Impact of rosiglitazone on body composition, hepatic fat, fatty acids, adipokines and glucose in persons with impaired fasting glucose or impaired glucose tolerance: a sub-study of the DREAM trial

AIMS

Thiazolidinediones reduce ectopic fat, increase adiponectin and reduce inflammatory adipokines, fatty acids and glucose in people with Type 2 diabetes. We aimed to measure these effects in people with impaired fasting glucose and/or impaired glucose tolerance.

METHODS

After approximately 3.5 years of exposure to rosiglitazone 8 mg (n = 88) or placebo (n = 102), 190 DREAM trial participants underwent abdominal computed tomography and dual-energy X-ray absorptiometry scans. Visceral and subcutaneous adipose tissue areas, estimated hepatic fat content, total fat and lean mass were calculated and changes in levels of fasting adipokines, free fatty acids, glucose and post-load glucose were assessed.

RESULTS

Compared with the placebo, participants on rosiglitazone had no difference in lean mass, had 4.1 kg more body fat (P < 0.0001) and 31 cm(2) more subcutaneous abdominal adipose tissue area (P = 0.007). Only after adjusting for total fat, participants on rosiglitazone had 23 cm² less visceral adipose tissue area (P = 0.01) and an 0.08-unit higher liver:spleen attenuation ratio (i.e. less hepatic fat; P = 0.02) than those on the placebo. Adiponectin increased by 15.0 μg/ml with rosiglitazone and by 0.4 μg/ml with placebo (P < 0.0001). Rosiglitazone's effect on fat distribution was not independent of changes in adiponectin. Rosiglitazone's effects on fasting (-0.36 mmol/l; P = 0.0004) and 2-h post-load glucose (-1.21 mmol/l; P = 0.0008) were not affected by adjustment for fat distribution or changes in adiponectin or free fatty acids.

CONCLUSIONS

In people with impaired fasting glucose/impaired glucose tolerance, rosiglitazone is associated with relatively less hepatic and visceral fat, increased subcutaneous fat and increased adiponectin levels. These effects do not appear to explain the glucose-lowering effect of rosiglitazone.

The Beta-Binomial Distribution for Estimating the Number of False Rejections in Microarray Gene Expression Studies

In differential expression analysis of microarray data, it is common to assume independence among null hypotheses (and thus gene expression levels). The independence assumption implies that the number of false rejections V follows a binomial distribution and leads to an estimator of the empirical false discovery rate (eFDR). The number of false rejections V is modeled with the beta-binomial distribution. An estimator of the beta-binomial false discovery rate (bbFDR) is then derived. This approach accounts for how the correlation among non-differentially expressed genes influences the distribution of V. Permutations are used to generate the observed values for V under the null hypotheses and a beta-binomial distribution is fit to the values of V. The bbFDR estimator is compared to the eFDR estimator in simulation studies of correlated non-differentially expressed genes and is found to outperform the eFDR for certain scenarios. As an example, this method is also used to perform an analysis that compares the gene expression of soft tissue sarcoma samples to normal tissue samples.

Summary of dose-response modeling for developmental toxicity studies

Developmental toxicity studies are an important area in the field of toxicology. Endpoints measured on fetuses include weight and indicators of death and malformation. Binary indicator measures are typically summed over the litter and a discrete distribution is assumed to model the number of adversely affected fetuses. Additionally, there is noticeable variation in the litter responses within dose groups that should be taken into account when modeling. Finally, the dose-response pattern in these studies exhibits a threshold effect. The threshold dose-response model is the default model for non-carcinogenic risk assessment, according to the USEPA, and is encouraged by the agency for the use in the risk assessment process. Two statistical models are proposed to estimate dose-response pattern of data from the developmental toxicity study: the threshold model and the spline model. The models were applied to two data sets. The advantages and disadvantages of these models, potential other models, and future research possibilities will be summarized.

