Use of the PATH Alliance database to measure adherence to IDSA guidelines for the therapy of candidemia

Candidemia is an increasing complication of the care of complex patients. Adherence to Infectious Diseases Society of America (IDSA) guidelines for the treatment of candidemia was investigated to assess the impact of compliance on outcomes of therapy. Data on the epidemiology, diagnosis, and treatment of patients with invasive fungal infections (IFIs) was extracted from the PATH Alliance registry, a prospective, multicenter, observational database of invasive fungal infections. Patients with proven candidemia were evaluated for adherence to the IDSA guidelines in terms of choice, dosage, and duration of antifungal therapy. Removal of central venous catheters and time to treatment initiation were assessed. Four-week survival data were compared. Of the 418 patients with candidemia who were included in the study, 361 patients with the necessary data sets were identified, of whom 262 (72.6%) were treated within the IDSA guidelines for the treatment of candidemia (IDSA group); the remaining 99 (27.4%) patients received treatment different from the guidelines (non-IDSA group). Kaplan-Meier (KM) survival analysis for patients in the IDSA and non-IDSA group showed mortality rates of 21.9 and 13.6%, respectively; the difference between the two groups was not statistically significant (P = 0.093). Following the exclusion of patients requiring mechanical ventilation or acute cardiac support, the modified survival KM curves were similar between the two groups. Significantly more patients in the IDSA group required mechanical ventilation and tunneled central catheters, had a concomitant IFI, and received caspofungin. The duration of treatment and inappropriate dosing did not appear to have had a significant impact on survival. Most of the deviations from IDSA guidelines were due to the inappropriate duration and dosing of therapy. No significant difference in mortality was noted between the IDSA and non-IDSA groups. The basis of these differences merit further study. Presented in part at the 44th Annual Meeting of Infectious Disease Society of America, Toronto, Canada, 2006.     

Erfolgreiche Behandlung einer thyreotoxischen Krise durch kontinuierliche Plasmapherese am Blutzellseparator

Zusammenfassung Bei einem 26jährigen Patienten im thyreotoxischen Koma erwies sich die kontinuierliche Plasmapherese am IBM-Blutzellseparator klinisch als akut wirksame Krisentherapie. Schon während der Plasmapherese mit Austausch von 51 Plasma in 3 1/2 h wurde der Patient aus einem tiefen Koma heraus ansprechbar. Mit den 51 Plasma wurden 633 µg Thyroxin (T₄) und 13,6 µg Trijodthyronin (T₃) entzogen. Dies führte erstaunlicherweise nicht zu einem Abfall der Gesamtspiegel von T₄ und T₃ im Serum, ein Befund, der als Hinweis auf einen raschen Rückstrom aus dem Gewebe in die Blutbahn zu interpretieren ist. Die freien Schilddrüsenhormonspiegel nahmen dagegen signifikant ab, erkennbar am Abfall der Werte des T₃-in vitro-Tests und der T₄- und T₃-Ausscheidung im Urin. Diese Befunde zeigen auf, daß neben dem Entzug von Schilddrüsenhormon vor allem die Zufuhr freier Bindungsstellen für Schilddrüsenhormon mit dem Spenderplasma bei der Behandlung der thyreotoxischen Krise von Bedeutung ist.Mit Unterstützung der Sonderforschungsbereiche SFB 51¹ und SFB 37²     

Case report: glomus tumor of the colon

Glomus tumors are tumors of pericytic origin and are usually found in the distal extremities. Glomus tumors have rarely been reported in viscera. The authors report a glomus tumor of the colon that caused rectal bleeding in a 40-yr-old man and was biopsied and excised endoscopically. The histology and immunohistochemical profile of the tumor are described and the literature on visceral glomus tumors is reviewed.     

Amnesic effects of bilateral lesions placed in the hyperstriatum ventrale of the chick after imprinting

