Pietro Serra

Outbreak of Saccharomyces cerevisiae Subtype boulardii Fungemia in Patients Neighboring Those Treated with a Probiotic Preparation of the Organism

ABSTRACT We report an outbreak of Saccharomyces cerevisiae subtype boulardii fungemia among three intensive care unit roommates of patients receiving lyophilized preparations of this fungus. The fungemia was probably due to central venous catheter contamination and resolved after fluconazole treatment. The need for stringent application of proper hygiene when using a probiotic preparation of this organism is emphasized.

Circadian rhythm of the autonomic nervous system in insulin resistant subjects with normoglycemia, impaired fasting glycemia, impaired glucose tolerance, type 2 diabetes mellitus.

BackgroundIn type 2 diabetes mellitus both insulin resistance and hyperglycemia are considered responsible for autonomic dysfunction. The relation between the autonomic activity, impaired fasting glycemia and impaired glucose tolerance is, however, unclear. The purpose of this study was to evaluate and compare the circadian autonomic activity expressed as heart rate variability (HRV) measured by 24-hours ECG recording in insulin resistant subjects (IR) with characteristics as follow: IR subjects with normal oral glucose tolerance test results, IR subjects with impaired fasting glucose, IR subjects with impaired glucose tolerance and subjects with type 2 diabetes mellitus.MethodsEighty Caucasian insulin resistant subjects (IR) and twenty five control subjects were recruited for the study. IR subjects were divided into four groups according to the outcoming results of oral glucose tests (OGTTs): IR subjects with normal glucose regulation (NGR), IR subjects with impaired fasting glycemia (IFG), IR subjects with impaired glucose tolerance (IGT) and subjects with type 2 diabetes mellitus (DM). Autonomic nervous activity was studied by 24-hours ECG recording. Heart rate variability analysis was performed in time and frequency domains: SDNN, RMS-SD, low frequency (LF) and high frequency (HF) were calculated.ResultsThe total SDNN showed statistically significant reduction in all four groups with insulin resistant subjects (IR) when compared to the control group (p <0,001). During night LF normalized units (n.u.) were found to be higher in all four groups including IR subjects than in the control group (all p < 0,001) and subjects with normal glucose regulation (NGR), with impaired fasting glycemia (IFG) and with impaired glucose tolerance (IGT) were found to have higher LF n.u. than those in the type 2 diabetes mellitus group. The linear regression model demonstrated direct association between LF values and the homeostasis model assessment-index (HOMA-I), in the insulin resistant group (r = 0,715, p <0,0001).ConclusionThe results of our study suggest that insulin resistance might cause global autonomic dysfunction which increases along with worsening glucose metabolic impairment. The analysis of sympathetic and parasympathetic components and the sympathovagal balance demonstrated an association between insulin resistance and sympathetic over-activity, especially during night. The results indicated that the sympathetic over-activity is directly correlated to the grade of insulin resistance calculated according to the HOMA-I. Since increased sympathetic activity is related to major cardiovascular accidents, early diagnosis of all insulin resistant patients should be contemplated.

Bone marrow-derived progenitors are greatly reduced in patients with severe COPD and low-BMI

Chronic obstructive pulmonary disease (COPD) patients have reduced circulating hemopoietic progenitors. We hypothesized that severity of COPD parallels the decrease in progenitors and that the reduction in body mass index (BMI) could be associated with more severe bone marrow dysfunction. We studied 39 patients with moderate to very severe COPD (18 with low-BMI and 21 with normal-BMI) and 12 controls. Disease severity was associated to a greater reduction in circulating progenitors. Proangiogenetic and inflammatory markers correlated with disease severity parameters. Compared to normal-BMI patients, low-BMI patients showed: greater reduction in circulating progenitors; higher VEGF-A, VEGF-C, HGF, Ang-2, TNF-alpha, IL-6 and MCP-1 levels. Furthermore, among patients with similar pulmonary impairment, those who displayed low-BMI had a more markedly reduced number of CD34(+) cells and late endothelial progenitors. We show that the reduction in hematopoietic and endothelial progenitor cells correlates with COPD severity. Our findings also indicate that, in severe low-BMI COPD patients, bone marrow function seems to be further impaired and may lead to reduced reparative capacity.

Circadian rhythm of autonomic activity in non diabetic offsprings of type 2 diabetic patients.

