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Objectives: Breakthrough candidemia (BTC) on fluconazole was associated with non-susceptible Candida spp. and increased mortality. This nationwide FUNGINOS study analyzed clinical and mycological BTC characteristics.Methods: A 3-year prospective study was conducted in 567 consecutive candidemias. Species identification and antifungal susceptibility testing (CLSI) were performed in the FUNGINOS reference laboratory. Data were analyzed according to STROBE criteria.Results: 43/576 (8%) BTC occurred: 37/43 (86%) on fluconazole (28 prophylaxis, median 200 mg/day). 21% BTC vs. 23% non-BTC presented severe sepsis/septic shock. Overall mortality was 34% vs. 32%. BTC was associated with gastrointestinal mucositis (multivariate OR 5.25, 95%CI 2.23-12.40, p < 0.001) and graft-versus-host-disease (6.25, 1.00-38.87, p = 0.05), immunosuppression (2.42, 1.03-5.68, p = 0.043), and parenteral nutrition (2.87, 1.44-5.71, p = 0.003). Non-albicans Candida were isolated in 58% BTC vs. 35% non-BTC (p = 0.005). 63% of 16 BTC occurring after 10-day fluconazole were non-susceptible (Candida glabrata, Candida krusei, Candida norvegensis) vs. 19% of 21 BTC (C. glabrata) following shorter exposure (7.10, 1.60-31.30, p = 0.007). Median fluconazole MIC was 4 mg/l vs. 0.25 mg/l (p < 0.001). Ten-day fluconazole exposure predicted non-susceptible BTC with 73% accuracy.Conclusions: Outcomes of BTC and non-BTC were similar. Fluconazole non-susceptible BTC occurred in three out of four cases after prolonged low-dose prophylaxis. This implies reassessment of prophylaxis duration and rapid de-escalation of empirical therapy in BTC after short fluconazole exposure. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To assess downstaging rates in patients with United Network for Organ Sharing stage T3N0M0 hepatocellular carcinoma (HCC) treated with doxorubicin-eluting bead transarterial chemoembolization to meet Milan criteria for transplantation. Materials and Methods: A single-center retrospective review of 239 patients treated with doxorubicin-eluting bead (DEB) chemoembolization between September 2008 and December 2011 was undertaken. Baseline and follow-up computed tomography or magnetic resonance imaging was assessed for response based on the longest enhancing axial dimension of each tumor (ie, modified Response Evaluation Criteria In Solid Tumors measurements), and medical records were reviewed. Fisher exact tests and exact logistic regression were used to test the association of patient and disease characteristics with downstaging. Results: After exclusions, 22 patients remained in the analysis, 17 of whom (77%) had their HCC downstaged to meet Milan criteria. Among those whose disease was downstaged, seven underwent transplantation, one remained listed for transplantation, six had disease progression beyond Milan criteria, two underwent conventional transarterial chemoembolization, and one underwent radiofrequency ablation. The seven patients who received transplants were still living, but recurrent HCC developed in two. Baseline age (P = .25), Model for End-stage Liver Disease score (P = .77), and α-fetoprotein (AFP) level (P = 1.00) were similar between patients with and without downstaged HCC. No associations were observed between the odds of downstaging and sex (P = .21), Child–Pugh class (P = .14), Child–Pugh class controlling for baseline tumor multiplicity (P = .15), Eastern Cooperative Oncology Group performance status (P = 1.00), tumor burden (P = .31), multiple tumors (P = .31), or hepatitis C virus infection (P = 1.00). Fifteen patients who did not receive transplants were alive at 1 year, with two progression-free. Baseline AFP levels differed between those who survived 1 year and those who did not (P = .02), but did not differ by progression-free survival status (P = .62). Conclusions: T3N0M0 HCC treatment with DEB chemoembolization has a high likelihood (77%) of downstaging the disease to meet Milan criteria. [Copyright &y& Elsevier]

Background: Reoperation for bleeding is a known emergency complication after cardiac operations. When performed in the intensive care unit (ICU), sterility issues arise. Our aim was to examine the incidence of sternal wound infection (SWI) after reexploration in the ICU for bleeding with routine use of local gentamycin. Methods: From January 2003 until December 2009, 4,863 patients underwent cardiac operations through a median sternotomy at our institution. We conducted a retrospective database review identifying all patients who required reoperations. The occurrence of SWI in this group was compared with the general cardiac surgical population. Reoperations for bleeding during this period were conducted routinely in the ICU with prophylactic application of a gentamycin sponge between the sternal halves before closure in all cases. Results: Reexploration for bleeding was necessary in 302 patients (6.2%), and SWI occurred in 11, for a rate of 3.6%. SWI occurred in 174 of the 4,561 non-reexplored patients, for a similar rate of 3.8% (p > 0.9). These values are similar to our overall rate of SWI of 3.8% (n = 185) in the total cohort of 4,863 patients. Conclusions: The incidence of SWI was not increased in our study group after emergency reoperation for bleeding in the ICU after the local use of gentamycin. Our data suggest that reexploration in an ICU setting for bleeding does not pose a sterility challenge and that life-threatening delays due to transfer to the operating theater may be avoided. [ABSTRACT FROM AUTHOR]

