Procedure-Focused Escape Room: A Pilot Study on Teaching High-Stakes Technical Skills in Anesthesia Residents.

Background: High-stakes yet clinically infrequent procedures are challenging to teach. Escape rooms may offer an innovative solution through game-based learning. There is limited guidance on how to design an escape room focused on physical puzzles. We designed and implemented a procedure-focused escape room to teach high-stakes procedures to anesthesiology residents. Methods: We selected 5 procedural skills relevant to anesthesiology residents through a modified Delphi technique: fiberoptic intubation, rapid infuser setup, intraosseous line placement, flexible bronchoscopy, and supraglottic airway exchange. We designed associated skills stations and linked them in sequence using an elaborate series of puzzles, locks, keys, and codes. The total cost of puzzle equipment was $169.53. After pilot testing, we implemented the escape room from July to November 2022. We assessed residents using a single group pretest-posttest study design. Results: Forty-three of 55 (78%) eligible anesthesiology residents participated in the escape room. Thirty-one residents completed the surveys. Resident self-efficacy significantly improved for each of the 5 procedures. Twenty-six of 27 (96%) residents preferred the escape room over a typical procedural skills workshop. Conclusions: This pilot study demonstrated the feasibility of a procedure-focused escape room for teaching high-stakes technical skills. We identified 3 lessons in procedure-focused escape room design: set participant caps intentionally, optimize resource usage, and maximize reproducibility. Participating in a single escape room session significantly increased resident self-efficacy. Residents strongly preferred the escape room format over a traditional procedural skills workshop.

A case report and anesthetic implications of situs inversus totalis in video-assisted thoracoscopic pulmonary resection.

Introduction and importance: Reports are limited on video-assisted thoracoscopic surgery for lung malignancy of patients with situs inversus totalis (SIT). Patients with SIT have significant anatomic differences with implications that are important for surgery, anesthesia, and nursing to understand in order to provide care for this patient population. Case presentation: A 64-year-old man with SIT and lung adenocarcinoma needed flexible bronchoscopy and wedge resection of a 9×8 mm adenocarcinoma in the right upper lobe and underwent video-assisted thoracoscopic surgery. Clinical discussion: Preoperative planning, including collaboration with the surgical team, allowed safe monitoring, induction of anesthesia, and airway isolation in this patient allowing them to have successful resection of their pulmonary malignancy. Postoperative care was enhanced by detailed communication and understanding of the patient's anatomy and implications of this condition for post anesthesia care unit nursing care. Conclusion: Patients with rare clinical conditions and backgrounds may require surgical and anesthetic intervention. The authors describe important anesthetic considerations of preoperative evaluation, airway management, cardiac monitoring, and vascular access that should be noted and taken into account for patients with SIT. Proper preparation, planning, and communication allow for patients with SIT to safely undergo surgical procedures.

Esophagectomy Enhanced Recovery After Surgery Initiative Results in Improved Outcomes.

BACKGROUND: Esophagectomy for esophageal cancer is a procedure with high morbidity and mortality. This study developed a Multidisciplinary Esophagectomy Enhanced Recovery Initiative (MERIT) pathway and analyzed implementation outcomes in a single institution. METHODS: The MERIT pathway was developed as a practice optimization and quality improvement initiative. Patients were studied from November 1, 2021 to June 20, 2022 and were compared with historical control subjects. The Wilcoxon rank sum test and the Fisher exact test were used for statistical analysis. RESULTS: The study compared 238 historical patients (January 17, 2017 to December 30, 2020) with 58 consecutive MERIT patients. There were no significant differences between patient characteristics in the 2 groups. In the MERIT group, 49 (85%) of the patients were male, and their mean age was 65 years (range, 59-71 years). Most cases were performed for esophageal cancer after neoadjuvant therapy. Length of stay improved by 27% from 11 to 8 days (P = .27). There was a 12% (P = .05) atrial arrhythmia rate reduction, as well as a 9% (P = .01) decrease in postoperative ileus. Overall complications were reduced from 54% to 35% (-19%; P = .01). CONCLUSIONS: This study successfully developed and implemented an enhanced recovery after surgery pathway for esophagectomy. In the first year, study investigators were able to reduce overall complications, specifically atrial arrhythmias, and postoperative ileus.

