Nosocomial Candidemia in Non-Neutropenic Patients at an Italian Tertiary Care Hospital

 In a retrospective study conducted in an Italian tertiary care hospital, the incidence of nosocomial candidemia was evaluated together with causative pathogens, treatment, and risk factors for death. Over a 6-year period (1992–1997), a total of 189 episodes of candidemia occurred in 189 patients (mean age 58±19 years), accounting for an average incidence of 1.14 episodes per 10,000 patient-days per year. The most common reasons for hospitalization were solid neoplasia (21%), trauma (17%), abdominal diseases requiring surgery (13%), and cardiovascular diseases (13%). No patient was neutropenic within 3 weeks prior to the onset of candidemia. One hundred thirty patients were hospitalized in intensive care units, 47 patients in surgical wards, and 12 patients in medical wards. Candida albicans was the most frequently isolated pathogen, accounting for 54% of fungal isolates, followed by Candida parapsilosis (23%), Candida glabrata (7%), Candida tropicalis (5%), Candida pelliculosa (4%), Candida lusitaniae (1%), Candida humicula (1%), and other non-albicans Candida spp. (5%). Seventy-six (41%) patients received adequate antifungal therapy. Seventy-one (58%) of the 123 evaluable patients with central venous catheters underwent line removal; 51 of them had catheter-related candidemia. The 30-day crude mortality rate was 45%. Older age, hospitalization in an intensive care unit, a longer duration of candidemia, retention of central lines, and inadequate antifungal therapy were significantly associated with poor outcome. In the present study, nosocomial candidemia was a frequent and relatively underestimated illness. Adequate antifungal therapy and central line removal independently reduced the high mortality of the disease.     

Masked hypertension in type 2 diabetes mellitus. Relationship with left-ventricular structure and function

BACKGROUND: To evaluate in type 2 diabetes mellitus the relationship between masked hypertension (MH) and left ventricular (LV) morpho-functional characteristics. METHODS: Using 24-hour BP monitoring and echocardiography, we evaluated 71 type 2 diabetic patients, without overt cardiac disease and never treated with antihypertensive drugs: 45 normotensive subjects with clinic BP <130/85 mmHg and 26 sustained hypertensives (SH)(clinic BP > or = 140 and/or 90 mmHg and 24-hour BP > or =125 and/or 80 mmHg), matched for age, gender, BMI and duration of diabetes with clinically normotensive patients. MH was diagnosed with clinic BP <130/85 mmHg and 24-hour BP > or =125 and/or 80 mmHg. RESULTS: Among clinically normotensive patients, 21 (47%) had MH and 24 were true normotensive (NT, 24-hour BP <125/80 mmHg). LV mass increased from NT to MH to SH (p < 0.001); the parameters of LV diastolic function were similar between MH and SH and significantly lower than in NT. CONCLUSION: In type 2 diabetic patients with clinic BP <130/85 mmHg, MH is frequent and is associated with LV remodelling characterized by increased myocardial mass and preclinical impairment of LV diastolic function; the remodelling is qualitatively and for some aspects also quantitatively similar to that found in sustained hypertensive patients. Therefore it would be useful to look for MH in diabetic subjects with clinic BP <130/85 mmHg, who, following the guidelines, are not entitled to antihypertensive treatment: the finding of MH could identify a subgroup of patients at higher cardiovascular risk and therefore needing a prompt antihypertensive treatment.     

Errors in medical literature: not a question of impact

The editorial and peer-review processes should guarantee readers as to the reliability of published data. The first step of these processes is to check for errors. The aim of our study was to look for the presence of objective errors in consecutive articles published on three of the most authoritative clinical journals. Two reviewers evaluated the presence of any error in 200 consecutive original articles containing at least two tables, allowing a reanalysis of the data, published between October 2010 and April 2011. Error was considered any action different from what was planned. Errors were listed as: methodological, numerical and slips. They were considered as severe if numbers in the abstract were completely different from numbers reported in the full text. Among the 125 articles included in the study, 102 (82 %, 95 % CI 74–88 %) contained some kind of error, even multiple. Nine articles (7 %, 95 % CI 3–13 %) contained one slip, 92 articles (74 %, 95 % CI 65–81 %) contained at least one numerical error, and 22 articles (18 %, 95 % CI 11–25 %) contained one methodological error. Five articles (4 %, 95 % CI 1–9 %) contained one serious error. None of the errors retrieved (0 %, 95 % CI 0–2 %) would have changed the results of the studies. Most of the articles published in the most important medical journals present mistakes. Our results could be a clue to editorial and peer review systems system weaknesses. A debate within the scientific medical community about these systems, and possible alternative adjustments are needed.     

Eligibility criteria in heart failure randomized controlled trials: a gap between evidence and clinical practice

The aim of the present study was to compare the characteristics of patients referred to our heart failure outpatient clinic with those of patients enrolled in clinical trials on heart failure pharmacological treatment. Thus, we estimated the proportion of patients admitted to our heart failure outpatient clinic who would have been included in randomized controlled trials evaluating the effects of medical treatments on heart failure mortality, published over a 10 years period (1993–2003). Sixteen studies (n = 45276) and 299 consecutive outpatients, were included. On average, only 34% of the outpatients would have been included in at least one of the 16 trials (8–71%). The main reasons for exclusion were: NYHA class (70% were in NYHA class II), ejection fraction (29% had EF > 35%), co-morbidity (51% had co-morbidity, mainly renal failure, COPD, and disthyroidism), age (22% were older than 80 years), and occurrence of a recent acute event (50% experienced an ischemic coronary syndrome, revascularization, pulmonary edema, or stroke in the prior 6 months). These results underline the crucial role of patient selection in clinical trials, raising uncertainties about the complete applicability of trial results to clinical practice.