A premature infant with fetal myocardial and abdominal calcifications and factor V Leiden homozygosity

We present a premature male neonate with confirmed factor V Leiden deficiency diagnosed prenatally with cardiac and abdominal calcifications. Our patient's findings suggest that clinicians consider thromboembolic conditions when multiple fetal calcifications are visualized.

Congenital long-QT syndromes: a clinical and genetic update from infancy through adulthood

Long-QT syndromes (LQTSs) have been described in all ages and are a significant cause of cardiovascular mortality, especially in structurally normal hearts. Abnormalities in transmembrane ion conduction channels and structural proteins produce these clinical syndromes, labeled LQT1-LQT12; however, genotype-positive patients still represent only about 70% of LQTSs. Future research will determine the etiology of the remaining cases, further risk-stratify the known genetic defects, improve current treatment options for these syndromes, and uncover novel therapies.

Digital music players cause interference with interrogation telemetry for pacemakers and implantable cardioverter-defibrillators without affecting device function

BACKGROUND

Concern exists regarding the potential electromagnetic interaction between pacemakers, implantable cardioverter-defibrillators (ICDs) and digital music players (DMPs). A preliminary study reported interference in 50% of patients whose devices were interrogated near Apple iPods.

OBJECTIVE

Given the high prevalence of DMP use among young patients, we sought to define the nature of interference from iPods and evaluate other DMPs.

METHODS

Four DMPs (Apple Nano, Apple Video, SanDisk Sansa and Microsoft Zune) were evaluated against pacemakers and ICDs (PM/ICD). Along with continuous monitoring, we recorded a baseline ECG strip, sensing parameters and lead impedance at baseline and for each device.

RESULTS

Among 51 patients evaluated (age 6 to 60 years, median 22), there was no interference with intrinsic device function. Interference with the programmer occurred in 41% of the patients. All four DMPs caused programmer interference, including disabled communication between the PM/ICD and programmer, noise in the ECG channel, and lost marker channel indicators. Sensing parameters and lead impedances exhibited no more than baseline variability. When the DMPs were removed six inches, there were no further programmer telemetry interactions.

CONCLUSIONS

Contrary to a prior report, we did not identify any evidence for electromagnetic interference between a selection of DMPs and intrinsic function of PM/ICDs. The DMPs did sometimes interfere with device-programmer communication, but not in a way that compromised device function. Therefore, we recommend that DMPs not be used during device interrogation, but suggest that there is reassuring counterevidence to mitigate the current high level of concern for interactions between DMPs and implantable cardiac rhythm devices.

Impact of transvenous ventricular pacing leads on tricuspid regurgitation in pediatric and congenital heart disease patients

INTRODUCTION

Transvenous ventricular pacing leads across the tricuspid valve may cause or exacerbate tricuspid regurgitation (TR). The literature in adults is inconclusive and no studies have investigated the association between pacing leads and TR in children or congenital heart disease patients.

METHODS AND RESULTS

A retrospective chart review was conducted at a large children's hospital, yielding 123 patients with initial placement of a transvenous lead across their tricuspid valve that had adequate echocardiographic data for review. The median age was 16 years (range 2-52) at time of lead placement. The pre-procedure echo was compared both to the first echo after lead placement and the most recent echo. Median time was 242 days from implant to first echo, and 827 days to most recent echo. There was no difference in TR between the pre-procedure echo and first follow-up echo (p = NS). However, TR was more likely to progress mildly between the pre-procedure echo and the most recent echo (p < 0.02) with a mean increase from 1.54 to 1.69 on a 0 to 4 ordinal scale. There were 76 pts (62%) with CHD. Mean pre-procedure TR was 1.82 in right-sided valvular CHD (e.g., tetralogy of Fallot, repaired AV canal) vs. 1.43 without right-sided CHD (p < 0.01).

CONCLUSIONS

In patients with transvenous ventricular leads across the tricuspid valve, echocardiography demonstrates a small, but statistically significant change in TR. The detected change is minimal, suggesting that there is little impact of transvenous leads on TR, even in growing children or patients with right-sided structural heart disease.

