Meningitis Caused by Candida Dubliniensis in a Patient with Cirrhosis: A Case Report and Review of the Literature.

Candida species, including Candida dubliniensis, are a rare cause of meningitis. Herein, we report the second case of C. dubliniensis meningitis in a 49-year-old man with a history of hepatitis C virus-related cirrhosis, substance use disorder, and recent exposure to intravenous antibiotic therapy, presenting with confusion, abnormal gait, and urinary incontinence. Magnetic resonance imaging (MRI) of the brain showed marked hydrocephalus and leptomeningeal enhancement. Initial cerebrospinal fluid (CSF) studies were concerning for bacterial meningitis, although cultures were negative. Despite empiric treatment with broad-spectrum antibiotics, the patient's mental status declined. The diagnosis of C. dubliniensis meningitis was not made until the third lumbar puncture. The patient was treated with liposomal amphotericin B and flucytosine. Despite improvement of hydrocephalus on MRI of the brain and sterilization of CSF, the patient's mental status declined and he expired. This case highlights the difficulty in the diagnosis of C. dubliniensis meningitis as multiple lumbar punctures may be necessary. C. dubliniensis meningitis should be considered in the differential diagnosis for a patient with risk factors such as end-stage liver disease, human immunodeficiency virus infection, recent chemotherapy, substance use disorders, and recent broad-spectrum antibiotic use. A high index of suspicion is necessary as delay in initiation of therapy is associated with high mortality. The optimal treatment strategy has not been determined.

Primary care physician communication at hospital discharge reduces medication discrepancies.

BACKGROUND: Medication discrepancies are common as patients transition from hospital to home. Errors with post-discharge medication regimens may play a role in hospital readmissions. OBJECTIVES: To determine whether primary care physician (PCP) contact with patients at hospital discharge impacts the frequency of medication discrepancies at 24 hours post-discharge. DESIGN: With the PCP-Enhanced Discharge Communication Intervention, PCPs were asked to speak with treating hospitalists and contact patients within 24 hours of hospital discharge (either in person or by phone) to discuss any hospital medication changes. Research staff enrolled subjects during their hospitalization and telephoned subjects 48 hours post-discharge to determine medication discrepancies and PCP contact. PARTICIPANTS: One hundred fourteen community-dwelling adults, admitted to acute medicine services >24 hours on ≥ 5 medications. RESULTS: Of the 114 subjects enrolled in the hospital, 75 subjects completed 48 hours postdischarge phone interviews. Of the 75 study patients, 39 patients (50.6%) experienced a total of 84 medication discrepancies (mean, 2.1 discrepancies/patient). Subjects who were contacted by their PCP at discharge were 70% less likely to have a discrepancy when compared with those not contacted (P = 0.04). Males were 4.34 times more likely to have a discrepancy (P = 0.02). CONCLUSION: PCP communication with patients within 24 hours of discharge was associated with decreased medication discrepancies. Our results further demonstrate the importance of PCP involvement in the hospital discharge process.

Gap junctions in Malpighian tubules of Aedes aegypti.

We present electrical, physiological and molecular evidence for substantial electrical coupling of epithelial cells in Malpighian tubules via gap junctions. Current was injected into one principal cell of the isolated Malpighian tubule and membrane voltage deflections were measured in that cell and in two neighboring principal cells. By short-circuiting the transepithelial voltage with the diuretic peptide leucokinin-VIII we largely eliminated electrical coupling of principal cells through the tubule lumen, thereby allowing coupling through gap junctions to be analyzed. The analysis of an equivalent electrical circuit of the tubule yielded an average gap-junction resistance (R(gj)) of 431 kOmega between two cells. This resistance would stem from 6190 open gap-junctional channels, assuming the high single gap-junction conductance of 375 pS found in vertebrate tissues. The addition of the calcium ionophore A23187 (2 micromol l(-1)) to the peritubular Ringer bath containing 1.7 mmol l(-1) Ca(2+) did not affect the gap-junction resistance, but metabolic inhibition of the tubule with dinitrophenol (0.5 mmol l(-1)) increased the gap-junction resistance 66-fold, suggesting the regulation of gap junctions by ATP. Lucifer Yellow injected into a principal cell did not appear in neighboring principal cells. Thus, gap junctions allow the passage of current but not Lucifer Yellow. Using RT-PCR we found evidence for the expression of innexins 1, 2, 3 and 7 (named after their homologues in Drosophila) in Malpighian tubules. The physiological demonstration of gap junctions and the molecular evidence for innexin in Malpighian tubules of Aedes aegypti call for the double cable model of the tubule, which will improve the measurement and the interpretation of electrophysiological data collected from Malpighian tubules.