A Regression Spline Model for Developmental Toxicity Data

Observed dose-response patterns of data from several developmental toxicity experiments appear to be nonlinear and should be characterized by an appropriate model to adequately fit this observed pattern. Information from these animal studies of ambient substances that are noncarcinogenic, yet potentially toxic, to humans is used by federal protection agencies (Environmental Protection Agency, Occupational Safety and Health Administration, Food and Drug Administration) to determine safe exposure levels, such as no observed adverse effects level and benchmark dose. We have developed a flexible regression linear B-spline model for application to developmental toxicity dose-response data from animal studies of these noncarcinogens. We apply our model to data from two CD-1 mice studies of the National Toxicology Program; the observed dose-response pattern from both appears nonlinear: (1) experiment of 131 pregnant mice allocated over five exposure levels (0, 0.025, 0.05, 0.10, and 0.15% diet) of diethylhexyl phthalate and (2) experiment of 111 pregnant mice exposed to five levels (0, 62.5, 125, 250, and 500 mg/kg/day) of diethylene glycol dimethyl ether. In each study, we measure litter response as the proportion of adversely affected fetuses. Upon applying our B-spline model to the data from both studies, we predict nonlinear dose-response, with improvement over the more typical logistic dose-response model in each of the two studies.

Multisensory plasticity in congenitally deaf mice: how are cortical areas functionally specified?

The neocortex of congenitally deaf mice was examined using electrophysiological recording techniques combined with cortical myeloarchitecture. Our results indicate that relative activity patterns across sensory systems during development contribute to modality assignment of cortical fields as well as the size of cortical fields. In congenitally deaf mice, "auditory cortex" contained neurons that responded to somatosensory, visual, or both somatosensory and visual stimulation; the primary visual area contained a larger proportion of neurons that responded to somatosensory stimulation than in normal animals, and the primary visual area had significantly increased in size. Thus, cortical architecture and functional specification were de-correlated. When results are considered in the light of molecular studies and studies in which peripheral activity is altered in development, it becomes clear that similar types of changes to the neocortex, such as alterations in cortical field size, can be achieved in more than one way in the developing and evolving neocortex.

Seizures in children with primary brain tumors: Incidence and long-term outcome

PURPOSE

To estimate the incidence and long-term outcome of brain tumor related seizures in children and to identify risk factors for adverse seizure outcome.

METHODS

Analysis of medical records of children treated for brain tumor and seizures in a single institution. Children were identified from hospital database and neurology clinic records. Seizure status was characterized for the 6 months prior to most recent follow-up.

RESULTS

Median follow-up after first seizure of the 157 analyzed children was 3.3 years. Tumor location was supratentorial in 81% and posterior fossa in 19%. Initial anti-epileptic drugs were phenytoin (n=52), carbamazepine (n=38), phenobarbital (n=14), gabapentin (n=31), or others (n=22). Seizures were controlled in 65% of the children and uncontrolled in 35% (17% intractable). Gabapentin showed a trend toward better seizure control (p=0.06). Neurologic deficit, T2 peri-cavity hyperintensity, and EEG slow waves were independently predictive of uncontrolled seizures by multivariate analysis.

CONCLUSIONS

T2 peri-cavity hyperintensity, focal neurologic deficits, and EEG slow waves predict poor seizure control in children with brain tumors. Seizures can be controlled in most patients with brain tumors. Gabapentin use as first anti-epileptic drug needs to be studied prospectively.

A new threshold dose-response model including random effects for data from developmental toxicity studies

Usually, in teratological dose finding studies, there are not only threshold effects but also extra variations that cannot be accounted for by the beta-binomial model alone. The beta-binomial model assumes correlation between fetuses in the same litter. The general random effect threshold (RE) model allows the additional variability that arises due to correlation and between litter variability to be modeled, in combination with threshold in the model. The goal of this research was to investigate a threshold dose-response model with random effects (RE) to model the variability that exists between litters of animals in studies of toxic agents. Data from a developmental toxicity study of a toxic agent were analysed, using the proposed RE threshold dose-response model, which is an extension of logit in form. Also, an approximate likelihood function was used to derive parameter estimates from this model, and tests were performed to determine the significance of the model parameters, in particular, the RE parameter. A simulation study was conducted to assess the performance of the RE threshold model in estimating the model parameters.

A parametric model for detecting hormetic effects in developmental toxicity studies

Hormetic effects have been observed at low exposure levels based on the dose-response pattern of data from developmental toxicity studies. This indicates that there might actually be a reduced risk of exhibiting toxic effects at low exposure levels. Hormesis implies the existence of a threshold dose level and there are dose-response models that include parameters that account for the threshold. We propose a function that introduces a parameter to account for hormesis. This function is a subset of the set of all functions that could represent a hormetic dose-response relationship at low exposure levels to toxic agents. We characterize the overall dose-response relationship with a piecewise function that consists of a hormetic u-shape curve at low dose levels and a logistic curve at high dose levels. We apply our model to a data set from an experiment conducted at the National Toxicology Program (NTP). We also use the beta-binomial distribution to model the litter response data. It can be seen by observing the structure of these data that current experimental designs for developmental studies employ a limited number of dose groups. These designs may not be satisfactory when the goal is to illustrate the existence of hormesis. In particular, increasing the number of low-level doses improves the power for detecting hormetic effects. Therefore, we also provide the results of simulations that were done to characterize the power of current designs in detecting hormesis and to demonstrate how this power can be improved upon by altering these designs with the addition of only a few low exposure levels.