The aim of the present study was to evaluate, by heart rate variability (HRV) with 24-hours ECG Holter (HRV), the circadian autonomic activity in offspring of type 2 diabetic subjects and the relation with insulin-resistance. METHODS: 50 Caucasian offsprings of type 2 diabetic subjects were divided in two groups: insulin-resistant offsprings (IR) and non insulin-resistant offsprings (NIR). Autonomic nervous activity was studied by HRV. Time domain and spectral analysis (low frequency, LF, and high frequency, HF, provide markers of sympathetic and parasympathetic modulation when assessed in normalized units) were evaluated. RESULTS. Time domain showed a reduction of total SDNN in IR (p < 0.001) and NIR (p 0.047) versus controls. Spectral analysis showed a total and night LF higher in IR and NIR than in control group (all p < 0.001). CONCLUSION. In frequency domain, the analysis of sympathetic (LF) and parasympathetic (HF) component evidenced an association between the offspring of type 2 diabetic subjects and a sympathetic overactivity. A global reduction and alteration of circadian rhythm of autonomic activity are present in offspring of type 2 diabetic patients with and without insulin resistance. The data of our study suggested that an autonomic impairment is associated with the familiarity for type 2 diabetes independently to insulin resistance and that an impairment of autonomic system activity could precede the insulin resistance.

Exogenous Lipid Clearance in Compensated Liver Cirrhosis

The tolerance to exogenous fats has been evaluated in patients with liver cirrhosis. A three-stage lipid clearance test with continuous infusion (3 hr) of a triglyceride emulsion, Intralipid, was performed on 10 patients with well compensated liver cirrhosis and 10 normolipidemic volunteers. During the infusion, blood samples were collected for the measurement of particulate triglycerides (TG) by nephelometry; samples were also collected for total TG, free fatty acids (FFA) and free tryptophan (TRP) determinations. Plasma endogenous triglycerides were calculated as the total minus exogenous, particulate, TG. The fractional removal rate (K2) and the maximal clearing capacity (K1) for exogenous TG were lower in patients than in controls, though a significant difference (p less than 0.05) was found only for K1. Endogenous TG and FFA showed a comparable rise in patients and controls during Intralipid infusion. A significant increase in free TRP was noted in cirrhotics upon maximal infusion rate. It is concluded that: in patients with well compensated liver cirrhosis the maximal clearing capacity (K1) for exogenous TG is impaired. Nonetheless, moderate amounts of fat may be removed at a normal rate from the bloodstream; a normal synthesis rate of exogenous TG may be maintained even in a severely damaged liver; considering the possible role of free TRP in the pathogenesis of hepatic encephalopathy (HE), the use of large amounts of lipids should be discouraged in patients with decompensated liver cirrhosis, or even avoided in those with impending or overt HE.

Superinfections during antimicrobial treatment with betalactam-aminoglycoside combinations in neutropenic patients with hematologic malignancies

SummaryThe frequency, etiology and risk factors of superinfections during and/or within one week after antibiotic therapy with betalactam-aminoglycoside combinations were evaluated in 631 patients with hematologic malignancies admitted to the Institute of Hematology of Rome from January 1982 to December 1984. 356 patients (56%) developed 402 episodes of proven or presumed infection. Of these patients, 78 developed 102 superinfections. Overall, superinfections responded less satisfactorily to antibiotic therapy than the primary febrile episodes (63% vs. 85%). The distribution of etiologic agents of superinfections differed from those responsible for primary infections, since fungi and anaerobes (especiallyClostridium difficile) were mostly isolated after antibiotic therapy had begun. Moreover, among aerobic bacteria, frequently antibiotic-resistant species, such asPseudomonas aeruginosa, Streptococcus faecalis andStaphylococcus epidermidis were the leading etiologic agents of superinfection. The risk of superinfection appeared to increase with the depth and persistence of granulocytopenia. On the other hand, the length of hospitalization, length of previous antibiotic therapy, previous chemoprophylaxis and presence of indwelling venous catheter did not affect the risk of superinfection.ZusammenfassungBei 631 Patienten mit malignen hämatologischen Erkrankungen, die von Januar 1982 bis Dezember 1984 am hämatologischen Institut Rom zur Behandlung kamen, wurde eine Auswertung bezüglich der Häufigkeit, Ursache und der Risikofaktoren von Superinfektionen während und/oder innerhalb einer Woche nach Behandlung mit Betalactam-Aminoglykosid-Kombinationen vorgenommen. Bei 356 Patienten (56%) traten 402 Episoden einer erwiesenen oder vermuteten Infektion auf. 78 dieser Patienten bekamen 102 Episoden von Superinfektionen. Insgesamt sprachen Superinfektionen weniger befriedigend auf die Antibiotika-Therapie an als die primären febrilen Episoden (63% gegenüber 85%). Die Verteilung der kausalen Erreger der Superinfektionen war gegenüber den primären Infektionen verschieden; Pilze und Anaerobier (vor allemClostridium difficile) wurden vorwiegend nach Beginn der Antibiotika-Therapie isoliert. Unter den aeroben Erregern waren häufig Antibiotika-resistente Spezies wiePseudomonas aeruginosa, Streptococcus faecalis undStaphylococcus epidermidis die führenden kausalen Erreger von Superinfektionen. Das Risiko für eine Superinfektion schien mit dem Grad und der Dauer der Granulozytopenie zuzunehmen. Die Dauer der stationären Behandlung, Dauer einer vorausgegangenen Antibiotikatherapie, frühere Chemoprophylaxe und Anwesenheit eines intravenösen Verweilkatheters hatte hingegen keinen Einfluß auf das Risiko für eine Superinfektion.

