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To test the hypothesis that in chronic obstructive pulmonary disease (COPD) patients the ventilatory and metabolic requirements during cycling and walking exercise are different, paralleling the level of breathlessness, we studied nine patients with moderate to severe, stable COPD. Each subject underwent two exercise protocols: a 1-min incremental cycle ergometer exercise (C) and a "shuttle" walking test (W). Oxygen uptake (VO(2)), CO(2) output (VCO(2)), minute ventilation (VE), and heart rate (HR) were measured with a portable telemetric system. Venous blood lactates were monitored. Measurements of arterial blood gases and pH were obtained in seven patients. Physiological dead space-tidal volume ratio (VD/VT) was computed. At peak exercise, W vs. C VO(2), VE, and HR values were similar, whereas VCO(2) (848 +/- 69 vs. 1,225 +/- 45 ml/min; P < 0. 001) and lactate (1.5 +/- 0.2 vs. 4.1 +/- 0.2 meq/l; P < 0.001) were lower, DeltaVE/DeltaVCO(2) (35.7 +/- 1.7 vs. 25.9 +/- 1.3; P < 0. 001) and DeltaHR/DeltaVO(2) values (51 +/- 3 vs. 40 +/- 4; P < 0.05) were significantly higher. Analyses of arterial blood gases at peak exercise revealed higher VD/VT and lower arterial partial pressure of oxygen values for W compared with C. In COPD, reduced walking capacity is associated with an excessively high ventilatory demand. Decreased pulmonary gas exchange efficiency and arterial hypoxemia are likely to be responsible for the observed findings.

Blastoschizomyces capitatus (formerly named Trichosporon capitatum or Geotrichum capitatum) is a rare cause of invasive fungal disease in immunocompromised hosts. We retrospectively studied epidemiologie, clinical, pathologic, and microbiologie features of this infection during a 68-month period at the Division of Hematology of the University La Sapienza in Rome. Twenty patients with evidence of B. capitatus were identified: 12 were infected, four were possibly infected, and four had evidence of B. capitatus colonization but were not infected by this fungus. Pulmonary infiltrates were seen in seven infected patients; four of these patients eventualfy developed mycetomalike cavitations. Eight infected patients presented clinical and radiologie features of focal hepatitis compatible with hepatosplenic candidiasis. Of the 12 infected patients, two did not receive any antifungal treatment and died, five did not show any response to systemic antifungal therapy, and five received prolonged amphotericin B plus 5-fluorocytosine therapy. Of the last group, three patients achieved stable remission of their acute leukemia and were cured, and two improved but had an apparent relapse of B. capitatus infection after their acute leukemia recurred.

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.

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. CASE REPORTSOutbreak cases. (i) Case 1. Case 1 involved a 34-year-old man hospitalized for hypoxia after head and thoracic trauma. He was placed on enteral nutrition, with insertion of a central venous catheter (CVC), and broad-spectrum antibiotic therapy was administered. On day 42 after admission (5 November 2000), he developed a fever, which was unsuccessfully treated with teicoplanin and imipenem. Multiple blood cultures yielded Saccharomyces cerevisiae. The fever and fungemia subsided under treatment with fluconazole at 400 mg/day. The CVC was removed 3 weeks after initiation of fluconazole treatment. The infectious episode resolved, but no catheter culture was performed.(ii) Case 2. Case 2 involved a 48-year-old man hospitalized for rupture of a cerebral aneurysm and fever. He was given enteral nutrition, and a CVC was inserted. Teicoplanin alone and then teicoplanin and meropenem were administered. On day 14 (10 November 2000), one blood culture yielded S. cerevisiae. On day 19, the CVC was removed and fluconazole therapy (400 mg/day) was immediately started. No catheter culture was performed. The fever subsided within 48 h of the initiation of fluconazole treatment.(iii) Case 3. Case 3 involved a 75-year-old woman admitted for acute myocardial infarction. She was given enteral nutrition, and a CVC was inserted. She was treated with various antibiotic regimens for several febrile episodes. On day 56 (10 April 2001), a blood culture yielded S. cerevisiae. The CVC was removed, leading to immediate defervescence. The CVC tip was positive for S. cerevisiae. Fluconazole therapy (400 mg/day) was started 2 days later and administered for 2 weeks.None of the three patients described above received any probiotic treatment. Case 4 (incomplete report).A 35-year-old woman with multiple traumas who had been hospitalized in the intensive care unit (ICU) at the same time as patients 1 and 2 had blood cultures positive for S. cerevisiae. Unfortunately, her medical record was sequestered for forensic purposes and whether she had received probiotic treatment or not could not be determined. This patient improved and was transferred to the orthopedic division, from which she was discharged 2 months later.The outbreak setting was an eight-bed ICU in a 400-bed secondary-care hospital in Rome, Italy. During the year preceding the outbreak, about 20% of the ICU patients were hospitalized for emergency surgery, 12% were hospitalized for elective surgery, 18% were hospitalized for trauma, and 50% were hospitalized for medical diseases. The mean (Ϯ standard deviation) age of patients was 66 Ϯ 16 years, the mean ICU hospitali...