate the course of left-sided infective endocarditis (LsIE) in patients with liver cirrhosis (LC) analyzing its influence on mortality and the impact of surgery. METHODS: Prospective cohort study, conducted from 1984 to 2013 in 26 Spanish hospitals. RESULTS: A total of 3.136 patients with LsIE were enrolled and 308 had LC: 151 Child-Pugh A, 103 B, 34 C and 20 were excluded because of unknown stage. Mortality was significantly higher in the patients with LsIE and LC (42.5% vs. 28.4%; p < 0.01) and this condition was in general an independent worse factor for outcome (HR 1.51, 95% CI: 1.23-1.85; p < 0.001). However, patients in stage A had similar mortality to patients without cirrhosis (31.8% vs. 28.4% p = NS) and in this stage heart surgery had a protective effect (28% in operated patients vs. 60% in non-operated when it was indicated). Mortality was significantly higher in stages B (52.4%) and C (52.9%) and the prognosis was better for patients in stage B who underwent surgery immediately (mortality 50%) compared to those where surgery was delayed (58%) or not performed (74%). Only one patient in stage C underwent surgery. CONCLUSIONS: Patients with liver cirrhosis and infective endocarditis have a poorer prognosis only in stages B and C. Early surgery must be performed in stages A and although in selected patients in stage B when indicated.

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La presente investigación aborda la temática “Discapacidad y legislación laboral chilena”, con el propósito de incorporar en el análisis la visión de sujetos en situación de discapacidad con experiencia organizativa y orientados a la acción política. El objetivo es analizar la visión respecto a la legislación laboral actual chilena desde sujetos en situación de discapacidad que participan activamente en política, pertenecientes al Colectivo Palos de Ciego durante el año 2014. Se utiliza una metodología participativa con enfoque cualitativo, orientada a la emancipación y con perspectiva etnográfica. La recolección de información se realiza a partir de la observación participante, notas de campo y entrevistas en profundidad. El análisis de la información se realiza mediante codificación abierta. Los resultados se estructuran a partir de tres ejes temáticos: visión política de la legislación laboral, limitantes percibidas y propuestas de transformación respecto de la inclusión laboral chilena. La problemática central tiene relación con la lógica dominante bajo la cual el Estado actúa de manera subsidiaria, no reconociendo los Derechos inherentes de los sujetos en situación de discapacidad. Los miembros del Colectivo proponen estrategias de transformación de orden político, con incidencia en aspectos globales y de acción política directa, destacándose la importancia de concientizar a la sociedad respecto a la comprensión de la discapacidad como problema político. Finalmente, se expresa el desafío de ampliar la Terapia Ocupacional al ámbito político, orientando la participación del profesional en los procesos de lucha política de los sujetos en situación de discapacidad.

This research is framed in the thematic “Disability and Chilean labor legislation” with the purpose of incorporating the vision of the subjects in disability situation with experience and political action. The aim of this research is to analyze the political vision regarding the current Chilean labor legislation, from the subjects in disability situation belonging to the group “Palos de ciego” during 2014. A participatory methodology with qualitative focusing is used, oriented to emancipation, with ethnographic perspective. Data gathering is from participant observation, field notes, and in-depth interviews. The analysis of information is done through open coding. Results are structured from three thematic axes: political vision of the labor legislation, limitations and proposals of transformation of the Chilean labor inclusion. The central issue is related to the dominant logic, under which the state acts on a subsidiary basis, not recognizing the inherent rights of the subjects in disability situation. The group proposes strategies of transformation of political order, with incidence in global and specific aspects, standing out the importance of awareness in society regarding compression of disability as a political problem. Finally, is expressed the challenge of enlarge occupational therapy to a political scope, encouraging the professional’s participation in the processes of political struggle of the subjects in situation of disability, as well as political participation thereof.

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One hundred and 26 faecal samples from healthy dogs (2009) and 157 faecal samples from healthy humans (2007) from La Rioja region (Spain) were tested to know the carriage of vancomycin-resistant enterococci (VRE). VRE with intrinsic resistance (vanC) were found in 12% of healthy dogs and humans (29 Enterococcus gallinarum and four Enterococcus casseliflavus). Nevertheless, VRE with acquired mechanism of resistance were not detected among these samples. Four Enterococcus faecalis isolates with vancomycin MIC of 8-16 mg L(-1) were recovered in human samples, but no single organism with known mechanism of acquired resistance could be identified. These 37 VRE isolates (33 E. gallinarum/E. casseliflavus and four E. faecalis) of dog and human origin were further characterized (PCR detection of antibiotic resistance, virulence and bacteriocin genes). High prevalence of tetracycline resistance was identified (70%), especially among dog isolates harbouring tet(M) ± tet(L) genes; erythromycin resistance was also higher among isolates from dogs and they harboured the erm(B) gene, associated with erm(A) gene in one case. Virulence genes were only identified among E. faecalis isolates of human origin (agg, cpd and/or gelE) and never among E. gallinarum/E. casseliflavus of human or dog origin. Five E. gallinarum isolates of dog and three E. faecalis of human origin expressed bacteriocin activity; among them, only one E. faecalis presented activity against Listeria monocytogenes. The bacteriocin structural gene ef1097 was identified in 3 bacteriocin-producing E. faecalis isolates, associated with ent1071 in one of them.

