Candiduria as an early marker of disseminated infection in critically ill surgical patients: the role of fluconazole therapy

The significance of candiduria in critically ill patients remains unclear. It may represent harmless colonization or a potentially life-threatening infection. We analyzed 47 patients in the surgical intensive care unit (SICU) (trauma: 20, general surgery: 15, neurosurgery: 12) who had candiduria, defined by a colony count greater than 100,000/mL. Twenty-seven of these patients were studied retrospectively. Twenty were evaluated prospectively. All patients were receiving broad-spectrum antibiotics for bacterial infections. Retrospective group: ten patients (group A) did not develop disseminated candidiasis, whereas 17 patients (group B) did. Group B had higher APACHE II scores on admission (13.4 +/- 7.8) and at the time of candiduria (13.7 +/- 4.4) when compared with group A [admission: 5.0 +/- 4.6; candiduria: 6.7 +/- 3.6 (p < 0.02)]. In group B, disseminated candidiasis was not diagnosed and treated until 9.9 +/- 4.4 days after development of candiduria. Prospective group: twenty patients with candiduria were treated with systemic fluconazole (group C) at the time of candiduria. The APACHE II scores of group C on admission (12.8 +/- 3.9) and at the time of candiduria (10.5 +/- 4.0) were comparable with those of group B. No patient in Group C developed disseminated candidiasis. The septic mortality rates of groups A, B, and C were 0%, 53%, and 5%, respectively (p < 0.05-0.0001). In patients exhibiting ongoing sepsis and organ failure (high APACHE scores), candiduria may be an early indicator of systemic infection. Diagnosis of disseminated infection and its treatment may be delayed if conventional criteria for candidiasis (positive blood cultures, multiple site isolation) are awaited.(ABSTRACT TRUNCATED AT 250 WORDS)

[Umbilical Doppler velocimetry in prolonged pregnancies]

One-hundred and eighty-seven single pregnancies, at full term determined accurately and confirmed by ultrasound before 17 weeks of amenorrhea and which were proceeding normally were monitored every 2 days after the expected end of term. This was done by conventional methods and in 132 cases by determining a placental resistance index (R = D/S). All the deliveries were carried out under monitoring and the infants examined by a pediatrician. The umbilical index at 280 to 300 days of gestation was found to be constant and equal to R = 0.52 +/- 0.041 (n +/- D) and the signs of fetal distress and post-maturity increased beyond term. In the first 80 pregnancies studies in this way, the determination of the value of the index R was not included in the decision-making process. Twelve of the 14 cases of fetal heart rate arrhythmia during delivery and all recorded cases of post-mature clinical signs and neonatal acidosis occurred when the index was above RI = 0.54. The next 107 pregnancies were randomly divided into two groups. In the 52 pregnancies in which the Doppler revealed an index at two consecutive determinations in excess of 0.54, this was taken to be a criterion for the induction of childbirth. In this group, some of the women gave birth earlier, without any increase in the number of Caesareans and this resulted in fewer post-mature infants.(ABSTRACT TRUNCATED AT 250 WORDS)

Trauma management in a war zone: the Lebanese war experience

Lessons learned from the Vietnam and Korean conflicts have emphasized the necessity of an organized preparedness for optimal management of casualties. The present report summarizes the experience of a tertiary care center in the present Lebanese war. Between 1975 and 1986, approximately 30,000 war casualties were treated at the American University of Beirut Medical Center (AUBMC). A disaster plan was implemented whenever more than 25 major trauma victims were received within 1 hour. In-field stabilization and emergency room (ER) thoracotomy were not employed. The results are illustrated by an analysis of 1,500 cases of abdominal trauma, (1,314 high-velocity gunshot wounds, 29 stab wounds, 157 blunt injuries). A total of 1,420 patients were operated on within 6 hours of admission and 711 within the first hour. Overall mortality was 130, 8.7%; 9.5% for gunshot wounds, 3.4% for stab wounds, and 2.5% for blunt trauma. One hundred forty-five patients or 9.7% had negative findings at laparotomy. The factors affecting mortality were hypotension on admission (26.5% for a BP less than 90 mm Hg and 2.8% for a BP higher than 90 mm Hg) and the presence of extra-abdominal injuries (14.4% with and 4.4% without). The chief causes of death were hemorrhage (3.7%), sepsis (2.1%), and ARDS (1.2%).