Development and Pilot Testing of a Programmatic System for Competency Assessment in US Anesthesiology Residency Training.

BACKGROUND: In 2018, a set of entrustable professional activities (EPAs) and procedural skills assessments were developed for anesthesiology training, but they did not assess all the Accreditation Council for Graduate Medical Education (ACGME) milestones. The aims of this study were to (1) remap the 2018 EPA and procedural skills assessments to the revised ACGME Anesthesiology Milestones 2.0, (2) develop new assessments that combined with the original assessments to create a system of assessment that addresses all level 1 to 4 milestones, and (3) provide evidence for the validity of the assessments. METHODS: Using a modified Delphi process, a panel of anesthesiology education experts remapped the original assessments developed in 2018 to the Anesthesiology Milestones 2.0 and developed new assessments to create a system that assessed all level 1 through 4 milestones. Following a 24-month pilot at 7 institutions, the number of EPA and procedural skill assessments and mean scores were computed at the end of the academic year. Milestone achievement and subcompetency data for assessments from a single institution were compared to scores assigned by the institution's clinical competency committee (CCC). RESULTS: New assessment development, 2 months of testing and feedback, and revisions resulted in 5 new EPAs, 11 nontechnical skills assessments (NTSAs), and 6 objective structured clinical examinations (OSCEs). Combined with the original 20 EPAs and procedural skills assessments, the new system of assessment addresses 99% of level 1 to 4 Anesthesiology Milestones 2.0. During the 24-month pilot, aggregate mean EPA and procedural skill scores significantly increased with year in training. System subcompetency scores correlated significantly with 15 of 23 (65.2%) corresponding CCC scores at a single institution, but 8 correlations (36.4%) were <30.0, illustrating poor correlation. CONCLUSIONS: A panel of experts developed a set of EPAs, procedural skill assessment, NTSAs, and OSCEs to form a programmatic system of assessment for anesthesiology residency training in the United States. The method used to develop and pilot test the assessments, the progression of assessment scores with time in training, and the correlation of assessment scores with CCC scoring of milestone achievement provide evidence for the validity of the assessments.

Intrathecal Opioid Use in Kidney Transplantation: An Observational Cohort Study.

BACKGROUND: Kidney transplant is the most common transplant operation performed in the United States. Although various approaches to pain management have been described, the optimal analgesic strategy remains undefined. Specifically, the role of intrathecal opioids in this patient population has not been comprehensively evaluated. METHODS: Using a retrospective cohort design, data from kidney transplant operations at a single tertiary care medical center between August 1, 2017, and July 31, 2022, were extracted. Inverse probability of treatment weighting (IPTW) was used to assess differences in clinical outcomes based on the presence or absence of intrathecal opioid administration before surgical incision. The primary outcome was total opioid exposure expressed in milligram morphine equivalents (MME) in the first 72 hours postoperatively, with secondary outcomes including total MME (intraoperative plus postoperative MME, postoperative pain scores, and the presence of postoperative nausea/vomiting [PONV], pruritus, or adverse events). RESULTS: A total of 1014 kidney transplants in 1012 unique patients were included, with 411 (41%) receiving intrathecal opioids preoperatively. Hydromorphone was the intrathecal opioid used in all cases with median dose of 100 µg (interquartile range [IQR], 100, 100; range 50-200). Subjects receiving intrathecal opioids had significantly lower postoperative opioid requirements at 72 hours (30 [0-68] vs 64 [22, 120] MME), with ratio of geometric means in the IPTW analysis (ratio of geometric means 0.34, 95% confidence interval [CI], 0.26-0.43; P < .001). Similar findings were observed for total opioids (45 [30-75] vs 75 [60-90] MME; ratio of geometric means 0.58, 95% CI, 0.54-0.63; P < .001). Maximum reported pain scores in the intrathecal group were lower at 24 hours (4 [2-7] vs 7 [5, 8]; OR, 0.28; 95% CI, 0.21-0.37 for experiencing a higher pain score with intrathecal opioids, P < .001) and 72 hours (6 [4-7] vs 7 [5-8]; OR, 0.41; 95% CI, 0.31-0.54; P < .001). Patients receiving intrathecal opioids were more likely to experience PONV (225 of 411 [55%] vs 232 of 603 [38%]; OR, 2.16; 95% CI, 1.63-2.86; P < .001). CONCLUSIONS: Intrathecal opioid administration was associated with improved pain outcomes in patients undergoing kidney transplantation, including lower opioid requirements and pain scores through 72 hours. However, this was accompanied by an increased risk of PONV.

