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Management of Invasive Candidiasis (IC) is one of the hottest topics while caring for critically ill patients: of the utmost importance are clear definitions of the deep-seated invasive infections caused by Candida spp., to have appropriate and correct epidemiological data. Both conventional (hystopathological and microbiological) and newer, nonconventional diagnostic approaches (antigen based biomarkers, molecular tests, genetic tests) will be also shortly reviewed. Predictive rules and clinical scores able to identify patients at a high risk for developing IC infections will be analyzed according to the most recent data. Treatment strategies (prophylaxis, preemptive, empirical, and targeted therapy) according to the most recent definitions and the latest guidelines (IDSA 2010; ESCMID/EFIGS, 2011–2012) will be finally considered.

Acute liver failure (ALF) is a rare syndrome characterized by sudden and acute hepatic injury which can be attributed to a number of different causes although not all of them are always clearly identifiable [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13]. A severe compromise of parenchymal function is followed, at different intervals, by the onset of hepatic encephalopathy, serious haemostasis alteration and, in many cases, multiple organ failure. In the 70s the term FHF (fulminant hepatic failure) had been introduced to describe serious hepatic damage, in absence of known pre-existing hepatic disease, with subsequent onset of encephalopathy within 8 weeks. The syndrome was described as “potentially reversible” [1, 2, 12]. The definition proposed by O’Grady in 1993 and still used today recognizes that the onset of encephalopathy and of altered awareness at different degree is fundamental from a prognostic point of view [2, 12]. Elevated transaminase, hyperbilrubinemia, encephalopathy and serious coagulopathy are the main characteristics of ALF [1, 2, 3, 4, 5, 6, 7, 10]. All the identifying factors that have been proposed include the onset of encephalopathy in the course of ALF, the lack of pre-existing hepatic disease and the high incidence of spontaneous mortality (>85%). This pathology presents itself in a variety of ways and it may be a combination of different aetiologies, each producing a very different outcome. ALF is identifiable by a progressive bilirubin increase [1, 2, 3, 4, 5, 6, 7] within a time span of 7 days to 26 weeks after acute liver damage. Depending on the interval between the onset of jaundice and the clinical signs of encephalopathy, the syndrome is classified as hyper-acute (jaundice-encephalopathy interval

Lung injury caused by a ventilator results from nonphysiologic lung stress (transpulmonary pressure) and strain (inflated volume to functional residual capacity ratio).To determine whether plateau pressure and tidal volume are adequate surrogates for stress and strain, and to quantify the stress to strain relationship in patients and control subjects.Nineteen postsurgical healthy patients (group 1), 11 patients with medical diseases (group 2), 26 patients with acute lung injury (group 3), and 24 patients with acute respiratory distress syndrome (group 4) underwent a positive end-expiratory pressure (PEEP) trial (5 and 15 cm H2O) with 6, 8, 10, and 12 ml/kg tidal volume.Plateau airway pressure, lung and chest wall elastances, and lung stress and strain significantly increased from groups 1 to 4 and with increasing PEEP and tidal volume. Within each group, a given applied airway pressure produced largely variable stress due to the variability of the lung elastance to respiratory system elastance ratio (range, 0.33-0.95). Analogously, for the same applied tidal volume, the strain variability within subgroups was remarkable, due to the functional residual capacity variability. Therefore, low or high tidal volume, such as 6 and 12 ml/kg, respectively, could produce similar stress and strain in a remarkable fraction of patients in each subgroup. In contrast, the stress to strain ratio-that is, specific lung elastance-was similar throughout the subgroups (13.4 +/- 3.4, 12.6 +/- 3.0, 14.4 +/- 3.6, and 13.5 +/- 4.1 cm H2O for groups 1 through 4, respectively; P = 0.58) and did not change with PEEP and tidal volume.Plateau pressure and tidal volume are inadequate surrogates for lung stress and strain. Clinical trial registered with www.clinicaltrials.gov (NCT 00143468).

