[Antifungal treatment for suspected or proved candidiasis in the critically ill]

OBJECTIVE

Describe systemic antifungal therapy in non-neutropenic adult patients in intensive care unit (ICU).

PATIENTS AND METHOD

A prospective, observational study was conducted during the first half of 2010 in the 7 ICU in a hospital with medical consultant on antimicrobial therapy. All non-neutropenic consecutive adult patients receiving systemic antifungal therapy for documented or suspected invasive fungal infection (IFI) apart from aspergillosis were included.

RESULTS

Out of 1502 patients admitted in ICU, 104 (7 %) underwent systemic antifungal therapy, including 30 (29 %) for a documented IFI and 74 (71 %) for a suspected IFI. Candida albicans was identified in 23 (77 %) of the IFI and 45/52 (86 %) of the broncho-pulmonary and/or urinary colonizations in suspected IFI. Echinocandin was significantly more prescribed in patients with a documented infection (19/30 patients) and fluconazole in patients with a suspected infection (48/74 patients). The first line therapy was primarily stopped after recovery (11/30 patients) or de-escalation (9/30 patients) in documented infections, and for lack of indication (34/74 patients) or due to recovery (21/74 patients) in suspected infections after on average of 7 days of treatment.

CONCLUSION

For ICU non-neutropenic adult patients in our center, antifungal therapy is prescribed two times out of three for suspected, unproved infections, in most cases with fluconazole. Documented infections were more often treated by echinocandin with secondary de-escalation. An interventional prospective study to assess the role of antifungal pre-emptive or empirical therapy is necessary.

[Esophageal cancer surgery: evolution of pain management, hemodynamics and ventilation practices during 16 years]

OBJECTIVE

To describe the evolution of perioperative anesthesia practices in for esophageal cancer surgery.

PATIENTS AND METHODS

We conducted an observational retrospective study in a single center evaluating main perioperative practices during 16 years (1994-2009). Statistical analysis was done on 4 chronologic quartiles of same sample size.

RESULTS

Two hundred and seven consecutive patients were included during the 4 periods 1994-1997 (n=52), 1997-1999 (n=52), 1999-2003 (n=52) and 2004-2009 (n=51). The main significant evolutions between the first and the fourth period were observed: (i) in ventilation: lower tidal volume (9.6[8.6-10.6] vs 7.6[7.0-8.3] mL/kg of ideal body weight (IBW), p<0.01), increased use of Positive End Expiratory Pressure (0 vs 83%, p<0.001) and increased use of post-operative non-invasive ventilation (0 vs 51%, p<0.001); (ii) in hemodynamic management: lower fluid replacement (20.6 [16.0-24.6] vs 12.6 [9.7-16.2] mL/h/kg of IBW, p<0.001); (iii) in analgesia: increased use of epidural thoracic anesthesia (31 vs 57%, p<0.001). Peroperative bleeding, type of fluid replacement, length of mechanical ventilation, length of stay in intensive care unit, ventilatory free days and mortality at day 28 didn't change.

CONCLUSIONS

During these previous years, anesthesia practices in ventilation, hemodynamics and analgesia for esophageal cancer surgery have changed.

Comparison of three high flow oxygen therapy delivery devices: a clinical physiological cross-over study

AIM

High-flow-oxygen-therapy is provided by various techniques and patient interfaces, resulting in various inspired-fraction of oxygen (FiO2) and airway-pressure levels. However, tracheal measurements have never been performed.

METHODS

Three oxygen-delivery-devices were evaluated: 1) standard-high-flow-oxygen-facemask with reservoir-bag, 2) Optiflow(TM)-high-flow-nasal-cannulae and 3) Boussignac(TM)-oxygen-therapy-system. Main judgment criteria were airway-pressure and FiO2 measured in the trachea. The three devices were randomly evaluated in cross-over in 10 Intensive-Care-Unit patients using three oxygen flow-rates (15, 30 and 45 L/min) and two airway-tightness conditions (open and closed mouth). Airway-pressures and FiO2 were measured by a tracheal-catheter inserted through the hole of a tracheotomy tube. Comfort was evaluated by self-reporting. Data are presented as median [25-75th].

RESULTS

1) Regarding oxygen-delivery devices, BoussignacTM provided the highest mean tracheal pressure (13.9 [10.4-14.5] cmH20) compared to Optiflow(TM) (2 [1-2.3] cmH2O, P<0.001). BoussignacTM provided both positive inspiratory and expiratory airway-pressures, whereas Optiflow(TM) provided only positive expiratory airway-pressure. Reservoir-bag-facemask provided airway pressure close to zero. For FiO2, highest value was obtained for both Optiflow(TM) and facemask (90%) compared to Boussignac(TM) (80%), P<0.01. 2) Regarding oxygen-flow, airway-pressure and FiO2 systematically increased with oxygen-flow with the three devices except airway-pressure for the facemask. 3) Regarding the open-mouth position, mean airway-pressure decreased with Optiflow(TM) only (2 [1.2-3.3] vs. 0.6 [0.3-1] cmH2O, P<0.001). Opening the mouth had little impact on FiO2. 4) finally, discomfort-intensities were low for both Optiflow(TM) and reservoir-bag-facemask compared to Boussignac(TM), P<0.01.