Intraoperative Dysrhythmias Cease After Venting During Intramedullary Nailing of an Impending Femur Fracture: A Case Report.

CASE: A 76-year-old woman with multiple myeloma and osteoporosis presented with right hip pain and an impending atypical femoral fracture in the setting of chronic bisphosphonate use. After preoperative medical optimization, she was scheduled for prophylactic intramedullary nail fixation. Intraoperatively, the patient experienced episodes of severe bradycardia and asystole associated with intramedullary reaming, which ceased after distal venting of the femur. No additional intraoperative or postoperative complications were encountered, and the patient recovered uneventfully. CONCLUSION: Femoral canal venting may be an appropriate intervention for similar transient dysrhythmias caused by intramedullary reaming.

A Novel Approach to Emergency Airway Simulation Using a 3D-printed Cricothyrotomy Task Trainer.

BACKGROUND: Cricothyrotomy is a final recourse for salvaging a difficult airway, yet most anesthesiology providers have little training, exposure, or comfort with the procedure. Pig tracheas are frequently used for training, but are single use and require special handling and storage. Other simulation models, such as mannequins and cadavers, are costly. Advances in 3dimensional (3D) printing have improved accessibility and decreased costs. This research project sought to determine whether an inexpensive 3D-printed task trainer was noninferior to pig tracheas for teaching surgical cricothyrotomy skills. METHODS: Anesthesiology residents were enrolled in an institutional review board-exempted, unblinded, randomized, controlled, single-institution, noninferiority trial. Participants were trained in the scalpel-finger-bougie technique for surgical cricothyrotomy. Participants were randomized to practice 5 repetitions on either a pig trachea or the 3D model and were assessed on time to cricothyrotomy completion on a pig trachea before and after practice. RESULTS: Demographic characteristics of the 25 workshop attendees were similar between study arms. Overall mean (SD) improvement in speed was 9 (12) seconds (P = .001). Postpractice times were similar between groups (analysis of covariance estimated difference of -0.1 seconds [95% confidence interval, -9.4 to 9.2]; P = .55). The 3D model was noninferior to the pig trachea at the prespecified noninferiority margin of 10 seconds (P = .017). CONCLUSIONS: The 3D model was noninferior to pig tracheas for improving the time to completion of a surgical cricothyrotomy. A 3D-printed model offers a viable alternative to pig tracheas for emergency airway simulation that is inexpensive, reusable, and readily modified to simulate challenging airway anatomy.

Real-World Clinical Use and Outcomes of Telavancin for the Treatment of Bone and Joint Infections: Results from the Telavancin Observational Use Registry (TOUR™).