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OBJECTIVES: We evaluate the clinical, echographic and prognostic characteristics of infective endocarditis (IE) in a large population of elderly patients, and the results of surgical approach. METHODS: Multicentric, prospective, observational cohort study with 961 consecutive left-sided IE: 356 patients aged ≥65 years were compared with 605 younger. Indications for cardiac surgery, potential surgical risk, time and outcome, were compared. RESULTS: Hospital-acquired endocarditis, comorbidity, renal failure and septic shock were more frequent in elderly, but embolisms were less. Intracardiac destruction and ventricular failure were similar in both groups, but significantly fewer elderly patients underwent cardiac surgery (36% vs 51%; p < 0.01), and this group showed a worse outcome (43.2% of mortality vs 27% in younger; p < 0.01), resulting age as an independent predictor of mortality (OR: 1.02 CI95%: 1.01-1.03). Compared with medical treatment, surgery showed lower percentages of mortality compared with medical treatment (23.3% vs 31.3%; p = 0.03) in younger group, but a high mortality was observed with both procedures (47.6% vs 40.3%; p = 0.1) in the elderly. CONCLUSIONS: Although similar percentages of heart failure and intracardiac complications, increasing age is associated with higher mortality in IE. Lower rates of surgical treatment and a worse outcome after operation are common features in elderly patients.

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The mutations in gyrA and parC genes were analyzed in 22 vancomycin-resistant enterococci of different origins and species, which had varying susceptibility to ciprofloxacin (minimum inhibitory concentration, MIC: 0.5- >256 mg/l). All vanA or vanb2-containing strains with ciprofloxacin MIC of >32 mg/l presented amino acid changes in GyrA protein (S83I, S83Y, S83R or S83I-E87G) with/without changes in ParC protein (S80I or S80R or S80l). Strains with lower ciprofloxacin MICs presented the GyrA and parC wild type. One vanA-containing Enterococcus durans strain with a ciprofloxacin MIC of 64 mg/l presented the S83I and S80I changes in GyrA and ParC proteins, respectively. Two vanB2 Enterococcus faecium strains were typed by multi-locus-sequencetyping and both were ascribed to the CC17 clonal complex with two sequence-types (ST78 and ST17-like). All seven vancomycin-resistant and ciprofloxacin-resistant E. faecium strains showed ampicillin resistance (MIC 32-256 mg/l), identifying the following amino acid changes in PBP5 protein: Q461K, V462K, H470Q, M485A, N496K, A499T, E525D, N546T, A558T, G582S, K632Q, P642L, E629V and P667S, together with a serine insertion at position 466´. The 12 Enterococcus gallinarum and Enterococcus casseliflavus isolates included in the study exhibited an MIC for ciprofloxacin in the range 0.5-16 mg/l and no amino acid changes were identified in GyrA or ParC proteins. Specific mutations in gyrA and parC genes are associated with fluoroquinolone resistance in E. faecium and E. durans of different origins.

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OBJECTIVES: To determine the effect of low (< or =7.5 mg/day; LD-PRD group) or medium (>7.5 mg/day; MD-PRD group) doses of prednisone over the past 4 months on insulin levels and insulin resistance (IR) in SLE patients. METHODS: SLE patients were categorised in prednisone non-users (No PRD) (n=41), LD-PRD (n=71) and MD-PRD (n=16) users. We compared insulin levels, presence of increased IR using homeostasis model assessment (HOMA index), metabolic syndrome (MetS), and other clinical, metabolic and inflammatory parameters in the 3 groups. A Spearman's rho test was used to identify independent associations between daily prednisone dose, HOMA index and insulin levels and other parameters, after adjusting for confounders. RESULTS: No differences in increased IR, HOMA index and insulin between No PRD and LD-PRD were found. In contrast, the MD-PRD group was younger (p=0.001) and had higher insulin (p=0.015), higher HOMA index (p=0.019) and increased IR (OR 5.8, 95% CI (1.7-20), p=0.007) in comparison with the LD-PRD group. The HOMA index strongly correlated with body mass index (BMI) (rs=0.460, p<0.001) but not with clinical activity or inflammatory state after adjusting for confounders. Prednisone dose correlated with the HOMA index and insulin but not with inflammatory parameters (erythrocyte sedimentation rate p=0.075) after adjusting for confounder. CONCLUSIONS: Daily medium-dose prednisone use (>7.5 mg/d) but not low-dose (< or =7.5 mg/d) use increased insulin levels and IR in SLE, which may contribute to increased CV risk experienced by these patients.

