Triple fungal infection in a patient with liver cirrhosis

The prevalence of invasive mycoses is increasing, especially among patients who are immunocompromised or hospitalized with serious underlying diseases. Such infections are associated with a high morbidity and significant mortality, requiring early diagnosis and appropriate treatment but also an optimal prophylaxis in patients with high risk factors. We report a case of triple fungal infection including an invasive pulmonary aspergillosis by Aspergillus fumigatus, a candidemia by Candida albicans and a Pneumocystis pneumonia. The overall clinical picture of this patient was liver cirrhosis with medical history of immunosuppressive treatment for Crohn disease and a non-hodgkin lymphoma. There was no antifungal prophylaxis for this patient. Under treatment, the issue was unfavourable with multivisceral failure.     

Review article: infliximab for Crohn's disease treatment--shifting therapeutic strategies after 10 years of clinical experience

Aliment Pharmacol Ther 2011; 33: 857–869

Summary

Background Crohn’s disease is a progressive condition, with most patients developing a penetrating or stricturing complication over time. A decade ago, treatment goals consisted of immediate symptomatic control. The introduction of anti‐tumour necrosis factor (anti‐TNF) therapies, however, has changed the way patients with Crohn’s disease are treated. Over 10 years of clinical data and experience have demonstrated these therapies to be highly effective in Crohn’s disease. Aim To provide clinicians guidance on optimising treatment with anti‐TNF therapies in Crohn’s disease by introducing an evidence‐ and personal opinion‐based treatment algorithm using infliximab initial anti‐TNF therapy. Methods Scientific literature was reviewed using MEDLINE to evaluate data on clinical trials with infliximab in luminal and fistulising Crohn’s disease. Results The data from several landmark infliximab trials have changed clinical practice and led to a readjustment of treatment goals in Crohn’s disease, allowing patients to achieve more than just symptomatic relief including sustained steroid‐free remission. Infliximab induces complete mucosal healing and reduces the rates of hospitalisation and surgery. Based on disease‐related risk factors, a treatment algorithm for infliximab is delineated in favour of a rapid step‐up approach in patients at high risk for a disabling course of disease. Conclusion Adopting the suggested treatment algorithm for infliximab into clinical routine is aimed to optimise outcomes for patients with Crohn’s disease.     

Predictive Factors for Ipsilateral Recurrence After Nephron-sparing Surgery in Renal Cell Carcinoma

Background

Ipsilateral recurrence after nephron-sparing surgery (NSS) is rare, and little is known about its specific determinants.

Objective

To determine clinical or pathologic features associated with ipsilateral recurrence after NSS performed for renal cell carcinoma (RCC).

Design, setting, and participants

We analysed 809 NSS procedures performed at eight academic institutions for sporadic RCCs retrospectively.

Measurements

Age, gender, indication, tumour bilaterality, tumour size, tumour location, TNM stage, Fuhrman grade, histologic subtype, and presence of positive surgical margins (PSMs) were assessed as predictors for recurrence in univariate and multivariate analysis by using a Cox proportional hazards regression model.

Results and limitations

Among 809 NSS procedures with a median follow-up of 27 (1–252) mo, 26 ipsilateral recurrences (3.2%) occurred at a median time of 27 (14.5–38.2) mo. In univariate analysis, the following variables were significantly associated with recurrence: pT3a stage (p = 0.0489), imperative indication (p < 0.01), tumour bilaterality (p < 0.01), tumour size >4 cm (p < 0.01), Fuhrman grade III or IV (p = 0.0185), and PSM (p < 0.01). In multivariate analysis, tumour bilaterality, tumour size >4 cm, and presence of PSM remained independent predictive factors for RCC ipsilateral recurrence. Hazard ratios (HR) were 6.31, 4.57, and 11.5 for tumour bilaterality, tumour size >4 cm, and PSM status, respectively. The main limitations of this study included its retrospective nature and a short follow-up.