BACKGROUND: Additional antibiotic options are needed to treat bone and joint infections caused by penicillin-resistant Gram-positive pathogens. OBJECTIVE: This subanalysis of the Telavancin Observational Use Registry (TOUR™) aimed to record real-world telavancin usage patterns in patients with bone and joint infections treated with telavancin. METHODS: TOUR was a multicenter observational-use registry study conducted at 45 US sites between January 2015 and March 2017. Patient characteristics, infection type, infecting pathogen(s), previous treatment, telavancin dosing and duration, clinical response, and adverse event data were collected by retrospective medical chart reviews. As such, inclusion/exclusion criteria were limited, and any patient receiving at least one dose of telavancin at the discretion of the treating physician was eligible. Patients were assessed as either positive clinical response, failed treatment, or indeterminate outcome. RESULTS: Of the 1063 patients enrolled in TOUR, 27.4% (291/1063) were patients with bone and joint infections including osteomyelitis (with or without prosthetic material), acute septic arthritis, and prosthetic joint infections. Most of these patients had osteomyelitis without prosthetic material (191/291; 66.0%). Among patients assessed at the end of treatment, 211/268 (78.7%) achieved a positive clinical response, 26/268 (9.7%) failed treatment, and 31/268 (11.6%) had an indeterminate outcome. The most frequent pathogen was methicillin-resistant Staphylococcus aureus (110/291; 37.8%). The median (interquartile range [IQR as Q1, Q3]) telavancin dose was 750.0 mg (IQR, 750, 750 mg) or 8.2 mg/kg (IQR, 6.8, 9.7 mg/kg) administered for a median of 26 days (IQR, 12, 42 days). These assessments were recorded in the registry ≥ 30 days after the last dose of telavancin was administered. CONCLUSIONS: Real-world data from the TOUR study show that clinicians are using once-daily telavancin with positive clinical outcomes for the treatment of bone and joint infections caused by Gram-positive pathogens. CLINICAL TRIAL REGISTRATION: This trial was registered with ClinicalTrials.gov (NCT02288234) on 11 November, 2014.

Training the Trainer: Preparing Anesthesiology Residents to be Trainers in the Operating Room.

Introduction: The transition into clinical anesthesiology is a challenging period that requires swift acquisition of clinical knowledge and procedural skills. Senior residents are in a prime position to help their junior colleagues into the operating room environment due to their ability to relate from personal experience. We created a workshop for enhancing peer apprenticeship during this transition. Methods: The workshop consisted of PowerPoint didactics interspersed with small-group practice sessions. Surveys were administered pre-, post-, 1-week post-, and 1-month postworkshop. The primary outcome was pre-post improvement in the proportion of residents prepared to be a trainer. Secondary outcomes included pre- to 1-week postworkshop improvement, pre-postworkshop change in knowledge of learning theory concepts, and pre-postworkshop change in first-year clinical anesthesiology perceptions of trainers. Results: Of residents, 12 of 43 (28%) eligible to be resident trainers attended the workshop. The proportion of residents who felt prepared increased from 75% preworkshop to 100% postworkshop and remained at 93% at 1 week. Knowledge of cognitive load and microskills improved from 0% preworkshop to 83% postworkshop but dropped to 0% at 1 month. Comfort using microskills improved from 0% preworkshop to 83% postworkshop. Discussion: Early anesthesiology training demands rapid acquisition of novel cognitive and procedural skills. Senior anesthesiology residents are in a prime position to train junior residents, yet many are uncomfortable with this role. We developed a workshop to transition residents into a peer trainer role and significantly increased their confidence to be a trainer. Other programs may benefit from implementing similar training.

Pulmonary Complications in Esophagectomy Based on Intraoperative Fluid Rate: A Single-Center Study.

OBJECTIVES: Esophagectomy is associated with significant morbidity and mortality. The authors assessed the relationship between intraoperative fluid (IOF) administration and postoperative pulmonary outcomes in patients undergoing a transthoracic, transhiatal, or tri-incisional esophagectomy. DESIGN: Retrospective cohort study (level 3 evidence). SETTING: Tertiary care referral center. PARTICIPANTS: Patients who underwent esophagectomy from 2007 to 2017. INTERVENTIONS: The IOF rate (mL/kg/h) was the predictor variable analyzed both as a continuous and binary categorical variable based on median IOF rate for this cohort (11.90 mL/kg/h). MEASUREMENTS: Primary outcomes included rates of acute respiratory distress syndrome (ARDS) within ten days after esophagectomy. Secondary outcomes included rates of reintubation, pneumonia, cardiac or renal morbidity, intensive care unit admission, length of stay, procedure-related complications, and mortality. Multivariate regression analysis determined associations between IOF rate and postoperative outcomes. Analysis was adjusted for age, sex, body mass index, procedure type, year, and thoracic epidural use. MAIN RESULTS: A total of 1,040 patients comprised this cohort. Tri-incisional esophagectomy was associated with a higher hospital mortality rate (7.8%) compared with transthoracic esophagectomy (2.6%, p = 0.03) or transhiatal esophagectomy (0.7%, p = 0.01). Regression analysis revealed a higher IOF rate was associated with greater ARDS within ten days (adjusted odds ratio [OR] = 1.03, p = 0.01). For secondary outcomes, a higher IOF rate was associated with greater hospital mortality (adjusted OR = 1.05, p = 0.002), although no significant association with 30-day hospital mortality was identified. CONCLUSIONS: Increased IOF administration during esophagectomy may be associated with worse postoperative pulmonary complications, specifically ARDS. Future well-powered studies are warranted, including randomized, controlled trials comparing liberal versus restrictive fluid administration in this surgical population.

