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Abstract Patients with chronic kidney disease (CKD) are at a high risk of cardiovascular (CV) complications. In these patients, sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been shown to reduce CV events. Mineralocorticoid receptor antagonists (MRAs) exert similar benefits in diabetic CKD, though their effects in non-diabetic CKD remain unclear. This study aimed to evaluated whether the combination of Dapagliflozin (DAPA) and Eplerenone (EPLE) would have positive effects on cardiorenal functions in a non-diabetic CKD model. CKD was induced in rats via 5/6 nephrectomy, followed by treatment with DAPA (5 mg/kg/day PO), EPLE (100 mg/kg/day PO) or the combination for 3 months following CKD induction. Cardiorenal functions were assessed after the treatment period. All treated groups showed reduced kidney fibrosis though plasma creatinine and urea levels remained unchanged. Compared to untreated CKD, EPLE or DAPA/EPLE reduced left ventricle (LV) end-diastolic pressure and LV end-diastolic pressure volume relationship, whereas DAPA alone did not achieve significant reductions. Compared to untreated CKD, EPLE and DAPA/EPLE improved cardiac perfusion but DAPA alone did not. Cardiac fibrosis in CKD was blunted by either DAPA or EPLE alone, with the combination showing an additive effect. In conclusion, co-treatment with DAPA and EPLE enhances diastolic function, cardiac perfusion and reduces myocardial fibrosis in non-diabetic CKD rats.

Introduction Psychopathological exploration (PPE) involves an assessment of the mental state of patients, where psychological signs and symptoms are analyzed, which collectively form a syndrome. To conduct this assessment, the clinician must utilize their expertise to identify the presence and authenticity of a series of symptoms that, once recognized, allow for a diagnosis (1). The presence of this subjective component could explain why, despite the continuous growth of artificial intelligence (AI), its application in clinical psychiatry practice remains limited. However, the combination of the clinician's work with AI could enhance diagnostic accuracy and our understanding of diseases (2). Objectives The objective of this study is to investigate whether AI can make accurate diagnoses through an initial psychopathological evaluation. Methods A random sample was selected from our medical records of all patients admitted to our acute mental health inpatient unit through the hospital's emergency services in the year 2022. An anonymized database was created, including sociodemographic information, the results of the psychopathological assessment in the emergency department, and the diagnosis at the time of discharge. The psychopathological assessment conducted in the emergency department was provided to the AI chatbot ChatGPT, with a request to establish a diagnosis according to the DSM-5. Diagnoses such as brief psychotic disorder, schizophreniform disorder, and schizophrenia were considered, given their acute symptom similarities, as well as major depressive disorder (unipolar) and bipolar disorder. The level of agreement between both diagnoses was evaluated using the kappa coefficient. Results The sample consisted of 15 patients, of whom 60% were male, with a mean age of 45 years (standard deviation = 15.6). 73.3% of the patients had prior mental health follow-up, and 66.7% had been previously hospitalized. Diagnoses included psychotic disorder in 33.3% of cases, bipolar disorder with manic episode in 26.7%, depressive disorder in 13.3%, delusional disorder in 13.3%, schizoaffective disorder in 6.7%, and borderline personality disorder in 6.7%. A kappa value of 0.561 was obtained, indicating a moderate degree of agreement between the diagnoses. Conclusions Despite the inherent subjectivity in psychopathological assessment, this study suggests that AI, in the form of natural language processing chatbots like ChatGPT, can be a useful tool to assist mental health professionals in the diagnostic process. While AI shows promising potential, it should not entirely replace the experience and clinical judgment of mental health professionals. Instead, the importance of potential collaboration between AI and clinicians for achieving more precise and comprehensive diagnoses is highlighted. Disclosure of Interest None Declared

Introduction It is estimated that the prevalence of severe Intellectual Disability (ID) is 6 per 1,000 people. ID is sometimes the cause of Behavioral Disorders (BD) with aggressive and impulsive behaviors that make family and social life difficult. However, despite its high prevalence, the number of studies on it is very scarce. When BD appears, it should be evaluated if there is a physical or psychiatric cause that causes it and assess non-pharmacological treatments. If they are insufficient, treatments such as risperidone are used to manage BD. When these are ineffective, the use of drugs with greater difficulties in their effects and clinical management, such as clozapine, is required. Objectives The objective is to describe the use of clozapine in patients with severe ID associated with BD. Methods Retrospective descriptive study. Patients older than 18 years with severe ID and BD, treated with clozapine for at least two years were included. Those with medical or psychiatric comorbidity were excluded. Results The sample consisted of 12 patients, 16.67% women (n=2) and 83.33% men (n=10), aged 47.57±9.27 years. Prior to the introduction of clozapine, a mean of 2.67±1.21 antipsychotics had been tested. The mean dose of clozapine was 264.24±70.50 mg/day. The patients had received treatment for 51.57±25.67 months, following the usual controls. None had hematological adverse effects or other serious adverse effects. Conclusions Clozapine can be an effective and safe therapeutic alternative in the treatment of BD in intellectual disabled patients which do not respond to other treatments. The clinical benefits of clozapine treatment seem to outweigh the potential risks associated with the treatment. However, more studies are needed to evaluate the effects of clozapine in patients with intellectual disabilities. Disclosure of Interest None Declared