Conclusions

RCC ipsilateral recurrence risk after NSS is significantly associated with tumour size >4 cm, tumour bilaterality (synchronous or asynchronous), and PSM. Careful follow-up should be advised in patients presenting with such characteristics.     

Check-list "Patient Safety" in the operating room: one year experience of 40,000 surgical procedures at the university hospital of Nice

Objectives

The implementation of the check-list “Safe surgery saves live” (CL) has proven effective to reduce morbidity and perioperative mortality. Since 1st January 2010 it is a requirement of the HAS as part of the process of certification of hospitals. The CL has been established on all the operating rooms of our hospital after the onset of a near accident.

Methods

The CL has been computerized to facilitate its adoption by professionals. An internal benchmarking was immediately implemented to allow each surgical specialty to benchmark themselves with other teams. We conducted an audit concerning the CL and periodic assessments in order to learn more precisely concerning the expectations and feelings of medical and nursing teams.

Results

Nearly 40 000 CL were collected in the patient record. The completeness of information of some items seems to reflect the difficulty for professionals to realize the difference between traceability and information sharing within the team on the implementation of a protocol. This audit has confirmed the difficulty in sharing information orally.

Conclusions

The CL is involved in developing a safety culture in the operating room and led to the establishment of a risk mapping in the operating room and the recovery room and participation in the program error prevention procedure and surgical site through international program “High 5s” whose purpose is to improve the safety of care.     

No Evidence for an Involvement of the P38 and JNK Mitogen-Activated Protein in Inflammatory Bowel Diseases

Involvement of mitogen-activated protein (MAPK) in inflammatory bowel disease (IBD) remains enigmatic. We sought to evaluate the expression and activity of p38 and JNK MAPK in IBD and 2,4,6-trinitrobenzene sulfonic acid (TNBS)-induced colitis; and the effects of a p38 inhibitor, SB203580, in TNBS colitis. P 38 and JNK were quantified in colonic mucosa of 28 IBD patients and 19 controls and in 77 TNBS or control mice treated or not with SB203580. Colitis severity was assessed by survival, macroscopic and microscopic scoring, and molecular markers. Expression and activity of p38 and JNK were similar in IBD patients and controls and not modified by inflammation. In mice, p38 and JNK expression or activity did not increase following the induction of colitis. SB203580 decreased the p38 activity but displayed no clinical nor biological therapeutic effect. In conclusion, these results minimize the role of p38 and JNK in inflammatory colitis and the interest of p38 as a therapeutic target in IBD.     

Does hormone therapy modify the position of the gold markers in the prostate during irradiation? A daily evaluation with kV-images

PurposeGold markers are frequently used for a better daily repositioning of the prostate before irradiation. The purpose of this work was to analyze if the combination of an androgen deprivation with the external irradiation could modify the position of the gold markers in the prostate.Patients and methodsTen patients have been treated for a prostate cancer, using three implanted gold markers. The variations of the intermarker distances in the prostate were measured and collected on daily OBI^® kilovoltage images acquired at 0° and 90°. Five patients had a 6-month androgen deprivation started before the external irradiation (H group) and five did not (NH group).ResultsA total number of 1062 distances were calculated. No distance variation greater than 3.7 mm was seen between two markers, in any of the two groups. The median standard deviations of the daily intermarker distance differences were 0.7 mm (range 0.3–1.2 mm) for the H group and 0.6 mm (range 0.2–1.2 mm) for the NH group. The intermarker distances variations were noted as greater than –2 mm, between –2 mm and 2 mm and greater than 2 mm in 16.4, 83.4 and 0.2% for the H group and 1.3, 98.5 and 0.2% for the NH group, respectively.ConclusionThe distance variations remained less than 4 mm in both groups and for all the measurements. In the NH group, the variation of the distance between two markers remained below 2 mm in 98.5%. In the H group, the presence of a reduction of distance above 2 mm in 16.4% of measurements could indicate the shrinkage of the prostate volume.