Antifungal therapy may be unable to eradicate invasive mycosis in leukemia patients. The presence of persisting pulmonary nodules owing to mycosis seems to increase the risk of fungal relapse after chemotherapy and transplant procedures. Between 1997 and 2004, 10 acute leukemia patients underwent pulmonary surgery for invasive mycosis. The median time from diagnosis of mycosis to surgery was 135 days (range 21-147). Three patients underwent emergency surgery, owing to hemoptysis. In the other seven patients with nodule/cavitation remaining after antifungal treatment, surgery (three wedge resections, four lobectomies) was scheduled before transplant. Pathologic examination confirmed two aspergillosis and three zygomycosis. The only side effect was pneumothorax in one case. Nine patients were considered cured. Six patients underwent bone marrow transplantation (three allogeneic, three autologous) with antifungal prophylaxis without relapse during the transplant procedure. In selected patients scheduled for bone marrow transplantation, surgical resection of localized pulmonary fungus nodules combined with antifungal prophylaxis seem to be an effective treatment for preventing mycotic relapse.

Background Indwelling central venous catheters (CVCs) are essential devices in the management of patients with hematological disorders treated with chemotherapy. However, their nature predisposes patients to unwanted complications. Methods CVC-related complications were retrospectively analyzed in 227 hematologic patients who were consecutively admitted to our hematology department between May 2002 and April 2004. Patients’ diagnoses comprised acute myeloid leukemia (36.8%), acute lymphoid leukemia (7.3%), lymphoproliferative disorders (28.3%), multiple myeloma (19.5%), myeloproliferative syndromes (5%) and others (3.1%). The CVCs used were polyurethane three lumen 7-Fr (111 patients) for chemotherapy and 12-Fr (114 patients) for chemotherapy and peripheral blood stem cell apheresis, plus two tunneled catheters. Results The pathological events were: bacteriaemias (n=46); occlusions (n=10); exit tunnel infections (n=8); thrombosis (n=6); lung emboli (n=2). Among febrile patients the bacteriemia frequency was 20%, of which 13.6% were CVC-related (with a higher incidence in leukemia patients (p=0.027). Among the isolates, gram-positive bacteria were found in 29 cases (23 CVC-related cases), and gram-negative bacteria in 16 cases (8 CVC-related cases). Only one patient had Candida albicans sepsis. At univariate and multivariate analysis significant risk factors for infection (pConclusions In our hematologic patients, the CVC complications were mainly septic, with only 10.1% of CVC-related bacteriemias, despite prolonged catheterization duration. Acute leukemia patients were at major risk for sepsis, probably due to a more severe neutropenia and prolonged catheterization duration.

Nowadays it is not clear whether the level of hypoxemia is related to the outcome. It has been shown that the pulmonary dead space fraction is an independent risk factor for death in the early phase of acute respiratory distress syndrome [1].

The computed tomography (CT) scan can be used to measure the lung weight-volume and to determine the degree of inflation (not aerated, poorly aerated, well aerated, over aerated tissue). Nowadays to accurately study the lung, a whole thoracic CT scan must be performed, thus exposing the patient to a large dose of ionizing radiation. A possible solution could be to acquire only three CT lung sections instead of scanning the whole lung. We previously showed that in ALI/ARDS patients three lung sections are able to accurately estimate the lung inflation similar to the whole CT scan.

