Strict glycaemic control in patients hospitalised in a mixed medical and surgical intensive care unit: a randomised clinical trial.

INTRODUCTION: Critically ill patients can develop hyperglycaemia even if they do not have diabetes. Intensive insulin therapy decreases morbidity and mortality rates in patients in a surgical intensive care unit (ICU) and decreases morbidity in patients in a medical ICU. The effect of this therapy on patients in a mixed medical/surgical ICU is unknown. Our goal was to assess whether the effect of intensive insulin therapy, compared with standard therapy, decreases morbidity and mortality in patients hospitalised in a mixed ICU. METHODS: This is a prospective, randomised, non-blinded, single-centre clinical trial in a medical/surgical ICU. Patients were randomly assigned to receive either intensive insulin therapy to maintain glucose levels between 80 and 110 mg/dl (4.4 to 6.1 mmol/l) or standard insulin therapy to maintain glucose levels between 180 and 200 mg/dl (10 and 11.1 mmol/l). The primary end point was mortality at 28 days. RESULTS: Over a period of 30 months, 504 patients were enrolled. The 28-day mortality rate was 32.4% (81 of 250) in the standard insulin therapy group and 36.6% (93 of 254) in the intensive insulin therapy group (Relative Risk [RR]: 1.1; 95% confidence interval [CI]: 0.85 to 1.42). The ICU mortality in the standard insulin therapy group was 31.2% (78 of 250) and 33.1% (84 of 254) in the intensive insulin therapy group (RR: 1.06; 95%CI: 0.82 to 1.36). There was no statistically significant reduction in the rate of ICU-acquired infections: 33.2% in the standard insulin therapy group compared with 27.17% in the intensive insulin therapy group (RR: 0.82; 95%CI: 0.63 to 1.07). The rate of hypoglycaemia (< or = 40 mg/dl) was 1.7% in the standard insulin therapy group and 8.5% in the intensive insulin therapy group (RR: 5.04; 95% CI: 1.20 to 21.12). CONCLUSIONS: IIT used to maintain glucose levels within normal limits did not reduce morbidity or mortality of patients admitted to a mixed medical/surgical ICU. Furthermore, this therapy increased the risk of hypoglycaemia. TRIAL REGISTRATION: clinicaltrials.gov Identifiers: 4374-04-13031; 094-2 in 000966421.

Orofacial infection by Conidiobolus coronatus.

Entomophtoramycosis is a type of subcutaneous mycosis which includes both basidiobolomycosis and conidiobolomycosis; the latter is caused by Conidiobolus coronatus, a saprophytic fungus which lives in tropical soils. This mycosis characteristically affects the paranasal sinuses and oropharynx, with the potential to deform the face in patients without apparent immunodeficiency. It has a chronic course of infection with a tendency to form granulomas visible using histology. We present the case of a 28 year-old male agricultural worker, with a clinical profile of 6 months' evolution of rhinofacial tumefaction, nasal obstruction and post-nasal drip who was diagnosed with conidiobolomycosis by means of tissue culture after multiple biopsies of the facial area. The patient received antifungal treatment with amphotericin B and subsequently with itraconazol, resulting in a dramatic improvement without the need for surgical treatment; itraconazol was administered for one year and there was no evidence of relapse at the end of this period. Due to the low frequency of this disease there is no established treatment strategy; however, the use of azoles such as itraconazol with or without adjuvant surgical treatment is increasingly seen in case reports. The present report adds to the clinical experience in Colombia of this rare mycosis and also describes the long-term clinical and therapeutic response.

Infección orofacial por Conidiobolus coronatus / Orofacial infection by Conidiobolus coronatus

La entomoftoromicosis es un tipo de micosis subcutánea en el cual se incluyen la basidiobolomicosis y la conidiobolomicosis; esta última es causada principalmente por Conidiobolus coronatus , un hongo saprobio que habita el suelo en países tropicales y genera una afección rinofacial que compromete los tejidos blandos de la cara, los senos paranasales y la orofaringe, y tiene la capacidad de deformar el rostro en personas sin inmunodeficiencia aparente. La infección tiene un curso crónico con tendencia a la formación de granulomas que se pueden observar en el estudio histopatológico. Se presenta el caso de un agricultor de 28 años con un cuadro clínico de tumefacción rinofacial, obstrucción nasal y escurrimiento posterior, de seis meses de evolución, a quien se le diagnosticó conidiobolomicosis a partir de un cultivo de tejido después de múltiples biopsias de tejidos del área facial. El paciente recibió tratamiento antifúngico con anfotericina B y posteriomente con itraconazol, con lo cual su mejoría fue notable, por lo que no requirió tratamiento quirúrgico. El tratamiento con itraconazol se extendió por un año, al cabo del cual no había evidencia de recaída. Dada la poca frecuencia de esta enfermedad, no hay una estrategia de tratamiento establecida; sin embargo, el uso de azoles, como el itraconazol, se señala cada vez más en los diferentes reportes de caso, haya habido tratamiento quirúrgico adyuvante o no. En este reporte de caso se describe, además, la respuesta clínica y terapéutica a largo plazo de esta micosis infrecuente en Colombia.

Entomophtoramycosis is a type of subcutaneous mycosis which includes both basidiobolomycosis and conidiobolomycosis; the latter is caused by Conidiobolus coronatus , a saprophytic fungus which lives in tropical soils. This mycosis characteristically affects the paranasal sinuses and oropharynx, with the potential to deform the face in patients without apparent immunodeficiency. It has a chronic course of infection with a tendency to form granulomas visible using histology. We present the case of a 28 year-old male agricultural worker, with a clinical profile of 6 months´ evolution of rhinofacial tumefaction, nasal obstruction and post-nasal drip who was diagnosed with conidiobolomycosis by means of tissue culture after multiple biopsies of the facial area. The patient received antifungal treatment with amphotericin B and subsequently with itraconazol, resulting in a dramatic improvement without the need for surgical treatment; itraconazol was administered for one year and there was no evidence of relapse at the end of this period. Due to the low frequency of this disease there is no established treatment strategy; however, the use of azoles such as itraconazol with or without adjuvant surgical treatment is increasingly seen in case reports. The present report adds to the clinical experience in Colombia of this rare mycosis and also describes the long-term clinical and therapeutic response.