Compliance with anti-reflux therapy in patients with otolaryngologic manifestations of gastroesophageal reflux disease

OBJECTIVES

The otolaryngologic manifestations of gastroesophageal reflux include sore throat, throat clearing, sensation of postnasal drip, hoarseness, and globus. This constellation of laryngeal and pharyngeal symptoms can be referred to as laryngopharyngeal reflux (LPR). Many patients with LPR are treated empirically and the results are often rewarding. The objective of this study is to evaluate compliance with antireflux therapy in this patient population.

STUDY DESIGN

A prospective analysis of 30 patients referred to an otolaryngology clinic for the above symptoms.

METHODS

The patients were treated for LPR using a standardized behavior modification form in combination with medical management. Patient compliance was followed with a patient questionnaire and evaluation of medication renewal from pharmacy records.

RESULTS

The patients were followed for an average of 4 months and 80% reported an improvement of their symptoms. Evaluation of patient questionnaires revealed that 50% of patients reported taking their medications as prescribed. Compliance varied widely with regard to behavioral modifications. The degree of symptomatic improvement was significantly correlated with overall compliance with both medications and behavioral changes (Pearson correlation coefficient, P < .05). The individual behavioral changes that were significantly correlated with the reduction of symptoms were avoidance of food and liquid before sleep and elevation of the head of bed, but not food habits.

CONCLUSIONS

The treatment plan for gastroesophageal reflux disease requires behavioral modifications and prescription medications that many patients may find difficult to follow. However, those patients who comply with the treatment plan can be expected to have an improvement of their symptoms. Furthermore, simplifying the treatment regimen including those elements most correlated with symptomatic improvement may increase patient compliance.

Recovery of Candida dubliniensis from non-human immunodeficiency virus-infected patients in Israel

Candida dubliniensis is a recently discovered yeast species principally associated with carriage and disease in the oral cavities of human immunodeficiency virus (HIV)-infected individuals. To date the majority of isolates of this species have been identified in Europe and North America. In this study, five Candida isolates recovered from separate HIV-negative hospitalized patients in Jerusalem, Israel, were presumptively identified as C. dubliniensis on the basis of their dark green coloration when grown on CHROMagar Candida medium. Their identification was confirmed by a variety of techniques, including carbohydrate assimilation profiles, absence of growth at 45 degrees C, positive reaction with C. dubliniensis-specific antibodies as determined by indirect immunofluorescence analysis, and positive amplification with C. dubliniensis-specific PCR primers. All five strains were shown to be susceptible to a range of antifungal agents, including fluconazole. One of the five isolates was recovered from urine specimens, while the remaining four were recovered from upper respiratory tract and oral samples. While none of the patients was HIV positive, all were receiving broad-spectrum antibacterials at the time isolates of C. dubliniensis were obtained from clinical specimens. This study describes the first isolates of C. dubliniensis from the Middle East and confirms that this yeast can be associated with carriage and infection in the absence of HIV infection.

Hepatic arterial infusion of chemotherapy after resection of hepatic metastases from colorectal cancer

BACKGROUND

Two years after undergoing resection of liver metastases from colorectal cancer, about 65 percent of patients are alive and 25 percent are free of detectable disease. We tried to improve these outcomes by treating patients with hepatic arterial infusion of floxuridine plus systemic fluorouracil after liver resection.

METHODS

We randomly assigned 156 patients at the time of resection of hepatic metastases from colorectal cancer to receive six cycles of hepatic arterial infusion with floxuridine and dexamethasone plus intravenous fluorouracil, with or without leucovorin, or six weeks of similar systemic therapy alone. Patients were stratified according to previous treatment and the number of liver metastases identified at operation. The study end points were overall survival, survival without recurrence of hepatic metastases, and survival without any metastases at two years.

RESULTS

The actuarial rate of overall survival at two years was 86 percent in the group treated with local plus systemic chemotherapy and 72 percent in the group given systemic therapy alone (P=0.03). The median survival was 72.2 months in the combined-therapy group and 59.3 months in the monotherapy group, with a median follow-up of 62.7 months. After two years, the rates of survival free of hepatic recurrence were 90 percent in the monotherapy group and 60 percent in the monotherapy group (P<0.001), and the respective rates of progression-free survival were 57 percent and 42 percent (P=0.07). At two years, the risk ratio for death was 2.34 among patients treated with systemic therapy alone, as compared with patients who received combined therapy (95 percent confidence interval, 1.10 to 4.98; P=0.027), after adjustment for important variables. The rates of adverse effects of at least moderate severity were similar in the two groups, except for a higher frequency of diarrhea and hepatic effects in the combined-therapy group.

CONCLUSIONS

For patients who undergo resection of liver metastases from colorectal cancer, postoperative treatment with a combination of hepatic arterial infusion of floxuridine and intravenous fluorouracil improves the outcome at two years.

Effects of postmenopausal hormone replacement therapy on central abdominal fat, glycemic control, lipid metabolism, and vascular factors in type 2 diabetes: a prospective study

OBJECTIVE

To examine the effects of hormone replacement therapy (HRT) on lipid metabolism, glycemic control, total body and central abdominal fat, blood pressure (BP), and arterial pulse wave velocity (APWV) in overweight postmenopausal females with type 2 diabetes.

RESEARCH DESIGN AND METHODS

This was a 12-month prospective study of 14 subjects (mean +/- SD age 57.5+/-5.6 years, BMI 29.5+/-4.8 kg/m2) randomized to 6 months of observation or HRT before crossover. HRT consisted of 2 months of conjugated equine estrogen (CEE) 0.625 mg daily, followed by 4 months CEE and medroxyprogesterone 5 mg daily. Measures included anthropometry, fasting glucose, insulin, HbA1c, total and HDL cholesterol, triglycerides, apolipoprotein B, LDL particle size, nonesterified fatty acids (NEFA), sex hormone-binding globulin, resting energy expenditure (REE), total and central abdominal fat (by dual-energy X-ray absorptiometry), resting BP, APWV (by applanation tonometry), physical activity, well-being, and sexual function.

