Dyspnea: when the preliminary imaging is unconvincing

A 73-year-old man was admitted to the Emergency Room (ER) for dyspnea and cough from several months. In ER were performed blood sampling, chest X-ray, electrocardiogram, echocardiogram and arterial blood gas. A thoracic ultrasound (US) revealed in the left side an abundant pleural effusion and a lung consolidation area of about 5 cm without air bronchogram. A thoracentesis showed the presence of hemorrhagic effusion. Chest computed tomography (CT) revealed micro-pulmonary embolism, abundant left pleural effusion with atelectasis of the lower ipsilateral lobe. Meanwhile the chest CT revised by the pulmonologist appeared suspicious for the presence of cancer, the cytological examination of pleural fluid revealed the presence of an adenocarcinoma. While the patient was waiting for the bronchoscopy he had a stroke and died in a few days. In conclusion, we believe that thoracic US has to be considered an extension of the physical examination, it is a bedside tool and it represents a valid diagnostic and therapeutic method. Therefore thoracic US, if closely linked to the physician's activity, can directly affect the decision-making process and management of the patient with dyspnea

Fungicidal activity and PK/PD of caspofungin as tools to guide antifungal therapy in a fluconazole-resistant C. parapsilosis candidemia

Candida parapsilosis may be responsible for bloodstream infections (BSI) and it is characterised by an increased incidence of fluconazole resistance. A 75-year old woman with severe comorbidities received the insertion of a peripherally inserted central venous catheter. Fluconazole did not prevent a C. parapsilosis BSI hence caspofungin was started after a nephrotoxic first-line treatment with amphotericin B. The ratio of peak plasma concentration over the minimum inhibitory concentration (Cmax/MIC) was adopted to maximise efficacy of caspofungin. MIC and plasma Cmax values were obtained by broth microdilution and LC-MS, respectively. Interestingly, daily doses of 1 mg/kg (total daily dose, 50 mg) allowed the achievement of Cmax/MIC values > 10. The optimised regimen was safe and effective, leading to negative blood culture at day 8. The patient was discharged home at day 21. Therefore, individualised dosing regimens of caspofungin may be effective and safe even in the case of C. parapsilosis BSI

A global cross-border insolvency framework for financial institutions

The recent financial crisis has shown that national frameworks have been insufficient to stem the cross-border effects of the failure of a systemically important financial institution. This paper refers to the challenges for governments, in the aftermath of the financial crisis starting in 2007/2008, to provide stability in financial markets and the role of financial institutions for national economies and on a global scale. It discusses the need for coordinated action to resolve SIFIs by evaluating the regional approaches in Europe and the US, as well as considering the recommendations of four international bodies on the insolvency of large and complex financial institutions: the Financial Stability Board, the United Nations Commission on International Trade Law, the International Monetary Fund and the Basel Committee on Banking Supervision. The paper argues that key implications need to be recognized in order to make a global cross-border insolvency framework work effectively to coordinate around another Lehman-like event. It concludes that much has been discussed and initiated in the last six years, however, many issues are still unsolved. While single measures with a regional character are fit and comprehensible as a starting point, the pursued goal should be a mandatory and internationally consistent, homogenous cross-border insolvency framework since the interconnectedness of global financial institutions and their importance for financial stability will make it very difficult to prevent the next crisis and its disruptive impact

Efficacy of intravenous immunoglobulin therapy in a case of autoimmune-mediated chronic active hepatitis

In a patient suffering from histologically-documented immuno-mediated chronic active hepatitis, intravenous immunoglobulin (IVIG) treatment was initiated as an obligatory alternative therapy because of femur head aseptic necrosis which had followed long-term therapy with steroids. The first cycle of IVIG was followed by remission of most symptoms, normalization of liver enzymes, disappearance of circulating immunecomplexes (CIC), and a negative lupus band test. Improvement in the patient's condition was demonstrated, in liver histology, by the disappearance of peri-portal mononuclear cells infiltrates, while immunohistochemistry showed the disappearance of the intracellular IgG deposits