Torsades de pointes associated with voriconazole use.

We describe 2 patients who developed prolonged QTc interval on electrocardiogram while being treated with voriconazole. The first patient had undergone induction chemotherapy for acute myelogenous leukemia, and her course had been complicated by invasive aspergillosis and an acute cardiomyopathy. She developed torsades de pointes 3 weeks after starting voriconazole therapy. She was re-challenged with voriconazole without recurrent QTc prolongation or cardiac dysfunction. The second patient had a significantly prolonged QTc interval while on voriconazole therapy. We recommend careful monitoring for QTc prolongation and arrhythmia in patients who are receiving voriconazole, particularly those who have significant electrolyte disturbances, are on concomitant QT prolonging medications, have heart failure such as from a dilated cardiomyopathy, or have recently received anthracycline-based chemotherapy. The potential for synergistic cardiotoxicity must be carefully considered.

Successful toxoplasmosis prophylaxis after orthotopic cardiac transplantation with trimethoprim-sulfamethoxazole.

BACKGROUND: The efficacy of trimethoprim-sulfamethoxazole (TMP/SMX) in the prevention of toxoplasmosis after orthotopic cardiac transplantation has been the subject of some controversy, with many transplant groups preferring to use the combination of pyrimethamine and sulfadiazine. Although effective, this latter regimen does not offer equal protection against other pathogens, such as or. To assess the value of TMP/SMX, we reviewed the experience in our heart transplant patients, all of whom received TMP/SMX (160/800 mg) three times weekly for approximately 8 months after transplantation. METHODS: We report on 417 orthotopic cardiac transplants during a 17-year period. We have 100% one-year patient follow-up after transplantation. Data was collected on pretransplantation donor and recipient anti- serology, immunosuppression, allograft rejection, survival, yearly posttransplantation anti- serology, development of acute toxoplasmosis, and the occurrence of other infections. RESULTS: In this cohort, acute toxoplasmosis developed after transplantation in one case (0.2%). Among the highest risk patients (D+R-) who were treated for at least one episode of rejection, the risk of acute toxoplasmosis was 5% (1 of 22 patients). No change in survival was found between the different anti- IgG serogroups (D-R-, D-R+, D+R-, or D+R+). Anti- IgG seroconversion occurred in eight -seronegative recipients after transplantation; all patients, except the case already noted, were asymptomatic and required no specific anti- therapy. No cases of, or infections were identified. Five proven and two suspected cases of pneumonia were found (only 2 of these 7 patients were receiving TMP/SMX at the time of pneumonia diagnosis). CONCLUSIONS: These data demonstrate that TMP/SMX prophylaxis (160/800 mg) three times per week is effective prophylaxis after orthotopic cardiac transplantation and has prophylactic benefits against other posttransplantation opportunistic pathogens.

Salvage therapy with voriconazole for invasive fungal infections in patients failing or intolerant to standard antifungal therapy.

BACKGROUND: Invasive fungal infections (IFI), particularly those caused by Aspergillus and other angioinvasive molds, are associated with an excessive mortality despite therapy. METHODS: Voriconazole was prescribed on a compassionate basis to patients with IFI who were intolerant to or who had progressed despite standard therapy. Outcome was determined by protocol-based criteria as established by the consensus definitions (complete response [CR], partial response [PR], stable disease, failure, and intolerance). RESULTS: Forty-five patients were enrolled in a compassionate release program (29 [64%] because of failure of response to standard therapy), between 1998 and 2002. Of the 45 patients enrolled, 35 (78%) had invasive Aspergillus, 3 (7%) had Fusarium, and 2 (4%) had Scedosporium infections. Underlying illnesses were as follows: 13 (29%) solid-organ transplant (SOT), 11 (24%) BMT, and 7 (13%) hematologic malignancy. Site of infection was as follows: 26 (58%) pulmonary, 9 (20%) disseminated, 5 (11%) central nervous system (CNS), and 3 (7%) sinus. Overall response rates were as follows: 9 (20%) CR, 17 (38%) PR, 15 (33%) failure, and 4 (9%) intolerant. Seven of the eight (88%) patients with sinus or CNS disease demonstrated stabilization of the IFI. The median duration of voriconazole therapy was 79 days with 9 (20%) patients receiving over 1 year of therapy. Nine thousand one hundred twenty-eight days of therapy were given with only four serious adverse events in two cases considered possibly or probably drug related. CONCLUSIONS: In this population of severely immunocompromised patients with life-threatening IFI who have failed or were intolerant to standard antifungal therapy, voriconazole demonstrated substantial efficacy and an acceptable level of toxicity.