Introduction Lithium associated with hypercalcemia may mimic a psychiatric condition and be confused for a relapse of bipolar disorder. The etiology seems to be due to a reduced sensitivity of the parathyroid cells to calcium, altering the parathyroid hormone (PTH) response. Lithium as an essential monovalent cation has some structural similarity to calcium (Ca) and can interact with protein receptors. This leads to changes in the inhibitory configuration of PTH and increased serum calcium concentrations, rising the threshold necessary to suppress hormone secretion. Lithium-induced hyperparathyroidism (HIL) is the main cause of hypercalcemia in these patients. Objectives Based on a clinical case of lithium-associated hypercalcemia in a patient with bipolar disorder, review the existing literature and state the needs for periodic monitoring protocols. Methods Case report and bibliographical review. Results A 38-year-old woman, diagnosed with bipolar affective disorder at the age of 18, has been treated with lithium during which she developed secondary tubulointerstitial nephropathy as an adverse effect. Recently, she requested medical evaluation for constitutional syndrome associated with deterioration of general condition with loss of strength and difficulty in walking. Analytically, mild hypercalcemia was detected, and the study was extended to include Ca and PTH. Chronic lithium therapy often develops mild hypercalcemia (approximately 10 to 20 percent of patients taking lithium), most likely due to increased secretion of PTH. Lithium can also unmask previously unrecognized mild hyperparathyroidism in patients with adenomas within a few years of starting therapy or induce parathyroid hyperplasia with a chronic use. The hypercalcemia usually, but not always, subsides when the lithium is stopped. Normalization of serum calcium is more likely to occur one to four weeks post-lithium withdrawal in patients with a relatively short duration of lithium use. It is less likely in patients receiving lithium for more than 10 years. Regarding the case to be presented, a review of the literature is carried out and the need to propose periodic calcium monitoring protocols is exposed. Conclusions Recommendations include determination of serum calcium every 6 months, urinary calcium and creatinine every 12 months, and bone mineral density monitoring every 1 to 3 years. Regular analytical monitoring including total calcium, PTH and vitamin D, would identify patients with a tendency to hypercalcemia so that appropriate measures could be taken. So as chronic treatment with lithium can develop mild hypercalcemia, I consider it necessary to develop periodic monitoring protocols for this adverse effect. Disclosure of Interest None Declared

Introduction Postictal suppression (PSI) is considered a key feature for ECT’s outcomes because higher values have been correlated with clinical efficacy. However, little is known about the demographic factors influencing this parameter. Objectives To analyze the influence of sex, age, diagnosis and treatment phase on ECT efficacy measured with PSI value. Methods 3251 ECT sessions were performed on 182 patients during two years at a university hospital. PSI was retrospectively analyzed comparing it according to sex (male, female), age, main diagnosis (major depressive disorder [MDD], bipolar disorder [BD], schizoaffective disorder [SZA], schizophrenia [SCZ]) and treatment phase (acute [a-ECT], continuation [c-ECT], maintenance [m-ECT]). Results PSI values were 69.76 % (SD 17.05) in women and 70.72 % (SD 16.81) in men without differences between sexes (F=0.979; p=0.607). PSI was correlated with age (r=-0.058; p=0.031). MDD PSI was 70.01 % (SD 16.88), for BD it was 69.48 % (SD 17.00), for SZA it was 68.62 % (SD 17.39), and for SCZ it was 70.73 % (SD 17.18), without differences between diagnosis (F=1.085; p=0.141). According to treatment phase, PSI in the a-ECT was 72.26 % (SD 16.43), in the c-ECT it was 67.83 % (SD 17.53), and in the m-ECT it was 68.47 % (SD 17.02), without differences between phases (F=0.901; p=0.915). Conclusions Although there exist statistically significant association between age and PSI it is a negligible correlation with no clinical relevance. Thus, we conclude that neither sex nor age, nor diagnosis, nor treatment phase seem to influence PSI to a relevant degree. Disclosure No significant relationships.

Abstract Clinical phenotypes of COVID-19, associated with mortality risk, have been identified in the general population. The present study assesses their applicability in solid organ transplant recipients (SOTR) hospital-admitted by COVID-19. In a cohort of 488 SOTR, nonvaccinated (n = 394) and vaccinated (n = 94) against SARS-CoV-2, we evaluated 16 demographic, clinical, analytical, and radiological variables to identify the clinical phenotypes A, B, and C. The median age was 61.0 (51–69) years, 330 (67.6%) and 158 (32.4%) were men and women, respectively, 415 (85%) had pneumonia, and 161 (33%) had SpO2

The objective of the extraction process in the ethanol production from sugarcane is to separate the sucrose-containing juice from the remainder of the cane, mainly fibre. The two currents, products of this process, are the juice and the bagasse. The juice is used to produce ethanol and the bagasse is the fuel for the boilers. Two types of devices are employed to perform this operation: mills and diffusers. Each one of them consumes different types of energy: mills consume mechanical energy, diffusers consume basically thermal energy. As both devices utilize an important quantity of energy, their effect in the energy balance of the factory needs to be taken into account. Aiming to discuss and characterize these effects, simulations of the complete ethanol production process, including the cogeneration system, were carried out using the Aspen Plus software, considering both devices. Process integration was also performed targeting to reduce the energy consumption. These results are presented and compared. Considering the integrated ethanol production process, with extraction -condensing steam turbines in cogeneration system, working with mills, it can produce an electricity surplus of 83.4 kWh/t of sugarcane, however, for the same conditions, working with the diffusion extraction process a production of 91.3 kWh/t of cane can be obtained, including also a small increase of 2 % in the ethanol production.

The sugarcane industry represents one of the most important economic activities in Brazil producing sugar and ethanol for the internal and external markets. Most of the sugarcane plants in Brazil have been projected to produce both sugar and ethanol, prioritizing one over the other according to market prices. There are also plants dedicated only to ethanol production. Nevertheless, this change in the production pattern affects parameters in their production such as water consumption, steam demands, bagasse surplus and electricity production. Thus, the aim of this study is to evaluate the production parameters for different configurations of sugarcane plant: (a) all sugarcane juice is destined to produce ethanol without sugar production and (b) distribution of 50 %/50 % of total recoverable sugars in sugar and ethanol production. Simulations in ASPEN PLUS® software were performed in order to evaluate the mass and energy balances and thermal integration using the Pinch Method was applied in order to minimize the utilities consumption.

Vapour recompression is a means of upgrading energy by the compressing of a lower pressure vapour up to a higher pressure, thus making the energy more available to do useful work. There are two types of vapour recompression: thermo-compression and mechanical recompression. Thermo-compression uses high pressure steam through a nozzle to compress a lower pressure vapour to an intermediate pressure. On the other hand, in mechanical recompression “mechanical” means that the compression task is done through the expenditure of mechanical energy for instance a steam turbine driven a compressor. Other means of driving could be also include an electric motor or an internal combustion engine. In both of cases the main advantage of vapour recompression is that it is not necessary to supply the latent heat of vaporization to the vapour being compressed. The aim of this study is to evaluate the possibilities of the incorporation of mechanical vapour recompression in the ethanol production process from the energy point of view. Thus mechanical vapour recompression is integrated to the juice evaporation system which is composed by a multiple effect evaporator. Simulations in Aspen Plus were accomplished to perform the mass and energy balances. Results showed that the introduction of vapour recompression promoted a reduction in steam consumption of approximately 10 % in evaporation system and 4 % in overall process. In order to further reduce the steam consumption of the plant, Pinch Analysis was applied to integrate the vapour recompression process coupled to evaporation system to all available streams in ethanol production process.

