Dalbavancin in catheter-related bloodstream infections: a pilot study

Background

Catheter-related bloodstream infections (CRBSI) represent a frequent complication of vascular catheterization, with high morbidity, mortality, and associated costs. Most infections are caused by Gram-positive bacteria; thus dalbavancin, a new long-acting lipoglicopeptide, may have a role in early patient discharge strategies optimizing treatment and reducing overall costs.

Methods

In this small pilot feasibility study, we assessed the efficacy and safety of a "single step" treatment strategy combining dalbavancin administration (1500 mg IV single dose), catheter removal, and early discharge in adult patients admitted to medical wards in a three-year period.

Results

We enrolled sixteen patients with confirmed Gram-positive CRBSI, with a mean age of 68 years and relevant comorbidities (median Charlson Comorbidity index=7). The most frequent causative agents were staphylococci, with 25% of methicillin-resistant strains, and the majority of infected devices were short term central venous catheter (CVC) and peripherally inserted central catheter (PICC). Ten out of sixteen patients had been treated empirically before dalbavancin administration. The mean time from dalbavancin administration to discharge was 2 days; none of the patients had adverse drug-related reactions; at 30- and 90-day follow-up, no patients have been readmitted to the hospital due to bacteraemia recurrence.

Conclusions

Our results indicate that single-dose dalbavancin is highly effective, well-tolerated, and cost-saving for Gram-positive CRBSI.

Doege-Potter Syndrome; A Case of Solitary Fibrous Pleura Tumor Associated with Severe Hypoglycemia: A Case Report in Internal Medicine

BACKGROUND

Doege-Potter syndrome is a rare paraneoplastic entity that is often diagnosed incidentally during the work-up of hypoglycemia of unclear etiology. It is characterized by a non-islet cell tumor hypoglycemia mostly associated with solitary fibrous tumors. These uncommon tumors have been reported in <5% of solitary fibrous tumors. Although not unique in its kind, this case is extremely important as this syndrome often conceals unrecognized tumors that can be surgically resolved.

CASE PRESENTATION

We present the case of a 59-year-old non-diabetic man with a 2-month history of severe and recurrent fasting hypoglycaemia presenting with severe dyspnea and sweating. Further workup revealed low insulin, C-peptide, and IGF-1 levels and a large right in-trathoracic solitary fibrous tumor. Unfortunately, bioassays for IGF-2 were unavailable at our hos-pital. Nevertheless, as hypoglycemia completely resolved after resection of the mass, Doege-Potter syndrome was highly suspected.

CONCLUSION

Doege-Potter syndrome is a complication of rare tumors. If hy-poglycemia is unexplained, this syndrome should always be suspected, and the presence of un-known masses should be investigated.

Melnick-Needles syndrome and GH-deficiency: a possible new association feature

We report a rare genetic disorder, the Melnick-Needles syndrome (MNS) in 3 members of the same family, the mother and 2 daughters. This syndrome is a rare X-linked genetic disorder characterized by abnormal bone development, showing a particular facial appearance; moreover, these patients may also have a relatively small chest cavity with irregular ribbon-like ribs, a short clavicle and narrow shoulders. Stature is mildly reduced. The 3 members of this family shared the same common clinical and radiographic features designating MNS. The mother and the younger daughter were of short stature, while the other daughter was of normal stature within her parental target height. The evaluation of the GH/IGF-I axis evidenced a GH deficiency in 1 out of 3 members of the family, specifically in the younger daughter. The auxological evaluation also showed her stature was nearly below a 3 standard deviation score. This case report describes for the first time a family affected by MNS, in which one of the members shows a truly severe idiopathic, isolated GH deficiency, the likely cause of the severe short stature.

Chemotherapy of Breast Cancer in the Elderly

Breast cancer arises in about 48% of patients older than 65 years and more than 30% occurs in those over 70 years being the leading cause of cancer-related death in women older than 65. Elderly patients tolerate chemotherapy poorly compared to their younger counterpart because of progressive reduction of organ function and comorbidities related to age. For this reason, the elderly have been excluded from or underrepresented in most cancer studies and, in clinical practice, they often receive inadequate and untested treatments. For adjuvant chemotherapy, a low percentage of patients over 70 years of age were included in few trials and always in a proportion much lower than the prevalence of cancer in that age group. Adjuvant chemotherapy, preferably including an anthracycline especially in patients with HER-2/neu-positive tumours, seems to be beneficial in older women who have substantial risk of dying of breast cancer. To date even if there is no specifically randomised study, single-agent chemotherapy probably might be considered a reasonable treatment for advanced breast cancer in the elderly. One of the actual main field of clinical research in the treatment of breast cancer is the role of targeted therapies. Chronologic age is a risk factor for toxicities such as myelosuppression and mucositis, and older patients may require more supportive care. In order to plan medical treatment in breast cancer elderly patients is mandatory to practice a comprehensive geriatric assessment that includes evaluation of comorbidities, functional dependence, socio-economic, emotional and cognitive conditions, an estimate of life expectancy and recognition of frailty. The authors review the literature regarding age-specific chemotherapeutic issues in the management of breast cancer elderly patients.