RESULTS

Six months of HRT resulted in significant reductions in waist-to-hip ratio (-0.03+/-0.01 vs. 0.01+/-0.009, P = 0.007), HbA1c (-0.34+/-0.24 vs. 0.6+/-0.4%, P = 0.04), total cholesterol (-0.6+/-0.1 vs. 0.2+/-0.2 mmol/l, P = 0.001), central abdominal fat (-175+/-51 vs. -24+/-56 g, P = 0.05), and improved physical functioning (P = 0.05), compared with observation. There was a minor increase in REE with HRT (33+/-23 vs. -38+/-23 kJ/day, P = 0.04). Total fat mass, fasting glucose, insulin, triglyceride, apolipoprotein B, NEFA, resting BP, APWV, and physical activity were unchanged.

CONCLUSIONS

Postmenopausal HRT in these overweight women with type 2 diabetes was associated with a reduction in central adiposity and improvement in lipid metabolism and glycemic control without deterioration in weight status or cardiovascular parameters measured. Whether HRT-induced improvements in these cardiovascular risk factors result in lower long-term cardiovascular morbidity and mortality, as observed in nondiabetic women, awaits further study.

Molecular diagnosis and epidemiology of fungal infections

A variety of methods are utilized for DNA strain subtyping of Candida spp. because no 'gold standard' exists. Random amplified polymorphic DNA (RAPD) or restriction enzyme analysis (REA) are useful to determine the source of an outbreak, but more reproducible and discriminatory methods such as Southern hybridization and pulsed field gel electrophoresis (PFGE) may be required. When applied to some nosocomial Candida infections, multiple strains and species have been identified. Microevolution of yeast species occurs and epidemiologically related isolates may show minor pattern differences, creating uncertainty as to whether they are distinct strains. Approximately 1000 isolates of Aspergillus fumigatus from environmental and clinical sources were typed by REA probed with an A. fumigatus-specific retrotransposon-like sequence. Patients with no symptom of aspergillosis may carry several strains, whereas patients with pulmonary aspergillosis may carry one or two strains; nocosomial transmission of aspergillosis was proven in 39% of the patients studied; any given environmental strain can be infectious; the environmental population of A. fumigatus is extremely diverse and no specific niche was found in the hospital. A PCR assay was designed to target conserved 18S-ribosomal DNA (rDNA) sequences shared by most fungi and a 687 bp product was amplified from 25 medically important fungal species. Studies with blood, cerebrospinal fluid and sputum specimens from patients with mycoses indicated that the PCR assay is more sensitive in diagnosing invasive fungal infections than blood culture methods. More specific identification is obtainable with genus/species-specif c probes designed from within the PCR-amplified sequences for C. albicans, C. krusei, C. lusitaniae, Pneumocystis carinii, Cryptococcus neoformans, Aspergillus/Penicillium spp. and C. glabrata/Saccharomyces cerevisiae. A. fumigatus and A. niger were differentiated by denaturing gradient gel electrophoresis. In situ hybridization (ISH) detected a 648 bp fragment of the 18S rDNA of C. neoformans and a 568 bp fragment of the alkaline proteinase gene of A. fumigatus in tissues from experimentally infected animals. In ISH, the entire process can be automated, making this procedure rapid and easy. The difficulty in establishing a diagnosis of invasive candidiasis has prompted the quest for a clinically useful PCR test for candidaemia. The universal fungal oligonucleotide primer pair, ITS3 and ITS4, amplifies portions of the 5.8S ad 28S rDNA subunits, and the ITS2 region. Although rRNA genes are highly conserved, the ITS regions are distinctive. DNA probes were designed from ITS2 that were specific for 16 different Candida species. Simple, rapid sample preparation was suitable for PCR analysis of BacT/Alert blood culture bottles. Sample preparation, PCR, and EIA detection of the amplicon from five different Candida species was accomplished in 7 h, 2.5 days sooner than by conventional culture methods. As well as saving time, minor yeast species among a major species, or among bacteria, were simultaneously detected. PCR-EIA using a microtitration plate format had sensitivity 10-times greater than that obtained with ethidium bromide-stained agarose gels. Taqman combines in one step PCR, probe hybridization, and fluorescent signal generation. Taqman PCR had sensitivity equivalent to PCR-EIA and required only 5 h, including sample preparation.

Natural and anthropogenic inputs of hydrocarbons to the Strait of Georgia

Sediment cores from the Fraser estuary, Vancouver Harbour and Strait of Georgia, suspended sediment samples from the Fraser River and sediment grabs from Vancouver Harbour have been analyzed for alkanes and parent and alkyl PAHs (polycyclic aromatic hydrocarbons). Principal components analysis (PCA) clearly distinguishes mixed sources by separating parent PAHs according to molecular size, and separating alkyl substituted PAHs from higher plant PAHs. We find the Fraser River to be the predominant source for natural and anthropogenic hydrocarbons to the Strait of Georgia. The natural hydrocarbon burden from the Fraser River is augmented principally by petroleum hydrocarbons and combustion PAHs from Vancouver. Contaminated sediments from Vancouver Harbour very likely have also been transported to a major ocean disposal site off the Fraser estuary. Petroleum alkanes, which dominate Fraser River suspended sediment samples, are lost by processes such as dissolution or microbial degradation during transport and sedimentation, while PAHs from the river are delivered essentially unchanged to sediments in the strait. Hydrocarbon composition undergoes little change with depth at a reference location in the Strait of Georgia, indicating that PAH inputs have changed very little since the early part of this century. In Vancouver Harbour the low rate of sediment accumulation coupled with surface mixing has led to the retention of contaminant PAHs within the surface mixed layer, while the rapid delivery of sediments from the Fraser River has buried contaminant PAHs from historical ocean disposal in the Strait of Georgia.

Combined ultrasound and near infrared diffused light imaging in a test object

We have investigated the use of combining near infrared (NIR) diffuse light and ultrasound imaging methods to increase the detection sensitivity and to reduce the false alarm rate in small target detection. A line-of-sight optical projection through a test object is identified from an amplitude null and a sharp phase transition produced by diffusive waves originating from two in-phase (initial phase 0 degrees ) and out-of-phase (initial phase 180 degrees ) light emitting diode sources. This line-of-sight is scanned across a scattering phantom. A complete ultrasound B-scan image is recorded at each projected line in the optical scan. Each acoustic image plane is bisected by the optical beam path and lies in the optical scan plane. The scattering phantom simulates acoustic and optical properties of homogeneous tissue. A single small cylinder-like object simulating some acoustic and optical breast tumor properties is inserted at various places in the scattering phantom. With this single object, the optical scanning identifies the line-of-sight passing through the simulated tumor quite well. Most of these simulated tumors were at or below the threshold for acoustic detection and were not seen consistently with unguided ultrasound. For tests in which a target was apparently detected optically, the selected line-of-sight was indicated in each of three adjacent ultrasound images. Two radiologist observers were statistically more accurate (83%) in identifying the target location on the optically-selected ultrasound images than in the unmarked images (52%). That is, in these single-targets of homogeneous scattering background, the optical technique usually provided the correct line-of-sight, and ultrasound generally showed the location along that line.