CONCLUSION

On one hand, Boussignac(TM) is the only device that generates a relevant positive-airway-pressure during both inspiration-and-expiration, independently of mouth-position. Optiflow(TM) provides a low positive-airway-pressure (<4 cmH2O), highly dependent of mouth-closing. The reservoir-bag-facemask provides no positive-airway-pressure. On the other hand, FiO2 are slightly but significantly higher for Optiflow(TM) and reservoir-bag-facemask than for Boussignac(TM). Discomfort was lesser for Optiflow(TM) and reservoir-bag-facemask.

[Risk of barotrauma when using non-reinhalation Waters valves: a comparative study on bench test]

OBJECTIVE

Manual ventilation is delivered in the operating room or the intensive care unit to intubated or non-intubated patients, using non-rebreathing systems such as the Waters valve. New generation Waters valves are progressively replacing the historic Waters valve. The aim of this study was to evaluate maximal pressure delivered by these 2 valves.

TYPE OF STUDY

Bench test.

MATERIAL AND METHOD

Thirty-two different conditions were tested, according to 2 oxygen flow rates (10 and 20L/min), without (static condition) or with manual insufflations (dynamic condition) and 4 valve expiratory opening pressures. The primary endpoint was maximal pressure measured at the exit of the valve, connected to a model lung and a bench test.

RESULTS

Measured pressures were different for most evaluated conditions. Increasing oxygen flow from 10 to 20L/min increased maximal pressure for both valves. Increasing valve expiratory opening pressure induced a significant increase in maximal pressure for the new generation valve (from 4 to 61cmH2O in static conditions and from 18 to 68cmH2O in dynamic conditions). For the historic valve, maximal pressure increased significantly but remained below 15cmH2O in both static and dynamic conditions.

CONCLUSION

Use of new generation Waters valves should be different from historic Waters valves. Indeed, barotrauma could be caused by badly adapted valve expiratory opening pressure settings.

Virus-mimicking optical nanomaterials: near infrared absorption and fluorescence characteristics and physical stability in biological environments

The use of viruses as platforms for the development of optical imaging materials has received increasing attention in recent years. We have engineered a hybrid nanomaterial composed of the capsid proteins of genome-depleted plant-infecting Brome mosaic virus that encapsulates the near-infrared (NIR) dye indocyanine green. Herein, we investigate the NIR absorption and fluorescence characteristics of these nanomaterials in biological environments consisting of cell culture media with and without serum proteins. Our results demonstrate that the NIR absorption and fluorescence emission of the constructs are enhanced in the presence of serum proteins. The constructs remain physically stable and maintain their NIR absorption and fluorescence properties for at least 79 days. The presence of serum proteins also reduces the aggregation of the constructs. These findings have relevance for the further development of optical imaging and phototherapeutic methods on the basis of such virus-mimicking nanomaterials as well as the expected optical and physical characteristics of these nanomaterials in vivo.

Population-based data from the Swedish Colon Cancer Registry

BACKGROUND

Evaluating the external validity of clinical trials requires knowledge not only of the study population but also of a relevant reference population. The main aim of this study was to present data from a large, contemporary, population-based cohort of patients with colonic cancer.

METHODS

Data on patients diagnosed between 2007 and 2011 were extracted from the Swedish Colon Cancer Registry. The data, registered prospectively in a national population of almost 10 million, included over 99 per cent of all diagnosed adenocarcinomas of the colon.

RESULTS

This analysis included 18,889 patients with 19,526 tumours (3·0 per cent had synchronous tumours). The sex distribution was fairly equal, and the median age was 74·1 (interquartile range 65-81) years. The overall and relative (cancer-specific) survival rates after 3 years were 62·7 and 71·4 per cent respectively. Some 88·0 per cent of the patients were operated on, and 83·8 per cent had tumours resected. Median blood loss during bowel resection was 200 (mean 311) ml, and the median operating time was 160 min; 5·6 per cent of the procedures were laparoscopic. Preoperative chemotherapy was administered to 2·1 per cent of patients; postoperative chemotherapy was planned in 90·1 per cent of fit patients aged less than 75 years with stage III disease. In patients operated on in an emergency setting (21·5 per cent), the preoperative evaluation was less extensive, the proportion of R0 resections was lower, and the outcomes were poorer, in both the short and long term.

CONCLUSION

These population-based data represent good-quality reference points.