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[This corrects the article DOI: 10.1371/journal.pone.0269875.].

It is currently recommended that antiretroviral prophylaxis to prevent mother-to-child transmission (MTCT) of HIV be initiated at 14 weeks of gestation. However, the relevance of early-gestation HIV viral load level for intrauterine MTCT is unknown. The objective of this study was to determine the relationship between prenatal maternal viral load and intrauterine MTCT. Records of HIV-infected pregnant women in two centers in Brazil, from 1999 to 2004 were analyzed. Three pregnancy periods were considered: earlier than 14 weeks, 14 to 27 6/7 weeks, and 28 weeks of gestation or more. Peripartum HIV exposure was also computed. Maximum viral load in each period was the measure of HIV exposure. Four hundred fifty-seven HIV-infected pregnant women were evaluated, but 53 were excluded. The MTCT rate was 0.49% (2/404-95% confidence interval (CI95) = 0.14-1.79%). Newborns were not breast-fed. Median viral load for the earlier-than-14-week period was 9,900 copies/mL (P25-75 1,000-50,775 copies/mL), 8,350 copies/mL (P25-75 707-42,000 copies/mL) for the 14 to 27 6/7-week period, and 435 copies/mL (P25-75 90-7,775 copies/mL) after the 28-week period. The peripartum median viral load was 400 copies/mL (P25-75 80-500 copies/mL). MTCT in mothers with VL > 1,000 copies/mL during the first 14 weeks (0.67%, 2/298) was not different from those with VL =1,000 copies/mL (0.0%, 0/96, P=1). Analogously, in the 14 to 27 6/7-week period, MTCT was similar in groups with VL higher (0.68%, 2/292) or lower (0%, 0/106) than 1,000 copies/mL (P=1). Regarding VL >1,000 copies/mL at 28-weeks-or-later and at peripartum periods, MTCT rates were 1.15% (2/173, P = 0.18) and 2.8% (2/71, P = 0.03), respectively. Intrauterine transmission does not seem to be influenced by HIV viremia during the first 28 weeks of pregnancy.

Se describe un bosque mesófilo de montalia dominado por Engelhardtia mexianna del norte del Estado de Oaxaca (México). Esta comunidad prospera entre 1400 y 1800 m de altitud, sobre laderas de fuerte pendiente, expuestas a un régimen de muy frecuentes neblinas, con precipitación media anual de 5000 a 6000 mm y sin que en ningún mes llueva en promedio menos de 200 mm. Es un bosque denso y perennifolio, de 30 a 40 m de alto, rico en epifitas, con predominancia absoluta de Engelhardtia en el estrato arbóreo superior. Una gramínea bambúsea (Yushania sp.) el helecho arbustivo Alsophla salvinii así como varias Melastomaceae (Miconia) y Palmae (Chamaedorea) destacan cuantitativamente a niveles inferiores. Con respecto a las relaciones geográficas de la flora, predominan elementos neotropicales, les siguen en import ancia los pantropicales y escasean los holárticos. Al realizar el anális palinológico de los sedimentos del Mioceno Inferior del NW del Estado de Chiapas (México), se encontraron tres muestras con franca predominancia de polen de Engelhardtia. Se presentan los espectros de estas muestras y al compararlos con gráficas y listas de la lluvia de polen actual del bosque de Engelhardtia del N de Oaxaca, se encuentra un buengrado de similitud. Las diferencias mas notables entre ambas lluvias de polen consisten en: 1a porcentajes ligeramente mayores de polen de Engelhardtia en el bosque actual, 2a porcentajes superiores de esporas de pteridofitas (sobre todo de Polypodiaceae) en los hosques miocénicos, 3a falta en los espectros actuales del polen de Tricolpopollenites y Picea, de los cuales el primero parece haberse extinguido por completo y el segundo dejó de existir en el centro y sur de México desde el Pleistoceno Superior. El género Engelhardtia tuvo una amplia distribución en el hemisferio boreal duralite el Terciario, pero en el presente parece hallarse restringid o a pequenas áreas en: a) el sureste de México y Centroamérica, y b) el sureste de Asia.

Introduction Ceftaroline, tedizolid, dalbavancin, ceftazidime-avibactam and ceftolozane-tazobactam are novel antibiotics used to treat infections caused by multidrug-resistant pathogens (MDR). Their use should be supervised and monitored as part of an antimicrobial stewardship programme (ASP). Appropriate use of the new antibiotics will be improved by including consensual indications for their use in local antibiotic guidelines, together with educational interventions providing advice to prescribers to ensure that the recommendations are clearly understood.Methods and analysis This study will be implemented in two phases. First, a preliminary historical cohort (2017–2019) of patients from 13 Andalusian hospitals treated with novel antibiotics will be analysed. Second, a quasiexperimental intervention study will be developed with an interrupted time-series analysis (2020–2021). The intervention will consist of an educational interview between prescribers and ASP leaders at each hospital to reinforce the proper use of novel antibiotics. The educational intervention will be based on a consensus guideline designed and disseminated by leaders after the retrospective cohort data have been analysed. The outcomes will be acceptance of the intervention and appropriateness of prescription. Incidence of infection and colonisation with MDR organisms as well as incidence of Clostridioides difficile infection will also be analysed. Changes in prescription quality between periods and the safety profile of the antibiotics in terms of mortality rate and readmissions will also be measured.Ethics and dissemination Ethical approval will be obtained from the Andalusian Coordinating Institutional Review Board. The study is being conducted in compliance with the protocol and regulatory requirements consistent with International Council of Harmonisation E6 Good Clinical Practice and the ethical principles of the latest version of the Declaration of Helsinki. The results will be published in peer-reviewed journals and disseminated at national and international conferences.Trial registration number NCT03941951; Pre-results.

