Propensity Score Analysis of the Role of Initial Antifungal Therapy in the Outcome of Candida glabrata Bloodstream Infections.

Candida glabrata isolates have reduced in vitro susceptibility to azoles, which raises concerns about the clinical effectiveness of fluconazole for treating bloodstream infection (BSI) by this Candida species. We aimed to evaluate whether the choice of initial antifungal treatment (fluconazole versus echinocandins or liposomal amphotericin B [L-AmB]-based regimens) has an impact on the outcome of C. glabrata BSI. We analyzed data from a prospective, multicenter, population-based surveillance program on candidemia conducted in 5 metropolitan areas of Spain (May 2010 to April 2011). Adult patients with an episode of C. glabrata BSI were included. The main outcomes were 14-day mortality and treatment failure (14-day mortality and/or persistent C. glabrata BSI for ≥48 h despite antifungal initiation). The impact of using fluconazole as initial antifungal treatment on the patients' prognosis was assessed by logistic regression analysis with the addition of a propensity score approach. A total of 94 patients with C. glabrata BSI were identified. Of these, 34 had received fluconazole and 35 had received an echinocandin/L-AmB-based regimen. Patients in the echinocandin/L-AmB group had poorer baseline clinical status than did those in the fluconazole group. Patients in the fluconazole group were more frequently (55.9% versus 28.6%) and much earlier (median time, 3 versus 7 days) switched to another antifungal regimen. Overall, 14-day mortality was 13% (9/69) and treatment failure 34.8% (24/69), with no significant differences between the groups. On multivariate analysis, after adjusting for baseline characteristics by propensity score, fluconazole use was not associated with an unfavorable evolution (adjusted odds ratio [OR] for 14-day mortality, 1.16, with 95% confidence interval [CI] of 0.22 to 6.17; adjusted OR for treatment failure, 0.83, with 95% CI of 0.27 to 2.61). In conclusion, initial fluconazole treatment was not associated with a poorer outcome than that obtained with echinocandins/L-AmB regimens in patients with C. glabrata BSI. (This study has been registered at ClinicalTrials.gov under registration no. NCT01236261.).

Espasmo del reflejo de cerca. Tratamiento con toxina botulínica / Spasm of the near reflex. Treatment with botulinum toxin

CASO CLÍNICO: Mujer de 38 años con diplopía y endotropía. Limitación total de la abducción en AO al explorar las versiones, que se normalizan al explorar el reflejo de los ojos de muñeca. Es diagnosticada de espasmo del reflejo de cerca (ERC) y tratada con inyecciones repetidas de Botox en rectos medios, resolviéndose temporalmente el espasmo. DISCUSIÓN: El ERC se caracteriza por miosis, seudomiopía y convergencia que producen diplopía, visión borrosa, cefalea y endotropía variable, progresiva e intermitente. Se puede confundir con una paresia bilateral del vi nervio. El tratamiento con inyecciones repetidas de bótox puede ser efectivo en algunos casos

CLINICAL CASE: A 38-year old female with diplopia and esotropia, with limitation of ocular abduction in both eyes, with full abduction after doll's head rotation also being observed. She was diagnosed with spasm of the near reflex. Treatment with injections of botulinum toxin in both medial rectus has temporally resolved the convergence spasm. DISCUSSION: Near reflex spasm is characterized as miosis, pseudomyopia, and convergent strabismus that lead to diplopia, blurred vision, headache, and variable, progressive, and intermittent esotropia. As the spasm worsens there will be limited ocular versions and ductions simulating a sixth nerve palsy. Botulinum toxin may be effective in some cases

[Spasm of the near reflex. Treatment with botulinum toxin]. / Espasmo del reflejo de cerca. Tratamiento con toxina botulínica.

CLINICAL CASE: A 38-year old female with diplopia and esotropia, with limitation of ocular abduction in both eyes, with full abduction after doll's head rotation also being observed. She was diagnosed with spasm of the near reflex. Treatment with injections of botulinum toxin in both medial rectus has temporally resolved the convergence spasm. DISCUSSION: Near reflex spasm is characterized as miosis, pseudomyopia, and convergent strabismus that lead to diplopia, blurred vision, headache, and variable, progressive, and intermittent esotropia. As the spasm worsens there will be limited ocular versions and ductions simulating a sixth nerve palsy. Botulinum toxin may be effective in some cases.

Klebsiella pneumoniae: development of a mixed population of carbapenem and tigecycline resistance during antimicrobial therapy in a kidney transplant patient.