The quality of terminal care in residential and nursing homes.

This article presents some of the findings from a large national multi-method study on the management of death and dying in residential and nursing homes for older people. The study included all types of registered homes and interviews were conducted with staff, residents and visitors to the homes. Stage 1 used a survey questionnaire to provide background demographic data. Stages 2 and 3 included 100 interviews with the heads of homes and 12 case studies. Particular consideration was given to internal and external influences on care provision in the interviews and observations were made in the case study homes. Clearly, home staff are committed to the provision of good quality terminal care for residents. This article focuses on some of the reasons why that commitment is difficult to translate into practice.

Human immunodeficiency virus-associated fever of unknown origin: a study of 70 patients in the United States and review.

To characterize the clinical features of human immunodeficiency virus (HIV)-associated fever of unknown origin (FUO) in the United States, we performed a retrospective analysis of cases that fulfilled specific criteria (published by Durack and Street in 1991) at two medical centers in the United States between 1992 and 1997. Seventy cases met criteria for HIV-associated FUO; the mean CD4 cell count was 58/mm3, and the mean duration of fever was 42 days. A cause of FUO was found in 56 of the 70 cases; 43 were of a single etiology, and in 13 cases multiple conditions were established. The most common diagnoses were disseminated Mycobacterium avium infection (DMAC; 31%), Pneumocystis carinii pneumonia (13%), cytomegalovirus infection (11%), disseminated histoplasmosis (7%), and lymphoma (7%). In this United States series, FUO occurs most often in the late stage of HIV infection, individual cases often have multiple etiologies, and DMAC is the most common diagnosis.

Self-association of cytochrome b5 in aqueous solution. Gel filtration and ultracentirfugational studies.

The aggregation state of detergent-extracted cytochrome b5 was examined by gel filtration and sedimentation equilibrium ultracentrifugation. Both techniques indicated the presence of a mixture of monomer and octomer. The proportion of monomer was decreased as the buffer salt concentration was raised and was approximately 1 muM in 10 mM Tris acetate/0.1 mM EDTA. The monomeric cytochrome b5 was isolated by gel filtration and showed a decreased tendency to aggregate in dilute buffer, although its other physical properties were identical to those of the original cytochrome b5. The monomer was found to have a Stokes radius of approximately 26 A, as determined by classical gel filtration and by an equilibrium saturation method where the sample was monitored in the gel by measuring the absorbance of the gel column directly in a dual wavelength spectrophotometer. The gel filtration and ultracentrifugation data together with the studied on the monomeric cytochrome b5 suggest the octomer is not a rapid equilibrium with monomer and this observation should be taken into account in lipid binding experiments with cytochrome b5.

Effect of cytochrome b5 on the size, density, and permeability of phosphatidylcholine vesicles.

Cytochrome b5, isolated from rabbit liver by a procedure using detergent, was incubated with phosphatidylcholine bilayer vesicles at 37 degrees for 30 min. A comparison of a number of physical properties was made between the cytochrome b5-phosphatidylcholine complex (at a molar ratio of 1:1000) and the phosphatidylcholine vesicles. The binding of the protein to the vesicle caused no aggregation and no detectable change in Stokes radius of the vesicle as monitored by gel filtration. Only small increases in s20 (from 2.67 up to 3.82 X 10(-13) s) and density (from 1.025 up to 1.042 g ml(-1)) were observed upon binding of the cytochrome b5 to phosphatidylcholine vesicles. At molar ratios of 5:1000, and above, two types of complexes could be detected by sucrose density gradient centrifugation: one had a molar ratio of approximately 1.066 g ml(-1)) the other, a more constant ratio of 20:1000 (density greater than 1.107 g ml(-1)). Cytochrome b5 was also incubated with phosphatidylcholine vesicles prepared with ferricyanide trapped inside. The leakage of the ferricyanide from inside the vesicles was increased when cytochrome b5 was present, but the vesicles, although leaking, were not completely depleted of their ferricyande, and so must still be intact. It is suggested that at molar ratios of cytochrome b5 to phosphatidylcholine below 5:1000, the binding of the protein causes minimal change in vesicle structure.