Bacillus Calmette-Guérin perfusion therapy for carcinoma in situ of the upper urinary tract

OBJECTIVE: To analyse the clinical and therapeutic consequences of bacillus Calmette-Guérin (BCG) perfusion therapy for carcinoma in situ (CIS) of the upper urinary tract. PATIENTS AND METHODS: Eight pyelo-ureteric systems in five patients with cytologically confirmed CIS of the upper urinary tract were treated using perfusion of BCG through a percutaneous nephrostomy tube in five and a retrograde ureteric catheter in three. Follow-up cystoscopy, retrograde pyelography and selective urinary cytology were obtained 4 weeks after the last treatment and every 3 months thereafter. RESULTS: In three patients (five pyelo-ureteric systems) the cytology remained negative for 10-46 months after the treatment was completed. The remaining two patients (three pyelo-ureteric systems) had persistently positive cytology. Of two patients who received BCG therapy through a ureteric catheter, one developed a ureteric stricture and the other developed renal tuberculosis. CONCLUSIONS: Although long-term adaptation to a nephrostomy tube disturbs the quality of life of the patient, percutaneous perfusion therapy through a nephrostomy tube seems to be safer than retrograde perfusion through a ureteric catheter.     

Castanospermine, an oligosaccharide processing inhibitor, reduces membrane expression of adhesion molecules and prolongs heart allograft survival in rats

The clinical characteristics and natural history of 55 cases with antenatally diagnosed fetal uropathy were investigated. Percutaneous aspiration of the fetal pelvic or vesical urine was performed to decompress progressive unilateral hydronephrosis in 2 cases and to evaluate renal function in another 2 cases of bilateral hydronephrosis. As the postnatal diagnosis, upper urinary tract dilatation (hydronephrosis or hydronephroureter, 33 cases) and renal dysplasia (15 cases) made up 87% of all cases. A combination of hydronephrosis in one kidney and renal dysplasia in the other was also found in another 2 cases. Among 35 cases with upper urinary tract dilatation, 27 cases demonstrated pelviureteric junction stenosis and surgical intervention was necessary in 15 cases. In 17 cases with renal dysplasia, spontaneous regression was observed in only 3 cases and surgical intervention by means of percutaneous nephrostomy and nephrectomy was performed in 4 and 6 cases, respectively.     

A randomized trial comparing fluconazole with amphotericin B for the treatment of candidemia in patients without neutropenia. Candidemia Study Group and the National Institute

BACKGROUND: Amphotericin B has long been the standard treatment for candidemia, but its use is complicated by its toxicity. More recently, fluconazole, a water-soluble triazole with activity against candida species and little toxicity, has become available. We conducted a multicenter randomized trial that compared amphotericin B with fluconazole as treatment for candidemia. METHODS: To be eligible, patients had to have a positive blood culture for candida species, a neutrophil count > or = 500 per cubic millimeter, and no major immunodeficiency. Patients were randomly assigned to receive either amphotericin B (0.5 to 0.6 mg per kilogram of body weight per day) or fluconazole (400 mg per day), each continued for at least 14 days after the last positive blood culture. Outcomes were assessed by a group of investigators blinded to treatment assignment. RESULTS: Of the 237 patients enrolled, 206 met all entry criteria. The most common diagnoses were renal failure, nonhematologic cancer, and gastrointestinal disease. There was no statistically significant difference in outcome: of the 103 patients treated with amphotericin B, 81 (79 percent) were judged to have been treated successfully, as were 72 of the 103 patients treated with fluconazole (70 percent P = 0.22; 95 percent confidence interval for the difference, -5 to 23 percent). The bloodstream infection failed to clear in 12 patients in the amphotericin group and 15 in the fluconazole group; the species most commonly associated with failure was Candida albicans. There were 41 deaths in the amphotericin group and 34 deaths in the fluconazole group (P = 0.20). Intravascular catheters appeared to be the most frequent source of candidemia. There was less toxicity with fluconazole than with amphotericin B. CONCLUSIONS: In patients without neutropenia and without major immunodeficiency, fluconazole and amphotericin B are not significantly different in their effectiveness in treating candidemia.     

