Fluconazole and Echinocandin Resistance of Candida glabrata Correlates Better with Antifungal Drug Exposure Rather than with MSH2 Mutator Genotype in a French Cohort of Patients Harboring Low Rates of Resistance

Candida glabrata is a major pathogenic yeast in humans that is known to rapidly acquire resistance to triazole and echinocandin antifungal drugs. A mutator genotype (MSH2 polymorphism) inducing a mismatch repair defect has been recently proposed to be responsible for resistance acquisition in C. glabrata clinical isolates. Our objectives were to evaluate the prevalence of antifungal resistance in a large cohort of patients in Saint-Louis hospital, Paris, France, some of whom were pre-exposed to antifungal drugs, as well as to determine whether MSH2 polymorphisms are associated with an increased rate of fluconazole or echinocandin resistance. We collected 268 isolates from 147 patients along with clinical data and previous antifungal exposure. Fluconazole and micafungin minimal inhibition concentrations (MICs) were tested, short tandem repeat genotyping was performed, and the MSH2 gene was sequenced. According to the European Committee on Antimicrobial Susceptibility breakpoints, 15.7% of isolates were resistant to fluconazole (MIC > 32 mg/L) and 0.7% were resistant to micafungin (MIC > 0.03 mg/L). A non-synonymous mutation within MSH2 occurred in 44% of the isolates, and 17% were fluconazole resistant. In comparison, fluconazole resistant isolates with no MSH2 mutation represented 15% (P = 0.65). MSH2 polymorphisms were associated with the short tandem repeat genotype. The rate of echinocandin resistance is low and correlates with prior exposure to echinocandin. The mutator genotype was not associated with enrichment in fluconazole resistance but instead corresponded to rare and specific genotypes.

The use of desflurane or propofol in combination with remifentanil in myasthenic patients undergoing a video-assisted thoracoscopic-extended thymectomy

BACKGROUND

Although several studies of the use of desflurane in anesthesia have revealed many desirable qualities, there are no data on the use and effects especially on the neuromuscular function of desflurane on myasthenia gravis (MG) patients. The purpose of this study was to evaluate the use of either desflurane or propofol, both combined with remifentanil, in patients with MG undergoing a video-assisted thoracoscopic-extended thymectomy (VATET).

METHODS

Thirty-six MG patients who underwent VATET were enrolled. Nineteen patients were anesthetized with remifentanil and propofol infused with a target-controlled infusion plasma model, and 17 patients with desflurane and remifentanil. No muscle relaxant was used. The intubating conditions, hemodynamic and respiratory changes, neuromuscular transmission and post-operative complications were evaluated.

RESULTS

Neuromuscular transmission was significantly decreased in the desflurane group (6.7%, from 3% to 9% during anesthesia P=or<0.05). The intubating conditions were good in all 36 patients and 35 patients were successfully extubated in the operating room. The time-to-awakening, post-operatory pH and base excess were significantly different in the two groups, with a decreasing mean arterial pressure in the group administered with desflurane. No patients required reintubation due to myasthenic or cholinergic crisis, or respiratory failure. No other significant differences between the two groups studied were observed.

CONCLUSION

Our experience indicates that anesthesia with desflurane plus remifentanil in patients with MG could determine a reversible muscle relaxation effect, but with no clinical implication, allowing a faster recovery with no difference in extubation time and post-operative complications in the two groups.

Combined double lung-liver transplantation for cystic fibrosis without cardio-pulmonary by-pass

Sequential bilateral single lung-liver transplantation (SBSL-LTx) is a therapeutic option for patients with end stage lung and liver disease (ESLLD) due to cystic fibrosis (CF). A few cases have been reported, all of them were performed with the use of cardio-pulmonary by-pass (CPB). We performed SBSL-LTx in three young men affected by CF. All the recipients had respiratory failure and portal hypertension with hypersplenism. Along with lung transplants, two patients received a whole liver graft and one an extended right graft from an in situ split liver. During transplantation neither CPB nor veno-venous by-pass (VVB) were employed. Immunosuppression was based on basiliximab, tacrolimus, steroids and azathioprine. The three recipients are alive with a median follow-up of 670 days (range 244-1,533). Combined SBSL-LTx is a complex but effective procedure for the treatment of ESLLD due to CF, not necessarily requiring the use of CPB or VVB.