Perinatal brain iron deficiency increases the vulnerability of rat hippocampus to hypoxic ischemic insult

Fetal brain iron deficiency occurs in human pregnancies complicated by diabetes mellitus or intrauterine growth retardation. Because neurocognitive deficits are more common in the offspring of these pregnancies, we tested the hypothesis that perinatal brain iron deficiency predisposes the neonatal hippocampus, a structure important for memory processing, to injury. Brain iron concentration was reduced by 45% in 45 neonatal rats by maternal dietary iron restriction during gestation. Right-sided neuronal injury in four hippocampal subareas was induced by hypoxic-ischemic insult (ipsilateral carotid artery ligation and subsequent hypoxia on postnatal d 7) and was quantified histochemically on d 8 by cytochrome c oxidase activity (n = 30), and on d 14 by Nissl staining (n = 15). Acute right-sided cytochrome c oxidase activity loss occurred in CA1 (P = 0.02), CA3c (P < 0.001) and dentate gyrus (P < 0.001) in the iron-deficient group, whereas only CA1 (P = 0. 003) was affected in the iron-sufficient group. Long-term right-sided Nissl substance loss occurred in CA1 (P = 0.001), CA3a,b (P < 0.001) and dentate gyrus (P = 0.008) in the iron-deficient group, but only in CA1 (P = 0.004) in the iron-sufficient group. No increase in right-sided free-iron staining was present in either group. Perinatal iron deficiency predisposes the neonatal hippocampus to a greater acute loss of neuronal metabolic activity after an hypoxic-ischemic event, suggesting compromised cellular energetics. The subsequently greater loss of hippocampal neuronal integrity suggests poorer recoverability after injury in the perinatal iron-deficient brain.

Borderline personality disorder and bone marrow transplantation: ethical considerations and review

Bone marrow transplantation (BMT) is rapidly becoming a part of conventional cancer treatment. However, it remains a 'last-ditch' treatment option for patients who have exhausted other treatment modalities. Patients experience a significant amount of emotional distress during all stages of the BMT process. Patients with personality disorders experience even more emotional distress than average and their behavior is often detrimental to effective patient-staff interactions. A case of a borderline patient is presented with a discussion of the ethical issues involved in the evaluation of these patients and the determination of their appropriateness for transplant.

High-Dose Chemotherapy in the Adjuvant Treatment of Breast Cancer: Benefit/Risk Analysis

BACKGROUND: High-dose chemotherapy (HDRx) may improve the prognosis of patients with high-risk breast cancer but at the expense of increased toxicity. However, no randomized, controlled trials have been published that clearly demonstrate the superiority of HDRx over conventional adjuvant chemotherapy. METHODS: We developed a simple model to compare benefits and risks of HDRx with conventional adjuvant chemotherapy (SDRx). The model integrates data on efficacy and risks of two competing treatment strategies into a single decision rule. RESULTS AND CONCLUSIONS: Using data from phase II studies, we show that if a disease-free survival is considered to be the most important outcome, HDRx should be administered when the probability of breast cancer relapse at five years exceeds 54% to 71% for patients with 4 to 9 positive nodes and exceeds 29% to 40% for patients with >9 positive nodes. If the endpoint of interest is five-year overall survival, then the treatment should be administered when the probability of relapse exceeds 77% to 83% for patients with 4 to 9 nodes involved and 22% to 31% for those with >9 lymph nodes involved. While awaiting results of randomized, controlled trials to definitively establish the efficacy rate of HDRx, we also found that HDRx could be considered in the management of high-risk breast cancer if its efficacy rate is at least 54% to 60% superior to SDRx in reducing relapse risk in breast cancer patients with 4 to 9 nodes and at least 31% to 38% for >9 positive nodes. If survival data are used instead of disease-free survival outcomes, HDRx efficacy should be at least 47% to 48% superior to SDRx in reducing death risk in breast cancer patients with 4 to 9 nodes and at least 27% to 30% superior for >9 positive nodes to consider its use in the adjuvant setting.

Simple, inexpensive, reliable method for differentiation of Candida dubliniensis from Candida albicans

Candida dubliniensis is a recently described pathogenic species which shares many phenotypic features with Candida albicans, including the ability to form germ tubes and chlamydospores. These similarities have caused significant problems in the identification of C. dubliniensis by the average clinical mycology laboratory. To facilitate the differentiation of these species, we investigated the growth of 120 isolates of C. dubliniensis and 98 C. albicans isolates at 42 and 45 degrees C on Emmons' modified Sabouraud glucose agar (SGA) and 10 isolates of each species in yeast-peptone-dextrose broth. None of the C. dubliniensis isolates grew on the agar or in the broth medium at 45 degrees C, while 11 isolates were capable of growing on SGA at 42 degrees C. In contrast, all of the C. albicans isolates but one grew at 45 degrees C on or in either medium. These reproducible results clearly demonstrate that the incubation of isolates suspected to be C. dubliniensis or C. albicans at 45 degrees C provides a simple, reliable, and inexpensive method for the differentiation of the two species.

Evidence for negative charge in the conduction pathway of the cardiac ryanodine receptor channel provided by the interaction of K+ channel N-type inactivation peptides

We have investigated the interaction of two peptides (ShB - net charge +3 and ShB:E12KD13K - net charge +7) derived from the NH2-terminal domain of the Shaker K+ channel with purified, ryanodine-modified, cardiac Ca2+-release channels (RyR). Both peptides produced well resolved blocking events from the cytosolic face of the channel. At a holding potential of +60 mV the relationship between the probability of block and peptide concentration was described by a single-site binding scheme with 50% saturation occurring at 5.92 +/- 1.06 microM for ShB and 0.59 +/- 0. 14 nM for ShB:E12KD13K. The association rates of both peptides varied with concentration (4.0 +/- 0.4 sec-1 microM-1 for ShB and 2000 +/- 200 sec-1 microM-1 for ShB:E12KD13K); dissociation rates were independent of concentration. The interaction of both peptides was influenced by applied potential with the bulk of the voltage-dependence residing in Koff. The effectiveness of the inactivation peptides as blockers of RyR is enhanced by an increase in net positive charge. As is the case with inactivation and block of K+ channels, this is mediated by a large increase in Kon. These observations are consistent with the proposal that the conduction pathway of RyR contains negatively charged sites which will contribute to the ion handling properties of this channel.

