Prevalence, risk factors and evolution of diabetes mellitus after treatment in primary aldosteronism. Results from the SPAIN-ALDO registry.

PURPOSE: To evaluate the prevalence, risk factors and evolution of diabetes mellitus (DM) after targeted treatment in patients with primary aldosteronism (PA). METHODS: A retrospective multicenter study of PA patients in follow-up at 27 Spanish tertiary hospitals (SPAIN-ALDO Register). RESULTS: Overall, 646 patients with PA were included. At diagnosis, 21.2% (n = 137) had DM and 67% of them had HbA1c levels < 7%. In multivariate analysis, family history of DM (OR 4.00 [1.68-9.53]), the coexistence of dyslipidemia (OR 3.57 [1.51-8.43]) and advanced age (OR 1.04 per year of increase [1.00-1.09]) were identified as independent predictive factors of DM. Diabetic patients were on beta blockers (46.7% (n = 64) vs. 27.5% (n = 140), P < 0.001) and diuretics (51.1% (n = 70) vs. 33.2% (n = 169), p < 0.001) more frequently than non-diabetics. After a median follow-up of 22 months [IQR 7.5-63.0], 6.9% of patients developed DM, with no difference between those undergoing adrenalectomy and those treated medically (HR 1.07 [0.49-2.36], p = 0.866). There was also no significant difference in the evolution of glycemic control between DM patients who underwent surgery and those medically treated (p > 0.05). CONCLUSION: DM affects about one quarter of patients with PA and the risk factors for its development are common to those of the general population. Medical and surgical treatment provides similar benefit in glycemic control in patients with PA and DM.

Differences in intraoperative and surgical outcomes between normotensive pheochromocytomas and sympathetic paragangliomas (PPGLs) and hypertensive PPGLs: results from the PHEO-RISK STUDY.

PURPOSE: To compare the intraoperative and surgical outcomes of normotensive pheochromocytomas and sympathetic paragangliomas (PPGLs), hypertensive PPGLs and non-PPGL adrenal lesions. METHODS: This a retrospective multicenter cohort study of patients with PPGLs from 18 tertiary hospitals. A control group of histologically confirmed adrenocortical adenomas (non-PPGL group) was selected to compare intraoperative and surgical outcomes with of the normotensive PPGLs. RESULTS: Two hundred and ninety-six surgeries performed in 289 patients with PPGLs were included. Before surgery, 209 patients were classified as hypertensive PPGLs (70.6%) and 87 as normotensive PPGLs. A higher proportion of normotensive PPGLs than hypertensive PPGLs did not receive alpha presurgical blockade (P = 0.009). When we only considered those patients who received presurgical alpha blockers (200 hypertensive PPGLs and 76 normotensive PPGLs), hypertensive PPGLs had a threefold higher risk of intraoperative hypertensive crisis (OR 3.0 [95% 1.3-7.0]) and of hypotensive episodes (OR 2.9 [95% CI 1.2-6.7]) than normotensive PPGLs. When we compared normotensive PPGLs (n = 76) and non-PPGLs (n = 58), normotensive PPGLs had a fivefold higher risk of intraoperative complications (OR 5.3 [95% CI 1.9-14.9]) and a six times higher risk of postoperative complications (OR 6.1 [95% CI 1.7-21.6]) than non-PPGLs. CONCLUSION: Although the risk of intraoperative hypertensive and hypotensive episodes in normotensive PPGLs is significantly lower than in hypertensive PPGLs, normotensive PPGLs have a greater risk of intraoperative and postoperative complications than non-PPGL adrenal lesions. Therefore, it is recommended to follow the standard of care for presurgical and anesthetic management of PPGLs also in normotensive PPGLs.

Interactions between Candida albicans and the human extracellular matrix component tenascin-C.

Tenascins are large multimeric proteins that contain repeated structural motifs that include epidermal growth factor (EGF)-like repeats, fibronectin type III repeats and a globular fibrinogen-like domain, and are involved in tissue and organ morphogenesis, as well as in adhesion and migration of cells. C. albicans germ-tubes, but not blastospores, were able to bind to soluble human tenascin-C as revealed by an indirect immunofluorescence assay. However, materials present in cell wall extracts from both morphologies attached to tenascin-C immobilized in wells of a microtiter plate. The binding specificity was demonstrated by the inhibitory effect of antibodies against C. albicans cell wall components and an anti-tenascin antibody, but not anti-laminin antibody. Fibronectin, but not fibrinogen, inhibited binding, thus indicating a role of the fibronectin type III repeats in the interaction between the fungus and tenascin-C. Binding of C. albicans cell wall materials to tenascin was RGD- and divalent cation-independent.

