Cutaneous effects associated with fluconazole in patients treated for coccidioidomycosis.

BACKGROUND: Fluconazole is the most commonly used antifungal treatment for various forms of coccidioidomycosis. Although we had anecdotally observed a high proportion of patients reporting cutaneous adverse effects associated with fluconazole treatment, this observation was not well described in the medical literature, and we were unsure of the additional effect of the arid desert environment of Arizona. METHODS: We performed a one-time, voluntary survey of patients with coccidioidomycosis and compared the responses of patients treated with fluconazole with those of untreated patients. RESULTS: From January 1, 2015, to August 22, 2017, 62 fluconazole-treated and 35 untreated patients with coccidioidomycosis provided consent and were enrolled in the study; demographics were similar between the two groups. Among the 62 fluconazole-treated patients, daily dosages ranged from 200 mg to 800 mg. However, most (44/62, 71%) took 400 mg daily, the typical dose for the treatment of coccidioidomycosis. The median fluconazole treatment duration at the time of study participation was 6 months. When compared with untreated patients, those taking fluconazole had more moderate to severe dry lips (74.2% [46/62] vs. 23.5% [8/34]; P < 0.001), dry skin (45.8% [27/59] vs. 22.9% [8/35]; P = 0.03), and alopecia (31.1% [19/61] vs. 11.4% [4/35]; P = 0.004). CONCLUSIONS: For the treatment of coccidioidomycosis, patients receiving fluconazole reported significantly more severe cutaneous effects, including dry lips, dry skin, and alopecia, than untreated patients. Our findings identify an association but do not prove causality.

Characteristics of the Contrast Enema Do Not Predict an Effective Bowel Management Regimen for Patients with Constipation or Fecal Incontinence.

BACKGROUND: A bowel management program using large volume enemas may be required for children with anorectal malformations (ARM), Hirschsprung's disease (HD), severe medically refractive idiopathic constipation (IC), and other conditions. A pretreatment contrast enema is often obtained. We sought to determine if the contrast enema findings could predict a final enema regimen. METHODS: A retrospective review was performed at a tertiary care children's hospital from 2011 to 2014 to identify patients treated with enemas in our bowel management program. Patient characteristics, contrast enema findings (including volume to completely fill the colon), and final enema regimen were collected. RESULTS: Eighty-three patients were identified (37 ARM, 7 HD, 34 IC, and 5 other). Age ranged from 10 months to 24 years, and weight ranged from 6.21 kg to 95.6 kg at the time bowel management was initiated. Linear regression showed contrast enema volume was of limited value in predicting effective therapeutic saline enema volume (R(2 )= 0.21). The addition of diagnosis, colon dilation, and contrast retention on plain x-ray the day after the contrast enema moderately improved the predictive ability of the contrast enema (R(2 )= 0.35). Median final effective enema volume was 22 mL/kg (range: 5 - 48 mL/kg). CONCLUSIONS: We were unable to demonstrate a correlation with contrast enema findings and the effective enema volume. However, no patient required a daily enema volume greater than 48 mL/kg to stay clean.

The morbidity of a divided stoma compared to a loop colostomy in patients with anorectal malformation.

PURPOSE: Loop colostomies may contaminate the genitourinary (GU) tract in patients with anorectal malformations (ARM) owing to incomplete diversion of stool. Stoma complications are also thought to be higher with a loop versus divided colostomy. We sought to compare the morbidity, including urinary tract infections (UTI), in these two types of colostomies in children with ARM. METHODS: A review was performed at a children's hospital (1989-2014). Children with ARM who had a colostomy performed were identified. Demographic data and outcome variables were collected. Analyses included Student's t-test, Fischer's exact and logistic regression as appropriate. RESULTS: 171 patients were identified (loop=78; divided=93). Thirty percent of patients with a divided colostomy and 24% with a loop experienced a stoma complication (p=0.5). A subgroup analysis of children with a rectourinary fistula (54 divided, 26 loop) was performed to assess for effect of colostomy type on UTI. After controlling for other UTI risk factors (major GU anomalies, vesicostomy, and prophylactic antibiotics), loop ostomies were not associated with risk of UTI (OR 0.83, 95% CI 0.27-2.63). No patient with a loop colostomy developed megarectum. CONCLUSIONS: Children with ARM who undergo a loop colostomy are not at a detectable increased risk of experiencing a UTI compared to a divided stoma. The rate of stoma complication is high regardless of the type of stoma created.

Behavioral training and predisposed coping strategies interact to influence resilience in male Long-Evans rats: implications for depression.

Effective coping strategies and adaptive behavioral training build resilience against stress-induced pathology. Both predisposed and acquired coping strategies were investigated in rats to determine their impact on stress responsiveness and emotional resilience. Male Long-Evans rats were assigned to one of the three coping groups: passive, active, or variable copers. Rats were then randomly assigned to either an effort-based reward (EBR) contingent training group or a non-contingent training group. Following EBR training, rats were tested in appetitive and stressful challenge tasks. Physiological responses included changes in fecal corticosterone and dehydroepiandrosterone (DHEA) metabolites as well as neuropeptide Y (NPY)-immunoreactivity in the hippocampus and amygdala. Regardless of a rat's predisposed coping strategy, EBR rats persisted longer than non-contingent rats in the appetitive problem-solving task. Furthermore, training and coping styles interacted to yield the seemingly most adaptive DHEA/corticosterone ratios in the EBR-trained variable copers. Regardless of training group, variable copers exhibited increased NPY-immunoreactivity in the CA1 region.