Above the GRADE: Evaluation of Guidelines in Critical Care Medicine.

OBJECTIVES: We examined recommendations within critical care guidelines to describe the pairing patterns for strength of recommendation and quality of evidence. We further identified recommendations where the reported strength of recommendation was strong while the reported quality of evidence was not high/moderate and then assessed whether such pairings were within five paradigmatic situations offered by Grading of Recommendations Assessment, Development and Evaluation methodology to justify such pairings. DATA SOURCES AND EXTRACTION: We identified all clinical critical care guidelines published online from 2011 to 2017 by the Society of Critical Care Medicine along with individual guidelines published by Surviving Sepsis Campaign, Kidney Disease Improving Global Outcomes, American Society for Parenteral and Enteral Nutrition, and the Infectious Disease Society of America/American Thoracic Society. DATA SYNTHESIS: In all, 15 documents specifying 681 eligible recommendations demonstrated variation in strength of recommendation (strong n = 215 [31.6%], weak n = 345 [50.7%], none n = 121 [17.8%]) and in quality of evidence (high n = 41 [6.0%], moderate n = 151 [22.2%], low/very low n = 298 [43.8%], and Expert Consensus/none n = 191 [28.1%]). Strength of recommendation and quality of evidence were positively correlated (ρ = 0.66; p < 0.0001). Of 215 strong recommendations, 69 (32.1%) were discordantly paired with evidence other than high/moderate. Twenty-two of 69 (31.9%) involved Strong/Expert Consensus recommendations, a category discouraged by Grading of Recommendations Assessment, Development and Evaluation methodology. Forty-seven of 69 recommendations (68.1%) were comprised of Strong/Low or Strong/Very Low variation requiring justification within five paradigmatic scenarios. Among distribution in the five paradigmatic scenarios of Strong/Low and Strong/Very Low recommendations, the most common paradigmatic scenario was life threatening situation (n = 20/47; 42.6%). Four Strong/Low or Strong/Very Low recommendations (4/47; 8.5%) were outside Grading of Recommendations Assessment, Development and Evaluation methodology. CONCLUSIONS: Among a large, diverse assembly of critical care guideline recommendations using Grading of Recommendations Assessment, Development and Evaluation methodology, the strength of evidence of a recommendation was generally associated with the quality of evidence. However, strong recommendations were not infrequently made in the absence of high/moderate quality of evidence. To improve clarity and uptake, future guideline statements may specify why such pairings were made, avoid such pairings when outside of Grading of Recommendations Assessment, Development and Evaluation criteria, and consider separate language for Expert Consensus recommendations (good practice statements).

Validating the Physiologic Model HumMod as a Substitute for Clinical Trials Involving Acute Normovolemic Hemodilution.