Plasma selenium concentrations in a Sikh population in Sydney, Australia

Selenium is essential for humans because it protects the heart against cardiomyopathy. It may also reduce ischaemic heart disease owing to its antioxidant activity. It is known that Indian migrants in a number of countries have high incidences of ischaemic heart disease. In this study, fasting plasma selenium concentrations of Sikh migrants in Sydney (Australia) were measured to investigate whether selenium concentration is reduced in this community. The mean concentration of selenium in plasma (91.8 +/- 15.0 ng ml-1, n = 196) was within the normal range. A significantly higher plasma selenium concentration was demonstrated in males than in females (p < 0.01). This was mainly due to the difference in mean selenium concentrations between genders in vegetarians because no significant difference was observed in non-vegetarian males versus females. The mean concentration of selenium in teetotal males was similar to those who consumed alcohol. Despite significant variations with gender and diet, the selenium concentrations were within the normal range. The results suggest that selenium status is adequate in the Sikh community even though vegetarian diet is common and alcohol use is condones in males.

Novel 5-(3-aryl-2-propynyl)-5-(arylsulfonyl)thiazolidine-2,4-diones as antihyperglycemic agents

Novel 5-(3-aryl-2-propynyl)-5-(arylsulfonyl)thiazolidine-2,4-diones and 5-(3-aryl-2-propynyl)-5-(arylsulfanyl)thiazolidine-2,4-diones were prepared and evaluated as oral antihyperglycemic agents in the obese, insulin resistant db/db mouse model at 100 mg/kg and, if the analogue had sufficient potency, 20 mg/kg. The sulfonylthiazolidinediones, 2, were more potent than the corresponding sulfanylthiazolidinedione congeners, 1. With regard to substituent effects on the 3-propynyl phenyl ring (Ar') of 2, 4-halogen substitution generally resulted in the more potent analogues. Substituent effects on the phenylsulfonyl moiety (Ar) of 2 were less clear, although para-halogen substitution on Ar generally was preferable. 2-Pyridinesulfonyl derivatives (Ar = 2-pyridine in 2) also had good potency. Several compounds from series 2 were effective at lowering glucose and insulin in the obese, insulin resistant ob/ob mouse at the 50 mg/kg oral dose. Compound 20 significantly improved the glucose tolerance of obese, insulin resistant Zucker rats at the 20 mg/kg dose level and had no effect on plasma glucose or on glucose tolerance in normal rats fasted for 18 h at the 100 mg/kg level.

A short questionnaire (IRQ) to assess injecting risk behaviour

AIM

To develop a short injecting risk questionnaire (IRQ) to measure sharing of injecting equipment.

DESIGN

Matrix design with quota assignment, designed to compare the questionnaire when used by interview and self-completion, in agency and community settings, by agency staff and fieldworkers, with different injectors (age < 26 vs. 26+; male vs. female, opiate vs stimulant injectors), and in different geographical areas.

SETTINGS

Drug treatment and helping agencies, and community settings, in England.

PARTICIPANTS

Drug users who had injected in the last 4 weeks.

MEASUREMENTS

Questions measured different aspects of equipment sharing. Questionnaire performance assessed by question acceptability, test-retest (parallel forms) reliability, inter-rater reliability, inter-instrument reliability, internal reliability, construct validity and internal collateral validity. Statistical tests included product moment correlation, principal components analysis, and Cronbach's alpha.

FINDINGS

The questionnaire was highly acceptable. Test-retest correlations were all high and significant, questions performed well in all conditions, with no differences by site (agency vs. out-of-contact), order (interview or self-completion first), administration (staff vs. fieldworker), elapsed time or subject characteristics. The questionnaire had high internal reliability (Cronbach's alpha > +0.86), and items measured a similar domain with all questions loading highly (> 0.32) on a single factor which accounted for > 42% of the variance. The complete IRQ elicited higher reports of equipment sharing (77%) than a single question (56%).

CONCLUSIONS

IRQ performs well in a variety of settings, when administered in different ways to different kinds of IDUs. A single question on 'sharing' elicits fewer positive responses than the use of multiple questions about different sharing practices.

Effects of atorvastatin monotherapy and simvastatin plus cholestyramine on arterial endothelial function in patients with severe primary hypercholesterolaemia

Endothelial dysfunction is an important early event in atherogenesis. Changes in arterial endothelial physiology were studied in patients with severe primary hypercholesterolaemia participating in an ongoing clinical trial evaluating atorvastatin and simvastatin. Endothelial function was assessed non-invasively using brachial ultrasound and the primary outcome measure was flow-mediated endothelium-dependent dilatation (FMD) in response to reactive hyperaemia. Patients were studied upon entry while still using simvastatin 40 mg daily and again after a 10-week washout (baseline). Over the next 30 weeks, 20 patients received atorvastatin titrated up to 80 mg daily and 12 patients received simvastatin titrated up to 40 mg daily (plus cholestyramine 4 g daily in 10/12), followed by a final ultrasound study. During simvastatin washout, total and low density lipoprotein (LDL) cholesterol rose by a median 23-29% and 30-34%, respectively. During atorvastatin therapy, total and LDL cholesterol fell by a median of 41 and 46%, respectively, triglycerides fell by 45%, and high density lipoprotein (HDL) cholesterol rose by 10%. During simvastatin plus cholestyramine therapy, the respective median changes were - 32, - 39, - 44 and + 11%. Patients at baseline showed evidence of impaired FMD and this improved significantly on either treatment, from a median + 2.2 to + 5.5% on atorvastatin and from + 1.8 to + 4.5% on simvastatin plus cholestyramine (P < 0.01 for both treatments). Typical response in healthy subjects would be from + 8 to + 9%. FMD at baseline was correlated with HDL cholesterol (r=0.49, P < 0.01). Change in FMD was inversely correlated with baseline FMD (r=-0.54, P < 0.001). Endothelial dysfunction in primary hypercholesterolaemia was improved by treatment with atorvastatin or simvastatin plus cholestyramine and this effect may result in the prevention of future coronary events.

