In the search for appropriateness in the cure of vaginitis: a model of anti-fungal stewardship?

Antimicrobial resistance remains a worldwide issue with a major clinical and economic impact, leading to exceeding mortality, increased frequency of hospitalization and a great burden on the healthcare systems. Vulvovaginitis, especially when due to mixed infections, has emerged as a condition for which appropriate selection of antimicrobial therapy and proper antimicrobial stewardship programs (ASPs) may contribute to minimizing the resistance development. This review discusses the appropriateness of selecting treatment for vulvovaginitis in order to reduce the development of resistance in gynecological practice. Narrative review based on a selection of literature performed according to the Authors' experience and a MEDLINE search using the following keywords: "vaginitis" OR "Candida" OR "fungal infection" AND "antifungal therapy". No limits were applied, but papers were selected for inclusion in this narrative review according to their relevance to the topic, as judged by the Authors. Worldwide, antimicrobial treatment in gynecology and ASPs focuses on prescribing systemic and expensive antifungal drugs, while treatment selection should consider several factors. Recently, topical azoles have been recommended as suitable alternatives to oral systemic azoles, given their similar efficacy in limiting clinical recurrence. In particular, fenticonazole has already been proposed as an alternative to systemic antifungal drugs to limit the onset of resistance. Optimizing the selection of antimicrobial treatment can help reduce the development of resistance in gynecological practice. Given its wide action spectrum and ability to exert antimicrobial activity against fungi, bacteria and mixed infections, fenticonazole may be considered a suitable first-line, empiric therapy for vaginal and mixed infections, avoiding alteration of intestinal microflora and minimizing the risk of selection of drug-resistant microbial strains.

MiCMA: an alternative treatment for refractory or recurrent Hodgkin's disease.

BACKGROUND: We determined the response rate to MiCMA (mitoxantrone, carboplatinum, methylprednisolone and aracytin) in a group of 29 patients with Hodgkin's disease (HD) and poor prognostic factors either resistant to first line or relapsing after conventional chemotherapy and subsequently evaluated the role of autologous stem-cell transplantation (ASCT) in these patients after MiCMA. PATIENTS AND METHODS: The treatment was intended as a brief tumor debulking program before ASCT. Twenty-nine patients with primary refractory HD or relapsed HD were submitted to two courses of MiCMA (mitoxantrone 10 mg/m2 day 1; carboplatinum 100 mg/m2 days 1-4; aracytin 2 g/m2 day 5; methylprednisolone 500 mg/m2 days 1-5) and subsequently evaluated for response. Those with responding or stable disease, received one or two other courses of MiCMA followed by ASCT. RESULTS: There were 10 complete responses (34% CR), 15 partial responses (52% PR) and 4 treatment failures with disease progression (14% PD). In total there were 25 evaluable responses out of 29 patients (86% CR + PR). Myelosuppression was the main toxicity of this treatment. At this time 20 patients (69%) are alive with a median follow-up of 26.5 months (7-100), 13 patients in CR (45%), 8 patients died, 7 of them from disease progression and one due to multi-organ failure, one patient is lost to follow-up. All but one of the patients who achieved CR after MiCMA are alive. Only the number of extranodal sites was found to predict a poor response to MiCMA. CONCLUSIONS: A short pre-transplantation treatment with MiCMA is an effective tumor debulking approach in patients with refractory or relapsed HD.

High-resolution EEG in poststroke hemiparesis can identify ipsilateral generators during motor tasks.

BACKGROUND AND PURPOSE: Multimodal neuroimaging with positron emission tomography (PET) scanning or functional MRI can detect and display functional reorganization of the brain's motor control in poststroke hemiplegia. We undertook a study to determine whether the new modality of 128-electrode high-resolution EEG, coregistered with MRI, could detect changes in cortical motor control in patients after hemiplegic stroke. METHODS: We recorded movement-related cortical potentials with left and right finger movements in 10 patients with varying degrees of recovery after hemiplegic stroke. All patients were male, and time since stroke varied from 6 to 144 months. All patients were right-handed. There was also a comparison group of 20 normal control subjects. RESULTS: Five of 8 patients with left hemiparesis had evidence of ipsilateral motor control of finger movements. There were only 2 cases of right hemiparesis; in addition, 1 patient had a posteriorly displaced motor potential originating behind a large left frontal infarct (rim). CONCLUSIONS: Reorganization of motor control takes place after stroke and may involve the ipsilateral or contralateral cortex, depending on the site and size of the brain lesion and theoretically, the somatotopic organization of the residual pyramidal tracts. Our results are in good agreement with PET and functional MRI studies in the current literature. High-resolution EEG coregistered with MRI is a noninvasive imaging technique capable of displaying cortical motor reorganization.