BACKGROUND: Blood conservation strategies and transfusion guidelines remain a heavily debated clinical topic. Previous investigational trials have shown that acute isovolemic hemodilution does not limit adequate oxygen delivery; however, a true critical hemoglobin level has never been investigated or defined due to safety concerns for human volunteers. Validated physiologic modeling may be useful to investigate hemodilution at critical hemoglobin levels without the ethical or safety hazards of clinical trials. Our hypothesis is that HumMod, an integrative physiological model, can replicate the cardiovascular and metabolic findings of previous clinical studies of acute isovolemic hemodilution and use coronary blood flow and coronary oxygen delivery in extreme hemodilution to predict a safety threshold. METHODS: By varying cardiovascular and sizing parameters, unique individuals were generated to simulate a population using HumMod, an integrative mathematical model of human physiology. Hemodilution was performed by simultaneously hemorrhaging 500 mL aliquots of blood while infusing equal volumes of hetastarch, 5% albumin balanced salt solution, or triple volumes of lactated Ringer's solution over 10 minutes. Five hemodilution protocols reported over 3 studies were directly replicated with HumMod to compare and validate essential cardiovascular and metabolic responses to hemodilution in moderately healthy, awake adults. Cardiovascular parameters, mental status, arterial and mixed venous oxygen content, and oxyhemoglobin saturation were recorded after the removal of each aliquot. The outputs of this simulation were considered independent variables and were stratified by hemoglobin concentration at the time of measurement to assess hemoglobin as an independent predictor of hemodynamic and metabolic behavior. RESULTS: The published reports exhibited discrepancies: Weiskopf saw increased heart rate and cardiac index, while Jones and Ickx saw no change in these variables. In HumMod, arterial pressure was maintained during moderate hemodilution due to decreases in peripheral resistance opposing increases in cardiac index. HumMod showed preserved ventilation through moderate hemodilution, compensated for by an increased oxygen extraction similar to the studies of Jones and Ickx. The simulation results qualitatively followed the clinical studies, but there were statistical differences. In more extreme hemodilution, HumMod had a lesser increase in cardiac index, which led to deficiencies in oxygen delivery and low venous saturation. In the simulations, coronary blood flow and oxygen delivery increase up to a critical hemoglobin threshold of 55-75 g/L in HumMod. In this range, coronary blood flow and oxygen delivery fell, leading to cardiac injury. The allowable amount of hemodilution before reaching the critical point is most closely correlated with nonmuscle mass (r = 0.69) and resting cardiac output (r = 0.67). CONCLUSIONS: There were significant statistical differences in the model population and the clinical populations, but overall, the model responses lay within the clinical findings. This suggests our model is an effective replication of hemodilution in conscious, healthy adults. A critical hemoglobin range of 5.5-7.5 g/L was predicted and found to be highly correlated with nonmuscle mass and resting cardiac output.

Correlation of clinical outcomes with ß-glucan levels in patients with invasive candidiasis.

The correlation of ß-glucan (BG) levels with clinical outcomes in invasive candidiasis (IC) remains unknown. Patients with proven IC were followed prospectively from diagnosis to outcome with twice-weekly serum BG sampling. Correlation of BG with clinical outcome was assessed in each patient. BG levels tend to decrease in successfully treated patients and increase in treatment failures. BG levels may be useful as surrogates for outcome evaluation of IC.

STICS: surface-tethered iterative carbohydrate synthesis.

A new surface-tethered iterative carbohydrate synthesis (STICS) technology is presented in which a surface functionalized 'stick' made of chemically stable high surface area porous gold allows one to perform cost efficient and simple synthesis of oligosaccharide chains; at the end of the synthesis, the oligosaccharide can be cleaved off and the stick reused for subsequent syntheses.

Contemporary treatment and outcomes of zygomycosis in a non-oncologic tertiary care center.

