Outcome Determinants of Fusariosis in a Tertiary Care Cancer Center: The Impact of Neutrophil Recovery

Factors associated with failure of antifungal therapy were examined in 42 cancer patients with fusariosis (1987-1997). Thirty-six patients (86%) had leukemia and 39 (93%) were neutropenic. Disseminated infection was the most common presentation. The majority (83%) received amphotericin B-based therapy. Thirty patients (71%) failed therapy. No patient with persistent neutropenia responded.

On-admission level of serum d-dimer and the severity of community-acquired pneumonia

This study aims at evaluating on-admission serum level of d-dimer in patients with community-acquired pneumonia concerning the severity of the disease and in-hospital outcome of the patients. Sixty patients with community-acquired pneumonia were studied during a one-year period in Imam Khomeini and Sina Hospitals, Tabriz, Iran. On-admission serum d-dimer was measured by enzyme-linked immunoabsorbent assay and the severity of disease determined according to PORT grading system. In-hospital outcome was determined in regard to the level of serum d-dimer. Sixty patients with community-acquired pneumonia, 39 males and 21 females were enrolled. There were twelve patients with PORT one, eight patients with PORT two, eight patients with PORT three, twenty patients with PORT four and twelve patients with PORT five. The mean level of serum d-dimer was significantly higher in severe disease (p < 0.001), patients with hospital stay longer than one week (p = 0.003), patients with bronchopulmonary pattern (p = 0.012), cases in-need of mechanical ventilation (p < 0.001) and patients who expired during hospital stay (p = 0.022). On-admission level of serum d-dimer was significantly and independently higher in patients with severe disease (p < 0.001) and in cases with bronchopulmonary pattern on chest x-ray (p = 0.035). On-admission level of serum d-dimer may predict the severity of community-acquired pneumonia. Further studies are recommended for accurate cut-off points.

Fasciola hepatica: a cause of obstructive jaundice in an elderly man from Iran

Fascioliasis is a zoonotic infection caused by Fasciola hepatica. Humans can become accidental hosts of this parasite by ingesting contaminated drinking water or plants in endemic area. The north of Iran is one of the regions. This disease is rarely seen with jaundice caused by obstruction of the biliary tree. We report a case of human fascioliasis with obstructive jaundice who was diagnosed using endoscopic retrograde cholangiopancreatography (ERCP). This report confirms the diagnostic role of ERCP in patients with obstructive jaundice caused by biliary fascioliasis.

Knowledge and attitude toward Crimean-Congo haemorrhagic fever in occupationally at-risk Iranian healthcare workers

We assessed the knowledge and attitude (K&A) toward Crimean-Congo haemorrhagic fever (CCHF) of occupationally at-risk healthcare workers (HCWs). A cross-sectional survey was performed in three referral hospitals in the Systan-Baluchestan and Isfahan provinces of Iran where CCHF is highly endemic. In all, 191/209 eligible HCWs were enrolled (response rate: 93%). All but 11 (5.8%) had heard of CCHF. The mean K&A scores of the respondents were 50.34% and 79.25%, respectively. The correlation between K&A was significant (correlation coefficient: 0.542; P<0.001). Being a physician, working in Isfahan (versus the relatively deprived Systan-Baluchestan) and relying on academic material rather than local media were independent factors significantly associated with more knowledge; higher education and laboratory staff with better attitude were also significant factors. Although HCWs showed the best K&A for preventive measures, only 44% wore gloves and masks for contact with CCHF patients and 22% failed to observe any safety measure. Those with a history of percutaneous contact (6.3%) had significantly lower knowledge scores (P=0.047). There is a need to establish professional education campaigns in highly endemic deprived areas in order to improve physicians' attitudes, encourage nurses' use of academic materials and increase the knowledge of less-educated HCWs.

Can sperm protamine deficiency induce sperm premature chromosomal condensation?