Orthotopic Liver Transplantation for Biliary Atresia

Biliary atresia (BA) represents the most frequent indication for liver transplantation (OLTX) in the pediatric population. The aim of this paper was to present a series collected over the last 7 years from October 1997 through July 2004, including 260 pediatric OLTX in 231 patients. BA was the indication in 137 patients. There were 69 boys and 68 girls of mean weight 10.68 kg and median age 0.9 years. As a primary transplant, 99 patients received a LLS graft; 27 a whole graft; four a I+IV-VIII segment, and two a I-IV segment. Mean follow up was 1047 days (range, 1-2496 day). Infections were diagnosed in 45 patients, vascular complications in 27 patients. Surgical complications that required reintervention occurred in 25 patients. In 41 cases biliary complications occurred, 11 requiring reintervention. 16 patients were retransplanted. In two cases another re-OLTx was performed. Currently 126 patients are alive, showing an actuarial 1 year survival of 92% and 5 year 91%, with actuarial graft survivals of 85% at 1 year and 82% at 3 and 5 years. Our results confirm the effectiveness of OLTx for the treatment of children with BA and a failed Kasai procedure. Split liver grafts represent an excellent organ supply for these patients, achieving optimal results with no mortality on the waiting list.

Impact of a new assessment system, the MDS-HC, on function and hospitalization of homebound older people: a controlled clinical trial

OBJECTIVES

To evaluate the impact of a new assessment system, the Minimum Data Set for Home Care (MDS-HC), on the functional status and hospitalization rates of frail, community-dwelling older people.

DESIGN

Single-blind randomized trial with 1-year follow-up.

SETTING

Bergamo, Italy.

PARTICIPANTS

All 187 subjects who were eligible for home care services delivered by two Health Districts between September 1998 and April 1999.

INTERVENTION

Random allocation to an intervention group undergoing MDS-HC assessment or to a control group receiving conventional geriatric assessment with Barthel, Lawton and Brody, and Mini-Mental State Examination (MMSE) scales.

MEASUREMENTS

Hospitalization, health services use and costs, and variations in functional status.

RESULTS

Survival analysis indicated that the intervention group was admitted to the hospital later and less often than were controls (relative risk = 0.49, 95% confidence interval = 0.56-0.97). Health services were used to the same extent, but intervention subjects used more in-home help services. Total costs for the intervention group were 21% lower than for the control group. The adjusted mean scores of the activities of daily living index (51.7+/-36.1 vs 46.3+/-33.7; P = .05) and MMSE (19.9+/-8.9 vs 19.2+/-10.7; P = .03) were significantly improved in the intervention group as compared with the control group.

CONCLUSIONS

The MDS-HC assessment instrument may provide a cost-saving approach to reducing institutionalization and functional decline in older people living in the community.

Minimum data set for home care: a valid instrument to assess frail older people living in the community

BACKGROUND

Optimal care for frail elderly patients depends on comprehensive assessment. This is especially true in the complex setting of interdisciplinary home care programs. To facilitate comprehensive assessment, as well as to generate a useful, policy-relevant patient database, standardized, multidimensional, and validated instruments are very helpful.

OBJECTIVES

The aim of the present study was to demonstrate that the Minimum Data Set assessment instrument for Home Care (MDS-HC) can be used to detect functional and cognitive impairment as defined by analogous research instruments.

RESEARCH DESIGN

This was a cross-sectional correlation study.

SUBJECTS

We studied 95 patients admitted to home care services of the Health Care Agency of Bergamo (Italy).

MEASURES

The MDS-HC form was completed for all patients by well-trained nurses, independently of and with nurses blinded to the results from the research rating scales. The Barthel Activities of Daily Living (ADL) Index, the Instrumental Activities of Daily Living of Lawton (IADL), and the Mini Mental State Examination (MMSE) were considered the gold standard.