The correlation among QTc interval, hyperglycaemia and the impaired autonomic activity

BACKGROUND The QT interval reflects the duration of the intracellular action potential. Little is known on the interval QT duration in non diabetic insulin-resistant subjects. OBJECTIVE The aims of the current study were to evaluate the QTc interval in three groups of non diabetic insulin-resistant subjects and the possible correlation between QTc and the autonomic nervous systems activity. DESIGN 90 subjects were divided in subjects with impaired fasting glycaemia (IFG) and, by the results of OGTT, according to the criteria of ADA, in subjects with normal glucose regulation (NGR) and impaired glucose tolerance (IGT). Insulin resistance was evaluated by the homeostasis model assessment-index (HOMA-I). Heart rate variability and Qtc were calculated. RESULTS QTc interval is correlated with SDNN, LF n.u. and LF/HF. CONCLUSION We have observed that the QTc interval is prolonged in insulin-resistant subjects with associated impaired glucose metabolism, while no difference was reported between insulin-resistant and non insulin-resistant subjects with normal glucose regulation. We hypothesize that hyperglycaemia could play a major role than hyperinsulinemia on the QTc prolongation.

Serious infections due to methicillin-resistant Staphylococcus aureus: An evolving challenge for physicians

Methicillin-resistant Staphylococcus aureus (MRSA) is a well-recognized major cause of nosocomial infection worldwide. During the past decade, however, the epidemiology of staphylococcal infections has partially changed, with an increase in the number of patients who acquire infections in the community. The changing epidemiology is a cause for concern among physicians, leading to an increase in the number of patients with infections due to MRSA diagnosed at hospital admission and in the emergency department. The aims of this article are to review the current state of knowledge regarding MRSA infections, to identify those factors which may help physicians to recognize the patients at high risk, and to manage these infections appropriately.

Multiple Myeloma and Acute Myelomonocytic Leukemia: Simultaneous Occurrence without Previous Chemotherapy

A patient with acute myelomonocytic leukemia was found to have IgG paraprotein on serum electrophoresis Bence Jones K proteinuria and increased plasma cells (30%) on marrow examination. The simultaneous occurrence of the two diseases was well documented by cytochemical immunological and electron-microscopic findings. Bone marrow chromosome investigations showed an abnormal karyotype: hypodiploidy was prevalent and marker chromosomes were present. A possible relationship between acute leukemia and multiple myeloma is discussed.

Clostridium difficile colitis in leukemia patients

Leukemia patients with diarrhea or other abdominal symptoms have been investigated for the presence of Clostridium difficile and its cytotoxin in stools. Of the patients studied 19% had C. difficile, in most cases together with cytotoxin. All patients but one had received antibiotics, while one had been treated with cytotoxic agents only. Symptoms of colitis were most often abdominal pain and distension rather than diarrhea. Owing to the not infrequent fatal evolution, it is recommended that routine search for C. difficile in leukemia patients with abdominal symptoms be performed and appropriate therapy started immediately.