Epidemiology of Candidemia and Fluconazole Resistance in an ICU before and during the COVID-19 Pandemic Era.

The objectives of this study were to investigate the incidence of candidemia, as well as the factors associated with Candida species distribution and fluconazole resistance, among patients admitted to the intensive care unit (ICU) during the COVID-19 pandemic, as compared to two pre-pandemic periods. All patients admitted to the ICU due to COVID-19 from March 2020 to October 2021, as well as during two pre-pandemic periods (2005-2008 and 2012-2015), who developed candidemia, were included. During the COVID-19 study period, the incidence of candidemia was 10.2%, significantly higher compared with 3.2% and 4.2% in the two pre-pandemic periods, respectively. The proportion of non-albicans Candida species increased (from 60.6% to 62.3% and 75.8%, respectively), with a predominance of C. parapsilosis. A marked increase in fluconazole resistance (from 31% to 37.7% and 48.4%, respectively) was also observed. Regarding the total patient population with candidemia (n = 205), fluconazole resistance was independently associated with ICU length of stay (LOS) before candidemia (OR 1.03; CI: 1.01-1.06, p = 0.003), whereas the presence of shock at candidemia onset was associated with C. albicans (OR 6.89; CI: 2.2-25, p = 0.001), and with fluconazole-susceptible species (OR 0.23; CI: 0.07-0.64, p = 0.006). In conclusion, substantial increases in the incidence of candidemia, in non-albicansCandida species, and in fluconazole resistance were found in patients admitted to the ICU due to COVID-19, compared to pre-pandemic periods. At candidemia onset, prolonged ICU LOS was associated with fluconazole-resistant and the presence of shock with fluconazole-susceptible species.

Renal Resistive Index on Intensive Care Unit Admission Correlates With Tissue Hypoperfusion Indices and Predicts Clinical Outcome.

BACKGROUND: Renal resistive index (RRI) has been used to evaluate renal blood flow. Our aim was to investigate the relation between RRI and global tissue hypoperfusion indices and their association with clinical outcome, in intensive care unit (ICU) patients. METHODS: RRI was measured within 24 h of ICU admission. Gas exchange and routine hemodynamic variables at the time of RRI assessment were recorded. An elevated RRI was defined as >0.7. The ratio of central venous-to-arterial carbon dioxide partial pressure difference by arterial-to-central venous oxygen content difference (P(cv-a)CO2/C(a-cv)O2) and lactate were used as global tissue hypoperfusion indices. RESULTS: A total of 126 patients were included [median age 61 (IQR 28) years, 74% males]. P(cv-a)CO2/C(a-cv)O2 ratio and arterial lactate were significantly higher in patients with RRI >0.7 compared with those with RRI ≤0.7 [2.88 (3.39) vs. 0.62 (0.57) mmol/L and 2.4 (2.2) vs. 1.2 (0.6)] respectively, both P < 0.001)]. RRI was significantly correlated with P(cv-a)CO2/C(a-cv)O2 ratio and arterial lactate for the whole patient population (rho = 0.64, both P < 0.0001) and for the subset of patients with shock (rho = 0.47, P = 0.001; and r = 0.64, P < 0.0001 respectively). Logistic regression models showed a significant association between RRI and P(cv-a)CO2/C(a-cv)O2 ratio with clinical outcome. The combination of RRI with P(cv-a)CO2)/(C(a-cv)O2 ratio and lactate better predicted mortality than RRI alone [AUC 84.8% (95% CI 5.1% -94.4%)] vs. [AUC 74.9% (95% CI 61%-88.8%)] respectively, P < 0.001. CONCLUSIONS: Renal blood flow assessed by RRI, on ICU admission, correlates with global tissue hypoperfusion indices. In addition, RRI in combination with tissue perfusion estimation better predicts clinical outcome than RRI alone.

Clinical characteristics and management of a Greek female patient cohort with breast conserving treatment.

PURPOSE: The purpose of this retrospective single-center study was to examine histopathological characteristics and treatment options in a cohort of Greek female patients treated with breast conserving surgery (BCS) and to evaluate potential predictive factors of breast cancer (BC) local recurrence. METHODS: The clinic's medical records from 1995 up to the end of July 2016 were scanned in order to identify female patients treated with BCS. We recognized 1175 patients who underwent BCS, representing 35.8% of the entire sample (3281 patients). RESULTS: The mean age of the patients enrolled in this study was 54.7 years, with a median follow-up period of 58.5 months. Nine deaths (0.8%) were registered with 5-year overall survival (OS) rate being 100%. Regarding adjuvant therapies, radiotherapy (RT) was assigned to 94.4% of the patients, endocrine therapy to 86.0%, chemotherapy to 51.3%, while all therapies were given simultaneously to 38.3% of the sample patients. Herceptin was administered to 14.1% of the patients. Twenty-eight recurrences (2.4%) with 3 deaths (10.7%) were confirmed. Over all traditional parameters studied, only lymph node status appeared to be statistically correlated with local recurrence (p=0.005). T3 stage can be considered as a hint that this tumor size might be a risk factor of local recurrence. Age at diagnosis seems to be an independent factor of BC local recurrence. CONCLUSIONS: A very low rate of local recurrence (2.4%) was validated which can be attributed to patients being appropriately selected for BCS, who were then enrolled in this study, and to the uniformity of the RT plan.