Problem of offering unsolicited clinical genetic advice and diagnoses to nonmedical friends and strangers

Systemic candidiasis with renal involvement is a rare but well-recognized complication during neonatal intensive care treatment. In addition to intravenous administration of amphotericin B, decompression of the renal pelvis and irrigation of the involved kidney with the same drug through a nephrostomy tube will provide a high concentration of antifungal agent with a flushing effect. This procedure is not always possible due to the small size of the neonatal kidneys. We have conceived a new percutaneous trocar nephrostomy which allows its application directly in an incubator without using X-rays during a single procedure. In 3 cases a bilateral percutaneous nephrostomy was performed directly in the incubator using a one-step ultrasonically guided maneuver under local anesthesia. The funguria was successfully eradicated in all cases. The availability of a nephrostomy trocar of small dimensions leads us to an improved renal approach in newborns.     

Management of invasive candidal infections: results of a prospective, randomized, multicenter study of fluconazole versus amphotericin B and review of the literature

We conducted a prospective, randomized, multicenter study comparing fluconazole and amphotericin B in the treatment of candidal infections. One hundred and sixty-four patients (60 of whom were neutropenic) with documented or presumed invasive candidiasis were assigned to treatment with either fluconazole (400 mg daily) or amphotericin B (25-50 mg daily; 0.67 mg/kg daily for neutropenic patients). Clinical response and survival rates were assessed at 48 hours, after 5 days, and at the end of therapy. Overall response rates to fluconazole and amphotericin B were similar (66% and 64%, respectively). There were no differences in response as related to site of infection, pathogen, time to defervescence, relapse, or survival rates between the groups. Adverse effects were more frequent with amphotericin B (35%) than with fluconazole (5%; P < .0001). The results of this study confirm that fluconazole is as effective as but better tolerated than amphotericin B in the treatment of candidal infections.     

Assessment of antifungal activities of fluconazole and amphotericin B administered alone and in combination against Candida albicans by using a dynamic in vitro mycotic infection model

We evaluated the pharmacodynamic activities of fluconazole and amphotericin B given alone and in combination against Candida albicans by using an in vitro model of bloodstream infection that simulates human serum pharmacokinetic parameters for these antifungals. Fluconazole was administered as a bolus into the model to simulate regimens of 200 mg every 24 h (q24 h) and 400 mg q24 h. Amphotericin B was administered at doses producing the peak concentration (2.4 micrograms/ml) observed with a regimen of 1 mg/kg of body weight q24 h. A combination regimen of fluconazole (400 mg q24 h) and amphotericin B (1 mg/kg q24 h) administered simultaneously and as a staggered regimen (amphotericin B bolus given 8 h after fluconazole bolus) was also simulated in the model to characterize possible antagonism between these agents. Fluconazole alone and amphotericin B alone demonstrated fungistatic (< 99.9% reduction in numbers of CFU per milliliter from the starting inoculum) and fungicidal (> 99.9% reduction) activity, respectively. When fluconazole and amphotericin B were administered simultaneously, fungicidal activity similar to that observed with amphotericin B alone was observed. Staggered administration of fluconazole and amphotericin B, however, resulted in a substantial reduction of the fungicidal activity of amphotericin B, producing fungistatic activity similar to that observed with noncombination fluconazole regimens. These results demonstrate the usefulness of this model for comparing the in vitro pharmacodynamic characteristics of different antifungal regimens and support the theory of azole-polyene antagonism. The effects of this antagonism on the in vivo activity and clinical usefulness of combination antifungal therapy, however, remain to be determined.     