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SUMMARY OBJECTIVE: To evaluate the current trends in the clinical characteristics and the prognosis of Streptococcus agalactiae infective endocarditis (IE), uncommon disease associated with high mortality. METHODS: Descriptive analysis of 27 cases of a large cohort (961 episodes) of infective endocarditis collected in seven hospitals of Andalusia (Spain) between 1984 and 2008. RESULTS: Native valves were affected in most cases (85. 2%), multiple valves were frequently involved (22.2%). The median age of the patients was 65 (51-76) years (59.3% men), with a comorbidity, according to the Charlson index, of 2.6+/-2.3. The most frequent underlying diseases were diabetes mellitus (25.9%), chronic obstructive pulmonary disease (14.8%), neoplasms (14.8%), urological disorders (11%) and chronic liver disease (11%). Clinical presentation was characterized by rapid worsening (median of 9 (5.7-15) days from onset of symptoms until diagnosis), a high rate of embolisms (37%) and cardiac complications (abscesses, fistulas or valve rupture) - 37% of cases. Surgery was performed in 12 patients (44.4%) and a high mortality (40.7%) was observed. CONCLUSION: S. agalactiae IE is a serious disease with aggressive course and high mortality rate and affects patients with debilitating diseases. We must be alert of the development of complications and consider early valve surgery when it is necessary.

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The objective of this article was to evaluate whether serum uric acid (SUA) correlates with arterial stiffness and inflammation markers in a cohort of women with systemic lupus erythematosus (SLE) without overt atherosclerotic cardiovascular diseases, who attended a community hospital. One hundred and two women with SLE were assessed as part of this cross-sectional study. Carotid-femoral pulse wave velocity (PWV) was measured using an automatic device (Complior). C-reactive protein (CRP), fibrinogen and homocysteine levels as well as other metabolic results were recorded. Duration and activity of SLE, damage accrual and treatments were recorded. SLE women were categorized as having or not having hyperuricaemia (HU) according to SUA levels (greater than or up to 6.2 mg/dl, respectively). A multiple linear regression analysis was used to determine the independent link between SUA levels and other variables. Women with SLE and HU (n = 15, 15%) had a worse cardiovascular risk profile that included ageing, hypertension, obesity, higher total cholesterol levels, renal failure and presence of metabolic syndrome. Also, the duration of SLE was increased and damage accrual was greater. In the unadjusted analysis, SUA levels correlated with PWV, CRP, fibrinogen and homocysteine. However, in a multivariate linear regression analysis, SUA levels independently correlated with the duration of SLE, creatinine, total cholesterol and homocysteine levels but did not correlate with PWV. In conclusion, SUA was associated with arterial stiffness, but not independently of age and homocysteine levels. Nevertheless, SUA might be an ancillary indicator of subclinical atherosclerosis in SLE women without clinically evident atherosclerotic cardiovascular disease.

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BACKGROUND: Chronic stress worsens the quality of life (QOL) of lupus patients by affecting their physical and psychological status. The effectiveness of a cognitive-behavioural intervention in a group of patients with lupus and high levels of daily stress was investigated. METHODS: Forty-five patients with lupus and high levels of daily stress were randomly assigned to a control group (CG) or a therapy group (TG); they received cognitive behavioural therapy (CBT) which consisted of ten consecutive weekly sessions. The following variables were evaluated at baseline and at 3, 9 and 15 months: (1) stress, anxiety, depression, (2) Systemic Lupus Erythematosus Disease Activity Index, somatic symptoms, number of flares, (3) anti-nDNA antibodies, complement fractions C3 and C4 and (4) QOL. A multivariate analysis of repeated measures and various analyses of variance were carried out. RESULTS: We found a significant reduction in the level of depression, anxiety and daily stress in the TG compared to the CG and a significant improvement in QOL and somatic symptoms in the TG throughout the entire follow-up period. We did not find any significant changes in the immunological parameters. CONCLUSIONS: CBT is effective in dealing with patients suffering from lupus and high levels of daily stress as it significantly reduces the incidence of psychological disorders associated with lupus and improves and maintains patients' QOL, despite there being no significant reduction in the disease activity index.

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