Effect of dietary nucleotide supplementation on performance and development of the gastrointestinal tract of broilers

1. Two experiments were conducted to determine the effects of dietary nucleotide supplementation on broiler performance, and physical and morphological development of the gastrointestinal tract. 2. Experiment 1: A total of 180 one-d-old male chicks were placed in battery brooders in 3 × 6 replicate pens containing 10 chicks each. Chicks were randomly assigned to one of the three dietary treatments; a maize-soyabean meal based diet supplemented with 0, 0·25, and 0·50% Torula yeast RNA (as a source of nucleotides) from 0 to 16 d of age. 3. Experiment 2: A total of 1344 one-d-old male chicks were placed in floor pens and reared on recycled wood shavings (two flocks) under a high stocking density (0·068 m(2)/bird). Chicks were randomly assigned to one of the 4 dietary treatments (0, 0·25% Torula yeast RNA, 2% and 6% Nupro®) for the starter period (0 to 14 d of age) with 6 replicate pens containing 56 chicks each. All the birds were fed on the same common grower diet with no supplementation of nucleotides from 15 to 32 d of age. 4. Experiment 1: Supplementing the diets with up to 0·50% Torula yeast RNA did not affect broiler performance, or relative intestinal tract weight and length of broilers at any periods measured. 5. Experiment 2: From 0 to 14 d of age, broilers fed on the diets supplemented with 0·25% Torula yeast RNA and 2 and 6% Nupro® were significantly heavier and had improved feed conversion (feed:gain) ratios as compared with the birds fed on the control diet. Supplementing the starter diet only with 2% Nupro® supplementation significantly improved body weight (BW) gain as compared with the control diet over the entire experiment (0 to 32 d of age). Broilers fed on the diets supplemented with 2 and 6% Nupro® from 0 to 14 d of age had better feed conversion (feed:gain) ratios over the entire experiment (0 to 32 d of age) as compared with the birds fed on the control diet, even though the birds were only fed on the diets supplemented with Nupro® from 0 to 14 d of age. The broilers fed on the diets supplemented with 0·25% Torula yeast RNA and 2% Nupro® had higher villus height and an improved villus height-to-crypt depth ratio as compared with birds fed on the control or 6% Nupro® diet at 14 d of age. 6. It is generally assumed that nucleotides are not an essential nutrient; thus there is no need to supplement the diets of broilers reared under normal conditions. However, dietary nucleotide supplementation may be important to maintain maximum growth performance when birds are exposed to stress conditions, such as high stocking density combined with dirty litter.

HLA-B*40:179, a novel allele identified by sequence-based typing in cord blood from a Korean woman

The novel allele B*40:179 showed one nucleotide difference with B*40:01:01 in exon 4.

Simple and robust in vivo and in vitro approach for studying virus assembly

In viruses with positive-sense RNA genomes pathogenic to humans, animals and plants, progeny encapsidation into mature and stable virions is a cardinal phase during establishment of infection in a given host. Consequently, study of encapsidation deciphers the information regarding the know-how of the mechanism regulating virus assembly to form infectious virions. Such information is vital in formulating novel methods of curbing virus spread and disease control. Virus encapsidation can be studied in vivo and in vitro. Genome encapsidation in vivo is a highly regulated selective process involving macromolecular interactions and subcellular compartmentalization. Therefore, study leading to dissect events encompassing virus encapsidation in vivo would provide basic knowledge to understand how viruses proliferate and assemble. Recently in vitro encapsidation has been exploited for the research in the area of biomedical imaging and therapeutic applications. Non-enveloped plant viruses stand far ahead in the venture of in vitro encapsidation of the negatively charged foreign material. Brome mosaic virus (BMV), a non-enveloped multicomponent RNA virus pathogenic to plants, has been used as a model system for studying genome packaging in vivo and in vitro. For encapsidation assays in Nicotiana benthamiana plants, Agrobacterium -mediated transient expression, refer to as agroinfiltration, is an efficient and robust technique for the synchronized delivery and expression of multiple components to the same cell. In this approach, a suspension of Agrobacterium tumefaciens cells carrying binary plasmid vectors carrying cDNAs of desiredviral mRNAs is infiltrated into the intercellular space withina leaf using nothing more sophisticated than a 1 ml disposable syringe (without needle). This process results in the transfer of DNA insert into plant cells; the T-DNA insert remains transiently in the nucleus and is then transcribed by the host polymerase II, leading to the transient expression. The resulting mRNA transcript (capped and polyadenylated) is then exported to the cytoplasm for translation. After approximately 24 to 48 hours of incubation,sections of infiltrated leaves can be sampled for microscopyor biochemical analyses. Agroinfiltration permits large numbers (hundreds to thousands) of cells to be transfected simultaneously. For in vitro encapsidation, purified virions of BMV are dissociated into capsid protein by dialyzing against dissociation buffer containing calcium chloride followed by removal of RNA and un-dissociated virions by centrifugation. Genome depleted capsid protein subunits are then reassembled with desired viral genome components or non-viral components such as indocyanine dye.