A novel mortality prediction model for the current population in an adult intensive care unit.

BACKGROUND: The accurate and reliable mortality prediction is very useful, in critical care medicine. There are various new variables proposed in the literature that could potentially increase the predictive ability for death in ICU of the new predictive scoring model. OBJECTIVE: To develop and validate a new intensive care unit (ICU) mortality prediction model, using data that are routinely collected during the first 24 h of ICU admission, and compare its performance to the most widely used conventional scoring systems. METHODS: Prospective observational study in a medical/surgical, multidisciplinary ICU, using multivariate logistic regression modeling. The new model was developed using data from a medical record review of 400 adult intensive care unit patients and was validated on a separate sample of 36 patients, to accurately predict mortality in ICU. RESULTS: The new model is simple, flexible and shows improved performance (ROC AUC = 0.85, SMR = 1.25), compared to the conventional scoring models (APACHE II: AUC = 0.76, SMR = 2.50, SAPS III: AUC = 0.76, SMR = 1.50), as well as higher predictive capability regarding ICU mortality (predicted mortality: 41.63 ± 31.61, observed mortality: 41.67%). CONCLUSION: The newly developed model is a quite simple risk-adjusted outcome prediction tool based on 12 routinely collected demographic and clinical variables obtained from the medical record data. It appears to be a reliable predictor of ICU mortality and is proposed for further investigation aiming at its evaluation, validation and applicability to other ICUs.

Laparoscopic Reversal of Tubal Sterilization; A Retrospective Study Over 135 Cases.

Objectives: To evaluate the pregnancy and delivery rates of laparoscopic tubal reanastomosis. Study Design: From 2003 to 2013, 135 laparoscopic tubal reversals were performed according to the four stitch technique. The parameters studied, included positive pregnancy test, miscarriage, ectopic pregnancy, termination of pregnancy, term delivery, post-operative time to conception, post-operative hysterosalpingography, and spermogram. Results: From the 135 patients operated, 93 fulfilled the inclusion criteria. The age of patients varied from 27 to 47 years old. All ages combined, positive ß-HCG blood sample rate was 75.3% (95% CI: 65.0-83.4%) and term delivery 52.7% (95%CI: 42.1-3.0%). The age-adjusted pregnancy and delivery rates were as follows: 27-35 y.o. (n = 23) 95.7% (95%CI: 76.0-99.8%) and 73.9% (95%CI: 51.3-88.9%),36-39 y.o. (n = 40) 77.5% (95%CI: 61.1-88.6%) and 47.5% (95%CI: 31.8-63.7%),40-42 y.o. (n = 19) 68.4% (95%CI: 43.5-86.4%) and 52.6% (95%CI: 29.5-74.8%),43-47 y.o. (n = 11) 36.4% (95%CI: 12.4-68.4%) and 27.3% (95%CI: 7.3-60.7%). Conclusions: In our series the pregnancy and delivery rates after laparoscopic reversal of tubal sterilization is estimated at 75.3 and 52.7%, respectively. For women with tubal sterilization and no other infertility factors, reanastomosis can restore anterior natural fertility related to age. Laparoscopic reversal should be proposed systematically to patients and performed by well-trained laparoscopists, avoiding potentially the inconvenient and adverse outcomes of an IVF treatment. Although, it may seem a more cost-effective technique compared to robotically assisted reversal, a prospective randomized trial could answer this question.

Impact of Oncotype DX on chemotherapy assignment: a retrospective single-center study on female breast cancer patients.

PURPOSE: This study was designed to determine the Recurrence Score (RS) distribution and its associated risk assessments based on traditional clinicopathologic characteristics in a single-center breast cancer (BC) deriving cohort in Greece, and to evaluate the impact of the RS results on adjuvant treatment decisions applied in this cohort. METHODS: This was a retrospective, single-center study regarding Greek female patients with early-stage breast cancer (ESBC). From 2009 to 2015, 114 cases lacking unanimity in the multidisciplinary breast meeting (MDM) fulfilled the inclusion criteria. The RS of the Oncotype DX (ODX) assay was the main outcome. RESULTS: The mean RS in the sample was 16.38 (SD=6.87). RS was positively correlated with Ki-67 (p=0.008). A negative progesterone receptor (PR) was associated with a higher RS (p<0.05). RS was higher for cases of chemotherapy assignment (p<0.001). According to the oncologists' pre-DX assay recommendations, 62.8% of the patients would have been 'wrongly' assigned to chemotherapy, while 14.3% of patients would have not been recommended this treatment even though they should have. The overall chemotherapy recommendation was significantly altered after the ODX RS assay was carried out (p=0.008) and, in the sample, it diminished by 39.5%. CONCLUSIONS: The distribution of the ODX RS in the specific cohort of Greek women is similar to that reported in other geographic regions of the world. Knowledge of the RS resulted in a shift in treatment recommendations towards lower-intensity regimens and in a greatly reduced proportion of chemotherapy recommendations.