Curative treatment with fluconazole in 5 cases of invasive candidiasis

BACKGROUND: Amphotericin B is the treatment of choice for invasive and disseminated Candida sp. infections. Fluconazole is an antifungal drug with less toxicity. Because of its pharmacokinetic properties, fluconazole can be specially useful in the treatment of invasive candidiasis. Although it is useful in several forms of candidiasis, its efficacy in deep-seated candidal infections is not totally proved due to the lack of comparative studies with amphotericin. In order to contribute new data about the usefulness of fluconazole in the treatment of invasive candidiasis, we report 5 patients which cured with this antifungal drug. METHODS: The clinical records of those patients with invasive candidiasis that cured with fluconazole were retrospectively reviewed. RESULTS: Fluconazole was used in 2 patients after detecting toxicity to amphotericin. Fluconazole was used from the beginning in the other 3 patients. None of the patients were neutropenic. All the patients cured without recurrence. CONCLUSIONS: In this series, the employment of fluconazole was a non-toxic and effective alternative to amphotericin B in nonneutropenic patients with invasive candidiasis.     

Current treatment of candidemia in non-neutropenic patients. Amphotericin B or fluconazole? A retrospective study of 62 consecutive patients

BACKGROUND: To analyze the epidemiologic characteristics of non-neutropenic patients with candidemia in a general hospital and the advantages and disadvantages of treatment with amphotericin B or fluconazole. PATIENTS AND METHODS: A total of 62 adult non-neutropenic patients with candidemia and treated with amphotericin B (n = 35) or fluconazole (n = 27) were studied. All episodes were considered to be associated with infection in a vein catheter. The demographic characteristics, risk factors for the development of candidemia, Candida species recovered from blood culture, underlying diseases, and clinical manifestations in both groups were compared. The evolution regarding secondary effects developed with both drugs, therapy failures, long term complications, and overall mortality rate associated with candidemia were analyzed. RESULTS: Both groups were comparable with the exception of the percentage of patients infected with species different from Candida albicans, which was higher in the group of patients who received amphotericin B (57%) than in the fluconazole group (26%) (p = 0.02), and in that patients with severe renal failure or AIDS had received preferentially fluconazole. There were no statistically significant differences regarding the evolution of patients treated with amphotericin B or fluconazole with the following factors: therapy failure (27% versus 19%; p = 0.7), overall mortality rate (40% versus 44%; p = 0.6), and mortality directly related to candidemia (33% versus 30%). Mortality was significantly higher among patients who had not their vein catheters removed early (78%) compared with those who had their vein catheters removed early (34%) (p = 0.01). Sixty-six percent of patients treated with amphotericin developed some severe secondary effect, whereas no patient in the fluconazole group developed such effects. CONCLUSIONS: Both amphotericin B and fluconazole seem to be effective drugs for the treatment of vein catheter related candidemia in the non-neutropenic patient, although fluconazole is far less toxic. The early removal of the vein catheter plays a prognostic role with at least the same relevance than the type of antifungal therapy chosen.     

Percutaneous management of upper-tract transitional cell carcinoma

Standard management of upper tract transitional cell carcinoma is a nephroureterectomy; however, there is a distinct subgroup of patients who would be rendered dialysis dependent, or at high risk for functionally significant renal insufficiency, and for whom a nephron-sparing approach is warranted. Historically, the options for such "conservative" management have been limited to variations of open pyelotomy or partial nephrectomy. More recently, endourologic techniques have been applied to the treatment of these difficult patients. Though a ureteroscopic approach can occasionally be therapeutic, it may be precluded by the size or location of the tumor, or by a urinary diversion that makes ureteroscopic access difficult or impossible. Many of these patients can, however, be managed with a well planned percutaneous approach that provides excellent access to virtually the entire upper tract. The subsequent addition of topical BCG as an adjunct to percutaneous upper tract tumor resection may then be beneficial in decreasing the incidence of local recurrence.     

Neonatal renal candidiasis

A case is presented of renal candidiasis complicated by obstructive uropathy in a 4 month old infant. Management was successful with surgical decompression combined with peri-operative amphotericin B, followed by 3 weeks of oral ketoconazole and subsequently 6 weeks of oral fluconazole. Fluconazole was substituted for ketoconazole owing to persistent candiduria, and achieved rapid urinary sterilization. Fluconazole is an effective and less toxic alternative to prolonged courses of amphotericin B in the treatment of neonatal renal candidiasis.     