Biotyping and virulence properties of skin isolates of Candida parapsilosis.

The biotype and virulence of skin isolates of Candida parapsilosis were compared with blood isolates of the same fungus. Morphotype, resistotype, and electrophoretic karyotype determinations did not reveal any special cluster with a unique or dominant pathogenic feature among all of the isolates, regardless of their source. However, all cutaneous isolates had uniformly elevated secretory aspartyl-protease (Sap) activity, more than four times higher than the enzyme activity of the blood isolates. They were also highly vaginopathic in a rat vaginitis model, being significantly more virulent than blood isolates in this infection model. In contrast, skin isolates were nonpathogenic in systemic infection of cyclophosphamide-immunodepressed mice, while some blood isolates were, in this model, highly pathogenic (median survival time, 2 days, with internal organ invasion at autopsy). Finally, skin isolates did not differ, as a whole, from blood isolates in their adherence to plastic. This property was associated with a morphotype, as defined by a colony with continuous fringe, which was present among both skin and blood isolates. While confirming the genetic heterogenicity of C. parapsilosis, our data strongly suggest that the potential of this fungus to cause mucosal disease is associated with Sap production and is substantially distinct from that of systemic invasion.

Multicenter evaluation of Neo-Sensitabs, a standardized diffusion method for yeast susceptibility testing.

The agar diffusion method Neo-Sensitabs for sensitivity testing, was evaluated with 33 reference strains by fourteen laboratories. Tablets with 5-fluorocytosine, amphotericin B, nystatin, fluconazole, itraconazole, ketoconazole and tioconazole were used on Shadomy modified medium. These tests classify each strain as susceptible, intermediate or resistant to all tested antifungals by measuring the inhibition zone diameters. Intra and interlaboratory reproducibility was studied. Neo-Sensitabs sensitivity for fungi was easy to perform and reliable method with a reproducibility of 97.1% and superior to other commercialized methods, being specially interesting for antifungal susceptibility in vitro testing of triazole derivatives fluconazole and itraconazole.

Multicenter survey of in vitro antifungal resistance in yeasts of medical importance isolated from Spanish patients.

Twelve Spanish laboratories collected 325 yeast clinical isolates during a 30 day's period, among them 224 Candida albicans, 30 Candida glabrata, and 27 Candida parapsilosis. In vitro antifungal susceptibility to amphotericin B, ketoconazole, fluconazole and itraconazole was determined by an agar diffusion test (Neo-Sensitabs, Rosco, Denmark). All the isolates tested were susceptible in vitroto amphotericin B and nearly all (97.2%) to itraconazole. In vitrosusceptibility to fluconazole and ketoconazole was high (90.2% and 91.4% of isolates, respectively) but showed variations depending on the species tested. Resistance to fluconazole and ketoconazole was low in C. albicans (4% and 3%, respectively), but 30% of Candida guilliermondii and 36% of C. glabrata isolates were resistant to fluconazole. Ketoconazole resistance was observed in 40% of C. glabrata, and 17% of Candida tropicalis. Resistance to antifungal drugs is very low in Spain and it is related to non-C. albicans isolates.

Detection of antibodies to Candida albicans germ tubes during experimental infections by different Candida species.

Identification and characterization of Candida albicans germ tube-specific antigens may be of relevance for the serodiagnosis of invasive candidiasis since they could be the basis for the development of new diagnostic tests. In this study, we have identified two antigens of 180 and >200 kDa in the cell wall of C. albicans germ tubes which are responsible for the induction of antibodies to C. albicans germ tubes. Antigens of similar molecular masses have been demonstrated in the cell walls of the Candida species C. stellatoidea, C. parapsilosis, C. guilliermondii, C. tropicalis, and C. krusei, but not C. glabrata. The kinetics of the antibody responses to C. albicans germ tubes were studied in rabbits infected with different Candida species. Although these antibodies were detected in rabbits infected with all Candida species except C. glabrata, the kinetics of the antibody responses to C. albicans germ tubes induced by the Candida species studied were different. Both the highest titer and the earliest response of antibodies to C. albicans germ tubes were observed in rabbits infected with either of the two serotypes of C. albicans used. However, the time needed to elicit the antibodies to C. albicans germ tubes can be reduced as the result of an anamnestic antibody response. The results presented in this study show that a test designed to detect antibodies against C. albicans germ tube antigens may be suitable for the diagnosis of infections caused by most of the medically important Candida species.

