Invasive pulmonary aspergillosis due to a multi-azole resistant Aspergillus fumigatus.

A patient with invasive pulmonary aspergillosis due to an azole-resistant Aspergillus fumigatus is described. Despite treatment change from voriconazole to amphotericin B as soon as the resistance data were available, the patient died. Azole resistance is an emerging problem, which significantly complicates the management of A. fumigatus infections. It should be considered in every patient with an invasive A. fumigatus infection who is not responding to voriconazole therapy.

Changing preferences for information and participation in the last phase of life: a longitudinal study among newly diagnosed advanced lung cancer patients.

PURPOSE: The objective is to explore changes over time in the information and participation preferences of newly diagnosed stage IIIb/IV non-small-cell lung cancer patients. METHODS: Patients were recruited by physicians in 13 hospitals and interviewed every 2 months until the fourth and every 4 months until the sixth interview. RESULTS: Sixty-seven patients were interviewed three times. Over a period of 4 months from diagnosis, half of patients changed their information preferences for palliative care and end-of-life decisions with a possible or certain life-shortening effect (ELDs, e.g., non-treatment decisions) in both directions, from not wanting to wanting the information, but also--and as much--from wanting to no longer wanting it. The latter were more likely to be in a better physical condition. Preferences for participation in medical decision making also changed: 50% to 78%, depending on the type of decision (general, treatment, transfer or ELD), changed their preference towards wanting more or less participation. Pain seemed to be a trigger for patients wanting more involvement, which contrasts with studies suggesting that patients who are more ill tend to give up more control. CONCLUSIONS: Doctors should regularly ask their advanced lung cancer patients how much information and participation they want because preferences do change in unexpected ways.

The Leuven staged supraperiosteal retropositioning repair: long-term velopharyngeal function in non-syndromic cleft palate.

BACKGROUND: From 1989 to 1993, 113 previously untreated patients were admitted to the Multi-disciplinary Cleft Lip and Palate Team of the University Hospitals Leuven. Palate repair was performed in our centre by one surgeon (FO) in 88 patients. Our current surgical technique consists of a single-stage supraperiosteal retropositioning (modified Veau-Wardill-Kilner) for patients with a soft cleft palate only (SCP) or a soft cleft palate with up to 1 cm of the hard palate (HSCPpa). Patients with a larger or complete cleft of the secondary hard palate (HSCP) and patients with unilateral (UCLP) or bilateral (BCLP) cleft lip and palate undergo two surgical stages for palate closure: a supra-periosteal retropositioning is performed around 12 months of age, and a modified Langenbeck closure of the hard palate around 60 months of age. AIM: To assess velopharyngeal function with speech as outcome measure. PATIENTS AND METHODS: Velopharyngeal function was assessed in two ways. In one assessment, a "hard" outcome measure was the number of patients undergoing pharyngoplasty following palate repair in our centre (n = 88). In the other assessment, velopharyngeal function was evaluated in a homogeneous sub-population of 44 non-syndromic cleft patients with normal to slight impairment of the following functions: mental development, language development, and hearing. In this group, prospectively collected data about hypernasality and nasal emission were analysed retrospectively using a semi-objective nasality index (NI). Articulation was evaluated using a subjective articulation index (AI) representing articulation errors (retro-articulation, glottal stops and facial grimacing) associated with velopharyngeal insufficiency (VPI). Mean follow-up was 114 months. RESULTS: Despite rigid assessment by a phoniatrician and speech pathologist, only 1 patient out of 88 patients with soft palate surgery in our institution was thought to need pharyngoplasty. In the sub-cohort of 44 non-syndromic patients, nobody needed a pharyngoplasty. In the latter cohort, at the age of about eight years, 27 patients (61.5%) had undetectable nasality, 13 patients (29.5%) had an NI of 1 or "mild" nasality, and 4 patients (9%) had moderate nasality. At this point in time, articulation errors associated with VPI were noted in 14% of patients. CONCLUSION: In this subgroup of cleft palate patients treated following the Leuven protocol, there was no need for secondary pharyngoplasty. Ninety-one per cent of patients had no, or only mild, rhinolalia aperta by the age of eight years, and 84% did not display VPI-related articulation disorders. This suggests that velopharyngeal function in patients treated by this protocol is excellent compared to results in the literature.

Optical coherence tomography of adult-onset vitelliform dystrophy.

PURPOSE: To report the cross-sectional structure of the retina and choroid in eyes with adult-onset vitelliform macular dystrophy as obtained by optical coherence tomography (OCT). METHODS: Seven patients with adult-onset vitelliform macular dystrophy and one patient with Best disease were examined by fundoscopy, fluorescein and indocyanine green angiography and OCT. Three patients underwent also electro-oculography. RESULTS: 1. Seven cases with adult-onset vitelliform macular dystrophy showed a well-circumscribed elevation of a highly reflective band, corresponding to the retinal pigment epithelium 2. In these 7 patients, the space below this band was inhomogeneous and moderately reflective. 3. Four cases out of 7 had a well defined posterior boundary. 4. The patient with Best disease disclosed a different aspect on OCT, although the contour of the lesion was similar to the others. CONCLUSION: Optical coherence tomography disclosed the structure of the vitelliform lesion in vivo and could be helpful for its pathological interpretation.

Features of age-related macular degeneration on optical coherence tomography.

PURPOSE: To describe Optical Coherence Tomographic (OCT) findings in age-related macular lesions. PATIENTS AND METHODS: We selected 6 patients with characteristic features of age-related macular disease on OCT, 4 of whom presented with Choroidal New Vessels (CNV). OCT is analogous to ultrasound, except that light is used instead of sound. The reflected light is analysed with the technique of low-coherence interferometry. RESULTS: Classic CNV present with well-defined boundaries on OCT, whereas occult CNV can present with well- or poorly defined boundaries. Findings in Chronic Central Serous Chorioretinopathy (CSCR) and Adult Onset Vitelliform Dystrophy (AOVD) need angiographic correlation when compared to findings in CNV. CONCLUSION: OCT cannot replace conventional diagnostic techniques in exsudative Age-related Macular Degeneration. Although it accurately depicts associated changes and especially the associated serous detachment in macular disease, the imaging of neovascular membranes faces limited penetration and resolution. The interpretation of the tomograms requires further clinico-histological correlation.

Lung volume reduction surgery as an emergency and life-saving procedure.

Lung volume reduction surgery (LVRS) is emerging as a promising and unique therapeutic option for rigorously selected patients with severe debilitating emphysema. A 51 yr old man with generalized emphysema developed bilateral pneumothoraces during his first holiday abroad. Due to respiratory insufficiency, intubation and mechanical ventilation were necessary. In total, six chest tubes were inserted but massive air leak persisted and his respiratory condition deteriorated due to bronchopneumonia and sepsis. The patient was transferred to Belgium. As a last resort, bilateral LVRS was performed through a median sternotomy. The most diseased areas of the upper lobes containing the air leak were resected bilaterally and a pleurectomy was associated. Three months after operation, there was a remarkable improvement in spirometric values with an increase in forced expiratory volume in one second of almost 100%. The results were sustained after a follow-up of 18 months. In this dramatic case, lung volume reduction surgery proved to be effective, and was even a life saving procedure.