Long-term experience with clonazepam in patients with a primary diagnosis of panic disorder

OBJECTIVE: To assess the effect of the relief of obstruction on the ultimate function of the affected renal unit in urinary tuberculosis, and to identify predictors of functional recoverability. PATIENTS AND METHODS: Of a total of 82 patients with urinary tuberculosis presenting over 7 years, 38 with evidence of upper tract obstruction were analysed. All patients were assessed with pre-operative excretory urography, urinary mycobacterial cultures and serum chemistry. Patients with subnormally functioning kidneys were assessed with baseline renal scans. Preliminary intervention in the form of JJ stenting or percutaneous nephrostomy (PCN) was carried out in patients with reasonable renal function. Function was reassessed after 4 weeks to detect evidence of improvement and factors which could affect the outcome were determined. RESULTS: Thirty-eight patients had documented upper tract obstruction, of whom six had bilateral obstruction (total of 44 renal units). Ten renal units were not functioning at presentation, with a mean (SD) glomerular filtration rate (GFR) of 3.0 (5.73) mL/min, and no preliminary intervention was performed. In the remaining 34, preliminary intervention was carried out before definitive surgery (JJ stenting in 14, PCN in 15 and PCN followed by antegrade JJ stenting in five); 21 of these renal units were salvaged but 13 were lost despite overcoming the obstruction. Three of the 13 units deteriorated from having acceptable pre-treatment GFRs to becoming non-functional. Good renal cortical thickness, a low grade of renal involvement (Semb 1 or 2), the presence of more distal disease in the form of ureteric stricture and a GFR of > 15 mL/min were good predictors of renal recovery after diversion. CONCLUSIONS: The loss of some renal units seems inevitable in patients with urinary tuberculosis, despite advances in chemotherapy. Having pre-operative predictors of renal recovery may ensure optimal patient selection, thereby reducing the number of procedures and economic burden on the patient who does not require intervention.     

Update on the use of percutaneous nephrostomy/balloon dilation for the treatment of renal transplant leak/obstruction

PURPOSE: Retrospective evaluation of the efficacy of percutaneous nephrostomy and nephroureteral stent placement for treatment of post-transplant ureteral leak, and percutaneous nephrostomy and balloon dilation for treatment of post-transplant ureteral obstruction. PATIENTS AND METHODS: Data were reviewed for all patients who underwent percutaneous therapy for complications after renal transplantation between January 1985 and June 1995. A total of 61 patients with complications (leak, n = 17; obstruction, n = 44) had been treated. Patients underwent percutaneous nephrostomy followed by antegrade placement of a nephroureteral stent. In addition, all patients with obstruction also underwent ureteral balloon dilation. Follow-up ranged from 9 weeks to 24 months. Positive outcome was defined as nonsurgical closure of leak, significant improvement in renal function, and removal of the nephroureteral stent with maintenance of stable renal function. RESULTS: Regarding ureteral leak, 10 of 17 patients (59%) healed after treatment. Seven patients (41%) did not respond and went on to surgical repair. All patients with early (n = 13) ureteral obstruction (< 3 months after transplantation), had improved renal function (P < .025). Sixty-two percent of patients with early obstruction were cured (tube out with stable renal function) and 38% went to surgery for ureteral repair. In patients with late (n = 31) obstruction (> 3 months after transplantation), renal function improved in only 58% (P < .01). Only 16% of patients with late obstruction were cured (tube out with stable renal function). Ureteral obstruction was persistent in the remaining patients and did not respond to multiple balloon dilations. All complications were minor and included 23 of 61 (38%) patients with urinary tract infections and nine of 61 (14%) patients with limited hematuria. CONCLUSION: Percutaneous nephrostomy is very effective in improving renal function in patients with early obstruction. It is moderately successful in treating ureteral leak. Ureteral balloon dilatation is moderately effective for treatment of obstruction in the early (< 3 months) postoperative period. However, balloon dilation is minimally successful in curing ureteric obstruction occurring more than 3 months after transplantation.     