Composition of Acridid gut bacterial communities as revealed by 16S rRNA gene analysis

The gut bacterial community from four species of feral locusts and grasshoppers was determined by denaturing gradient gel electrophoresis (DGGE) analysis of bacterial 16S rRNA gene fragments. The study revealed an effect of phase polymorphism on gut bacterial diversity in brown locusts from South Africa. A single bacterial phylotype, consistent with Citrobacter sp. dominated the gut microbiota of two sympatric populations of Moroccan and Italian locusts in Spain. There was evidence for Wollbachia sp. in the meadow grasshopper caught locally in the UK. Sequence analysis of DGGE products did not reveal evidence for unculturable bacteria and homologies suggested that bacterial species were principally Gammaproteobacteria from the family Enterobacteriaceae similar to those recorded previously in laboratory reared locusts.

Bacterial community structure, compartmentalization and activity in a microbial fuel cell

AIMS

To characterize bacterial populations and their activities within a microbial fuel cell (MFC), using cultivation-independent and cultivation approaches.

METHODS AND RESULTS

Electron microscopic observations showed that the fuel cell electrode had a microbial biofilm attached to its surface with loosely associated microbial clumps. Bacterial 16S rRNA gene libraries were constructed and analysed from each of four compartments within the fuel cell: the planktonic community; the membrane biofilm; bacterial clumps (BC) and the anode biofilm. Results showed that the bacterial community structure varied significantly between these compartments. It was observed that Gammaproteobacteria phylotypes were present at higher numbers within libraries from the BC and electrode biofilm compared with other parts of the fuel cell. Community structure of the MFC determined by analyses of bacterial 16S rRNA gene libraries and anaerobic cultivation showed excellent agreement with community profiles from denaturing gradient gel electrophoresis (DGGE) analysis.

CONCLUSIONS

Members of the family Enterobacteriaceae, such as Klebsiella sp. and Enterobacter sp. and other Gammaproteobacteria with Fe(III)-reducing and electrochemical activity had a significant potential for energy generation in this system.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study has shown that electrochemically active bacteria can be enriched using an electrochemical fuel cell.

Assessment of dermal ethanol emission sensors: experimental design

This paper discusses methods that will be used to experimentally determine the limitations of transdermal ethanol alcohol sensors when used on human subjects. Transdermal ethanol sensors are used to measure the concentration of ethanol emitted by the surface of the skin. The maximum concentration of ethanol in the skin is proportional to the concentration of ethanol in the blood stream but is offset temporally because of the diffusion delay intrinsic to body tissue. Methods to evaluate different model ethanol sensors are discussed as well as the development and function of a portable, transdermal ethanol sensing device suitable for measuring ethanol concentration on the palm of a test subject's hand. In addition, the designs of several experiments are described to test the functional limitations of transdermal ethanol sensors in practical use settings. These experiments include tests to correlate a subject's peak blood and skin ethanol concentrations and experimental determination of different false positive sources.

Comparison of the epidemiology and co-morbidities of heart failure in the pediatric and adult populations: a retrospective, cross-sectional study

Background

Heart failure is a clinical syndrome that is associated with a significant number of interventional procedures and has received a large amount of scrutiny in the adult literature; however, the epidemiology in children is less well described.

Methods

We analyzed two large, commercially available inpatient datasets collected in 1997 by the Agency for Healthcare Research and Quality: the Kids' Inpatient Database and the National Inpatient Study, accounting for 50% of the U.S. pediatric discharges and 20% of the U.S. adult discharges in 1997.

Results

The database contained 5,610 children and 732,752 adults with a diagnosis of HF. When compared with the adult sample, the pediatric sample showed a higher proportion with cardiac procedures (61.4% vs. 0.28%, p < 0.01), a higher prevalence of congenital heart disease (61% versus 0.3%, p < 0.01), a higher percentage of male patients (50% pediatric vs. 44% adult, p < 0.01), and a lower percentage of white patients (40.9% vs. 65.6%, p < 0.01). Children had a significantly different spectrum of co-morbidities compared with adults. There was no difference in mortality rate between children and adults (7.5% vs. 7.9%, p = NS).

Conclusion

There are significant differences in the epidemiological profile of children and adults with heart failure. Children suffer from different types of co-morbidities and require different procedures in the hospital setting. As such, children with heart failure who are hospitalized may require significantly different facilities, management and therapeutic intervention than adults with similar symptoms.