RESULTS

Agreement between the MDS-HC scales and the research rating scales was assessed with Pearson's correlation coefficient. This coefficient was 0.74 for MDS-ADL versus Barthel Index, 0.81 for MDS-IADL versus Lawton Index, and 0.81 for Cognitive Performance Scale versus MMSE, indicating an excellent agreement.

CONCLUSIONS

The MDS-HC scales, when performed by trained nurses using recommended protocols, provide a valid measure of function and cognitive status in frail home care patients. These findings point out the overall validity of the functional and clinical data contained in the MDS-HC assessment. Use of the MDS-HC gives the unique opportunity of setting up a database, a prerequisite for all epidemiological evidence-based medicine studies.

[Traumatic rupture of the aortic isthmus. Our experience with 23 cases]

BACKGROUND

Traumatic rupture of the aortic isthmus is a highly lethal lesion. Controversy currently exists regarding the best management of the lower body circulation system during repair of an acute aortic transsection. The aim of this study was to evaluate our results using different methods of distal aorta perfusion in order to prevent ischemia of the spinal cord.

METHODS

Between October 1987 and October 1999, 23 patients (20 males, 3 females, mean age 28 years) with rupture of the thoracic aorta underwent surgical repair; 18 of these were acute ruptures and 5 post-traumatic pseudoaneurysms.

RESULTS

All cases of rupture were associated with violent, sudden deceleration and in all but one subject it was due to a traffic accident. Twenty patients had severe associated lesions involving the cranium, abdomen, thorax or leg fractures. The operation was performed with a left postero-lateral thoracotomy in all but one case which underwent sternotomy (the patient with an associated lesion of the distal part of the arch). In 1 patient repair was accomplished using simple aortic cross-clamping, in another with total cardiopulmonary bypass, deep hypothermia and cardiac arrest and in 4 cases with partial cardiopulmonary bypass (1 left atrium-femoral artery and 3 femoro-femoral bypass). Seventeen patients were treated using the centrifugal pump (Bio-Medicus) for left atrium-femoral artery bypass. The perioperative mortality was 8.6%, including 2 patients operated in cardiogenic shock. In the 21 surviving patients the postoperative period was free from any cardiovascular complications, with no cases of paraplegia. There were no late deaths (mean follow-up 4 years) and all patients are in good clinical conditions.

CONCLUSIONS

These results indicate that the outcome mainly depends on preoperative clinical conditions, associated lesions and the timing of the operation. We conclude that the Bio-Medicus centrifugal pump is a simple and safe means of perfusing the lower body, kidney, and spinal cord without heparinization in a patient with multiple injuries.

[The effect of antithrombin iii concentrations during cardiopulmonary surgery]

BACKGROUND

Evaluation of influence of pre-op continuous e.v. heparin infusion in patients undergoing urgent myocardial surgical revascularization, on the anticoagulation threshold needed for cardiopulmonary bypass. Analysis of the efficacy of ATIII substitutional therapy to allow best ACT values during extracorporeal circulation, and to reduce intra and post-op bleeding and need for homologus transfusion.

SETTING

Operative room and ICU of a cardiac surgery unit in a regional hospital.

METHODS

Two groups of coronary patients in preoperative treatment with heparin were randomized in a prospective double blind study for an intraoperative treatment with heparin and ATIII (Group A) and heparin plus placebo (Group B). An investigation was made on the influence of preoperative heparin treatment regarding extracorporeal circulation, the variation of the coagulation parameters in CEC with substitutive therapy of ATIII and the reduction of the therapeutic strength of heparin during perfusion, the problem of bleeding and the incidence of blood transfusions and lastly the economic questions of the two procedures.

RESULTS

The study showed the necessity of repeated bolus of heparin during CEC and the rapid loss of its effect in the group not subjected ATIII therapy. A less incidence of bleeding in Group A was observed; for this reason the patients received significantly less packed red cells and FFP and a discrete number of patients of this group were not transfused. Surely the method of using the ATIII is much more expensive from the economic point of view, but the benefits of avoiding the problems of a blood transfusion (infections, immunodepression etc.), of the reduced stay in the Intensive Care Unit, of the riduced risk involved with problems of bleeding and the need of repeated operative procedures make this method fundamental in patients with reduced plasma levels of ATIII such as coronary patients who are under heparin treatment for several days.