Candida dubliniensis: an emerging opportunistic pathogen

The incidence of opportunistic fungal infections continues to increase, partly as a result of the continuing AIDS epidemic. Candida albicans remains the most important fungal pathogen and is frequently associated with oral candidiasis in HIV-infected individuals. Over the past decade, however, there has been an increasing number of reports implicating other Candida species, such as C. tropicalis, C. glabrata and C. krusei, in disease in these patients and in other patient groups. During the same period there have also been frequent reports in the literature describing what have generally been termed "atypical" C. albicans strains. These isolates have usually been recovered from symptomatic HIV-infected individuals and are unidentifiable as any recognized Candida species using conventional criteria. Two such groups of isolates recovered from cases of oral candidiasis in Irish and Australian HIV-infected and AIDS patients have been postulated to constitute a novel species which has been termed C. dubliniensis. These isolates are phenotypically very similar to C. albicans in that they produce germ tubes and chlamydospores. However, they have unusual carbohydrate assimilation patterns and grow poorly or not at all at 42 degrees C. Using a variety of DNA fingerprinting techniques and karyotype analysis, the genomic organization of C. dubliniensis was shown to be distinctly different from that of C. albicans. Classification of C. dubliniensis as a separate species was confirmed by phylogenetic analysis, whereby the comparison of ribosomal RNA sequences demonstrated that C. dubliniensis isolates formed a cluster clearly distinct from other Candida species, including C. albicans, to which it is most closely related. Since its original identification, atypical Candida isolates from around the world have been positively identified as belonging to this species. To date, isolates of C. dubliniensis have been recovered mainly from the oral cavities of HIV-infected individuals and are most frequently implicated in cases of recurrent infection following antifungal drug treatment. The clinical importance of this species and the role of drug resistance in its epidemiology have yet to be determined.

Evaluating and treating nutritional problems in older patients

Up to 65% of elderly hospitalized patients are protein-energy undernourished at admission or acquire nutritional deficits while hospitalized. For the elderly patient who requires nutritional support therapy, a strategy of intervention should be carefully formulated based on the results of a clinical assessment. While receiving nutritional support, the patient should be monitored carefully for complications and changing metabolic requirements. Modifications to the original regimen should be made to meet the patient's needs as necessary.

Flight muscle function in Drosophila requires colocalization of glycolytic enzymes

Structural relationships between the myofibrillar contractile apparatus and the enzymes that generate ATP for muscle contraction are not well understood. We explored whether glycolytic enzymes are localized in Drosophila flight muscle and whether localization is required for function. We find that glycerol-3-phosphate dehydrogenase (GPDH) is localized at Z-discs and M-lines. The glycolytic enzymes aldolase and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) are also localized along the sarcomere with a periodic pattern that is indistinguishable from that of GPDH localization. Furthermore, localization of aldolase and GAPDH requires simultaneous localization of GPDH, because aldolase and GAPDH are not localized along the sarcomere in muscles of strains that carry Gpdh null alleles. In an attempt to understand the process of glycolytic enzyme colocalization, we have explored in more detail the mechanism of GPDH localization. In flight muscle, there is only one GPDH isoform, GPDH-1, which is distinguished from isoforms found in other tissues by having three C-terminal amino acids: glutamine, asparagine, and leucine. Transgenic flies that can produce only GPDH-1 display enzyme colocalization similar to wild-type flies. However, transgenic flies that synthesize only GPDH-3, lacking the C-terminal tripeptide, do not show the periodic banding pattern of localization at Z-discs and M-lines for GPDH. In addition, neither GAPDH nor aldolase colocalize at Z-discs and M-lines in the sarcomeres of muscles from GPDH-3 transgenic flies. Failure of the glycolytic enzymes to colocalize in the sarcomere results in the inability to fly, even though the full complement of active glycolytic enzymes is present in flight muscles. Therefore, the presence of active enzymes in the cell is not sufficient for muscle function; colocalization of the enzymes is required. These results indicate that the mechanisms by which ATP is supplied to the myosin ATPase, for muscle contraction, requires a highly organized cellular system.

Diagnostic performance characteristics of architectural features revealed by high spatial-resolution MR imaging of the breast

OBJECTIVE

Our objective was twofold: to determine which architectural features revealed by high spatial-resolution MR imaging of the breast contribute to diagnostic accuracy and to evaluate the diagnostic performance characteristics of those architectural features.

MATERIALS AND METHODS

Eligible patients with suspicious mammographic or palpable findings or both underwent MR imaging. Ninety-three patients whose MR images revealed lesions that corresponded to the mammographically visible or palpable findings were included in the study. Patients were examined with sagittal T1-weighted spin-echo MR imaging, fat-saturated T2-weighted fast spin-echo MR imaging, and dynamically enhanced fat-saturated fast gradient-echo MR imaging. All patients underwent subsequent excisional biopsy or cyst aspiration. Lesions were identified initially by an experienced radiologist who was aware of the patient's clinical or mammographic information. Two radiologists who were unaware of the patients' histories and who had less experience in MR imaging of the breast then independently evaluated each lesion for the architectural-features and predicted each lesion's potential for malignancy.

RESULTS

Architectural features that were highly predictive of benign disease included smooth or lobulated borders (97-100%), the absence of mass enhancement (100%), and enhancement that was less than the enhancement of surrounding breast fibroglandular tissue (93-100%). Nonenhancing internal septations were specific for the diagnosis of fibroadenoma. Architectural features that were highly predictive of malignant disease included spiculated borders (76-88%) and peripheral rim enhancement in the presence of central lesion enhancement (79-92%).

CONCLUSION

Architectural features revealed by high spatial-resolution MR imaging of the breast can help distinguish benign from malignant disease.