Fluconazole versus amphotericin B as empirical antifungal therapy of unexplained fever in granulocytopenic cancer patients: a pragmatic, multicentre, prospective and randomised clinical trial

Amphotericin B, despite its intrinsic servere toxicity, is the most commonly used empirical antifungal therapy in cancer patients with unexplained fever not responding to empirical antibacterial therapy. The aim of this study was to show whether fluconazole was as effective as, and less toxic than, amphotericin, with no effort made to compare the antifungal activity of the two drugs. A group of 112 persistently febrile (> 38 degrees C) and granulocytopenic (< 1000 cells/mm3) cancer patients, not receiving any absorbable antifungal antibiotic for prophylaxis, with a mean age of 27 years (range 1-73 years), undergoing chemotherapy for a variety of malignancies and with a diagnosis of unexplained fever after at least 96 h of empirical antibacterial therapy, were randomised to receive either fluconazole (6 mg/kg/day up to 400 mg/day) or amphotericin B (0.8 mg/kg/day) as empirical antifungal treatment. Patients were required to have normal chest X-rays at randomisation, no previous history of aspergillosis and negative surveillance cultures for Aspergillus. The intention-to-treat analysis showed defervescence and survival without treatment modification in 42 of 56 patients (75%) in the fluconazole group and in 37 of 56 (66%) in the amphotericin B group (P = 0.4). Duration of therapy was 6 days (95% CI = 4-8 days) in both groups. Death occurred in 3 patients (5%) in the fluconazole and in 2 (4%) in the amphotericin B group. No fungal death was documented in either group. Adverse events developed in 18 of 56 patients (32%) in the fluconazole group and in 46 of 56 (82%) in the amphotericin B group (P < 0.001). In the amphotericin B group, 5 patients had treatment discontinued because of toxicity, versus none in the fluconazole group, a difference which approached statistical significance (P = 0.06). This study shows that fluconazole is by far less toxic than amphotericin B and suggests that it might be as effective as amphotericin B, in pragmatical terms and for this specific indication. However, numbers are too small to allow definitive conclusions about efficacy, and the use of fluconazole for this indication remains experimental. Future studies should try to identify patients more at risk of fungal infections, with the aim of individualising antifungal approaches.     

Distal ureteral atresia associated with crossed renal ectopia with fusion: recovery of renal function after release of a 10-year ureteral obstruction

We report on a 10-year-old boy with distal ureteral atresia associated with crossed renal ectopia with fusion. He was admitted with a high fever associated with a urinary tract infection. The diagnosis was established by antegrade and retrograde pyelography. The upper hydronephrotic portion of the kidney, obstructed for 10 years, recovered its function after nephrostomy placement. To our knowledge, this is the first patient whose renal function has recovered despite an ureteral obstruction of 10-years' duration. Therefore, we recommend a transient nephrostomy placement even for far advanced pediatric hydronephrosis, to test for the possibility of functional recovery.     

Comparative evaluation of macrodilution and alamar colorimetric microdilution broth methods for antifungal susceptibility testing of yeast isolates