Summary: Background: Worldwide, the burden of multidrug-resistant bacteria (MDR) is increasing, especially in the hospital setting. Aim: To explore characteristics and clinical relevance of MDR obtained from travellers transferred from hospitals abroad. Methods: This retrospective study included patients transferred from hospitals abroad to the University Hospital Zurich, Switzerland, who routinely underwent admission screening for possible colonization with meticillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase-producing bacteria (ESBL) and multidrug-resistant Gram-negative bacteria (MR Gram negative). Findings: Forty-six (17%) of 259 subjects were found to be colonized with MDR and nine (3.5%) patients to be infected. Thirty-three (12%) patients were colonized with one bacterial species, 12 (4.6%) with two, and three (1.2%) were colonized with three different bacterial species. In total, 36 ESBL, 21 MR Gram-negative and three MRSA isolates were detected. Escherichia coli (N = 18, 30%), Klebsiella pneumoniae (N = 14, 23%) and Acinetobacter baumannii (N = 14, 23%) were most frequently isolated. The most common sites of detection were skin (97%) and respiratory tract (41%). Being colonized contributed to an increased length of ICU stay [median (range): 8 (1–35) vs 3.5 (1–78) days; P = 0.011]. In-hospital mortality in patients colonized with MDR (10.9%) was higher than in uncolonized patients (2.3%, P = 0.018). Being colonized with MDR was associated with death (adjusted odds ratio: 5.176; 95% confidence interval: 1.325–20.218). Conclusions: A substantial proportion of patients transferred from abroad are colonized with MDR, a fact which is associated with poor clinical outcome. [ABSTRACT FROM AUTHOR]

Abstract: This article investigates the interplay of expectation dynamics and innovation processes at the level of organizations and at the innovation system level. We examine how different kinds of organizations contributed and responded to a recent hype and disappointment cycle in the field of stationary fuel cells. Among others, we trace how innovation and discourse activities changed and we explain the observed differences in strategic responses. We show that the sensitivity of organizations to expectation dynamics depends on at least three factors: the strategic embedding of the new technology, the organization''s dependence on external legitimacy and its role in the innovation system. Moreover, we show that – in their aggregation – strategic responses affected the level of the technological innovation system as well. Not only did the pace and direction of innovation activities change, but structures such as actor constellations and institutions were also modified. Our study thus provides insights into the interplay of expectation and innovation dynamics, which is important for our understanding of larger transformation processes, e.g. toward more sustainable modes of energy supply. [Copyright &y& Elsevier]

Abstract: The sustainable transformation of infrastructure sectors represents a challenge of prime importance worldwide. Due to long life times of infrastructures, strategic decision making has to explicitly consider uncertainties in context conditions, value considerations and available technological alternatives. However currently, strategic infrastructure planning is often carried out in a very narrow perspective. The present paper argues that foresight informed strategic planning, allows addressing trade-offs related to context uncertainties, value conflicts and sustainability deficits in a structured way. The paper introduces a specific procedural proposal, the Regional Infrastructure Foresight method (RIF) and illustrates its potential virtues through an application to urban water management planning in a Swiss region (Kiesental). [Copyright &y& Elsevier]

Since Simmel’s early work on forms of association, the processes guiding group composition have commanded considerable attention in structural sociology, but have not led to a general methodology for examining compositional properties. By introducing a structural event approach, this study offers a new technique that is not restricted to analysis of dyads or triads nor post hoc analysis of those structural arrangements that are observed in a given sample. The approach is illustrated using data on 745 organizational founding teams. Structural event analysis separates choice behavior guiding team composition (with respect to ascribed and achieved characteristics of members) from structurally-induced behavior based on contact opportunities. Results suggest that the strong impact of ascriptive homophily may be tempered when functional considerations of group composition are addressed. However, many of the other arrangements that ostensibly pass as ‘functional’ are in fact induced by opportunity structures. [Copyright &y& Elsevier]