Introduction Patients with negative blood cultures (BCx) represent 85%–90% of all patients with BCx taken during hospital admission. This population usually includes a heterogeneous group of patients admitted with infectious diseases or febrile syndromes that require a blood culture. There is very little evidence of the clinical characteristics and antibiotic treatment given to these patients.Methods and analysis In a preliminary exploratory prospective cohort study of patients with BCx taken, the clinical/therapeutic characteristics and outcomes/antimicrobial stewardship opportunities of a population of patients with negative BCx will be analysed. In the second phase, using a cluster randomised crossover design, the implementation of an antimicrobial stewardship intervention targeting patients with negative BCx will be evaluated in terms of quality of antimicrobial use (duration and de-escalation), length of hospital stay and mortality.Ethics and dissemination This study has been and registered with clinicaltrials.gov. The findings of our study may support the implementation in clinical practice of an antimicrobial stewardship intervention to optimise the use of antibiotics in patients with negative BCx. The results of this study will be published in peer-reviewed journals and disseminated at national and international conferences.Trial registration number NCT03535324.

Abstract Background Kawasaki disease (KD) is an acute self-limited systemic vasculitis of unknown etiology. Intravenous immunoglobulin (IVIG) is an effective treatment and decreases the risk of cardiac complications to less than 5%. In spite of its effectiveness, some children do not respond to this therapy and still develop coronary aneurysms (CAA). The optimal treatment for IVIG non-responsive patients remains controversial although corticoids have been suggested to be an effective treatment in some patients. For those patients still resistant to IVIG and corticoids, interleukin-1 receptor antagonists (IL-1RA) such anakinra could be an alternative. Case presentation We present a 3 year-old Caucasian patient with KD without cardiac complications but with important resistance to treatment. After becoming resistant to IVIG and corticoids, anakinra proved to be an effective treatment. Conclusions To our knowledge, this is the first report of the utility of IL-1RA in refractory KD without coronary impairment. The patient fulfilled the classical criteria for KD and, after becoming resistant to first and second line treatments, anakinra proved to be an effective treatment. Further studies are required to determine if this is an effective treatment option for other cases of resistant Kawasaki disease.

Este estudio evalúa el impacto en el bienestar social de los hogares mexicanos de una posiblereforma impositiva mediante el uso de simulaciones de algunas opciones planteadas al Congreso mexicano, así como el análisis de una estructura óptima de imposición indirecta. El análisis utilizael enfoque global de M. King y el análisis marginal de Ahmad y Stern para calcular las respectivas estimaciones bajo un enfoque de equilibrio parcial y analizar su impacto sobre el sector consumo. Adicionalmente se hace uso de la extensión deUrzúa, al análisis Ahmad y Stern, para reformas mínimas, más no marginales.

La presencia de pandillas delincuentes en los barrios de zonas pobres de las grandes y medianas ciudades del mundo entero ha contribuido a aumentar los problemas de violencia social. En Colombia el problema adquiere dimensiones aún mayores teniendo en cuenta la historia y el contexto de violencia socio-política; sin embargo, no es hasta hace poco cuando se empieza a estudiar de forma detallada el problema, aunque no desde el análisis del comportamiento sino desde la sociología y otras ciencias sociales. En este trabajo se presenta la aplicación del análisis del comportamiento a la formulación de un caso de pandilla en un barrio del Nororiente de Bogotá. Se aplica el método de análisis funcional, el cual permite una comprensión amplia de las diversas variables de las cuales es función el comportamiento de estos grupos sociales. Se discuten algunas implicaciones para la intervención.

Carbon cycling in the Amazon fundamentally depends on the functioning of ecosystems and atmospheric dynamics, which are highly intricate. Few studies have hitherto investigated or measured the radiative effects of aerosols on the Amazon and Cerrado. This study examines the effects of atmospheric aerosols on solar radiation and their effects on net ecosystem exchange (NEE) in an area of semideciduous tropical forest in the north of Mato Grosso. Our results show that for a relative irradiance (f) 1.10–0.67, a decrease in incident solar radiation is associated with a reduction in the NEE. However, an average increase of 25 %–110 % in NEE was observed when pollution levels and aerosol optical depth (AOD) were above ≈ 1.25 and f < 0.5. The increase NEE was attributed to the increase of up to 60 % in the diffuse fraction of photosynthetically active radiation. The change in AOD and f was mainly attributable to biomass burning organic aerosols from fires. Important influences on vapor pressure deficit (VPD) as well as air temperature (Tair) and canopy (LCT), induced by the interaction between solar radiation and high aerosol load in the observation area, were also noticed. On average, a cooling of about 3–4 ∘C was observed for Tair and LCT, and a decrease of up to 2–3 hPa was observed for VPD. Given the long-distance transport of aerosols emitted by burning biomass, significant changes in atmospheric optical properties and irradiance will impact the CO2 flux of semideciduous forests distributed in the region.

This research proposes a methodological approach to search floating bodies or floating body parts in rivers using hydroinformatic tools. These tools may allow possible search locations and potential release sites to be determined. The approach draws from hydrometric field information, two-dimensional (2D) hydrodynamic modeling, particle tracking (PT) models, and large-scale particle image velocimetry (LSPIV). This methodology was applied to a case study of the La Miel river in Colombia, where existing reports of deceased persons are available. A series of hydraulic accidents have been defined to represent the hydrodynamic and transport processes that occur in such situations. The results indicate that potential search locations, namely places where human floating bodies or floating body parts may be found, are principally on the left and right shores of recirculation systems. [ABSTRACT FROM AUTHOR]