CONCLUSIONS

Intraoperative administration of ATIII can reduce most problems due to heparinization of the extracorporeal circuit, such as onset of fibrinolysis, CID and platelets depletion or inactivation causing intra and post-op massive bleeding.

A mini-invasive technique for axillary lymphadenectomy in early breast cancer: a study of 15 patients

Axillary lymphadenectomy is the major cause of morbidity reported in breast surgery, but remains the gold standard in breast cancer staging procedures. The aim of this study was to evaluate if endoscopic lymphadenectomy, preceded by fat suction, could reduce morbidity and hospitalization, giving better aesthetic results, while conserving the same oncologic radicality as the traditional open technique. We studied 15 cases of breast cancer with tumour diameter < or = 25 mm, N0. The subjects underwent endoscopic lymphadenectomy. We removed an average of 15.5 node/patient, the volume of lymphorrea was 580 ml, the drainage was kept up for 5 days, the mean length of hospitalization was 6 days. One seroma (4.6%) was found. No shoulder restriction has been reported and aesthetic results were excellent. The follow-up will demonstrate if this technique can reduce the incidence of lymphoedema.

[Perforation of the esophagus during pneumatic dilatation in achalasia]

Esophageal perforation is a serious complication of pneumatic dilatation. We studied the cases of 4 patients (2 men and 2 women, mean age 58 years, range 56-62) who had surgical treatment for achalasia, two of which had had previous dilatation. The main symptoms were pain and dyspnea. Pneumomediastinum was present in all patients, pleural effusion in 2 and cervical emphysema in 1. Esophagographic results showed evidence of perforation in all four cases and gastric patches were surgically placed on the esophageal tear within 12 hours. Three patients received enteral nutrition for an average of 13 days. Mean hospital stay was 14 days. No post-operative complications were exhibited although one patient did develop gastroesophageal reflux 3 months later and underwent surgery to repair a hernia in the thorax 5 years later. Early and aggressive treatment is considered the best therapy and the gastric patch, in our opinion, is an effective and reliable technique for esophageal perforation repair in achalasia patients.

[Rationale for anesthesia in non-cardiac surgery on patients with heart transplant]

The introduction of cyclosporine in the prevention of rejection, together with the improvement of surgical and anaesthetic techniques, produced a tangible increase in long term survival time and the life quality of heart-transplanted patients, so that, they have to undergo non-cardiac surgical operation, more and more frequently. The aim of this report is to analyse the essential physio-pathological, clinical, haemodynamic and pharmacological knowledge in order to perform a safe anaesthesia on the above mentioned patients. The Authors are basing this report on experience obtained in deep study of their own cases. In fact they have anaesthetized 190 patients during heart transplantation; later on, 27 of these patients have undergone subsequent major or minor non-cardiac surgical operations.

Clinical experience with a new pulsatile pump for infant and pediatric cardiopulmonary bypass

A pulsatile pump of new concept has been developed for infant and pediatric cardiopulmonary bypass (cpb) (Parenzan-Fumero pump). A segment of elastic tubing is compressed by a pneumatically driven pushing plate under control of a microprocessor. Flow parameters such as pulse rate and stroke volume can be set. The pump can be synchronized with the patient's ECG for counterpulsation heart assist. A total of 87 open-heart procedures were performed using randomly either a conventional roller pump or the Parenzan-Fumero pump (respectively 39 and 48 patients). A previously published cpb protocol and anesthetic regimen were adopted in all cases. The results show increased cooling and rewarming rate (p less than 0.05) and urinary output, decreased vascular resistance, intensive care unit time and need for blood transfusion in the pulsatile group compared to the continuous perfusion group. In the pulsatile group, mortality was significantly lower (10.4% vs 25.6%) and low cardiac output syndrome was less frequent in the post-operative course.