Antifungal agents use in a French administrative region.

BACKGROUND: The increased use of new costly antifungal agents has led to a considerable increase in pharmaceutical expenditure. In December 2011, the Lorraine Regional Health Agency commissioned the Antibiolor network to evaluate costly antifungal agent stewardship using as reference regional, French, and international recommendations. METHODS: We performed a regional retrospective multicenter study. The criteria for evaluation were the appropriateness of the indication for treatment, the choice of the agent or of a combination, compliance with dose and treatment duration, and the absence of any alternative. RESULTS: One hundred and fourteen prescriptions were analyzed, in 7 intensive care units, 4 hematology units, and 1 infectious diseases unit. The indication for costly antifungal treatment was appropriate in 110 cases (96.5%), the choice of the antifungal agent in 102 cases (93%), the dose in 98 cases (89%), treatment duration in 102 cases (93%), and an alternative antifungal treatment was possible in 10 cases (9%). Eighty-two prescriptions (74.5%) complied with the marketing authorization, 19 (17%) were related to a protocol for temporary use, and 9 (8%) were considered as inappropriate. CONCLUSION: Our results show a high rate of appropriate prescriptions. The easily accessible and regularly updated local recommendations probably resulted in the standardization and optimization of costly antifungal agent prescriptions.

Pituitary-adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood.

CONTEXT: Evidence suggests that early adverse experiences play a preeminent role in development of mood and anxiety disorders and that corticotropin-releasing factor (CRF) systems may mediate this association. OBJECTIVE: To determine whether early-life stress results in a persistent sensitization of the hypothalamic-pituitary-adrenal axis to mild stress in adulthood, thereby contributing to vulnerability to psychopathological conditions. DESIGN AND SETTING: Prospective controlled study conducted from May 1997 to July 1999 at the General Clinical Research Center of Emory University Hospital, Atlanta, Ga. PARTICIPANTS: Forty-nine healthy women aged 18 to 45 years with regular menses, with no history of mania or psychosis, with no active substance abuse or eating disorder within 6 months, and who were free of hormonal and psychotropic medications were recruited into 4 study groups (n = 12 with no history of childhood abuse or psychiatric disorder [controls]; n = 13 with diagnosis of current major depression who were sexually or physically abused as children; n = 14 without current major depression who were sexually or physically abused as children; and n = 10 with diagnosis of current major depression and no history of childhood abuse). MAIN OUTCOME MEASURES: Adrenocorticotropic hormone (ACTH) and cortisol levels and heart rate responses to a standardized psychosocial laboratory stressor compared among the 4 study groups. RESULTS: Women with a history of childhood abuse exhibited increased pituitary-adrenal and autonomic responses to stress compared with controls. This effect was particularly robust in women with current symptoms of depression and anxiety. Women with a history of childhood abuse and a current major depression diagnosis exhibited a more than 6-fold greater ACTH response to stress than age-matched controls (net peak of 9.0 pmol/L [41.0 pg/mL]; 95% confidence interval [CI], 4.7-13.3 pmol/L [21.6-60. 4 pg/mL]; vs net peak of 1.4 pmol/L [6.19 pg/mL]; 95% CI, 0.2-2.5 pmol/L [1.0-11.4 pg/mL]; difference, 8.6 pmol/L [38.9 pg/mL]; 95% CI, 4.6-12.6 pmol/L [20.8-57.1 pg/mL]; P<.001). CONCLUSIONS: Our findings suggest that hypothalamic-pituitary-adrenal axis and autonomic nervous system hyperreactivity, presumably due to CRF hypersecretion, is a persistent consequence of childhood abuse that may contribute to the diathesis for adulthood psychopathological conditions. Furthermore, these results imply a role for CRF receptor antagonists in the prevention and treatment of psychopathological conditions related to early-life stress. JAMA. 2000;284:592-597

Lithium augmentation of antidepressants in treatment-refractory depression.

The use of lithium to convert antidepressant nonresponders to responders is reviewed. Although there is little doubt that lithium is effective in a sizable percentage of patients who do not respond to tricyclic antidepressants (TCAs) and serotonin selective reuptake inhibitors (SSRIs), much remains obscure about this effect. Does it work preferentially on antidepressants that act primarily on serotonergic neurons, or is it equally effective with agents that act upon other neurotransmitter systems? When should lithium, compared with other strategies, be utilized in antidepressant nonresponders? Are certain subtypes of depression more likely than others to respond to lithium augmentation? The available literature highlights the efficacy of lithium as an augmenting agent in refractory depression and serves as an impetus for additional neurobiological and clinical studies of this phenomenon.

Evaluation of cerebrospinal fluid (CSF) C-reactive protein in the diagnosis of suspected meningitis.

Cerebrospinal fluid C-reactive protein (CSF-CRP) was studied in 183 consecutive infants and children with suspected meningitis, using a nephelometric technique. Cerebrospinal fluid C-reactive protein was above an empirically chosen level of 1 mg/1 in seven of 19 children with culture-proven bacterial meningitis, in only one of 15 children with viral meningitis, and three of 139 children with no meningitis. All 10 children with partially treated meningitis had CSF-CRP levels below 1 mg/1. There was good correlation between CSF-CRP and total protein levels in children with bacterial meningitis (R value 0.4999 P less than 0.05). The test was not sensitive enough for early differentiation between bacterial and viral meningitis. The test also did not add extra information regarding aetiology in partially treated meningitis.