Imatinib Mesilate (Glivec) is able to induce a high rate of Complete Cytogenetic Response (CCyR) with low treatment-related toxicity. The long-term duration of this Ph-negative status is, however, still undefined. Therefore, some groups (Drummond et al, Br J Haematol 123:479, 2003; Hui et al, Leukemia 17:821,2003) decided to mobilize and to collect Ph-negative PBSCs in patients reaching CCyR with Glivec. In our experience we studied 12 Ph-negative, FISH-negative patients, median age 50 yrs (26–61). Three of them were also PCR-negative, being the minimal residual disease assessed using RT-PCR. All patients received Imatinib Mesilate at the daily dose of 400 mg. The median duration of treatment with Glivec was 25 months (range 11–35). Eight of 12 pts (67%) were pre-treated with α-interferon (α-IFN) for a median time of 9.5 months (range 3–54). The median duration of CML was 39 months (range: 21–152). We discontinued Imatinib four days (range 3–5) before starting rHu-G-CSF as single agent (5–10 μg/Kg/day), which was maintained until WBC 10/μ L. Eleven of 12 pts (92%) reached the threshold of 10/μ L and started harvesting. The single patient failing collection had been pretreated with IFN and was PCR negative at the time of mobilization. The remaining 11 reached the target of 2.5 x106 CD34+ cells/Kg with a median of two apheresis (range 1–3). The median harvest was 3.14 CD34+ x 106/Kg (range 2.56–4.55). Conventional cytogenetic analysis, RT-PCR and coltural tests were performed in all apheretic samples. All the 11 mobilized patients obtained a Ph-negative harvest, which was also PCR negative in 4/11 (36%). In our experience adequate yields of PBSCs were collected with rHu-G-CSF alone in 11/12 patients achieving CCyR with Glivec, as well as in the majority of those previously treated with α-IFN (7/8). Results of harvesting after rHu-G-CSF alone in 11 CML patients achieving CCyR after Imatinib Mesilate | Patient | N. Apheresis | CD34+ x 10^6/kg | RT-PCR | |:------- | ------------ | --------------- | ------ | | T.M | 2 | 4.55 | pos. | | O.I | 2 | 3.34 | neg. | | V.E. | 1 | 3.33 | neg. | | S.G. | 3 | 3.07 | neg. | | R.R. | 1 | 4.45 | pos. | | M.G. | 3 | 2.56 | pos. | | S.C. | 1 | 3.2 | pos. | | S.C. | 2 | 2.6 | pos. | | C.A. | 1 | 3.75 | pos. | | T.G. | 2 | 3.14 | neg. | | V.M. | 2 | 2.65 | pos.

Introduction The helmet may be an effective interface for the delivery of noninvasive positive pressure ventilation. The high internal gas volume of the helmet can act as a 'mixing chamber', in which the humidity of the patient's expired alveolar gases increases the humidity of the dry medical gases, thus avoiding the need for active humidification. We evaluated the temperature and humidity of respiratory gases inside the helmet, with and without a heated humidifier, during continuous positive airway pressure (CPAP) delivered with a helmet. Methods Nine patients with acute respiratory failure (arterial oxygen tension/fractional inspired oxygen ratio 209 ± 52 mmHg) and 10 healthy individuals were subjected to CPAP. The CPAP was delivered either through a mechanical ventilator or by continuous low (40 l/min) or high flow (80 l/min). Humidity was measured inside the helmet using a capacitive hygrometer. The level of patient comfort was evaluated using a continuous scale. Results In patients with acute respiratory failure, the heated humidifier significantly increased the absolute humidity from 18.4 ± 5.5 mgH2O/l to 34.1 ± 2.8 mgH2O/l during ventilator CPAP, from 11.4 ± 4.8 mgH2O/l to 33.9 ± 1.9 mgH2O/l during continuous low-flow CPAP, and from 6.4 ± 1.8 mgH2O/l to 24.2 ± 5.4 mgH2O/l during continuous high-flow CPAP. Without the heated humidifier, the absolute humidity was significantly higher with ventilator CPAP than with continuous low-flow and high-flow CPAP. The level of comfort was similar for all the three modes of ventilation and with or without the heated humidifier. The findings in healthy individuals were similar to those in the patients with acute respiratory failure. Conclusion The fresh gas flowing through the helmet with continuous flow CPAP systems limited the possibility to increase the humidity. We suggest that a heated humidifier should be employed with continuous flow CPAP systems.