Gabapentin to control seizures in children undergoing cancer treatment

Hepatic clearance of chemotherapy drugs is increased by many antiepilepsy drugs. At our institution, new-onset seizures in children on chemotherapy are treated with gabapentin, a nonhepatic enzyme inducer. The charts of all children given gabapentin for seizures were reviewed. At a median follow-up of 34 months, seizures were controlled in 74% of 50 children given gabapentin monotherapy as initial treatment: 91% of the leukemia group, 57% of the brain tumor group, and 75% of the other tumor group. Seizures were controlled in 49% of 59 children in whom gabapentin was added to other antiepilepsy drugs: 43% of the leukemia group, 53% of the brain tumor group, and 50% of the other tumor group. More than one seizure at presentation, focal neurologic deficits, high-dose methotrexate, brain irradiation, and T2-weighted signal abnormality around the brain tumor cavity predicted uncontrolled seizures. Only 8 children (7%) reported adverse effects, and the drug was discontinued in two. Gabapentin effectively controls seizures in children receiving chemotherapy and is well tolerated.

Outcome of children with centrally reviewed low-grade gliomas treated with chemotherapy with or without radiotherapy on Children's Cancer Group high-grade glioma study CCG-945

BACKGROUND

The objectives of the current study were to determine the outcome of children who were treated with chemotherapy and radiotherapy on the Children's Cancer Group (CCG) high-grade glioma protocol (CCG-945) who were diagnosed with low-grade gliomas on post hoc central pathologic review and to identify clinical and biologic features associated with prognosis.

METHODS

Between 1985 and 1991, 250 children with institutionally classified high-grade gliomas were enrolled on CCG-945. Patients older than 24 months with intracranial lesions were assigned randomly to receive either lomustine, vincristine, and prednisone (control regimen) or the 8-drugs-in-1-day regimen (experimental regimen); younger patients and those with primary spinal cord tumors were assigned nonrandomly to the experimental regimen. Central independent review by 5 neuropathologists led to a reclassification of low-grade glioma in 70 patients, who were the focus of the current study.

RESULTS

The study involved 42 males and 28 females (median age, 7.7 years) with a median follow-up of 10.4 years. At 5 years, the progression-free survival (PFS) rate was 63% +/- 6%, and the overall survival (OS) rate was 79% +/- 5%, compared with a PFS rate of 19% +/- 3% (P < 0.0001) and an OS rate of 22% +/- 3% (P < 0.0001) in the remainder of the cohort. Significantly poorer 5-year PFS was seen in children younger than 24 months, those with fibrillary astrocytoma, and those with posterior fossa tumors. Patients demonstrated a modest improvement in PFS but no improvement in OS compared with children with low-grade gliomas who were treated with contemporary chemotherapy-alone approaches.

CONCLUSIONS

The current report calls attention to the importance of central pathologic review in large multiinstitutional trials of children with gliomas and suggests that aggressive front-line combined chemoradiotherapy does not confer a survival advantage in this highly selected population of patients.

Using old technology to implement modern computer-aided decision support for primary diabetes care

BACKGROUND

Implementation rates of interventions known to be beneficial for people with diabetes mellitus are often suboptimal. Computer-aided decision support systems (CDSSs) can improve these rates. The complexity of establishing a fully integrated electronic medical record that provides decision support, however, often prevents their use.

OBJECTIVE

To develop a CDSS for diabetes care that can be easily introduced into primary care settings and diabetes clinics. THE SYSTEM: The CDSS uses fax-machine-based optical character recognition software for acquiring patient information. Simple, 1-page paper forms, completed by patients or health practitioners, are faxed to a central location. The information is interpreted and recorded in a database. This initiates a routine that matches the information against a knowledge base so that patient-specific recommendations can be generated. These are formatted and faxed back within 4-5 minutes.

IMPLEMENTATION

The system is being introduced into 2 diabetes clinics. We are collecting information on frequency of use of the system, as well as satisfaction with the information provided.