Clinical characteristics and management of a Greek female patient cohort with breast ductal carcinoma in situ.

PURPOSE: The purpose of this retrospective single-centre study was to examine the histopathological characteristics of breast ductal carcinoma in situ (DCIS) lesions in a cohort of Greek female patients and describe our experience regarding the clinical management of the disease. METHODS: The medical records from 1995 up to mid-2014 were scanned in order to trace DCIS cases. One hundred and seventy two patients (6.8% of all breast cancer cases) were diagnosed with pure DCIS and no invasive components; 32.0% underwent a second surgery, mainly due to first surgery positive margins. RESULTS: Age at first surgery ranged from 27 to 79 years (mean±SD 50±11) and median tumor size was 10mm (interquartile range/IQR7equals;12mm). Comedo necrosis (CN) was identified in 28.5% of the cases. The detection of CN was significantly associated with older age at diagnosis, larger tumor size and lower probability of highly differentiated tumors. Radiotherapy (RT) and hormonotherapy (HT) were applied to 44.8% and 63.4% of the patients, respectively. CONCLUSIONS: We implemented international practices (surgery, radiotherapy and prophylactic hormonal therapy) to patients diagnosed with DCIS and have observed only two relapses. It is our belief that DCIS requires a multidisciplinary approach and patient-tailored therapy which can potentially contribute to minimization of the local recurrence risk.

Scoring Systems for Outcome Prediction in a Cardiac Surgical Intensive Care Unit: A Comparative Study.

BACKGROUND: Most scoring systems used to predict clinical outcome in critical care were not designed for application in cardiac surgery patients. OBJECTIVES: To compare the predictive ability of the most widely used scoring systems (Acute Physiology and Chronic Health Evaluation [APACHE] II, Simplified Acute Physiology Score [SAPS] II, and Sequential Organ Failure Assessment [SOFA]) and of 2 specialized systems (European System for Cardiac Operative Risk Evaluation [EuroSCORE] II and the cardiac surgery score [CASUS]) for clinical outcome in patients after cardiac surgery. METHODS: Consecutive patients admitted to a cardiac surgical intensive care unit (CSICU) were prospectively studied. Data on the preoperative condition, intraoperative parameters, and postoperative course were collected. EuroSCORE II, CASUS, and scores from 3 general severity-scoring systems (APACHE II, SAPS II, and SOFA) were calculated on the first postoperative day. Clinical outcome was defined as 30-day mortality and in-hospital morbidity. RESULTS: A total of 150 patients were included. Thirty-day mortality was 6%. CASUS was superior in outcome prediction, both in relation to discrimination (area under curve, 0.89) and calibration (Brier score = 0.043, χ(2) = 2.2, P = .89), followed by EuroSCORE II for 30-day mortality (area under curve, 0.87) and SOFA for morbidity (Spearman ρ= 0.37 and 0.35 for the CSICU length of stay and duration of mechanical ventilation, respectively; Wilcoxon W = 367.5, P = .03 for probability of readmission to CSICU). CONCLUSIONS: CASUS can be recommended as the most reliable and beneficial option for benchmarking and risk stratification in cardiac surgery patients.

Cell cycle and apoptosis regulatory gene expression in the bone marrow of patients with de novo myelodysplastic syndromes (MDS).

Deregulation of cell cycle and apoptosis pathways are known contributors to the pathogenesis of myelodysplastic syndromes (MDS). However, the underlying mechanisms are not fully clarified. The aim of our study was to examine mRNA expression levels of cell cycle and apoptosis regulatory genes, as well as the percentage of apoptotic and S phase cells and to correlate the findings with clinical characteristics and prognosis. Sixty patients with MDS, classified according to FAB (17 RA, five RARS, 19 RAEB, nine RAEBT, ten CMML) and WHO (ten RA, three RARS, seven RCMD, two RCMD-RS, 11 RAEBI, eight RAEBII, ten CMML, and nine AML) were included in the study. We found increased expression of anti-apoptotic bclxL and mcl1 genes and decreased expression of p21 gene in MDS patients. Moreover, we found increased expression of anti-apoptotic mcl1 gene in patients with higher than Intermediate-1 IPSS group. Multivariate analysis confirmed that combined expression of apoptotic caspases 8, 3, 6, 5, 2, 7, and Granzyme B was decreased in MDS patients. Regarding cell cycle regulatory genes expression, we demonstrated increased expression of cyclin D1 in patients with CMML Increased combined expression of cyclins B, C, D1, and D2 was found in patients with cytogenetic abnormalities. The two pathways seem to be interconnected as shown by the positive correlation between CDKs 1, 2, 4, p21 and the level of apoptosis and positive correlation between apoptotic caspase 3 expression and the percentage of S phase cells. In conclusion, our study showed altered expression of genes involved in apoptosis and cell cycle in MDS and increased expression of cyclin D1 in patients with CMML.