AbstractThe prevalence of low HDL-C levels in an HIV population and its related factors was investigated. We undertook a multicenter, cross-sectional study of all HIV patients on regular follow-up in five hospitals (Southern Spain). A physical examination and fasting laboratory analysis were performed and a questionnaire about cardiovascular risk factors was provided. One thousand and seventy-two patients were included, 43.8% of whom had low HDL-C levels. The prevalence of low HDL-C was higher among patients diagnosed with AIDS, those not on antiretroviral therapy, those with a detectable HIV viral load, those with CD4 cell counts ≤350 cells/μl, smokers, and those with hypertriglyceridemia. For patients on antiretroviral therapy, the prevalence of low HDL-C was higher for those on protease inhibitors than those taking nonnucleoside reverse transcriptase inhibitors. In the multivariate analysis, low HDL-C levels were associated with tobacco use (OR 1.37, 95% CI 1.04–1.8; p= 0.04), hypertriglyceridemia (OR 2.94, 95% CI 2.2–3.8; p< 0.00001), CD4 cells count ≤350 cells/μl (OR 1.74, 95% CI 1.2–2.3; p< 0.0001), and a detectable HIV viral load (OR 1.85, 95% CI 1.3–2.5; p< 0.0001). The immunological and virological conditions, in addition to traditional cardiovascular risk factors such as tobacco use and hypertriglyceridemia, affect HDL-C levels in HIV-infected patients. For patients on antiretroviral therapy, the use of protease inhibitors is associated with a higher probability of low levels of HDL-C. Although it is not clear if the higher HDL-C levels associated with antiretroviral use are surrogates for decreased cardiovascular disease risk, this may be another reason to start antiretroviral therapy earlier. [ABSTRACT FROM AUTHOR]

The aim of this work is to carry out a thermoeconomic analysis of a single and double-effect LiBr/H20 absorption refrigeration system. The methodology of functional analysis with negentropy is used. The exergetic cost of the main product, the cooling cost, was calculated as a function of the exergy of the heat source. Two cases were analyzed for each system: the first considers a direct-fired system while the second considers a hot-water driven system for the single-effect system and a steam-driven system for the double effect system as part of a cogeneration system. As expected, the resultant exergetic cost of the main product was higher for the direct-fired system. [ABSTRACT FROM AUTHOR]

Zygophyllum fabago is a herbaceous plant found widely in the Mediterranean area. There are no previous reports of its allergenicity. An aerobiologic and clinical survey was conducted in Murcia, southern Spain, to determine the quantity of airborne pollen and establish the possible role of this pollen as a cause of allergic symptoms. With a Hirst volumetric trap, we determined the atmospheric concentrations of this pollen in 1993, 1994,1995, and 1996. Of 1180 patients tested, 181 (15,34%) had a positive skin test. To determine its allergenicity, we divided 47 patients into three groups: in group 1, all the patients had symptoms of rhinoconjunctivitis plus asthma; in groups 2 and 3, rhinoconjunctivitis. In group 1, we performed a bronchial provocation test (BPT): in groups 2 and 3, we performed nasal provocation (NPT) and conjunctival provocation (CPT) tests, respectively, SDS-PAGE was used to characterize the antigenic fractions and RAST inhibition to determine cross-reactivity with other pollens. The pollen dispersion period is from May to September (445 grains/m³), BPT was positive in 13 of 15 patients, NPT in 14 of 16 patients, and CPT in 13 of 16 patients. RAST inhibition revealed cross-reactivity with Mercurialis, Ricinus, Olea, and Betula. SDS-PAGE identified 25 IgE antibody-binding components, five of which (60, 65, 41, 38, and 15.5/14,7 kDa) were recognized by 40% of the sera. By SDS-PAGE immunoblotting with sunflower antiprofilin rabbit serum and affinity chromatography we established that the Z. fabago extract has profilin. This study shows that this pollen becomes airborne and elicits an IgE response which triggers respiratory symptoms in allergic subjects. [ABSTRACT FROM AUTHOR]

B Background: b attention deficit hyperactivity disorder (ADHD) is the most common neurobehavioral disorder in children, and its prevalence is increasing. Since every treatment consideration depends on a risk/benefit analysis, the patients and their parents should fully understand short and long-term risks as well as benefits compared to non-treatment of ADHD. [Extracted from the article]

Public health qualitative research has largely failed to achieve full inclusion of people with disabilities and Black people and Latinx/as. Although there is a small, but growing, community of academic researchers from each of these communities, there has been limited involvement of non-academic community members in research. While Community-Based Participatory Research (CBPR) has informed the inclusion of marginalized groups in research for decades, instances of full inclusion of disabled Black people and Latinx/as in public health research have been minimal. One way to ensure the inclusion of Black/Latinx community members with disabilities is to involve them as peer researchers. As part of a qualitative study examining pregnancy experiences of individuals with physical disabilities from Black/Latinx communities, academic researchers trained four peer researchers to conduct interviews and analyze the data. This paper describes our approach, which may serve as a model for training peer researchers in qualitative research methodology for future studies. All peer researchers were women who identified as Black or Latina parents with physical disabilities. This approach was chosen due to the study’s focus on the intersections of disability, race, ethnicity, and pregnancy, and applied a disability justice lens. Although CBPR offers important principles for research existing literature suggests CBPR is not always inclusive and power sharing. Therefore, we developed a research training model which places a unique and timely focus on the intersections of CBPR, racial and disability justice, the importance of building the capacity of Black and Latina disabled peer researchers, and its importance to building community relationships and trust.

ABSTRACT: Objectives: Information is scarce on clinical experiences with non-neutropenic patients with invasive fungal infection (IFI) receiving isavuconazole. We aimed to report the safety and effectiveness of this drug as a first-line treatment or rescue in real life. Methods: A retrospective, observational multicentric study of non-neutropenic patients who received isavuconazole as an IFI treatment at 12 different university hospitals (January 2018-2022). All patients met criteria for proven, probable or possible IFI according to EORTC-MSG. Results: A total of 238 IFIs were treated with isavuconazole during the study period. Combination therapy was administered in 27.7% of cases. The primary IFI was aspergillosis (217, 91.2%). Other IFIs treated with isavuconazole were candidemia (n = 10), mucormycosis (n = 8), histoplasmosis (n = 2), cryptococcosis (n = 2), and others (n = 4). Median time of isavuconazole treatment was 29 days. Only 5.9% (n = 14) of cases developed toxicity, mainly hepatic-related (10 patients, 4.2%). Nine patients (3.8%) had treatment withdrawn. Successful clinical response at 12 weeks was documented in 50.5% of patients. Conclusion: Isavuconazole is an adequate treatment for non-neutropenic patients with IFIs. Toxicity rates were low and its effectiveness was comparable to other antifungal therapies previously reported.