Summary The purpose of this study was to investigate whether bilateral lesions to a part of the hyperstriatum ventrale (IMHV) impair retention if they are placed after chicks have been imprinted. Domestic chicks were hatched and reared in darkness and exposed to an imprinting (training) stimulus for 2 h commencing 22 h post hatch. The chicks were then anaesthetised and bilateral lesions placed in IMHV (N = 16) birds, hyperstriatum accessorium (HA; N = 16) or the lateral part of the cerebral hemispheres (LCA; N = 16). Forty-eight sham-operated chicks served as controls. Chicks were returned to the dark incubator, and, 15–20 h after the operation, their approach towards the training stimulus and to a second novel stimulus was measured. The controls and the chicks with lesions in HA and LCA showed a strong preference for the training stimulus and hence a high level of retention. The preferences of these three experimental groups did not differ significantly from one another. The mean preference of chicks with lesions in IMHV was significantly less than that of the sham-operated controls (P<0.01) and of chicks lesioned in HA (P<0.05). Bilateral lesions to IMHV therefore selectively impair retention of a preference acquired through imprinting. This impairment is unlikely to be a non-specific consequence of defective sensory processing or motor performance because the four groups did not differ from each other in (i) the time taken accurately to peck a rocking bead, (ii) the accuracy of pecking millet seeds and (iii) the performance of a simultaneous visual discrimination task involving heat reinforcement.Supported by grants from the Science Research Council, the Leverhulme Trust, the Wellcome Trust and FAPESP (Brazil)     

Monocyte-mediated growth control and the induction of tumor cell death

In the present article a hypothesis is put forward and supporting data are referred that explain the elimination of tumorigenic cells as a consequence of their failure to comply with the rules of ubiquitous negative growth control mechanisms involving among others also mononuclear phagocytes as effector cells. This hypothesis does not invoke the recognition of altered cell surface structures on tumorigenic cells as the basis for discriminating them from normal cells and thus avoids one of the most irritating problems of hypothetical tumor defense mechanisms involving the recognition of spontaneously arising tumor cells as 'non-self' by immunologic effector cells.     

The incidence of thyroglobulin antibodies and thyroid enlargement in a general practice in north-east England

Antibodies to thyroglobulin in a titre of 1:25 or more were found in 16·2% of women and 4·3% of men between the ages of 21 and 80 years in a random sample of the population from a general practice in the north-east of England. The incidence of antibodies was highest in the seventh decade in both sexes. High antibody titres (1:78125 or more) were found in 4·6% of women and 1·6% of men and it is suggested that this may represent the incidence of diffuse thyroiditis in the population.

Significant thyroid enlargement was found in 12% of women and 0·9% of men, the corrected incidence of goitre obtained by averaging the frequency of goitres in each decade between 21 and 80 years was 8·9% and 0·9% respectively.

     

Initial evaluation of a continuous speech recognition program for radiology

The aims of this work were to measure the accuracy of one continuous speech recognition product and dependence on the speaker's gender and status as a native or nonnative English speaker, and evaluate the product's potential for routine use in transcribing radiology reports. IBM MedSpeak/Radiology software, version 1.1 was evaluated by 6 speakers. Two were nonnative English speakers, and 3 were men. Each speaker dictated a set of 12 reports. The reports included neurologic and body imaging examinations performed with 6 different modalities. The dictated and original report texts were compared, and error rates for overall, significant, and subtle significant errors were computed. Error rate dependence on modality, native English speaker status, and gender were evaluated by performing ttests. The overall error rate was 10.3 +/- 3.3%. No difference in accuracy between men and women was found; however, significant differences were seen for overall and significant errors when comparing native and nonnative English speakers (P = .009 and P = .008, respectively). The speech recognition software is approximately 90% accurate, and while practical implementation issues (rather than accuracy) currently limit routine use of this product throughout a radiology practice, application in niche areas such as the emergency room currently is being pursued. This methodology provides a convenient way to compare the initial accuracy of different speech recognition products, and changes in accuracy over time, in a detailed and sensitive manner.     

Large-cell calcifying Sertoli cell tumor of the testis: a case report with ultrastructural study

Large-cell calcifying Sertoli cell tumor (LCCSCT) is a rare histologic variant of Sertoli cell tumor. Recently we observed a case of LCCSCT of the testis with no associated endocrine abnormality. Our ultrastructural findings of rows of tight junctions, numerous intracytoplasmic filaments, and abundant rough endoplasmic reticulum in whorled formations support the Sertoli cell origin of this neoplasm.     

Improving the fixation of an artificial intervertebral disc

The fixation of an artificial intervertebral disc has been studied especially with respect to the dimensions, the convexity of the endplates and the size of the fixation elements. From literature and cadaveric vertebrae, the dimensions and shape of the lumbar vertebral endplates were determined and the dimensions of fixation ribs for the artificial intervertebral disc were calculated. To withstand shear forces and prevent dislocation, two sagittal ribs, each 3.5 mm in height and at least 20 mm in length and four transversal ribs, each 1.5 mm in height and with a total length of 60 mm are sufficient. A range of five different sagittal diameters was selected as sufficient for all patients. At least 72.6 % of the endplate of the vertebrae is covered. A convexity with a radius of 140 mm limits the gap to 0.62 mm.