BACKGROUND: Zygomycosis is an emerging mycosis of increasing relevance. Limited data exist for outcomes with contemporary therapies. METHODS: A 6-year retrospective chart review was performed in a non-oncological tertiary care center for patients with zygomycosis. RESULTS: Sixteen episodes of proven (EORTC/MSG criteria) zygomycosis were identified. The average age was 49.2 years. Sites of infection were surgical/traumatic wound [5], rhinocerebral [4], disseminated [2], pulmonary [2], peritoneal [2], and localized skin [1]. Associated conditions included diabetes [7], ketoacidosis [2], end-stage renal disease [4], surgery/trauma [4], steroids [3], solid organ transplant [2], neutropenia [1], and intravenous drug use [1]. Twelve patients had surgical debridement. Medical therapy included liposomal amphotericin B, conventional amphotericin B (CAB), and amphotericin B lipid complex. Overall mortality was 4/16 (25%), occurring in a patient each with rhinocerebral, pulmonary, surgical wound infection, and disseminated disease. Mortality with surgical treatment was 2/12 (17%) vs. 2/4 (50%) without surgery. Mortality for patients treated with CAB was 1/3 vs. 3/12 for those treated with any lipid preparation. Serious morbidity occurred in 7/12 survivors. CONCLUSIONS: In this limited study of contemporary therapies, patients with zygomycosis from a non-oncological tertiary care center have lower mortality than classically described. This disease and its treatments are still associated with severe morbidity, disfigurement, and disability.

Correlation between microdilution, E-test, and disk diffusion methods for antifungal susceptibility testing of posaconazole against Candida spp.

Agar-based antifungal susceptibility testing is an attractive alternative to the microdilution method. We examined the correlation between the microdilution, E-test, and disk diffusion methods for posaconazole against Candida spp. A total of 270 bloodstream isolates of Candida spp. with a broad range of posaconazole MICs were tested using the CLSI M27-A2 method for microdilution, as well as the M-44A method and E-test methods for agar-based testing on Mueller-Hinton agar supplemented with 2% glucose and 0.5 microg of methylene blue. MICs and inhibitory zone diameters at the prominent growth reduction endpoint were recorded at 24 and 48 h. The Candida isolates included Candida albicans (n = 124), C. parapsilosis (n = 44), C. tropicalis (n = 41), C. glabrata (n = 36), C. krusei (n = 20), C. lusitaniae (n = 3), and C. dubliniensis (n = 2). The overall concordance (i.e., the percentage of isolates within two dilutions) between the E-test and microdilution was 64.8% at 24 h and 82.6% at 48 h. When we considered an arbitrary breakpoint of < or = 1 microg/ml, the agreement between the E-test and microdilution methods was 87.8% at 24 h and 93.0% at 48 h. The correlation of MICs with disk diffusion zone diameters was better for the E-test than the microdilution method. Zone correlation for diameters produced by the disks of two manufacturers was high, with a Pearson test value of 0.941 at 24 h. The E-test and microdilution MICs show good concordance and interpretative agreement. The disk diffusion zone diameters are highly reproducible and correlate well with both the E-test and the microdilution method, making agar-based methods a viable alternative to microdilution for posaconazole susceptibility testing.

Invasive candidiasis in immunocompromised hospitalized patients.

The frequency of infections by Candida species is increasing worldwide, with candidemia representing the fourth most common bloodstream infection in the U.S. The risk of infection is especially high in the immunocompromised, hospitalized patient. The treatment of and prophylaxis for Candida infection have led to the emergence of resistant species and the acquisition of resistance in previously susceptible species. Current therapeutic options include amphotericin B and its lipid compounds, fluconazole, itraconazole, voriconazole, and caspofungin. Research is focusing on better diagnostics and the evaluation of strategies such as prophylaxis in high-risk hosts and pre-emptive therapy.

Milk-alkali syndrome in pregnancy.

BACKGROUND: Severe hypercalcemia, a potentially life-threatening medical emergency, is rare in pregnancy. CASE: We report a 32-year-old woman presenting early in the second trimester with severe hypercalcemia (total calcium 22 mg/dL), alkalosis, and acute renal insufficiency resulting from excessive ingestion of calcium carbonate-containing antacid for gastroesophageal reflux. The patient was treated with aggressive hydration and furosemide, and received 1 dose of intravenous etidronate, leading to short-term symptomatic hypocalcemia. To our knowledge, this is the third reported case of milk-alkali syndrome in pregnancy. CONCLUSION: Milk-alkali syndrome is an uncommon cause of hypercalcemia in pregnancy. Intravenous hydration with saline should be the cornerstone of treatment, reserving bisphosphonates for selected cases.