Abstract Background Medications for opioid use disorder (MOUD; methadone, buprenorphine, naltrexone) are the most effective treatments for OUD, and MOUD is protective against fatal overdoses. However, continued illegal drug use can increase the risk of treatment discontinuation. Given the widespread presence of fentanyl in the drug supply, research is needed to understand who is at greatest risk for concurrent MOUD and drug use and the contexts shaping use and treatment discontinuation. Methods From 2017 to 2020, Massachusetts residents with past-30-day illegal drug use completed surveys (N = 284) and interviews (N = 99) about MOUD and drug use. An age-adjusted multinomial logistic regression model tested associations between past-30-day drug use and MOUD use (current/past/never). Among those on methadone or buprenorphine (N = 108), multivariable logistic regression models examined the association between socio-demographics, MOUD type; and past-30-day use of heroin/fentanyl; crack; benzodiazepines; and pain medications. Qualitative interviews explored drivers of concurrent drug and MOUD use. Results Most (79.9%) participants had used MOUD (38.7% currently; 41.2% past), and past 30-day drug use was high: 74.4% heroin/fentanyl; 51.4% crack cocaine; 31.3% benzodiazepines, and 18% pain medications. In exploring drug use by MOUD history, multinomial regression analyses found that crack use was positively associated with past and current MOUD use (outcome referent: never used MOUD); whereas benzodiazepine use was not associated with past MOUD use but was positively associated with current use. Conversely, pain medication use was associated with reduced odds of past and current MOUD use. Among those on methadone or buprenorphine, separate multivariable logistic regression models found that benzodiazepine and methadone use were positively associated with heroin/fentanyl use; living in a medium-sized city and sex work were positively associated with crack use; heroin/fentanyl use was positively associated with benzodiazepine use; and witnessing an overdose was inversely associated with pain medication use. Many participants qualitatively reported reducing illegal opioid use while on MOUD, yet inadequate dosage, trauma, psychological cravings, and environmental triggers drove their continued drug use, which increased their risk of treatment discontinuation and overdose. Conclusions Findings highlight variations in continued drug use by MOUD use history, reasons for concurrent use, and implications for MOUD treatment delivery and continuity.

Renal cell carcinoma with level IV tumor thrombus is a condition necessitating aggressive surgical management. Many solid organ malignancies often benefit from neoadjuvant treatments for tumor debulking and improvement of surgical outcomes. However, neoadjuvant treatments for renal cell carcinoma have been limited by its resistance to traditional chemotherapy and radiation. Emerging treatment modalities, such as immunotherapies, are exciting new options that may be therapeutically effective. The combination of nivolumab and ipilimumab has exhibited success in managing metastatic renal cell carcinoma. Limited data exist for its use in nonmetastatic renal cell carcinoma with tumor thrombus. This case illustrates the use of nivolumab and ipilimumab combination therapy in delaying tumor growth, producing observable tumor thrombus histologic and radiologic treatment changes, and, most importantly, facilitating a less invasive surgical approach of a level IV renal cell carcinoma tumor thrombus.

Introduction Enterococcus spp is responsible for 8%–15% of total bacteraemias with an associated global mortality around 23%–30%. Regarding the clinical management of enterococcal bacteraemia, the evidence on the duration of antibiotic treatment is scarce and the studies do not discriminate between complicated and uncomplicated bacteraemia.Methods The INTENSE study is a multicentre, open-label, randomised, pragmatic, phase-IV clinical trial to demonstrate the non-inferiority of a 7-day vs 14-day course for the treatment of uncomplicated enterococcal bacteraemia and incorporating the early switching to oral antibiotics when feasible. The primary efficacy endpoint is the clinical cure at day 30±2 after the end of the treatment. Secondary endpoints will include the rate of relapse or infective endocarditis, length of stay, duration of intravenous therapy, Clostridioides difficile infection and the evaluation of the safety of both treatment arms through the recording and analysis of adverse events. For a 6% non-inferiority margin and considering a 5% withdrawal rate, 284 patients will be included.Analysis The difference in proportions with one-sided 95% CIs will be calculated for the clinical cure rate using the control group as reference. For secondary categorical endpoints, a similar analysis will be performed and Mann-Whitney U-test will be used to compare median values of quantitative variables. A superiority analysis applying the response adjusted for days of antibiotic risk will be performed if there were incidents in recruitment; will allow obtaining results with 194 patients recruited.Ethics and dissemination The study has obtained the authorisation from the Spanish Regulatory Authority, the approval of the ethics committee and the agreement of the directors of each centre. Data will be published in peer-reviewed journals.Trial registration number NCT05394298.

Background: Injection drug use poses significant risk for skin and soft tissue infections, such as abscesses. In places with endemic fentanyl and an increasingly contaminated drug supply, injecting and injection-related harms may be increasing, yet are understudied. We aimed to explore abscess prevalence, experiences, and themes among people who inject drugs (PWID) in the context of an evolving drug supply. Methods: Between 2019 and 2022, we surveyed and interviewed Massachusetts- based PWID about current drug use behaviors and abscess experiences. Chi-square tests explored correlates of abscess history and trends for past-year abscess percentages over time. Transcribed interview data were analyzed to identify themes related to abscess risk and opportunities for intervention. Results: Of the 297 PWID surveyed, 65.3% reported having an abscess at the injection site in their lifetime; 67.5% of these instances occurred within the last year. Reported past-year abscesses increased from 36.7% to 75.6% between 2019 and 2022. Correlates of past-year abscesses included frequent injection; methamphetamine, crack, or fentanyl use; and injection into the neck or calf. Methadone treatment was associated with significantly fewer recent abscesses. Interview data (n=151) confirmed the identified abscess risks, including syringe sharing and lack of hygienic supplies. Qualitative interviews provided additional data regarding healthcare provider stigma contributing to healthcare avoidance and the self-treatment of abscesses with adverse results. Conclusions: Abscesses are an increasing concern among PWID residing in areas of high fentanyl prevalence and a contaminated drug supply. Community drug checking, overdose prevention sites, injection hygiene interventions, and improved access to care are indicated.

