Role of fluconazole in a case of rapid onset ritonavir and inhaled fluticasone-associated secondary adrenal insufficiency.

A 52-year-old man with well-controlled HIV infection taking ritonavir and increasing doses of inhaled fluticasone for chronic bronchitis developed thrush. Within days of discontinuing fluticasone and initiating fluconazole, he presented with fatigue, malaise, lower-extremity oedema and orthostasis. Testing confirmed exogenous Cushing's syndrome and secondary adrenal insufficiency. Although ritonavir-fluticasone interactions have been previously reported as a cause for adrenal insufficiency, we propose that fluconazole increased the rapidity of onset and severity of symptoms through synergistic inhibition of the adrenal axis.

Improving clinical practice: should we give influenza vaccinations to heart transplant patients?

BACKGROUND: Current practice recommends that immunosuppressed patients (pts) receive yearly influenza (flu) vaccinations. However, disparity exists between current recommendations and clinical practice regarding the decision to administer flu vaccinations to heart transplant (Tx) pts. The purpose of this study was to examine the common clinical practices and outcome characteristics in Tx pts in a multi-institutional database. We assess the incidence of rejection, infection and flu in the months after administration of flu vaccinations. METHODS: Between 1990 and 2001, 5,581 pts underwent Tx at 28 institutions. Pts who were >1 year post-Tx as of January 1, 2002 (N = 3,601) constituted the study group. RESULTS: During the years 2002 and 2003, 89% of the institutions administered flu vaccines, with 7 institutions requiring pts to be >3 months (N = 1), 6 months (N = 1) and 12 months (N = 5) post-Tx. All 25 centers that vaccinated pts used trivalent inactivated vaccines during the months of October through January. Three centers did not vaccinate Tx pts due to a purported association with increased allograft rejection. There were no significant differences in the total number of rejection episodes (0.4% vs 0.3%, p = 0.7), rejection episodes by month (January: 0.4% vs 0%, p = 0.2; February: 0.5% vs 1.5%, p = 0.08; March: 0.5% vs 0%, p = 0.14), all infections (0.7% vs 0.6%, p = 0.6) and viral infections (0.1% vs 0%, p = 0.17) between centers that administered flu vaccines and those that did not, respectively. The incidence of flu was low in both groups. CONCLUSIONS: Flu vaccinations can be given safely to heart transplant pts without an increased incidence of rejection or infection. This information provides clinicians with data to improve clinical practice.

Steep-dip seismic imaging of the shallow San Andreas fault near Parkfield.

Seismic reflection and refraction images illuminate the San Andreas Fault to a depth of 1 kilometer. The prestack depth-migrated reflection image contains near-vertical reflections aligned with the active fault trace. The fault is vertical in the upper 0.5 kilometer, then dips about 70 degrees to the southwest to at least 1 kilometer subsurface. This dip reconciles the difference between the computed locations of earthquakes and the surface fault trace. The seismic velocity cross section shows strong lateral variations. Relatively low velocity (10 to 30%), high electrical conductivity, and low density indicate a 1-kilometer-wide vertical wedge of porous sediment or fractured rock immediately southwest of the active fault trace.

"A beacon of light". Spirituality in the heart transplant patient.

For the cardiac transplant recipients in this study, spirituality was like a beacon of light, providing illumination and sustaining hope while enduring illness. Spirituality was nurtured by Developing Faith and by the Presence of significant others, health care providers, and the Divine to sustain hope. Spirituality throughout the transplantation process was described by concepts of faith, presence, enduring illness, and sustaining hope. The four dynamic phases of Enduring Illness can assist health care providers in understanding what spirituality means to transplant patients. This conceptual model of spirituality demonstrates the important role that spirituality plays in recovery. Clinical application of this model will allow health care providers involved in the care of cardiac transplant patients to integrate spirituality into their patients' plan of care. With future research, this model can be easily modified and built upon to meet the needs of cardiac transplant patients in all phases of transplantation.

Neonatal assessment procedures: a historical review.

A historical review of neonatal assessment procedures is presented to demonstrate the trends in advancement of the field and attempts toward collaboration of medicine and psychology in contributions to the area. The literature suggests that the medically oriented neurological examinations have continued to be altered and improved. The growth of behaviorism within psychology and the view that behavior is closely related to underlying neurological mechanisms have contributed to the development of behaviorally oriented assessment procedures. These trends have combined successfully in the development of the Brazelton Neonatal Assessment Scale, which focuses on assessment of behavioral capabilities reflecting the quality of parent-infant relationships. The most recent contributions are directed toward development of specialized assessment techniques to fulfill specific research needs. Suggestions and cautions for use of available procedures are presented.