Assessment of fluconazole and itraconazole for birth defects
September 02 2013
In a study of nearly a million Danish pregnant women of whom 7352 were exposed to fluconazole and 687 to itraconazole in the first trimester, Ditte Molgaard-Nielsen and colleagues from the Serums Staten Institute in Copenhagen found a 3-fold increase in the heart defect tetralogy of Fallot and a 2-fold increase in hypoplastic left heart with fluconazole exposure. Numerous other birth defects were not associated with fluconazole exposure. No birth defect was associated with itraconazole exposure.
Most prescriptions for fluconazole in pregnancy are for Candida vaginitis. The standard dose is 150mg as a single dose, but larger doses are used for patients with recurrence or non-responsive disease. There did not appear to be a dose relationship with tetralogy of Fallot occurrence. However the exposures are quite modest by comparison (350-6000mg total dose) with women requiring long term fluconazole maintenance therapy. Fluconazole is extensively used in patients with AIDS to suppress cryptococcal meningitis and oesphageal candidiasis, and avoidance of fluconazole in early pregnancy is clearly required. Whether much higher doses would confer additional is not known, but the lack of a dose response in the large Danish cohort is suggestive that it does not.
How many fungal species are on our planet?
August 27 2013
Professor Xingzhong Liu of the Institute of Microbiology, Chinese Academy of Sciences in Beijing addressed this question at the 13th Asian Mycological Congress on 22nd August (meeting Aug 19th -23 rd Beijing). The current listing of fungi in the Dictionary of Fungi includes ~100,000 species, up from ~50,000 in 1970. But novel molecular methods are identifying large numbers of presumptive species, many of which are not yet cultured or are unculturable with current growth methods. In diversity studies, ratios if cultured to uncultured fungi detected are 1:9, suggesting at least 10-fold more than the current list. In addition, “Several environments and potential habitats have barely been sampled and analysed, such as plants, lichens, insects and tropical forests”, said Professor Lui. Another contributor to diversity are cryptic species which also are being discovered at a phenomenal rate currently.
Berwick report, protecting patient safety in the NHS
August 20 2013
The Berwick report examining NHS patient safety was released on August 6th. This report was requested by the Prime Minister from Professor Don Berwick a renowned international expert in patient safety, following on from the Francis report into the breakdown of care at Mid Staffordshire Hospitals, UK.
The report details the advisory group’s summary and recommendations for the way forward view full report. Berwick also released three separate letters aimed at medical professionals, the public and the NHS leadership. View letter to clinicians and NHS staff
In his letter to clinicians, managers and NHS staff, he outlines how the NHS can learn from the instances of quality of care problems and how the system can rapidly aim for improvements in patient care and safety.
Some of the recommendations reflect the need to tighten surveillance of and responses to serious problems in care, which will need systemic fixes to protect patients. The commitment to reliability and adherence to proper standards need to be enforced and early warning signs from patients and carers must be heeded and prompt actions taken.
However he outlines that real sustainable improvement depends more on learning and growth than rules and regulations and that balance will be the key.
A Large Community Outbreak of Blastomycosis
August 15 2013
The largest ever reported outbreak of blastomycosis occurred in 2010 in Marathon County, Wisconsin. Blastomycosis is an infection caused by B dermatitidis a soil based dimorphic fungus. Health officials noticed an increase in the number of cases of blastomycosis in October 2009. Initial investigation showed clustering within neighbourhoods and households with a disproportionate number of cases amongst those of Hmong ethnicity. Originally from SE Asia many Hmong people settled in the US after the Vietnam war, particularly in Wisconsin. An epidemiological investigation to examine the high rates of blastomycosis in Marathon County, Wisconsin in June - July 2010 has now been published.
WHO reinstates Amphotericin B and flucytosine on the Essential medicines List
August 08 2013
Following representation from the Cryptococcal Meningitis Action Group (CryptoMAG), the 19th Expert Committee on Selection and Use of Essential Medicines has placed intravenous amphotericin B and flucytosine and oral flucytosine on WHO Model List of Essential Medicines (EML) for both adults and children. In addition to improved survival of patients with cryptococcal meningitis, both drugs have other uses, such as disseminated histoplasmosis, invasive candidiasis and aspergillosis.
The decision-making meeting was held in the WHO Headquarters in Geneva from 8 – 12 April 2013 and reviewed and updated the 17th WHO Model List of Essential Medicines and the 3rd list of WHO Essential Medicines for Children.
The CryptoMag group, (see news) partly funded by GAFFI, met prior to this to finalize the reviewer responses to a prior EML submission. The arguments were evidenced based, primarily on the definitive trial from Vietnam lead by Dr Jeremy Day (who trained in Manchester, showing that this combination yielded a 40% lower chance of death).
Commenting on this, GAFFI's President, Professor David Denning said; “The WHO’s enlightened decision opens the door to saving many thousands of lives weekly from this devastating fungal meningitis in AIDS. The challenge now is to translate this recommendation into local availability and actual treatment on the ground in every country.”