Summary: Background: Lack of specific definitions of clinical characteristics, disease severity, and risk and preventive factors of post-COVID-19 syndrome (PCS) severely impacts research and discovery of new preventive and therapeutics drugs. Methods: This prospective multicenter cohort study was conducted from February 2020 to June 2022 in 5 countries, enrolling SARS-CoV-2 out- and in-patients followed at 3-, 6-, and 12-month from diagnosis, with assessment of clinical and biochemical features, antibody (Ab) response, Variant of Concern (VoC), and physical and mental quality of life (QoL). Outcome of interest was identification of risk and protective factors of PCS by clinical phenotype, setting, severity of disease, treatment, and vaccination status. We used SF-36 questionnaire to assess evolution in QoL index during follow-up and unsupervised machine learning algorithms (principal component analysis, PCA) to explore symptom clusters. Severity of PCS was defined by clinical phenotype and QoL. We also used generalized linear models to analyse the impact of PCS on QoL and associated risk and preventive factors. CT registration number: NCT05097677. Findings: Among 1796 patients enrolled, 1030 (57%) suffered from at least one symptom at 12-month. PCA identified 4 clinical phenotypes: chronic fatigue-like syndrome (CFs: fatigue, headache and memory loss, 757 patients, 42%), respiratory syndrome (REs: cough and dyspnoea, 502, 23%); chronic pain syndrome (CPs: arthralgia and myalgia, 399, 22%); and neurosensorial syndrome (NSs: alteration in taste and smell, 197, 11%). Determinants of clinical phenotypes were different (all comparisons p

This large, multicenter, retrospective cohort study including onco-hematological neutropenic patients with Pseudomonas aeruginosa bloodstream infection (PABSI) found that among 1213 episodes, 411 (33%) presented with septic shock. The presence of solid tumors (33.3% vs. 20.2%, p < 0.001), a high-risk Multinational Association for Supportive Care in Cancer (MASCC) index score (92.6% vs. 57.4%; p < 0.001), pneumonia (38% vs. 19.2% p < 0.001), and infection due to multidrug-resistant P. aeruginosa (MDRPA) (33.8% vs. 21.1%, p < 0.001) were statistically significantly higher in patients with septic shock compared to those without. Patients with septic shock were more likely to receive inadequate empirical antibiotic therapy (IEAT) (21.7% vs. 16.2%, p = 0.020) and to present poorer outcomes, including a need for ICU admission (74% vs. 10.5%; p < 0.001), mechanical ventilation (49.1% vs. 5.6%; p < 0.001), and higher 7-day and 30-day case fatality rates (58.2% vs. 12%, p < 0.001, and 74% vs. 23.1%, p < 0.001, respectively). Risk factors for 30-day case fatality rate in patients with septic shock were orotracheal intubation, IEAT, infection due to MDRPA, and persistent PABSI. Therapy with granulocyte colony-stimulating factor and BSI from the urinary tract were associated with improved survival. Carbapenems were the most frequent IEAT in patients with septic shock, and the use of empirical combination therapy showed a tendency towards improved survival. Our findings emphasize the need for tailored management strategies in this high-risk population.

Objectives To appraise the rate of grade 3–4 transaminase elevations (TEs) and grade 4 total bilirubin elevation (TBE) in patients co-infected with human immunodeficiency virus (HIV) and hepatitis C or hepatitis B virus (HCV or HBV, respectively) who receive atazanavir/ritonavir. Moreover, the relationship between these events and the degree of prior liver fibrosis was evaluated. Methods A cohort of 189 HIV-infected patients, 175 co-infected with HCV, 4 with HBV and 10 with both, receiving atazanavir/ritonavir, was analysed. Baseline liver fibrosis was assessed in 113 (60%) patients. Twenty-four patients had cirrhosis, whereas such a diagnosis was ruled out in 58 patients. Results Twelve (6%) and 28 (15%) patients developed grade 3–4 TEs and grade 4 TBE, respectively. Eight (10%) of 84 patients with fibrosis ≥F2 versus 1 of 29 (3%) with F0-F1 (P = 0.51) developed grade 3–4 TEs. The frequencies of grade 3–4 TEs in patients with and without cirrhosis were 8% and 5% (P = 0.63), respectively. Grade 4 TBE was more common among patients with cirrhosis (35% versus 13%, P = 0.05) in the univariate analysis. In the multivariate study, the only predictor of grade 3–4 TEs was baseline CD4 cell count P = 0.04]. The factors independently associated with grade 4 TBE were baseline total bilirubin >1 mg/dL [AOR (95% CI) = 3.2 (1.21–8.45), P = 0.01] and age >40 years [AOR (95% CI) = 2.98 (1.19–7.47), P = 0.02]. Conclusions Prior significant liver fibrosis or cirrhosis do not increase substantially the risk of severe TE associated with atazanavir/ritonavir in patients co-infected with HIV and hepatitis viruses. [ABSTRACT FROM AUTHOR]

PurposeSarcopenia is associated with decreased survival and increased complications in patients with renal cell carcinoma. Readily identifying patients with low muscle composition that may experience worse outcomes or would benefit from preoperative intervention is of clinical interest. Traditional body composition analysis methods are resource intensive; therefore, linear segmentation with routine imaging has been proposed as a clinically practical alternative. This study assesses linear segmentation’s prognostic utility in nonmetastatic renal cell carcinoma.Materials and MethodsA single institution retrospective analysis of patients that underwent nephrectomy for nonmetastatic renal cell carcinoma from 2005-2021 was conducted. Linear segmentation of the bilateral psoas/paraspinal muscles was completed on preoperative imaging. Total muscle area and total muscle index associations with overall survival were determined by multivariable analysis.Results532 (388 clear cell) patients were analyzed, with median (IQR) total muscle index of 28.6cm2/m2 (25.8-32.5) for women and 33.3cm2/m2 (29.1-36.9) for men. Low total muscle index was associated with decreased survival (HR=1.96, 95% CI 1.32-2.90, p