Sperm premature chromatin condensation (PCC) has been considered as the second cause of failed fertilization post-intracytoplasmic sperm injection (post-ICSI). Cytoplasmic factors, including oocyte cytoplasmic immaturity have been suggested to induce PCC sperm. However, recent studies suggest that sperm chromatin anomaly might also lead to PCC sperm. During this study, human sperm from infertile patients with protamine deficiency or with adequate amount of protamine assessed by chromomycin A3 were injected into metaphase II mouse oocyte, treated with colcemid. Chromatin analysis was carried out on the injected oocyte. The results of this study show that contrary to the percentage of intact sperm, percentage of PCC sperm was significantly higher in oocytes injected with protamine deficient sperm (36.43 +/- 4.46) compared to oocytes injected with sperm with an adequate amount of protamine (11.99 +/- 3.54, P < 0.001). A significant correlation was also observed between percentage of PCC sperm and protamine deficiency (r = 0.46, P = 0.004). Therefore, it can be suggested that oocytes injected with protamine deficient sperm have a higher chance of forming PCC sperm and may result in failed fertilization post-ICSI.

Relationship between protamine deficiency with fertilization rate and incidence of sperm premature chromosomal condensation post-ICSI

After aneuploidy, sperm premature chromatin condensation (PCC) is the next prevalent cause of fertilization failure. Therefore the aim of this study was to evaluate the effect of sperm protamine deficiency on sperm PCC formation post-ICSI. Chromatin analysis was carried out on failed fertilized oocytes post-ICSI and incidences of sperm PCC were evaluated and the results were compared with the extent of protamine deficiency assessed by chromomycin A3. The results show that incidence of sperm PCC was significantly different in failed fertilized oocytes injected from semen samples with greater or less than 30% CMA3 positivity (P = 0.04). However, except for fertilization rate (P < 0.001), the mean number of MII, MI and germinal vesicles oocytes and percentage normal sperm were not significantly different between the two groups (P > 0.05). A significant correlation was observed between sperm protamine deficiency with fertilization rate. Hence sperm protamine deficiency affects fertilization rate and possibly prones sperm to PCC post-ICSI.

Effect of protamine-2 deficiency on ICSI outcome

During spermiogenesis, histones are replaced by protamines (P1 and P2), resulting in sperm chromatin condensation followed by a halt to gene expression in haploid spermatids and spermatozoa. As a consequence, protamine deficiency and aberrant P1/P2 ratio have a profound effect on both fertilization and embryo development. However, reports on the effect of the P1/P2 ratio on fertilization and embryo development after intracytoplasmic sperm injection (ICSI) are contradictory between human and animal studies. The question that still remains to be elucidated is which type of protamine deficiency is most common among protamine deficient samples. The present study has a direct bearing on this issue investigating the correlation of the P1/P2 ratio with protamine deficiency, fertilization, embryo quality and embryo development in ICSI patients. This study was carried out on 71 patients. Chromomycin A3 (CMA3) staining was used to determine protamine deficiency. Since this procedure does not indicate the type of protamine deficiency, the P1/P2 ratio was evaluated by nuclear protein extraction, acetic acid urea polyacrylamide gel electrophoresis and analysis of protein bands with software. Polyclonal anti-P1 and anti-P2 antibodies were used to confirm P1 and P2 presence. Results show a negative significant correlation of fertilization rate with protamine deficiency and P1/P2 ratio. No significant correlation was observed between protamine deficiency and P1/P2 ratio. Therefore, it can be concluded that altered P1/P2 ratio effects fertilization rate and embryo quality which subsequently may affect implantation and pregnancy outcome.

Effect of human sperm chromatin anomalies on fertilization outcome post-ICSI

The aim of this study was to evaluate the effect of sperm chromatin anomalies on fertilization outcome post-intracytoplasmic sperm injection (ICSI). Therefore, along with semen parameters, Chromomycin A3 (CMA3) staining for protamine deficiency, aniline blue staining for excessive histones, SDS for sperm chromatin stability and SDS + EDTA for the ability of sperm to undergo decondensation were carried out on 55 semen samples from patients referred to the Isfahan Fertility and Infertility Center for ICSI. The results showed that among the aforementioned tests and semen parameters only CMA3 showed a significant correlation with fertilization outcome post-ICSI. Patients were also grouped according to CMA3 level of <30% or >30% or fertilization rate of <50% or >50%. The results show that the mean percentage fertilization and mean percentage of CMA3 positivity is different in both groups, respectively. The area under receiver operator characteristics curve shows that CMA3 is a highly sensitive and specific test for prediction of fertilization outcome post-ICSI. In conclusion, that sperm protamine deficiency has profound effect on fertilization failure in ICSI.