Gefitinib in elderly and unfit patients affected by advanced non-small-cell lung cancer

Elderly and poor performance status advanced non-small-cell lung cancer (NSCLC) patients often tolerate chemotherapy poorly. Special approaches are needed for these patient populations. Gefitinib (Iressa) was used in 59 elderly and/or unfit NSCLC pretreated patients participating in a compassionate use programme showing some activity and good tolerability.

[Complex family association in autoimmune polyendocrine syndrome]

Autoimmune polyglandular syndromes (APS) are conditions characterized by the association of two or more endocrine and non-endocrine autoimmune disorders. Diabetes mellitus type 1 (T1DM) is one of the most frequent components of APS and is often its first symptom. The frequency of autoimmune pathologies in patients affected by T1DM is proportional to the persistance of ICA. Even in first relatives of these patients, an increase in incidence of latent or manifest autoimmune pathology is noticed. The association of T1DM with autoimmune thyroiditis and celiac disease in a girl from a family affected by high incidence of autoimmune pathology is described. The role of gluten in the pathogenesis of T1DM and some other autoimmune conditions in genetically predisposed subjects. Infact studies are still inadequate for demostrating how a gluten-free diet could delay or mitigate the course of T1DM and of other autoimmune pathologies in genetically predisposed subjects. Nevertheless, it is suggested that gluten could represent a starting or a maintenance factor of autoimmune processes and the risk of autoimmune pathologies is proportional to the duration of the exposure to gluten. A screening for a quick singling out of autoimmune pathologies is suggested for T1DM patients, their first relatives and for subjects affected by other autoimmune diseases or celiac disease.

[Floating-Harbor syndrome: first case in Italy associated with growth hormone deficiency]

The Floating-Harbor Syndrome (FHS) is a rare entity characterised by a clinical triad: facial dysmorphism, retarded speech development and short stature with delayed bone age. The case of a 9-year and 8/12 months old boy showing the typical features of this syndrome associated to a severe GH deficiency is reported. At diagnosis of FHS, the weight was 16 kg (< 3 degrees percentile), height 112 cm (< 3 degrees percentile), cranial circumference 53.8 cm (> 90 degrees percentile). The evaluation of growth hormone secretion by two Insulin Tolerance Tests confirmed an insufficient GH peaks response (2.7 ng/ml and 4.6 ng/ml). He had a slight mental delay (IQ: 60) involving language skills. After 1 year of treatment with r-hGH (0.6 IU/kg/week), an increase in growth velocity (11 cm/year) in the length (123 cm), and in body weight (20.5) has been observed. This case is the 22nd report with this syndrome and the first in Italy. The association between GH deficiency and FHS, and the beneficial effects of a substitutive treatment are described.

Freezing gait in Parkinson's disease

Freezing is a well-known problem in Parkinson's disease (PD) and is characterized by an abrupt difficulty in starting or continuing rhythmic and repetitive movements. We utilized a questionnaire in order to assess the occurrence of the freezing gait phenomenon (FG) in a population of 100 consecutive PD patients. Our PD population included 70 males and 30 females, with a mean age of 61.1 +/- 9.1 years. Mean duration of PD was 6.5 +/- 4.0 years. 92/100 patients were under L-Dopa treatment. The FG phenomenon occurred in 60% of patients. It appeared on average 4.8 years after the beginning of PD; in 16% of the cases it was evident before starting L-Dopa treatment. FG was more frequent among female patients. There was no significant correlation between the occurrence of FG and the age of the patients; on the other hand, a significant correlation was found with the duration of the disease (p < 0.001). FG occurred more frequently in the subgroup of patients with the akinetic form (odds ratio: 3.05); whilst an opposite tendency was evident in the subgroup with the tremor predominant form (odds ratio: 0.29).

[Eye movement disorders in hereditary degenerative ataxia. Electro-oculographic study of 11 cases]

An electro-oculographic study has been performed in 11 patients affected by hereditary degenerative ataxias (5 Friedreich's ataxias, 4 olivopontocerebellar atrophies and 2 late onset cerebellar ataxias). Electrooculographic records were obtained during saccades, pursuit movements and fixed gaze. Saccadic latency, saccadic speed and morphologic features were studied. In Friedreich's ataxia ocular motility was less accurate than in olivopontocerebellar atrophy and in late onset cerebellar ataxia.