Characterization of Scedosporium prolificans clinical isolates by randomly amplified polymorphic DNA analysis.

Fingerprinting by randomly amplified polymorphic DNA (RAPD) analysis was used to differentiate Scedosporium prolificans isolates. A total of 59 arbitrary primers were screened with six unrelated S. prolificans isolates, and a panel of 12 primers was selected. The 12 primers were then used to detect DNA polymorphisms among 17 S. prolificans isolates from 11 patients with systemic S. prolificans infections diagnosed in three hospitals located in geographically different areas of Spain. Eight patients were diagnosed with S. prolificans infection in a single institution over a 6-year period, and two other patients were diagnosed with S. prolificans infection in a different hospital over a 1-year period. No single primer allowed for the discrimination of all the isolates from different patients, but this was possible by combining the RAPD patterns from three primers (UBC 701, AB1.08, and AB1.11 or UBC 701, AB1.08, and UBC 707). However, multiple isolates from the same patient were identical. In this study, we also compared a visual method and a computerized method for the analysis of the RAPD patterns. Both methods were satisfactory and gave few discordances, but given the advantages and disadvantages of each method, both systems should be used together. RAPD analysis provided a fast and economical means of typing S. prolificans isolates, with a high level of discrimination among unrelated isolates. Typing by RAPD analysis confirmed that the S. prolificans infections were epidemiologically unrelated.

Evaluation of bichro-latex albicans, a new method for rapid identification of Candida albicans.

A method for identification of Candida albicans within 5 min was evaluated by using 4,643 yeast isolates. Six false-positive and three false-negative reactions were observed. The specificity (99.87%) and sensitivity (99.74%) obtained indicate that the Bichro-latex albicans test is a useful method for the rapid identification of C. albicans colonies.

Clinical isolates of Candida guilliermondii include Candida fermentati.

Clinical isolates of Candida guilliermondii that were investigated by isoenzyme and randomly amplified polymorphic DNA analyses represented two distinct species. The two species were distinguished on the basis of delayed fermentation of galactose. The larger group of isolates was closely related to the anamorph C. guilliermondii ATCC 6260T (T = type strain) and its teleomorph, Yamadazyma (= Pichia) guilliermondii ATCC 46036T. The remaining group, whose members fermented galactose, was very similar to Candida fermentati CBS 2022, which had for many years been placed in synonymy with C. guilliermondii. Three additional groups were represented by individual strains; these strains included C. guilliermondii var. soya ATCC 20216, which was found to represent Yamadazyma ohmeri. The type strain of Y. guilliermondii is redefined.

[Utility of Fluoroplate Candida for the rapid identification of Candida albicans]. / Utilidad de las placas de agar Fluoroplate Candida para la identificación rápida de Candida albicans.

BACKGROUND: Candida albicans infections are frequent in immunocompromised patients and a prompt diagnosis could favor an early and proper antifungal treatment. The rapid identification of clinical yeast isolates facilitate this diagnosis. METHODS: The utility of Fluoroplate Candida ready-to-use plates for Candida albicans rapid identification was evaluated with 653 clinical isolates from 23 yeast species, including 307 C. albicans plated onto Fluoroplate Candida agar (Merck, Germany). Rapid identification of C. albicans was based on the hydrolysis of 4-methylumbelliferyl-N-acetyl-beta-D-galactosaminide by the galactosaminidase activity of C. albicans producing white fluorescent colonies under ultraviolet light. Identification on Fluoroplate Candida was confirmed by germ tube, chlamydoconidia formation and API-ATB ID 32C assays. RESULTS: Three hundred and five of 306 isolates showing fluorescent colonies were C. albicans and one was Candida glabrata (false positive). The rest of the isolates showed colonies without fluorescence and with the exception of two false negatives, these isolates were identified as non-C. albicans by other methods. CONCLUSIONS: Fluoroplate Candida allows a rapid and excellent identification of C. albicans showing a sensitivity and specificity of 99.3 and 99.7%, respectively.