Air pollution and daily hospitalization rates for cardiovascular and respiratory diseases in London, Ontario

In this paper, we examine the role that ambient air pollution plays in exacerbating cardiovascular and respiratory disease hospitalization in London, Ontario from 1 November 1995 to 31 December 2000. The number of daily cardiac and respiratory admissions was linked to concentrations of air pollutants (sulphur dioxide, nitrogen dioxide, ozone, carbon monoxide, coefficient of haze, PM(10)) and weather variables (maximum and minimum of temperature and humidity). Results showed that current day carbon monoxide and coefficient of haze produced significant percentage increase in daily cardiac admissions of 8.0% (95% CI: 1.5-11.5%) and 5.7% (95% CI: 0.9-10.8%) for people < 65 years old. PM(10) was found to be significantly associated with asthma admission in the > 65 group, with percentage increase in cardiac admission of 25% (95% CI: 2.8-52.3%) and 26.0% (95% CI: 5.3-50.9%) for current day and 2-day means, respectively.

Diversity of bacteria associated with natural aphid populations

The bacterial communities of aphids were investigated by terminal restriction fragment length polymorphism and denaturing gradient gel electrophoresis analysis of 16S rRNA gene fragments generated by PCR with general eubacterial primers. By both methods, the gamma-proteobacterium Buchnera was detected in laboratory cultures of six parthenogenetic lines of the pea aphid Acyrthosiphon pisum and one line of the black bean aphid Aphis fabae, and one or more of four previously described bacterial taxa were also detected in all aphid lines except one of A. pisum. These latter bacteria, collectively known as secondary symbionts or accessory bacteria, comprised three taxa of gamma-proteobacteria (R-type [PASS], T-type [PABS], and U-type [PAUS]) and a rickettsia (S-type [PAR]). Complementary analysis of aphids from natural populations of four aphid species (A. pisum [n = 74], Amphorophora rubi [n = 109], Aphis sarothamni [n = 42], and Microlophium carnosum [n = 101]) from a single geographical location revealed Buchnera and up to three taxa of accessory bacteria, but no other bacterial taxa, in each aphid. The prevalence of accessory bacterial taxa varied significantly among aphid species but not with the sampling month (between June and August 2000). These results indicate that the accessory bacterial taxa are distributed across multiple aphid species, although with variable prevalence, and that laboratory culture does not generally result in a shift in the bacterial community in aphids. Both the transmission patterns of the accessory bacteria between individual aphids and their impact on aphid fitness are suggested to influence the prevalence of accessory bacterial taxa in natural aphid populations.

Jarisch-Herxheimer reaction associated with ciprofloxacin administration for tick-borne relapsing fever

A 14-year-old girl was seen at a community clinic with a chief complaint of abdominal pain and fevers and was treated with oral ciprofloxacin for presumed pyelonephritis. She became tachycardic and hypotensive after her first dose of antibiotic, and she developed disseminated intravascular coagulation. She was admitted to our hospital for presumed sepsis. Her outpatient peripheral blood smear was reviewed, revealing spirochetes consistent with Borrelia sp. To our knowledge this is the first reported case of the Jarisch-Herxheimer reaction to ciprofloxacin.

Quantity and quality of virus-specific CD8 cell response: relevance to the design of a therapeutic vaccine for chronic HBV infection

Chronic hepatitis B virus (HBV) infection is a major cause of morbidity and mortality worldwide, yet currently available therapies fail to provide long-term control of viral replication in most patients. Strategies to boost the weak virus-specific T-cell response typically found in patients with chronic hepatitis B have been proposed as a means of terminating persistent HBV infection. The potential problems arising from the stimulation of virus-specific immunity in a disease caused by a non-cytopathic virus, where viral control and liver injury are mediated by the immune system, are discussed. Furthermore, the concept of augmenting the HBV-specific T-cell response, which has previously been focused solely on quantitative issues, is expanded in the light of new findings of qualitative differences in the HBV-specific CD8 cell response.