Hyperuricemia and renal handling of urate in primary hyperparathyroidism

Serum urate and the renal handling of urate were measured in 37 patients with primary hyperparathyroidism and in normal sex- and age-matched subjects. Serum urate was increased in the hyperparathyroid group compared to the control group (6.23 +/- 1.46 versus 4.64 +/- 1.24 mg/100 ml; p less than 0.005), whereas the fractional excretion of urate was decreased in hyperparathyroid patients compared to the controls (6.80 +/- 2.69 versus 8.73 +/- 3.47%; p less than 0.005). Twenty-four of these hyperparathyroid patients were studied 6 months after surgical correction of their disease. Serum urate decreased after surgery (5.14 +/- 1.65 mg/100 ml) compared to the preoperative state (5.92 +/- 1.46 mg/100 ml) and was no longer different from the normal values. The possible mechanisms of hyperuricemia associated with the hyperparathyroid state are discussed.

Retinal pigment epithelium decompensation. I. Clinical features and natural course

We studied 97 eyes (73 patients) that showed a sharp contrast between the grossly normal appearance of the posterior pole by funduscopy and the fluorescein angiography findings of multiple patches of retinal pigment epithelium (RPE) transmission defect in the early transit, associated with focal areas of RPE staining in the late transit. The staining was located primarily at the superior edge of the RPE defect (63 eyes). The average age of the patients was 52.2 years at the time of diagnosis, and the ratio of men to women was 3.5 to 1. Ocular histories were unremarkable, except for 27 eyes with documented central serous retinopathy. Thirty-two consecutive eyes have been followed for an average of 3.9 years, and 30 of those eyes have shown visual deterioration.

Retinal pigment epithelium decompensation. II. Laser treatment

Forty-one of 97 eyes with retinal pigment epithelium decompensation (RPED) were treated with monochromatic green argon laser photocoagulation to the focal area of RPE staining detected in the late fluorescein transit. Nineteen eyes were treated because of progressive visual deterioration. The other 22 eyes already had visual acuities of 20/50 or worse. Vision stabilized or improved in 34 eyes (82.9%) after an average of 1.6 years following treatment, compared with improvement in only 5 of 56 untreated eyes after an average follow-up period of 2.1 years. After an average follow-up of 7.1 years, 12 of 97 eyes with RPED developed choroidal neovascularization (9 spontaneously and 3 after photocoagulation) in the area where late RPE staining had been observed.

Ultrasonographic findings in eyes with giant retinal tears and opaque media

A preoperative diagnosis of giant retinal tear was suspected as a result of ultrasonography in six eyes with opaque media, and the diagnosis was then confirmed during surgery. All eyes showed a discontinuity in the high amplitude linear retinal echo, representing the location of a retinal tear involving more than one retinal quadrant. In five eyes there was a double linear echo attached to the optic nerve. The linear echo that was discontinuous with the contour of the globe corresponded to the inverted posterior flap of the giant retinal tear. The linear echo that was continuous with the contour of the globe represented detached retina. The preoperative discovery of a giant retinal tear by ultrasonography in eyes with opaque media influences the subsequent management of the patient.

Penetration of intravenous moxalactam into human aqueous humor

Intraocular penetration of moxalactam disodium, a new broad-spectrum oxa-beta-lactam antibiotic, was studied in 18 patients undergoing cataract surgery. The antibiotic was administered in a 2-g single dose by intravenous drip during a 20-minute period. After 40 to 230 minutes, moxalactam aqueous humor concentrations ranged from 1.1 to 5.0 micrograms/mL (mean, 2.3 micrograms/mL). The ratio of aqueous humor concentrations to concomitant serum concentrations ranged from 1.6% to 9.8%. The achievable aqueous moxalactam concentrations were well above the minimum inhibitory concentrations of most Gram-negative enteric bacilli but not of Pseudomonas and staphylococci.

Intracranial solitary extraskeletal plasmacytoma resembling meningioma

A patient had an intracranial solitary extraskeletal plasmacytoma (SEP). To date, only 12 similar cases have been reported in the English literature. This report includes the first description of computed tomographic findings in a patient with intracranial SEP. There is a striking similarity between the features of intracranial SEP and meningiomas. A detailed comparative study of the features of these two neoplasms was done. The findings indicate that the age and sex distribution, clinical features, location of the tumors, roentgenographic findings, and even the gross pathologic nature of the two neoplasms are very similar. The course and prognosis, however, are probably different. Intracranial SEP, although rare, should be included in the differential diagnosis of brain tumors that arise in areas where meningiomas commonly arise.