Effect of monoclonal antibodies directed against Candida albicans cell wall antigens on the adhesion of the fungus to polystyrene.

The adhesion of Candida albicans to polystyrene and the effect of three monoclonal antibodies (mAbs) reactive with C. albicans cell wall surface antigens on this process was assessed in vitro with several C. albicans strains. In the absence of mAbs, adhesion of C. albicans to polystyrene increased in parallel with germ-tube formation. However, the growth of the strains in the yeast phase at 25 degrees C or the use of an agerminative mutant inhibited adhesion to polystyrene. Serotype A and B strains showed similar kinetics of adhesion to polystyrene and no statistically significant differences in germination or adhesion were observed when strains from the two serotypes were compared. The three mAbs had different effects on both germination and adhesion of C. albicans. mAbs 3D9 showed no influence on either germination or adhesion to polystyrene in two C. albicans strains. mAb B9E decreased both adhesion (45.6%) and filamentation (52.6%), and mAb 21E6 decreased filamentation (34.0%) but enhanced adhesion by 23.3%. This enhancement was also observed with the agerminative mutant and it was dose-dependent. It was not related to the binding capacity of the MAb to polystyrene nor to an increase in cell surface hydrophobicity of the antibody-treated cells. In conclusion, both growth phases of C. albicans can adhere to polystyrene, although the conditions for this process seem to be different in each phase. The two types of adhesion of C. albicans to polystyrene might have a role in the colonization of medical implants. The disparate effects shown by mAbs directed against cell wall mannoproteins of C. albicans on the adhesion of the fungus to polystyrene should be taken into consideration when designing strategies to block the adhesion of C. albicans to plastic materials with mAbs.

Evaluation of a commercial medium for identification of Candida species.

CHROMagar Candida (CHROMagar, France) was evaluated as a medium for the presumptive identification and isolation of yeasts using 1,537 isolates of medically important yeasts, including 970 Candida albicans, 165 Candida parapsilosis, 131 Candida glabrata, 62 Candida guilliermondii, 35 Candida krusei, 32 Candida tropicalis, 31 Rhodotorula rubra, 23 Trichosporon spp. (17 Trichosporon beigelii), 17 Candida famata, 16 Candida pelliculosa, 10 Pichia etchelsii, 10 Saccharomyces cerevisiae, 8 Candida lusitaniae, 7 Cryptococcus spp., and 20 isolates of other Candida spp. After 48 h of incubation at 37 degrees C, the sensitivity and specificity were, respectively, 99% and 100% for Candida albicans, 93.8% and 99.1% for Candida tropicalis, and 100% and 100% for Candida krusei. In addition to colony color, other colony characteristics were important for identification of some species, such as rough colonies in Candida krusei isolates or the halo around the colonies of Candida tropicalis. A great variety of colors was observed among species other than Candida albicans, Candida tropicalis, and Candida krusei. For identification purposes, CHROMagar Candida medium has an accuracy similar to that of germ-tube tests and chlamydospore development tests for Candida albicans and to that of the ATB ID32C kit (API, bioMérieux, France) for Candida tropicalis and Candida krusei.

A new method of antibiotyping yeasts for subspecies discrimination and distribution in human clinical specimens.

A study of the antibiotypes of 764 isolates of the genera Candida and Torulopsis from different clinical specimens is reported. The typing method was based on the susceptibility results obtained by the standardized and partially automated kit ATB-Fungus (API-bioMérieux), giving to each strain a code of six figures, according to these criteria: susceptibility to 5-fluorocytosine, amphotericin B, nystatin, miconazole, econazole, and ketoconazole. Candida albicans serotypes were determined by the Candida Check test (Iatron, Japan). Twenty-six antibiotypes were found in C. albicans (482 isolates), 21 types in serotype A, and 15 in serotype B strains. Candida parapsilosis (115 isolates) was divided into 11 antibiotypes, Torulopsis glabrata (53 isolates) into five, Candida guilliermondii (36 isolates) into 10 and Candida tropicalis (31 isolates) into eight. Depending on the sample origin, 000000 (susceptibility to all the antifungals tested) was the predominant C. albicans antibiotype (92.9% of blood isolates, 41.2% of vaginal isolates, 33.3% of respiratory isolates, isolates, 31.01% or oral and digestive tract isolates, and 25.0% of nail and skin isolates). No predominant antibiotypes were found in strains from respiratory tract, skin ad nails. A reproducibility close to 99% was found with the test. Simplicity and standardization could make this method useful for typing Candida and Torulopsis isolates.