Crystal structure of the PDZ1 domain of human Na(+)/H(+) exchanger regulatory factor provides insights into the mechanism of carboxyl-terminal leucine recognition by class I PDZ domains

The Na(+)/H(+) exchanger regulatory factor (NHERF; also known as EBP50) contains two PDZ domains that mediate the assembly of transmembrane and cytosolic proteins into functional signal transduction complexes. The NHERF PDZ1 domain interacts specifically with the motifs DSLL, DSFL, and DTRL present at the carboxyl termini of the beta(2) adrenergic receptor (beta(2)AR), the platelet-derived growth factor receptor (PDGFR), and the cystic fibrosis transmembrane conductance regulator (CFTR), respectively, and plays a central role in the physiological regulation of these proteins. The crystal structure of the human NHERF PDZ1 has been determined at 1.5 A resolution using multiwavelength anomalous diffraction phasing. The overall structure is similar to known PDZ structures, with notable differences in the NHERF PDZ1 carboxylate-binding loop that contains the GYGF motif, and the variable loop between the beta2 and beta3 strands. In the crystalline state, the carboxyl-terminal sequence DEQL of PDZ1 occupies the peptide-binding pocket of a neighboring PDZ1 molecule related by 2-fold crystallographic symmetry. This structure reveals the molecular mechanism of carboxyl-terminal leucine recognition by class I PDZ domains, and provides insights into the specificity of NHERF interaction with the carboxyl termini of several membrane receptors and ion channels, including the beta(2)AR, PDGFR, and CFTR.

An evolutionary computational approach to the phase problem in macromolecular X-ray crystallography

The ab initio computation of the molecular envelopes of two proteins exclusively from their corresponding diffraction amplitudes demonstrates that an efficient and inherently parallel evolutionary search algorithm can assist in the direct phasing of macromolecules for which almost no a priori structural information is available. The applicability of this evolutionary computational approach is general and should not be limited to the examples described nor to extremes of data resolution, symmetry or structural size.

Crystallographic characterization of the PDZ1 domain of the human Na+/H+ exchanger regulatory factor

The Na(+)/H(+) exchanger regulatory factor (NHERF) contains two PDZ domains that mediate the assembly of transmembrane and cytosolic proteins into functional signal transduction complexes. The human NHERF PDZ1 domain, which spans residues 11-99, interacts specifically with carboxy-terminal residues of the beta2 adrenergic receptor and the cystic fibrosis transmembrane conductance regulator. The NHERF PDZ1 was expressed in Escherichia coli as a soluble protein, purified and crystallized in the unbound form using the vapor-diffusion method with 2 M ammonium sulfate as the precipitant. Diffraction data were collected to 1.5 A resolution using synchrotron radiation. The crystals belong to space group P3(1)21 or P3(2)21, with unit-cell parameters a = b = 51.6, c = 58.9 A, and one molecule in the asymmetric unit.

Combination azelaic acid therapy for acne vulgaris

There is no topical antiacne medication that acts against all four of the major pathophysiologic features of acne: hyperkeratinization, sebum production, bacterial proliferation, and inflammation. Topical azelaic acid cream helps both to normalize keratinization and to reduce the proliferation of Propionibacterium acnes, and has proven to be effective against both noninflammatory and inflammatory lesions. The results of a recent study now demonstrate that its efficacy can be enhanced, and patient ratings of overall impression improved, when it is used in combination with other topical medications such as benzoyl peroxide 4% gel, clindamycin 1% gel, tretinoin 0.025% cream, and erythromycin 3%/benzoyl peroxide 5% gel. Furthermore, another study has shown that azelaic acid plus benzoyl peroxide achieves greater efficacy and higher patient ratings of convenience than monotherapy with erythromycin-benzoyl peroxide gel.

Crystallization and structure determination of the catalytic trimer of Methanococcus jannaschii aspartate transcarbamoylase

Aspartate transcarbamoylase (ATCase) catalyzes the first step in the pyrimidine biosynthetic pathway, the reaction between carbamoyl phosphate and L-aspartate to form N-carbamoyl-L-aspartate and phosphate. The structural analysis of the ATCase catalytic trimer from Methanococcus jannaschii, a unicellular thermophilic archaeabacterium, has been undertaken in order to gain insight into the structural features that are responsible for the thermostability of the enzyme. As a first step, the catalytic trimer was crystallized in space group R32, with unit-cell parameters a = b = 265.3, c = 195.5 A and two trimers in the asymmetric unit. Its structure was determined using molecular replacement and Patterson methods. In general, structures containing multiple copies of molecules in the asymmetric unit are difficult to determine. In this case, the two trimers in the asymmetric unit are parallel to each other and use of the Patterson function greatly simplified the structure solution.