A multicenter, double-blind, one-year study comparing safety and efficacy of atorvastatin versus simvastatin in patients with hypercholesterolemia

We directly compared the safety and efficacy of atorvastatin and simvastatin in hypercholesterolemic patients. This 1-year, randomized, double-blind study was performed at 9 community- and university-based research hospitals in Australia. One-hundred seventy-seven patients between the ages of 18 and 80 years with baseline low-density-lipoprotein (LDL) cholesterol > or = 4.14 and < or = 7.76 mmol/L (160 and 300 mg/dl, respectively) and triglycerides < or = 4.52 mmol/L (400 mg/dl) received once-daily dosing with atorvastatin (Lipitor) 10 mg or simvastatin (Zocor) 10 mg. At week 16, the dose of medication was titrated to atorvastatin 20 mg or simvastatin 20 mg if patients did not meet LDL cholesterol target of < or = 3.36 mmol/L (130 mg/dl). Efficacy was reported as percent change from baseline in LDL cholesterol, total cholesterol, very low density lipoprotein cholesterol, total triglycerides, high-density lipoprotein cholesterol, apolipoproteins AI and B, and lipoprotein(a). Atorvastatin caused significantly greater reductions from baseline than did simvastatin for LDL cholesterol, total cholesterol, very low density lipoprotein cholesterol, triglycerides, and apolipoprotein B (p <0.05). No patient in either treatment group had clinically important elevations in creatine phosphokinase, alanine aminotransaminase, or aspartate aminotransaminase. No serious adverse events were considered associated with treatment. With atorvastatin 10 mg, 46% of the patients achieved LDL cholesterol target goal by week 16, whereas only 27% of the simvastatin patients achieved the target goal at the 10-mg dose. This cholesterol-lowering profile affords utility in many patient types.

Molecular and phenotypic analysis of Candida dubliniensis: a recently identified species linked with oral candidosis in HIV-infected and AIDS patients

The discovery and characterisation of a novel species of Candida, termed Candida dubliniensis, associated with oral candidosis in HIV-infected individuals is described. These organisms share several phenotypic characteristics in common with Candida albicans and Candida stellatoidea, including the ability to produce germ tubes and chlamydospores. However, in contrast to these latter two species, C. dubliniensis isolates produce abundant chlamydospores, which are often arranged in contiguous pairs, triplets and other multiples suspended from a single suspensor cell. They belong to C. albicans serotype A and exhibit atypical substrate assimilation profiles. Genomic DNA fingerprinting analysis with the C. albicans-specific probe 27A and five different oligonucleotide probes consisting of short repeat sequence-containing motifs, demonstrated that C. dubliniensis has a distinct genomic organisation relative to C. albicans and C. stellatoidea. This was confirmed by karyotype analysis and random amplified polymorphic DNA (RAPD) analysis. Comparison of 500 bp of the V3 variable region of the large ribosomal subunit genes from 14 separate C. dubliniensis isolates and the corresponding sequences from C. albicans, C. stellatoidea, C. tropicalis, C. glabrata, C. parapsilosis, C. kefyr and C. krusei demonstrated that the C. dubliniensis isolates formed a homogenous cluster (100% similarity), representing a discrete taxon within the genus Candida that was significantly different from the other species analysed.

Detection of hepatitis C virus RNA sequences in hepatocellular carcinoma and its precursors by microdissection polymerase chain reaction

OBJECTIVE

Chronic hepatitis C virus (HCV) infection is frequently associated with the development of hepatocellular carcinoma (HCC), but the mechanism of malignant transformation is unknown. To analyze the association of HCV with HCC, we developed a microdissection technique for the detection by polymerase chain reaction of positive (genomic)- and negative (replicative)-strand HCV RNA in histologically confirmed HCC and the surrounding cirrhotic and macroregenerative nodules.

MATERIALS AND METHOD

Five HCCs and one macroregenerative nodule and the surrounding cirrhotic liver tissues of all cases were selected for this study. The method entails extraction of RNA from selected areas of formalin-fixed, hematoxylin-stained histologic sections, followed by strand-specific reverse-transcription double polymerase chain reaction and Southern blotting.

RESULTS

Positive- and negative-strand HCV RNA sequences were detected in five of six tumors and the surrounding cirrhotic livers.

CONCLUSIONS

These results verify the method of polymerase chain reaction detection of HCV RNA from histologically defined, selected lesions. In addition, the findings suggest that HCV RNA persists and replicates in hepatocytes during malignant transformation.

Widespread geographic distribution of oral Candida dubliniensis strains in human immunodeficiency virus-infected individuals

Candida dubliniensis is a recently identified chlamydospore-positive yeast species associated with oral candidiasis in human immunodeficiency virus (HIV)-infected (HIV+) patients and is closely related to Candida albicans. Several recent reports have described atypical oral Candida isolates with phenotypic and genetic properties similar to those of C. dubliniensis. In this study 10 atypical chlamydospore-positive oral isolates from HIV+ patients in Switzerland, the United Kingdom, and Argentina and 1 isolate from an HIV-negative Irish subject were compared to reference strains of C. albicans and Candida stellatoidea and reference strains of C. dubliniensis recovered from Irish and Australian HIV+ individuals. All 11 isolates were phenotypically and genetically similar to and phylogenetically identical to C. dubliniensis. These findings demonstrate that the geographical distribution of C. dubliniensis is widespread, and it is likely that it is a significant constituent of the normal oral flora with the potential to cause oral candidiasis, particularly in immunocompromised patients.

A comparative study of the efficacy of simvastatin and gemfibrozil in combined hyperlipoproteinemia: prediction of response by baseline lipids, apo E genotype, lipoprotein(a) and insulin

Combined hyperlipoproteinemia (CHL) can be difficult to treat because of the heterogeneous nature of the lipoprotein abnormalities. We compared the relative efficacies of simvastatin and gemfibrozil and sought predictors of responsiveness in terms of the baseline lipids and other potential metabolic determinants (plasma insulin, Lp(a) and apo E genotype). Sixty-six subjects entered a cross-over, randomized trial involving 12 weeks on each drug. Efficacy was assessed after 6 and 12 weeks on each treatment. Simvastatin lowered total cholesterol 24%, triglycerides 12%, LDL cholesterol 33%, raised HDL cholesterol 13% and substantially reduced the cholesterol:triglyceride ratio in VLDL and IDL. Gemfibrozil lowered total cholesterol 5%, triglycerides 44%, raised HDL 26% and reduced VLDL and IDL lipids more than simvastatin did. LDL size increased with both treatments and HDL size increased with simvastatin. Responsiveness (25% fall in cholesterol or 40% fall in triglycerides) was shown by 31/61 subjects when taking simvastatin (cholesterol-lowering) and by 44/60 taking gemfibrozil (triglyceride-lowering). Responsiveness was greatest in those with apo E2 genotype with both drugs (P < 0.05). Unexpectedly, responders to simvastatin tended to have lower baseline total cholesterol but higher triglyceride levels than those whose cholesterol or triglyceride was lowered by gemfibrozil. Nevertheless, more hypercholesterolemic subjects responded to simvastatin and more hypertriglyceridemic subjects to gemfibrozil. Lp(a) (P = 0.04) and plasma insulin concentrations (P = 0.03) were negative predictors of percentage triglyceride-lowering with gemfibrozil. The difference between the two drugs in triglyceride-lowering lessened with rising insulin and falling HDL cholesterol. Thus, the responsiveness to the two major classes of lipid lowering drugs can be partly predicted from baseline lipids and related metabolic parameters.

