To determine the differences in outcome in cases of enterococcal bacteremia due to vancomycin-resistant organisms, we compared consecutive patients on a liver transplant service who had clinically significant bacteremia due to vancomycin-resistant Enterococcus faecium (VREF) (n = 54) with a contemporaneous cohort of patients who had vancomycin-susceptible E. faecium (VSEF) bacteremia (n = 48). VREF bacteremia occurred significantly later in the hospitalization than did VSEF bacteremia (43 days vs. 24 days, respectively; P < .01); in addition, VREF was more frequently the sole blood pathogen isolated (91% of patients) than was VSEF (56% of patients) (P = .0002). Invasive interventions for intraabdominal and intrathoracic infection were required more often in the VREF cohort than in the VSEF cohort (34 of 45 patients vs. 20 of 41 patients, respectively; P = .01). Vancomycin resistance more frequently resulted in recurrent bacteremia (22 of 54 patients infected with VREF vs. 7 of 48 patients infected with VSEF; P = .006), persistent isolation of Enterococcus species at the primary site (27 of 33 patients infected with VREF vs. 7 of 18 patients infected with VSEF; P = .005), and endovascular infection (4 patients infected with VREF vs. none infected with VSEF). The decrement in patient survival, as measured from the last bacteremic episode, was greater in the VREF cohort (P = .02). Vancomycin resistance, shock, and liver failure were independent risk factors for Enterococcus-associated mortality. Higher rates of refractory infection, serious morbidity, and attributable death occurred in the VREF cohort and were partially mediated by the lack of effective antimicrobial therapy.

Fibrolamellar hepatoma (FL-HCC) is an uncommon variant previously reported4-6 ), less than 100 such cases can be found in the literature. 2,3,[7][8][9][10][11][12][13][14][15][16][17] In our series, we have compared the of hepatocellular carcinoma (HCC), distinguished by histopathological features suggesting greater differentiation than survival of patients with FL-HCC with that of patients with conventional HCC who were treated by the same team over conventional HCC. However, the optimal treatment and the prognosis of FL-HCC have been controversial. Follow-up a 27-year period. studies are available from 1 year to 27 years, after 41 patients with FL-HCC were treated with partial hepatectomy (PHx) PATIENTS AND METHODS (28 patients) or liver transplantation (13 patients). In thisCase Material retrospective study, the effect on outcome was determined for the pTNM stage and other prognostic factors routinely Between 1968 and 1995, 477 (range, 9-66; median, 25) (Fig. 1). The median follow-up was 58 tumor-free survival than those with negative nodes (P õ .015).{ 9.3 months. Patient survival was most adversely affected by the presence of vascular invasion (P õ .05). FL-HCC is an indolently grow- Clinicopathological Characteristicsing tumor of the liver, which usually was diagnosed in our patients at a stage too advanced for effective surgical treatmentThe pathology reports and operative findings were used to deterof most conventional HCC. Nevertheless, long-term survival mine: the principal tumor size, number of lesions, lobar distribufrequently was achieved with aggressive surgical treatment. tion, vascular and lymphatic tumor extension, surgical margins, When a subtotal hepatectomy could not be performed, total distant metastases, and the presence or absence of associated cirrhosis. When available, the tumor markers were recorded as well as hepatectomy (THx) with liver transplantation was a valuable the virus markers (hepatitis C virus, hepatitis B virus).

Thirty-two patients with coronary artery disease who underwent liver transplantation between 1990 and 1994 were identified. Coronary artery disease was managed medically (n = 9), by angioplasty (n = l), or surgically (n = 22) prior to liver transplantation. Two patients underwent simultaneous coronary artery bypass gralting and liver transplantation. Complete preoperative cardiac evaluation was performed in all patients. Perioperative and postoperative morbidity and mortality were retrospectively determined. Overall mortality was 50%, whereas morbidity was 81 %. Follow-up was between 1 and 3 years after liver transplantation.Subgroup analysis revealed that medically managed patients had a 56% mortality and a 100% morbidity. The patient who underwent angioplasty survived without morbidity. One patient who underwent simultaneous coronary artery bypass grafting and liver transplantation died intraoperatively. The second patient survived but required pacerthotopic liver transplantation (OLT) has be-

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