CONCLUSION

Computer-aided decision support can be provided in any setting with a fax machine, without the need for integrated electronic medical records or computerized data-collection devices.

How to read a systematic review

A systematic review is a carefully planned and conducted study designed to answer a specific focused clinical question. A systematic review differs from the frequently encountered narrative review article. Systematic review must be completed using a prespecified methodology. The reader must ask eight important questions when reading a systematic review: (i) did the review address a focused clinical question (ii) is it likely that important, relevant studies are missed (iii) were the inclusion criteria used to select appropriate articles (iv) was the validity of the included studies assessed (v) were the assessments of studies reproducible (vi) were the results similar from study to study (vii) what were the overall results and how precise are they and (viii) will the results help in caring for patients. The article also provides sources for systematic reviews.

Clinical examination for the detection of protective sensation in the feet of diabetic patients. International Cooperative Group for Clinical Examination Research

OBJECTIVE

We compared the reproducibility and accuracy of conventional clinical examination of the diabetic foot to monofilament examination. We also sought to simplify the monofilament examination by reducing it to fewer touch points.

METHODS

In a cross-sectional study at 10 centers in the United States, Canada, and Switzerland, general internists and residents performed a structured history and physical examination for neuropathy on the feet of diabetic patients. Independent examination by two observers included monofilament sensation, pinprick, vibration, position sense, and ankle reflexes.

MAIN RESULTS

A total of 304 patients were examined by at least one practitioner, and 200 received duplicate examinations. Monofilament examination and ankle reflexes had the best reproducibility, with moderate agreement (kappa = 0.59); pinprick, position, and vibration sense had fair agreement (kappa = 0.28-0.36). No component of the history or physical examination, singly or in aggregate, was both sensitive and specific for identifying a patient with an abnormal monofilament examination. A simplified monofilament examination using only 4 sites per foot (total 8 sites) detected 90% of patients with an abnormal 16-site monofilament evaluation.

CONCLUSIONS

Conventional clinical examination had low reproducibility and correlated poorly with monofilament examination for the identification of the at-risk patient. The Semmes-Weinstein monofilament examination, a reproducible, valid, and generalizable test of foot sensation, is recommended as the screening procedure of choice for examining diabetic feet.

Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review

CONTEXT

Many computer software developers and vendors claim that their systems can directly improve clinical decisions. As for other health care interventions, such claims should be based on careful trials that assess their effects on clinical performance and, preferably, patient outcomes.

OBJECTIVE

To systematically review controlled clinical trials assessing the effects of computer-based clinical decision support systems (CDSSs) on physician performance and patient outcomes.

DATA SOURCES

We updated earlier reviews covering 1974 to 1992 by searching the MEDLINE, EMBASE, INSPEC, SCISEARCH, and the Cochrane Library bibliographic databases from 1992 to March 1998. Reference lists and conference proceedings were reviewed and evaluators of CDSSs were contacted.

STUDY SELECTION

Studies were included if they involved the use of a CDSS in a clinical setting by a health care practitioner and assessed the effects of the system prospectively with a concurrent control.

DATA EXTRACTION

The validity of each relevant study (scored from 0-10) was evaluated in duplicate. Data on setting, subjects, computer systems, and outcomes were abstracted and a power analysis was done on studies with negative findings.

DATA SYNTHESIS

A total of 68 controlled trials met our criteria, 40 of which were published since 1992. Quality scores ranged from 2 to 10, with more recent trials rating higher (mean, 7.7) than earlier studies (mean, 6.4) (P<.001). Effects on physician performance were assessed in 65 studies and 43 found a benefit (66%). These included 9 of 15 studies on drug dosing systems, 1 of 5 studies on diagnostic aids, 14 of 19 preventive care systems, and 19 of 26 studies evaluating CDSSs for other medical care. Six of 14 studies assessing patient outcomes found a benefit. Of the remaining 8 studies, only 3 had a power of greater than 80% to detect a clinically important effect.

CONCLUSIONS

Published studies of CDSSs are increasing rapidly, and their quality is improving. The CDSSs can enhance clinical performance for drug dosing, preventive care, and other aspects of medical care, but not convincingly for diagnosis. The effects of CDSSs on patient outcomes have been insufficiently studied.