Oral L-arginine improves endothelium-dependent dilatation and reduces monocyte adhesion to endothelial cells in young men with coronary artery disease

L-Arginine is the physiological substrate for nitric oxide synthesis by the vascular endothelium. In hypercholesterolaemic rabbits, oral L-arginine reduces atheroma, improves endothelium-dependent dilatation and reduces monocyte/endothelial cell adhesion. The effect of oral L-arginine on endothelial physiology is unknown, however, in humans with established atherosclerosis. In a prospective, double-blind, randomised crossover trial, ten men aged 41 +/- 2 years with angiographically proven coronary atherosclerosis took L-arginine (7 g three times per day) or placebo for 3 days each, with a washout period of 10 days. After L-arginine, compared to placebo, plasma levels of arginine were increased (318 +/- 18 vs. 124 +/- 9 mumol/l, P < 0.01) and endothelium-dependent dilatation of the brachial artery (measured as the change in diameter in response to reactive hyperaemia, using external vascular ultrasound) was improved (4.7 +/- 1.1 vs. 1.8 +/- 0.7%, P < 0.04). No changes were seen in endothelium-independent dilatation of the brachial artery (measured as the change in diameter in response to sublingual nitroglycerine), blood pressure, heart rate or fasting lipid levels. Serum from six of the ten subjects after L-arginine and placebo was then added to confluent monolayers of human umbilical vein endothelial cells for 24 h, before human monocytes obtained by countercurrent centrifiguation elutriation were added and cell adhesion assessed by light microscopy. Adhesion was reduced following L-arginine compared to placebo (42 +/- 2 vs. 50 +/- 1%, P < 0.01). In young men with coronary artery disease, oral L-arginine improves endothelium-dependent dilatation and reduces monocyte/endothelial cell adhesion.

Effects of dietary L-arginine on atherosclerosis and endothelium-dependent vasodilatation in the hypercholesterolemic rabbit. Response according to treatment duration, anatomic site, and sex

BACKGROUND

Nitric oxide (NO) may protect arteries against atherosclerosis. In the present study, we examined whether dietary L-arginine, the precursor of NO, could chronically preserve endothelium-dependent vasodilatation in vivo and/or limit atherogenesis.

METHODS AND RESULTS

Rabbits were randomized according to sex to receive 2% dietary cholesterol, with or without L-arginine (2.25% solution), for 7 or 14 weeks. Hindlimb vasodilator responses to acetylcholine and nitroprusside were measured with an electromagnetic flow probe. Atherosclerosis was measured with planimetry of aortic lesions stained with Oil-Red-O. In rabbits administered L-arginine, plasma arginine levels increased to 483 +/- 30 mumol/L at 3 weeks (mean +/- SEM, P < .0001 versus control animals) but declined to 224 +/- 25 mumol/L at 7 weeks (P = .02) and to 100 +/- 23 mumol/L at 14 weeks (NS versus control animals). At 7 weeks, peak hindlimb conductance in response to acetylcholine in cholesterol-fed males was 249 +/- 49% of baseline compared with 332 +/- 9% in control animals (P = .04), but peak response in arginine-fed rabbits (314 +/- 24%) did not differ from that of control animals. At 14 weeks, peak responses to acetylcholine were equally reduced in males fed cholesterol with (266 +/- 21%, P = .02 versus control) or without (263 +/- 13%, P = .01 versus control) L-arginine. Similar impairment of endothelium-dependent vasodilatation was seen in females at 14 weeks. Vasodilator responses to nitroprusside did not differ from those of control animals in any treatment group. After 14 weeks, atherosclerosis was less in the descending aorta of arginine-fed males (16 +/- 4% surface area) than that of males fed cholesterol only (42 +/- 8%, P = .04), but no treatment benefit was seen in the ascending aorta or in females.

CONCLUSIONS

Dietary L-arginine supplementation causes an early rise in plasma arginine levels, with limitation of atherosclerosis in the descending aorta and preservation of endothelium-dependent vasodilatation in resistance arteries, but this treatment effect is not sustained. Dietary L-arginine may not be of long-term benefit in the prevention of atherosclerosis in humans.

Strength of Motion Aftereffect Varies with Segregation of Test Field and Surround

It is widely accepted that the motion aftereffect (MAE) results from the adaptation of visual motion detectors. However, recent work suggests that how the effects of that adaptation are expressed (the nature of the perceived MAE) depends on the nature of the inducing and test fields. We investigated how the strength of the MAE varied with the nature of the boundary between the test field and the surround. The surround (18.5 deg wide × 13.5 deg high) to the adapting and test fields was an area of vertical square-wave grating of 0.7 cycle deg−1. During adaptation, vertical stripes of the same spatial frequency as the background moved horizontally at a speed of 2 deg s−1 for 14 s within a central rectangular window of 9.7 deg wide × 7.6 deg high. At the end of adaptation, one of six different test fields was presented in the central window. In three of these, the stationary test stripes were exactly aligned with the surrounding stripes, and in the other three they were offset by half a stripe width. For two of these conditions (one aligned, one offset), a black outline was drawn around the edge of the adapting window (and so was visible only where it crossed white areas), and for two others (one aligned, one offset) the outline was red, and so visible in its entirety. The strength of MAEs in twelve subjects was assessed both by ratings at an auditory signal which occurred 0.5 s after the end of adaptation and also by measurement of their durations. There was good agreement between these two measures. MAEs were significantly stronger on the offset than on the aligned test fields. The presence of an outline increased MAE strength compared with no outline, but these outline effects were much weaker than those of offsetting the test stripes from the surround. We suggest that the MAE depends in part on the presence of a visually separable test pattern to which motion may be allocated.