Antibiotic stewardship programs (ASP) have already demonstrated clinical benefits. We aimed to describe the Point Prevalence Surveys (PPS) methodology implemented in our hospital as an efficient tool to guide ASP strategies. Annually repeated PPS were conducted from 2012 to 2019 at a 750-bed university hospital in South Spain. Key quality indicators and inappropriateness of antimicrobial treatment, defined strictly according to local guidelines, were described. Variables associated with inappropriate treatment were identified by bi/multivariable analysis. A total of 1,600 patients were included. We found that 49% of the prescriptions were inappropriate due to unnecessary treatment (14%), not first line drug recommended (14%), inadequate drug according to microbiological results (9%), unsuitable doses (8%), route (3%) or duration (7%). Samples collection presented a significant protective effect together with sepsis presentation at onset and intensive care unit admission. However, age, receiving an empirical treatment and an unknown or urinary source of the infections treated were independent risk factors for inappropriateness. Site and severity of infection were documented in medical charts by prescribers (75 and 61% respectively). PPS may allow identifying the main risk factors for inappropriateness. This simple methodology may be useful for ASP to select modifiable factors to be prioritized for targeted interventions.

Abstract Background People who experience non-fatal overdose (NFOD) are at high risk of subsequent overdose. With unprecedented increases in fentanyl in the US drug supply, many Massachusetts (MA) communities have seen a surge in opioid-related overdoses. The objective of this study was to determine factors associated with lifetime and past year NFOD in at-risk MA communities. Methods We conducted multiple rapid assessments among people who use drugs (PWUD) in eight MA communities using non-probability sampling (purposive, chain referral, respondent-driven) methods. We collected sociodemographic, substance use, overdose history, substance use treatment, and harm reduction services utilization data. We examined the prevalence of NFOD (lifetime and past year) and identified factors associated with NFOD through multivariable logistic regression analyses in a subset of 469 study participants between 2017 and 2019. Results The prevalence of lifetime and last year non-fatal opioid overdose was 62.5% and 36.9%, respectively. Many of the study participants reported heroin (64%) and fentanyl (45%) use during the 30 days preceding the survey. Nonprescription buprenorphine and fentanyl use were independently associated with higher odds of lifetime NFOD, while marijuana use was associated with lower odds of lifetime NFOD (p

Adult survivors of childhood Wilms tumor are at an increased risk of secondary malignant neoplasms. The presence of a solitary kidney further complicates clinical management in this population. Herein, we present the case of a 37 year old female with a history of childhood Wilms tumor presenting with a secondary renal neoplasm. We highlight important clinical considerations for renal function preservation and present a finding of predisposition to kidney stone formation due to urinary stasis from distorted ureter architecture secondary to tumor mass effect.

ObjectivesCARB-ES-19 is a comprehensive, multicenter, nationwide study integrating whole-genome sequencing (WGS) in the surveillance of carbapenemase-producing K. pneumoniae (CP-Kpn) and E. coli (CP-Eco) to determine their incidence, geographical distribution, phylogeny, and resistance mechanisms in Spain.MethodsIn total, 71 hospitals, representing all 50 Spanish provinces, collected the first 10 isolates per hospital (February to May 2019); CPE isolates were first identified according to EUCAST (meropenem MIC > 0.12 mg/L with immunochromatography, colorimetric tests, carbapenem inactivation, or carbapenem hydrolysis with MALDI-TOF). Prevalence and incidence were calculated according to population denominators. Antibiotic susceptibility testing was performed using the microdilution method (EUCAST). All 403 isolates collected were sequenced for high-resolution single-nucleotide polymorphism (SNP) typing, core genome multilocus sequence typing (cgMLST), and resistome analysis.ResultsIn total, 377 (93.5%) CP-Kpn and 26 (6.5%) CP-Eco isolates were collected from 62 (87.3%) hospitals in 46 (92%) provinces. CP-Kpn was more prevalent in the blood (5.8%, 50/853) than in the urine (1.4%, 201/14,464). The cumulative incidence for both CP-Kpn and CP-Eco was 0.05 per 100 admitted patients. The main carbapenemase genes identified in CP-Kpn were blaOXA–48 (263/377), blaKPC–3 (62/377), blaVIM–1 (28/377), and blaNDM–1 (12/377). All isolates were susceptible to at least two antibiotics. Interregional dissemination of eight high-risk CP-Kpn clones was detected, mainly ST307/OXA-48 (16.4%), ST11/OXA-48 (16.4%), and ST512-ST258/KPC (13.8%). ST512/KPC and ST15/OXA-48 were the most frequent bacteremia-causative clones. The average number of acquired resistance genes was higher in CP-Kpn (7.9) than in CP-Eco (5.5).ConclusionThis study serves as a first step toward WGS integration in the surveillance of carbapenemase-producing Enterobacterales in Spain. We detected important epidemiological changes, including increased CP-Kpn and CP-Eco prevalence and incidence compared to previous studies, wide interregional dissemination, and increased dissemination of high-risk clones, such as ST307/OXA-48 and ST512/KPC-3.

Immunosuppressant conditions such as hematological malignancies increase the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. It has been described in the literature that patients on anti-CD20 maintenance therapies for lymphoid malignancies are susceptible to having recurrent flares together with viral replication or reinfections, although these cases are scarce. These patients are not well represented in randomized controlled trials, and as a consequence, the evidence for the use of certain treatments in this scenario is lacking. We present two cases of patients with B-cell lymphoma on remission and treated with rituximab on maintenance. They developed at least 1 flare of coronavirus disease 2019 (COVID-19) after acute infection and always after receiving rituximab. RT-PCR was positive in the nasopharyngeal swab and also in plasma. Patients were treated during flares with remdesivir, hyperimmune plasma, and corticosteroids. These two cases showed the unresolved problem of COVID-19 in immunosuppressant patients and showed that despite the vast amount of information available on SARS-CoV-2, information in this subgroup of patients is lacking.

The aim of this study is to evaluate the sociodemographic factors modulating psychopathological response of the general population in Spain during the first two weeks of confinement due to COVID-19 state of alarm. Psychological distress in the last 7 days was assessed using the Global Severity Index (GSI) of the Spanish adaptation of the Brief Symptom Inventory. [Extracted from the article]