Utility of Albicans ID plate for rapid identification of Candida albicans in clinical samples. Rapid identification of Candida albicans.

Albicans ID (bioMérieux, Marcy l'Etoile, France) is a ready-to-use medium that contains a chromogenic substrate that allows rapid detection and specific identification of Candida albicans. We have evaluated its clinical performance by culturing 846 clinical specimens from pregnant women and neonates. A 99.2% sensitivity and a 100% specificity were observed in the identification of C. albicans isolates from primary culture.

Variability in expression of antigens responsible for serotype specificity in Candida albicans.

The monoclonal antibody (mAb) B9E, which reacts with a cell wall surface determinant of Candida albicans serotype A, and a polyclonal monospecific antiserum against the antigen 6 (IF6) were used to investigate the expression of the antigens responsible for the serotype specificity in C. albicans under different growth conditions. By indirect immunofluorescence, both antibodies reacted with the cell wall surface of serotype A yeast cells and germ tubes grown in vitro but no reactivity was observed with serotype B yeast cells. In some cases, only a weak reactivity restricted to a zone close to the parent yeast cell was observed in serotype B germ tubes stained with mAb B9E. Both antibodies reacted strongly with yeast cells and germ tubes present in kidney abscesses from rabbits infected with both serotypes, but only serotype A yeast cells and germ tubes present in smears from patients with vulvovaginal candidiasis reacted with B9E and IF6 antibodies. The expression of antigens reactive with both antibodies was modulated by the pH of the environment in which the fungus was grown. Both antibodies showed a similar pattern of reactivity when studied with a spectrofluorometer. Serotype A yeast cells showed maximum reactivity when cells were grown on Sabouraud dextrose broth supplemented with yeast extract at pH 4.6. The lowest reactivity was observed in cells grown at pH 2.0. Conversely, the reactivity of serotype B yeast cells increased at alkaline pH values, the highest being in cells grown at pH values of 7.2 and 9.5.(ABSTRACT TRUNCATED AT 250 WORDS)

[Assessment of the sensitivity to antifungal agents of clinical isolates of Candida albicans serotype A and B by the ATB Fungus method]. / Evaluación de la sensibilidad a los antifúngicos de aislamientos clínicos de los serotipos A y B de Candida albicans mediante el método ATB Fungus.

BACKGROUND: Candida albicans is the most frequently species isolated in patients with candidiasis. This species may be antigenically divided in serotypes A and B, which have a different pathogenic behavior and antifungal susceptibility pattern. METHODS: The antifungal susceptibility of 443 clinical isolates from both serotypes of C. albicans to 5-fluorocytosine (5FC), amphotericin B, nystatin, econazole, miconazole and ketoconazole has been tested by means of the ATB Fungus method. RESULTS: Both serotypes showed a similar in vitro susceptibility to amphotericin B, nystatin, econazole, miconazole and ketoconazole. All the isolates were susceptible to amphotericin B and nystatin. A small number of in vitro resistant isolates were observed to azole compounds. However, serotype B was significantly more resistant than serotype A (p = 0.0001) to 5FC. CONCLUSIONS: C. albicans serotype B shows a lower susceptibility than serotype A to 5FC, an antifungal product not marketed in Spain. Serotyping of C. albicans does not offer additional information on antifungal susceptibility of clinical isolates from this species.

Multicenter evaluation of ATB fungus: a standardized micromethod for yeast susceptibility testing.

The micromethod for yeast susceptibility testing, ATB Fungus, was evaluated with 30 reference strains in three laboratories. Ready-to-use strips with 5-fluorocytosine, amphotericin B, nystatin, miconazole, econazole and ketoconazole were used. The test allowed the categorization of each strain as susceptible, intermediate or resistance to all the antifungals tested, and 5-fluorocytosine and amphotericin B MIC determination. The results were compared with the MIC for each reference strain obtained by a microdilution method on RPMI 1640 buffered with MOPS. The repeatability and intralaboratory and interlaboratory reproducibility were evaluated. ATB Fungus was a reliable and reproducible method with a repeatability of 96.6%, a reproducibility of 95.4% and showed an excellent correlation 91.7%) with reference MICs.