Persistence, replacement, and microevolution of Cryptococcus neoformans strains in recurrent meningitis in AIDS patients

Six separate human immunodeficiency virus-positive patients with cryptococcal meningitis were each found to have been infected with a unique strain of Cryptococcus neoformans on the basis of genomic DNA finger-printing analysis with the microsatellite sequence-containing oligonucleotide probe (GGAT)4 and by random amplification of polymorphic DNA. Two patients (A and B) experienced a recurrent episode of infection. Between 12 and 16 single-colony isolates recovered from primary isolation media (> 50% of C. neoformans colonies recovered) from cerebrospinal fluid specimens were fingerprinted from both patients during each episode. The fingerprints of both isolate collections from patient B were very similar, although minor polymorphisms were evident in both sets of profiles. The fingerprints of the isolate collection from the initial episode of infection in patient A were also identical to each other, apart from minor polymorphisms, but they were clearly different from the corresponding profiles of the isolate collection from the recurrent episode, the latter of which were completely identical, apart from minor polymorphisms in a single isolate. Furthermore, prolonged storage and in vitro subculture of the isolates did not alter the fingerprint profiles. These results provided convincing evidence that patients A and B were each infected with a single C. neoformans strain during each episode of infection and that in patient B, the same strain persisted and caused both episodes, while in patient A, a different strain was responsible for each episode. The prevalence of polymorphisms in multiple single-colony isolates from both patients also suggested that C. neoformans populations may undergo microevolution.

Killer factor interference in mixed opportunistic yeast cultures

The interaction of the killer yeast Pichia anomala UP 25F with the killer toxin-sensitive clinical isolate Candida albicans UCSC 10S and its natural toxin-resistant mutant derivative C. albicans UCSC 10R were studied under various conditions. A differential inhibition was shown to occur in vitro at pH and temperature values, which are not encountered in vivo, only by using preformed killer toxin, since antagonism due to yeast growth proved to be predominant on the killer effect. Under adverse growth conditions, the P. anomala killer yeast proved to be able to produce an anatoxin antigenically related to the active or heat inactivated killer toxin. These findings suggest that killer toxins may not function as potential virulence factors in the competition between the opportunistic killer yeast P. anomala and sensitive microorganisms for colonization in the course of natural human infections.

An epidemiological study of Candida species infection in cancer patients using genetic fingerprinting and morphotyping

During a six-week period a cluster of four cases of Candida fungaemia occurred in a mixed haematology/oncology unit of a large Dublin teaching hospital. A study was conducted to determine whether the cluster of cases was caused by a particular strain. Nine patients were studied; five who were colonized with Candida spp. and four who developed Candida fungaemia. Twenty-two clinical isolates of Candida spp. were collected and identified. Three of the patients with fungaemia yielded Candida albicans from blood cultures and C. tropicalis was isolated from the fourth patient. C. albicans isolates were serotyped, morphotyped and analysed by DNA fingerprinting of total cellular DNA using the cloned C. albicans-specific, mid-repeat sequence element 27A as a molecular probe. All C. albicans isolates were of serotype A. Eight distinguishable types were identified by both morphotyping and DNA typing from 19 C. albicans isolates recovered from seven individual patients, although there were several discrepancies. Of three patients from whom two or more isolates of C. albicans were recovered on separate occasions, two yielded recurrent isolates with different morphotype codes. However, in both cases, the recurrent isolates from individual patients yielded indistinguishable, or closely related, DNA fingerprint profiles. Both morphotyping and DNA fingerprint analysis readily distinguished the three blood culture isolates of C. albicans. We conclude that the Candida spp. infections in the unit were not due to cross-infection and were probably related to the patients' indigenous flora.

Managing pharmaceutical sales activities in an academic anesthesiology department

To contain costs, departments of anesthesiology must control the use of new, expensive drugs. Conflicts with pharmaceutical companies can arise when they promote drug sales. Pharmaceutical company sales represent anesthesiology department expenses. Anesthesiologists hold diverse opinions on this clash of interests, on the proper roles of pharmaceutical sales representatives in anesthesiology departments, and on the ethics of accepting industry gifts. Our department has managed pharmaceutical sales activities by encouraging discussion of the ethics and legal limits of industry gifts, by banning sales representatives from bringing food into the department, and by adopting The American Medical Association Guidelines on Gifts.

Insulin resistance is associated with abnormal dephosphorylation of a synthetic phosphopeptide corresponding to the major autophosphorylation sites of the insulin receptor

Insulin resistance in the ob/ob mouse model is associated with a reduction in insulin-induced protein-tyrosine phosphorylation in tissues such as liver. To ascertain whether this decrease in phosphorylation may be due to increased phosphatase activity, protein-tyrosine phosphatase (PTPase) activity was determined in particulate and soluble fractions from livers of 5- to 23-week-old ob/ob mice and age-matched lean littermates. PTPase activity was measured using a synthetic phosphopeptide, TRDIY(P)ETDY(P)Y(P)RK, as the substrate, corresponding to residues 1142 to 1153 of the insulin receptor and containing the major autophosphorylation sites of the regulatory domain. The ob/ob mice were hyperinsulinemic across all age groups, but only the youngest mice (aged 5 to 7 weeks) were hyperglycemic. Most PTPase activity was present in the liver particulate fraction and was 19% to 114% greater in ob/ob mice as compared with controls. PTPase activity in the liver soluble fraction was 26% less than control values in the youngest ob/ob mice (5 to 7 weeks), but increased with age and was 41% and 131% above control values at 21 to 23 and 25 to 27 weeks of age, respectively. Oral administration of the PTPase inhibitor sodium orthovanadate (0.6 mg/mL in drinking water for 2 weeks) to young ob/ob mice caused a significant reduction in the elevated particulate PTPase activity, with concomitant decreases in plasma insulin and plasma glucose. Assessment of PTPase activity with a monophosphate form of the same synthetic peptide, TRDIY(P)ETDYYRK, showed lower PTPase activities as compared with the triphosphate form and no significant differences between ob/ob and control preparations.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of DNA fingerprinting and biotyping methods to study a Candida albicans outbreak in a neonatal intensive care unit

During a 15-day period, 7 premature infants hospitalized in a neonatal intensive care unit presented with sepsis caused by Candida albicans. The local environment and hands of all 54 persons involved in the intensive care unit were examined for the presence of this organism. Five techniques were used in the analysis of the isolates recovered from blood cultures of the children, the hands of personnel and 10 control isolates. The methods used were serotype determination, genetic fingerprinting, morphotyping, resistotyping and killer yeast typing. Morphotyping and genetic fingerprinting proved to be the most discriminatory techniques, and only combined analysis of the results obtained with these various methods allowed the source of the outbreak to be identified. An isolate from the hands of a healthy staff member and isolates from infected children all belonged to the same strain.