Cortical motor reorganization after paraplegia: an EEG study.

OBJECTIVE: To determine whether a previously identified posterior reorganization of the cortical motor network after spinal cord injury (SCI) is correlated with prognosis and outcome. METHODS: We applied the techniques of high-resolution EEG and dipole source analysis to record and map the motor potentials (MPs) of the movement-related cortical potentials in 44 patients after SCI. Twenty normal controls were also tested. Results were analyzed using a distance metric to compare MP locations. EEG was coregistered with individual specific MR images and a boundary element model created for dipole source analysis. RESULTS: MPs with finger movements were mapped to a posterior location in 20 of 24 tetraplegics compared with normal controls. Two patients, one studied 4 and one 6 weeks after injury, initially had posterior MPs that, on serial testing, moved to an anterior position with recovery. Dipole source localization of the MP generators confirmed these results. Nine of 20 paraplegics had a posterior MP location with actual or attempted toe movements. All 5 patients who could move their toes had posterior MPs. The MP was posterior in 4 of the 15 paralyzed patients. This is a significant difference in proportions. The only patient with paraparesis whose testing was repeated had an MP that moved to an anterior position with recovery. CONCLUSIONS: Posterior reorganization has a significant relationship to prognosis in paraplegia and is reversed in some SCI patients who recover function. Posterior reorganization may result from a preferential survival of axons that originate in somatosensory cortex and contribute to the corticospinal tract. These preliminary results should be verified by a larger prospective study.

Cortical sensorimotor reorganization after spinal cord injury: an electroencephalographic study.

The aim of this study was to determine if cortical motor representation and generators change after partial or complete paralysis after spinal cord injury (SCI). Previously reported evidence for a change in cortical motor function after SCI was derived from transcranial magnetic stimulation. These studies inferred a reorganization of the cortical motor system. We applied the new technique of high-resolution EEG to measure changes in cortical motor representation directly. We recorded and mapped the motor potential (MP) of the movement-related cortical potentials in 12 SCI patients and 11 control subjects. Results were analyzed using a distance metric to compare MP locations between patients and control subjects. EEG was coregistered with subject-specific MR images and a boundary element model created for dipole source analysis (DSA). When compared with normal control subjects, seven quadriparetics had posteriorly located MPs with finger movements. One paraparetic had a posterior MP with toe movements, but three who could not move the toes had normally located MPs on attempts to move. DSA confirmed the electrical field map distributions of the MPs. We are reporting a reorganization of cortical motor activity to a posterior location after SCI. These results suggest an important role of the somatosensory cortex (S1) in the recovery process after SCI.

An electroencephalographic study of imagined movement.

OBJECTIVE: Determine the generator sources for actual and imagined (simulated) movements of fingers and toes. DESIGN: Observational. SETTING: Electroencephalography laboratory. SUBJECTS: Ten asymptomatic adult volunteers. MAIN OUTCOME MEASURE: Comparison of cortical electrical fields and their dipole sources in actual and imagined movements. RESULTS: Cortical electrical fields tend to be contralateral with actual movements and midline with imagined movements. Dipole sources of actual movements include a contralateral contribution from the frontal (primary motor) area. Sources of imagined movements are midline or ipsilateral. CONCLUSIONS: (1) The motor networks underlying the generation of actual and imagined movements are different. (2) Imagined movements lack a primary motor area source, but involve medial and ipsilateral structures. (3) The effectiveness of imagined movements in rehabilitation may stem from activation of premotor or supplementary motor areas.