A comparative evaluation of the macrodilution method and the Alamar colorimetric method for the susceptibility testing of amphotericin B, fluconazole, and flucytosine was conducted with 134 pathogenic yeasts. The clinical isolates included 28 Candida albicans, 17 Candida tropicalis, 15 Candida parapsilosis, 12 Candida krusei, 10 Candida lusitaniae, 9 Candida guilliermondii, 18 Torulopsis glabrata, and 25 Cryptococcus neoformans isolates. The macrodilution method was performed and interpreted according to the recommendations of the National Committee for Clinical Laboratory Standards (document M27-P), and the Alamar colorimetric method was performed according to the manufacturer's instructions. For the Alamar colorimetric method, MICs were determined at 24 and 48 h of incubation for Candida species and T. glabrata and at 48 and 72 h of incubation for C. neoformans. The overall agreement within +/- 1 dilution for Candida species and T. glabrata against the three antifungal agents was generally good, with the values for amphotericin B, fluconazole, and flucytosine being 85.3, 77.9, and 86.2%, respectively, at the 24-h readings and 69.3, 65.2, and 97.2%, respectively, at the 48-h readings. Most disagreement was noted with fluconazole against C. tropicalis and T. glabrata. Our studies indicate that determination of MICs at 24 h by the Alamar colorimetric method is a valid alternate method for testing amphotericin B, fluconazole, and flucytosine against Candida species but not for testing fluconazole against C. tropicalis and T. glabrata. For flucytosine, much better agreement can be demonstrated against Candida species and T. glabrata at the 48-h readings by the Alamar method. Excellent agreement within +/- dilution can also be observed for amphotericin B, fluconazole, and flucytosine (80, 96, and 96%, respectively) against c. neoformans when the MICs were determined at 72 h by the Alamar method.     

Optimal method of urgent decompression of the collecting system for obstruction and infection due to ureteral calculi

PURPOSE: We compare the efficacy of percutaneous nephrostomy with retrograde ureteral catheterization for renal drainage in cases of obstruction and infection associated with ureteral calculi. MATERIALS AND METHODS: We randomized 42 consecutive patients presenting with obstructing ureteral calculi and clinical signs of infection (temperature greater than 38 C and/or white blood count greater than 17,000/mm.3) to drainage with percutaneous nephrostomy or retrograde ureteral catheterization. Preoperative patient and stone characteristics, procedural parameters, clinical outcomes and costs were assessed for each group. RESULTS: Urine cultures obtained at drainage were positive in 62.9% of percutaneous nephrostomy and 19.1% of retrograde ureteral catheterization patients. There was no significant difference in the time to treatment between the 2 groups. Procedural and fluoroscopy times were significantly shorter in the retrograde ureteral catheterization (32.7 and 5.1 minutes, respectively) compared with the percutaneous nephrostomy (49.2 and 7.7 minutes, respectively) group. One treatment failure occurred in the percutaneous nephrostomy group, which was successfully salvaged with retrograde ureteral catheterization. Time to normal temperature was 2.3 days in the percutaneous nephrostomy and 2.6 in the retrograde ureteral catheterization group, and time to normal white blood count was 2 days in the percutaneous nephrostomy and 1.7 days in the retrograde ureteral catheterization group (p not significant). Length of stay was 4.5 days in the percutaneous nephrostomy group compared with 3.2 days in the retrograde ureteral catheterization group (p not significant). Cost analysis revealed that retrograde ureteral catheterization was twice as costly as percutaneous nephrostomy. CONCLUSIONS: Retrograde ureteral catheterization and percutaneous nephrostomy effectively relieve obstruction and infection due to ureteral calculi. Neither modality demonstrated superiority in promoting a more rapid recovery after drainage. Percutaneous nephrostomy is less costly than retrograde ureteral catheterization. The decision of which mode of drainage to use may be based on logistical factors, surgeon preference and stone characteristics.     

Caroli''s disease]

Radiotherapy given during treatment of oral and pharyngeal malignancy is frequently associated with colonization of the oral mucosa by Candida species. Treatment of these infections has included topical and systemic agents. In the present study 73 patients with oropharyngeal candidosis were treated with either amphotericin B (10 mg lozenges, four times daily for 14 days, 36 patients) or fluconazole (50 mg daily for 7 days, 37 patients). The yeasts most frequently isolated were C albicans and C glabrata. Clinical signs and symptoms showed improvement at end of treatment in 72% of patients who received amphotericin B compared with 92% of patients who received fluconazole. Mycological cure at end of treatment was achieved in 31% of the amphotericin B group and 46% of patients who received fluconazole. For both treatments the cure rate was less in denture wearers than in non denture wearers.     