The efficacy of oral ribavirin in the treatment of crimean-congo hemorrhagic fever in Iran

We compared the mortality rate among patients suspected of having Crimean-Congo hemorrhagic fever (CCHF) who received treatment with oral ribavirin and those who did not. Ninety-seven (69.8%) of 139 treated patients suspected of having CCHF survived, and 61 (88.9%) of 69 treated patients with confirmed CCHF survived. The efficacy of oral ribavirin was 80% among patients with confirmed CCHF and 34% among patients suspected of having CCHF. Considering the limitations of observational studies, we conclude that oral ribavirin is an effective treatment for the hemorrhagic form of CCHF.

Relation between different human sperm nuclear maturity tests and in vitro fertilization

PURPOSE

To consider the relationship between different sperm nuclear maturity tests and in vitro fertilization (IVF) rate, in order to select the most sensitive, specific, and independent factor(s) for prediction of in vitro fertilization.

METHODS

Infertile couples (101) were randomly selected from IVF candidates referred to Isfahan Fertility and Infertility center. Semen samples were collected on the day of oocyte recovery. Following routine semen analysis, major portion of the semen was prepared for routine IVF insemination and the remaining was used for following sperm nuclear maturity tests: chromomycin A3 (CMA3), aniline blue, sodium dodecyl sulphate (SDS) test, and acridine orange test with or without heat shock (87 degrees C, 5 min). Sperms (200) were evaluated for each test. The results were recorded and analyzed for their correlation to fertilization rate, using correlation coefficient, logistic regression analysis, student t-test, and receiver operating characteristics (ROC) curve.

RESULTS

Among these tests, aniline blue and CMA3, and semen parameters, sperm morphology, and sperm motility showed a significant correlation with fertilization rate. Using logistic regression analysis, sperm morphology and CMA3 were the only independent factors related to in vitro fertilization. ROC curves showed that among above tests, CMA3 is the most specific and sensitive for sperm nuclear maturity.

CONCLUSION

Among CMA3, aniline blue, SDS test, and acridine orange, CMA3 was the most sensitive and specific test that can be used along with routine semen analysis for more precise prediction of fertilization rate.

Candida krusei fungemia. An escalating serious infection in immunocompromised patients

BACKGROUND

Candida krusei is inherently resistant to fluconazole and is emerging as a frequent cause of fungemia in patients with hematologic malignant neoplasms.

OBJECTIVE

To determine the risk and prognostic factors associated with C krusei fungemia in comparison with Candida albicans fungemia in patients with cancer.

METHODS

Retrospective study of 57 cases of C krusei fungemia occurring at the M. D. Anderson Cancer Center, Houston, Tex, from 1989 to 1996. The C krusei cases were compared with 57 cases of C albicans fungemia with respect to demographics, underlying cancer, Acute Physiology and Chronic Health Evaluation II score, immunosuppression status, chemotherapy, and the use of central venous catheters, as well as fluconazole prophylaxis.

RESULTS

At our institution, C krusei accounted for 5% of fungemias during 1989 through 1992 and for 10% during 1993 through 1996. Patients with C krusei fungemia more often had leukemia than patients with C albicans (77% vs 11%; P =.02), whereas catheter-related infections were more common among patients with C albicans fungemia (42% vs 0%; P<.001). Patients with C krusei fungemia had a lower response rate (51% vs 69%; P =.05), largely because they more frequently were neutropenic and had disseminated infection. Mortality related to fungemia was 49% in the cases with C krusei vs 28% in C albicans. Multiple logistic regression analysis showed that persistent neutropenia (P =.02) and septic shock (P =.002) were predictors of poor prognosis.

CONCLUSION

In neutropenic patients, C krusei fungemia is associated with high mortality. It should be suspected in patients with leukemia who are receiving fluconazole prophylaxis and should be treated aggressively with an amphotericin B regimen.

Nosocomial Candida guilliermondii fungemia in cancer patients

From 1988 to 1998, we identified nine patients with Candida guilliermondii fungemia. Four of the five patients with nosocomial infection died, while all of the non-nosocomial cases survived, even though one half of them (2/4) did not receive any treatment Nosocomial C guilliermondii fungemia is often associated with poor outcome despite aggressive antifungal therapy.