Patient-specific evidence-based care recommendations for diabetes mellitus: development and initial clinic experience with a computerized decision support system

BACKGROUND

adherence with evidence-based recommendations for chronic disease management is often suboptimal. Providing patient-specific reminders at the time of clinical encounters has the potential to improve this situation. A necessary prerequisite for providing such reminders, however, is to have an efficient means of acquiring patient information that can be matched to an underlying knowledge base. The decision support system: we have developed a computer-based, self-administered questionnaire for diabetes care. The questionnaire assesses numerous diabetes-related topics. Patients complete the questionnaire using a touchscreen interface, and their responses are then matched to evidence-based guidelines so that patient-specific care suggestions can be provided for both the patients and their health care professionals. The guidelines are derived from a database of abstracts of studies of diabetes care that are screened for scientific merit and clinical relevance, supplemented by recommendations from diabetes organizations.

EVALUATION

initial evaluation of the system included an assessment of the agreement of responses to the automated questionnaire with responses to similar questions administered during a structured, personal interview. Overall agreement was 92.5% and the majority of disagreements were minor. More recently, patients aged 18-69 years have been completing the automated questionnaire before appointments at a diabetes clinic. The average time required has been 10.9 min and a mean of 3.0 recommendations have been provided per patient. Patient and health care practitioner satisfaction with the questionnaire and the patient-specific feedback have been high.

CONCLUSIONS

evidence-based patient-specific diabetes care recommendations can be provided using a self-administered computer-based questionnaire.

Locating and appraising systematic reviews

Several methods can be used to identify systematic reviews. These include bibliographic databases, such as MEDLINE, Best Evidence, and the Cochrane Library. In the future, the Cochrane Library could become the source of choice for systematic reviews because it provides the full text for Cochrane reviews and citations to many other systematic reviews. Moreover, the Library is growing rapidly and becoming more readily available, and its searching capabilities are being improved with each update. Although Best Evidence contains fewer systematic reviews than the Cochrane Library, it is specifically designed for practicing internists and primary care physicians and includes systematic reviews on diagnosis, cause, prognosis, and quality improvement. At present, however, MEDLINE and other bibliographic databases are probably the most up-to-date and readily available sources of systematic reviews. Systematic reviews are a powerful and useful way to assemble evidence; however, just because a review has been done using systematic review methods does not guarantee that its results are credible. Regardless of the source, all systematic reviews (like all types of research evidence) require critical appraisal to determine their validity and to establish whether and how they will be useful in practice.

Automated direct-from-patient information collection for evidence-based diabetes care

BACKGROUND

Computer-based clinical decision support tools can improve physician performance in ambulatory care settings. Acquiring and entering the patient-specific information necessary to take advantage of this technology, however, can often be a major impediment.

OBJECTIVE

To develop and evaluate a self-administered electronic questionnaire for acquiring patient-specific information to be used for generating diabetes-related evidence-based care recommendations.

METHODS

An initial paper questionnaire was developed that evaluated current diabetes management, complications, and screening interventions. This was then coded for electronic presentation using software that can also analyze patient responses and produce personal feedback. To evaluate the electronic questionnaire, 47 patients completed it using a small laptop computer and also responded to a personal interview that assessed similar topics.

RESULTS

Patients required between 7-29 minutes to complete the questionnaire (mean: 15 min.). For 21 of the 23 topic assessed, the agreement between the electronic questionnaire and the personal interview was 80% or higher.

CONCLUSIONS

An electronic, self-administered questionnaire can be used to acquire information for generating patient-specific care recommendations.

Recognizing and investigating iron-deficiency anemia in hospitalized elderly people

OBJECTIVE

To determine whether anemia is documented and appropriately investigated for iron deficiency in hospitalized elderly people.

DESIGN

Retrospective chart review.

SETTING

Medical clinical teaching unit (CTU) in secondary care hospital in Hamilton, Ont.

PARTICIPANTS

Consecutive patients 65 years of age or older admitted between April 1992 and March 1993.

OUTCOME MEASURES

Proportion of anemic patients for whom documentation was adequate (included in problem list in patient chart) and for whom adequate investigations were performed (measurement of serum ferritin level in anemic patients in whom iron deficiency was suspected, bone-marrow aspiration for those with intermediate probability of iron deficiency after determination of serum ferritin level, and endoscopy of upper or lower gastrointestinal tract, or both, in patients with iron deficiency).