Aspartyl tRNA-synthetase from Escherichia coli: flexibility and adaptability to the substrates

The crystal structure of aspartyl-tRNA synthetase from Escherichia coli has been determined to a resolution of 2.7 A. The structure is compared to the same enzyme co-crystallized with tRNA(Asp) and containing aspartyl adenylate or ATP. The asymmetric unit contains three monomers of the enzyme. While most parts of the protein show no significant differences in the three monomers, a few regions cannot be superimposed. Those regions are characterized by a high B-factor, and consist mostly of loops that make contacts with the tRNA in the complexes. The flexibility of the protein is seen at a global level, by the observation of a 10 to 15 degrees rotation of the N-terminal and insertion domains upon tRNA binding, and at the level of the individual amino acid residues, by main-chain and side-chain rearrangements. In contrast to these induced-fit conformational changes, a few residues essential for the tRNA anticodon or aspartyl-adenylate recognition exist in a predefined conformation, ensured by specific interactions within the protein.

An intermediate step in the recognition of tRNA(Asp) by aspartyl-tRNA synthetase

The crystal structures of aspartyl-tRNA synthetase (AspRS) from Thermus thermophilus, a prokaryotic class IIb enzyme, complexed with tRNA(Asp) from either T. thermophilus or Escherichia coli reveal a potential intermediate of the recognition process. The tRNA is positioned on the enzyme such that it cannot be aminoacylated but adopts an overall conformation similar to that observed in active complexes. While the anticodon loop binds to the N-terminal domain of the enzyme in a manner similar to that of the related active complexes, its aminoacyl acceptor arm remains at the entrance of the active site, stabilized in its intermediate conformational state by non-specific interactions with the insertion and catalytic domains. The thermophilic nature of the enzyme, which manifests itself in a very low kinetic efficiency at 17 degrees C, the temperature at which the crystals were grown, is in agreement with the relative stability of this non-productive conformational state. Based on these data, a pathway for tRNA binding and recognition is proposed.

HCV genotypes--role in pathogenesis of disease and response to therapy

Hepatitis C virus (HCV) shows considerable variation in its genomic structure, allowing classification into six main genotypes. Epidemiological studies have shown marked differences in genotype distribution by geographical region, and between patient groups. Improved understanding of the rate of nucleotide sequence mutation in HCV has allowed the approximate time of divergence of major genotypes to be estimated, and the origin and spread of the present epidemic of hepatitis C to be better defined. Improved methods of genotype definition over the last few years have enabled the importance of genotype in the progression of HCV-related disease and response to anti-viral therapy to be studied. Present data strongly indicates that HCV genotype is an important determinant of response to treatment, but the effect of genotype on disease progression has been harder to clarify. This is largely due to the absence of model systems of HCV infection, the epidemiological differences in patient groups infected with the different genotypes, and the lack of good prospective longitudinal clinical data. As a result of advances in methodology, and recent results of large clinical trials of combination therapy, a knowledge of HCV genotype is now central to the clinician in the management of patients with chronic hepatitis C.

Long-term efficacy of treatment of chronic hepatitis C with alpha interferon or alpha interferon and ribavirin

The major objective of treatment of chronic hepatitis C virus (HCV) infection is to prevent progression to cirrhosis, and thereby prevent complications of end-stage liver disease. The established treatment of chronic HCV is with alpha interferon. Recent results with ribavirin and alpha interferon together suggest that combination antiviral therapy will become the benchmark treatment. For both naive and relapsed patients, however, it has become important to assess the long-term outcome of treatment, in order to gauge whether treatment has indeed modified the natural history of chronic hepatitis C virus infection. It seems likely that most sustained responders (85-90%) treated with combination ribavirin and alpha interferon will continue to have a long-term biochemical and virological response, as has been demonstrated with alpha interferon alone, but further long-term follow-up of patients treated with combination therapy is required.

Predictors of a favorable response to alpha interferon therapy for hepatitis C

The most consistently identified predictive factors for a response to both IFN-alpha monotherapy and IFN-alpha in combination with ribavirin are a low HCV RNA level, the absence of fibrosis, infection with HCV genotype 2 and 3, and a prolonged duration of treatment. In addition, an early response to IFN-alpha predicts response to IFN-alpha monotherapy but not necessarily to combination therapy. There does not appear to be any major gain in treating IFN-naive patients with HCV genotype 2 or 3 infection with a combination of IFN-alpha and ribavirin for longer than 6 months. The identification of these predictive factors has allowed improvement in study design and assessment and may provide a patient with an idea of the likelihood of response, making possible a more informed decision regarding treatment. At present, none of these factors, either alone or in combination, completely predicts response to IFN-alpha. Thus, individual patients should not be denied treatment on the basis of these factors.