Nine isolates of Klebsiella pneumoniae were isolated from a renal transplant patient suffering from recurrent urosepsis over a period of 4 months. Imipenem resistance was detected after imipenem-ertapenem therapy. When treatment was switched to tigecycline the K. pneumoniae developed resistance to tigecycline (MIC = 8 mg/L). The nine isolates were tested by determination of agar dilution MICs, phenotypic carbapenemase, extended-spectrum beta-lactamases and metallo-beta-lactamase (MBL) testing and pulsed-field gel electrophoresis. Polymerase chain reaction and sequencing analysis were employed for identification of bla genes and mapping of the integron carrying the MBL gene. The nine isolates were clonally related and all produced the SHV-12 enzyme. Five MBL-producing isolates showed imipenem MICs ranging from 2 to 64 mg/L and all were detected by testing with imipenem and EDTA. The five isolates harboured the bla(VIM-1) gene. Three isolates showed increased tigecycline MICs (4-8 mg/L). Serial blood cultures obtained on the same day resulted in a VIM-positive/tigecycline-susceptible and a VIM-negative/tigecycline-resistant K. pneumoniae isolate. No isolate developed concurrent imipenem and tigecycline resistance. The patient had a persistent urinary tract infection and recurrent bacteraemia caused by a mixed population of Klebesiella pneumoniae isolates adapting to the selective pressure of antimicrobial therapy at the time. The present study is a worrisome example of what could happen when an immunocompromised host is subjected to the pressures of antimicrobial therapy. In addition, we report the first treatment-emergent MIC increase of tigecycline from 0.5 to 8 mg/L in K. pneumoniae.

Nutritional and management strategies on nitrogen and phosphorus use efficiency of lactating dairy cattle on commercial farms: an environmental perspective.

Dairy farm activities contribute to environmental pollution through the surplus N and P that they produce. Optimization of animal feeding and management has been described as a key strategy for decreasing N and P excretion in manure. Sixty-four commercial dairy farms were studied to assess the efficiency of N and P use in lactating herds and to identify dietary and management factors that may contribute to improving the efficiency of nutrient use for milk production, and decrease N and P excretion. The average ration was formulated to 50:50 forage:concentrate ratio with grass silage and corn silage as the main forage sources. Mean N and P intakes were 562 g/d [16.4% crude protein (CP)] and 84.8 g/d (0.40% P), respectively. Milk yield averaged 29.7 kg/d and contributed to 25.8% (standard deviation +/- 2.9) of N utilization efficiency (NUE) and 31.9% (standard deviation +/- 4.5) of P utilization efficiency (PUE). Dietary N manipulation through fitting the intake of CP to animal requirements showed a better response in terms of decreasing N excretion (R(2) = 0.70) than that estimated for P nutrition and excretion (R(2) = 0.30). Improvement in NUE helped increase PUE, despite the widespread use of feedstuffs with a high P content. Management strategies for lactating herds, such as the use of different feeding groups, periodical ration reformulation, and selection of feeding system did not show any consistent response in terms of improved NUE and PUE. The optimization of NUE and PUE contributed to decreasing the N and P excretion per unit of milk produced, and therefore, reductions in N and P excretion of between 17 and 35%, respectively, were estimated. Nevertheless, nutritional and herd management strategies were limited when N and P excretion were considered in relation to the whole lactating herd and farmland availability. Dietary CP manipulation was estimated to decrease herd N excretion by 11% per hectare, whereas dietary P manipulation would be decreased by no more than 17%. We conclude that the correct match between the ingested and required N and P, together with an increase in milk productivity, may be feasible strategies for decreasing N and P excretion by lactating herds on commercial farms.

[Diplopia after sub-Tenon's anesthesia for cataract surgery]. / Diplopía postcirugía de catarata con anestesia subtenoniana.

PURPOSE: To study the clinical signs, treatment and prognosis of strabismus after sub-Tenon's anesthesia for cataract surgery. METHODS: Eight patients without previous strabismus developed incomitant diplopia immediately after cataract surgery; the left eye was affected in five patients and the right eye in three. Restrictive strabismus was diagnosed with the cover test, prisms, and active and passive ductions in all cases. In seven cases the deviation was vertical and in one patient it was horizontal. The average deviation was 17.5 S.D. 9.84 (range 5-35) prismatic dioptres in primary position. The deviation increased looking upward in seven cases, and looking sideways to the left in the other. It was considered to be a good result if the diplopia disappeared after treatment. RESULTS: Botulinum toxin was the first treatment applied in four patients, but only one showed a good response and required no further therapy. Strabismus surgery was required in four cases, and prisms were adapted in three. Three patients required two strabismus operations. A good result was achieved in all cases, with the average time interval being 10.12 (SD 5.5) months. CONCLUSIONS: Sub-Tenon's anesthesia may result in restrictive strabismus and incomitant diplopia which does not resolve spontaneously. The inferior rectus is the most commonly affected muscle. Strabismus surgery is required to resolve the diplopia in half of the cases. Good results have been achieved in all patients.