RESULTS

Of 183 eligible patients admitted to the CTU 66 (36%) had anemia, in 47 cases (71%) the anemia was documented by house staff or attending physicians. Of the 66 anemic patients 49 had a non-macrocytic anemia of unknown cause: 26 had their serum ferritin level measured, 5 underwent bone-marrow aspiration, and 21 were referred for gastrointestinal endoscopy. Six of eight patients with probable iron deficiency (i.e., a serum ferritin level that was diagnostic [less than 18 micrograms/L] or suggestive [18 to 45 micrograms/L]) underwent endoscopy, two were found to have cancer of the stomach or cecum. Only 26 of the 49 patients had adequate investigation.

CONCLUSIONS

Anemia is common among elderly patients in hospital. However, iron deficiency is underrecognized and underinvestigated.

Effects of dietary calcium supplementation on blood pressure. A meta-analysis of randomized controlled trials

OBJECTIVE

To review the effect of supplemental calcium on blood pressure.

DATA SOURCE

We searched MEDLINE and EMBASE for 1996 to May 1994. We contacted authors of eligible trials to ensure accuracy and completeness of data and to identify unpublished trials.

STUDY SELECTION

We included any study in which investigators randomized people to calcium supplementation or placebo and measured blood pressure for at least 2 weeks. Fifty-six articles met the inclusion criteria, and 33 were eligible for analysis, involving a total of 2412 patients.

DATA EXTRACTION

Two pairs of independent reviewers abstracted data and assessed validity according to six quality criteria.

DATA SYNTHESIS

We calculated the differences in blood pressure change between the calcium supplementation group and the control group and pooled the estimates, with each trial weighted with the inverse of the variance using a random-effects model. Predictors of blood pressure reduction that we examined included method of supplementation, baseline blood pressure, and the methodological quality of the studies. The pooled analysis showed a reduction in systolic blood pressure of -1.27 mm Hg (95% confidence interval [CI], -2.25 to -0.29 mm Hg; P=.01) and in diastolic blood pressure of -0.24 mm Hg (95% CI, -0.92 to 0.44 mm Hg; P=.49). None of the possible mediators of blood pressure reduction explained differences in treatment effects.

CONCLUSIONS

Calcium supplementation may lead to a small reduction in systolic but not diastolic blood pressure. The results do not exclude a larger, important effect of calcium on blood pressure in subpopulations. In particular, further studies should address the hypothesis that inadequate calcium intake is associated with increased blood pressure that can be corrected with calcium supplementation.

A case-control study of nosocomial ampicillin-resistant enterococcal infection and colonization at a university hospital

OBJECTIVE

To assess risk factors for colonization and nosocomial infection with ampicillin-resistant enterococci (ARE).

DESIGN

Patients with ampicillin-resistant enterococci were compared retrospectively by logistic regression analysis with controls harboring susceptible strains. ARE were characterized by whole plasmid DNA analysis and restriction enzyme analysis of plasmid (REAP) DNA with EcoRI.

SETTING

The study was done at a 1,125 bed, tertiary-care teaching hospital in North Carolina with patients from whom enterococci were isolated from June 1, 1989, to March 30, 1991.

PATIENTS

The final study group comprised 44 cases with nosocomially-acquired colonization or infection with ARE and 100 controls with ampicillin-susceptible strains. Clinical and epidemiological risk factors for ARE were abstracted by chart review.

RESULTS

After controlling for age and site of infection, patients with ARE were more likely to have been admitted previously to our hospital and to have received third-generation cephalosporins and clindamycin. However, only advanced age and clindamycin therapy were independently associated with presence of ARE. REAP with EcoRI showed 20 groups of enterococci on 19 different wards.

CONCLUSIONS

These results suggest that ARE are endemic and multifocal in origin in our hospital and that advanced age and use of clindamycin are important selective risk factors for ARE colonization and infection.

The use of amphotericin B in nosocomial fungal infection

The use of potent broad-spectrum antibacterial agents, the increasing number of immunocompromised hosts, and the use of invasive treatment modalities have exacerbated the problems involved in the management of nosocomial fungal infection. The hospital records at a tertiary-care medical center were retrospectively reviewed in an effort to determine the magnitude of these problems. A plethora of fungal species were isolated from patients. Hospital infection surveillance revealed between 30 and 40 nosocomial yeast infections per month, with 20% of nosocomial urinary tract infections caused by yeasts rather than by bacterial pathogens and one or two cases of fungemia per week. Although these figures represent a large number of nosocomial fungal infections, a significant increase in the number of such infections over the last several years could not be documented. The use of amphotericin B was found to have increased each year. The patterns of use of amphotericin B changed little between 1983 and 1987, but the number of patients treated with this agent increased dramatically.