Antifungal susceptibility of clinically isolated Candida albicans by broth microdilution method

In this study we investigated the antifungal susceptibility of 285 strains of Candida albicans isolates at Kinki University Hospital from March 1995 to December 1996. The antifungal agents tested were fluconazole, miconazole, intraconazole, amphotericin B and flucytosine. The susceptibility testing were performed according to the broth microdilution method standardized by National Committee for Clinical Laboratory Standards (M27-T). Most isolates of C. albicans showed relatively a low MIC value and the MIC90S were calculated at 1 microgram/ml; fluconazole, 0.125 microgram/mg; miconazole, 0.06 microgram/ml; itraconazole, 1 microgram/ml; amphotericin B, 0.25 microgram/ml; flucytosine. There was only one strain that showed high resistance against fluconazole and it showed cross-resistance against miconazole and itraconazole. There were two flucytosine resistant strains. The MICs of amphotericin B were tightly clustered and resistant strain were not observed.     

Antisocial personality disorder as a prognostic factor for pharmacotherapy of cocaine dependence

OBJECTIVES: The effects of verapamil (VRP), prostaglandin F2 alpha (PGF2 alpha), phenylephrine, and noradrenaline on upper urinary tract dynamics were studied in vivo, using a pig model involving 12 miniswine which were subjected to acute pharmacologic perfusion studies of the upper urinary tract. METHOD: Changes in renal pelvic pressure (Ppvs) and ureteral peristalsis frequency were recorded at 2 mL/min perfusion rate premedication, and then during perfusion with different concentrations of each drug tested in three experiments. RESULTS: Ppvs showed no significant variations with VRP perfusion when compared with premedication readings, whereas ureteral peristalsis frequency was decreased significantly by 10(-3) mol/L of VRP. PGF2 alpha perfusion caused no statistically significant changes in Ppvs when compared with premedication values, but increased ureteral peristalsis frequency from 3 to 6.5/min at a concentration of 2 x 10(-1) mg (200 micrograms). Phenylephrine HCl and noradrenaline perfusion increased Ppvs from 8 +/- 1.1 to 11.9 +/- 1.6 cm water at a concentration of 100 micrograms. They augmented the frequency of ureteral peristalsis from about 2.5 +/- 1.2 to 4.1 +/- 1.3/min. No systemic effects were recorded since pulse, respiration, and left ureteral activity were unchanged during pharmacologic perfusion of the right side. CONCLUSION: Pharmacologic manipulation of ureteral activity can be achieved via direct perfusion with no significant modulation of Ppvs or systemic impact. VRP-induced smooth muscle relaxation of the upper urinary tract may be useful in percutaneous surgery for stones.     

Trends in antifungal use and epidemiology of nosocomial yeast infections in a university hospital

This report describes both the trends in antifungal use and the epidemiology of nosocomial yeast infections at the University of Iowa Hospitals and Clinics between fiscal year (FY) 1987-1988 and FY 1993-1994. Data were gathered retrospectively from patients' medical records and from computerized databases maintained by the Pharmacy, the Program of Hospital Epidemiology, and the Medical Records Department. After fluconazole was introduced, use of ketoconazole decreased dramatically but adjusted use of amphotericin B decreased only moderately. However, the proportion of patients receiving antifungal therapy who were treated with amphotericin B declined markedly. In FY 1993-1994, 26 patients of the gastrointestinal surgery service received fluconazole. Among these patients, fluconazole use was prophylactic in 16 (61%), empiric in 3 (12%), and directed to a documented fungal infection in 7 (27%). Rates of nosocomial yeast infection in the adult bone marrow transplant unit increased from 6.77/1,000 patient days in FY 1987-1988 to 10.18 in FY 1989-1990 and then decreased to 0 in FY 1992-1993. Rates of yeast infections increased threefold in the medical and surgical intensive care units, reaching rates in FY 1993-1994 of 6.95 and 5.25/1,000 patient days, respectively. The rate of bloodstream infections increased from 0.044/1,000 patient days to 0.098, and the incidence of catheter-related urinary tract infections increased from 0.23/1,000 patient days to 0.68. Although the proportion of infections caused by yeast species other than Candida albicans did not increase consistently, C. glabrata became an important nosocomial pathogen.