Relationship and family breakdown following acquired brain injury: the role of the rehabilitation team

Although the literature documents the considerable problems acquired brain injury causes for the survivor's family and close relationships, and the corresponding significantly inflated rate of separation and divorce, few papers offer practical solutions. The objective of this paper is to respond to this gap in the literature by presenting some of the problems raised for the rehabilitation team when a family separates, and some suggestions for ways in which these problems could be overcome. The literature is reviewed briefly, followed by reflections and suggestions which are based on this review and on clinical experience. The discussion indicates that there are a number of practical dilemmas raised for the rehabilitation team when a family already involved in the rehabilitation process starts to break up. Some specific suggestions for addressing these issues are made; further research is needed to evaluate their effectiveness.

Finasteride in the treatment of men with frontal male pattern hair loss

BACKGROUND

Finasteride, a specific inhibitor of type II 5alpha-reductase, decreases serum and scalp dihydrotestosterone and has been shown to be effective in men with vertex male pattern hair loss.

OBJECTIVE

This study evaluated the efficacy of finasteride 1 mg/day in men with frontal (anterior/mid) scalp hair thinning.

METHODS

This was a 1-year, double-blind, placebo-controlled study followed by a 1-year open extension. Efficacy was assessed by hair counts (1 cm2 circular area), patient and investigator assessments, and global photographic review.

RESULTS

There was a significant increase in hair count in the frontal scalp of finasteride-treated patients (P < .001), as well as significant improvements in patient, investigator, and global photographic assessments. Efficacy was maintained or improved throughout the second year of the study. Finasteride was generally well tolerated.

CONCLUSION

In men with hair loss in the anterior/mid area of the scalp, finasteride 1 mg/day slowed hair loss and increased hair growth.

Pharmacokinetics of three once-weekly dosages of fluconazole (150, 300, or 450 mg) in distal subungual onychomycosis of the fingernail

BACKGROUND

Fluconazole has proven to be safe and effective for a variety of superficial and systemic fungal infections. Preliminary analysis of extensive Phase III studies suggests that it is very effective for the treatment of onychomycosis. Its pharmacokinetic properties, including low molecular weight and high water-solubility, suggest a unique ability to penetrate the nail. This feature is likely to account in part for fluconazole's effectiveness in the treatment of onychomycosis.

OBJECTIVE

Determinations of plasma and fingernail concentrations of fluconazole were performed as part of a larger study comparing the safety and efficacy of once-weekly fluconazole (150, 300, and 450 mg) to placebo in the treatment of distal subungual onychomycosis of the fingernails caused by dermatophytes. The relationship between fluconazole concentrations and efficacy was also examined.

METHODS

Pharmacokinetic studies were performed by means of plasma and fingernail samples from 133 patients, a subset of 349 patients participating in a double-blind, placebo-controlled clinical trial of fluconazole administered in once-weekly doses of 150, 300, or 450 mg until cure of onychomycosis or for a maximum of 9 months. Blood and fingernail samples for pharmacokinetic analysis were taken at baseline, at week 2, and at monthly intervals during the treatment phase of the study. Patients considered clinically cured or improved also participated in a 6-month follow-up study. During this phase, patients were monitored and samples taken every 2 months.

RESULTS

Significant amounts of fluconazole were detected in the earliest fingernail samples taken (after 2 weeks of treatment). After two weekly doses, 30% to 33% of steady-state concentrations had been achieved in healthy nails and 22% to 29% in affected nails. Steady state was achieved in 3 to 5 months. Fluconazole concentration in nails as well as plasma followed dose-proportional pharmacokinetics. Nail:plasma ratios in affected nails were 0.4 to 0.6 at 2 weeks and 1.7 to 1.8 at 6 months. Fluconazole concentrations fell slowly after drug discontinuation and were still detectable 4 months after end of treatment. A statistically significant correlation was found between steady-state concentration and clinical and global outcomes.

CONCLUSION

Fluconazole rapidly penetrates the fingernail, where it is retained at detectable levels for at least 4 months after drug discontinuation. A significant correlation exists between fluconazole concentration in the fingernails and clinical and global outcomes.