The Clinical and Laboratory Standards Institute (CLSI) M38-A2 reference broth microdilution (BMD) method for the antifungal susceptibility testing of filamentous fungi now includes guidelines for testing echinocandin activity using the minimum effective concentration (MEC) as the endpoint measurement. In this study, we compared the caspofungin Etest MIC on RPMI agar and Mueller-Hinton agar (supplemented with glucose and methylene blue [MGM]) to the BMD MEC for 345 clinical Aspergillus isolates, including A. flavus, A. fumigatus, A. nidulans, A. niger, and A. terreus. The essential agreement (؎1 log 2 dilution) of the Etest on MGM and RPMI agar with the reference BMD MEC was 18 and 26%, respectively. The geometric mean values for BMD MEC and MGM Etest were 0.137 and 0.024 g/ml, respectively, and the geometric mean values for BMD and RPMI agar were 0.128 and 0.031 g/ml, respectively. Comparatively, 91% of paired MGM and RPMI Etest results were within 2 log 2 dilutions of each other and consistently produced clearly defined endpoints. In conclusion, the caspofungin Etest MIC, like the BMD MEC, is a reproducible endpoint but is markedly lower than the reference BMD. In anticipation of susceptibility breakpoint assignments, optimization studies will be required to improve the concordance of these two assays so that the potential for underreporting echinocandin resistance in Aspergillus is mitigated.A reference method for the antifungal susceptibility testing of filamentous fungi using broth microdilution (BMD) has been developed by the Clinical and Laboratory Standards Institute (CLSI) and has been updated recently with guidelines for testing echinocandins (4). Unlike other antifungal classes, the approved endpoint for measuring echinocandin activity against molds is the minimum effective concentration (MEC), as opposed to the conventional MIC, which demonstrates more consistent and reproducible susceptibility data (4). Initially described by Kurtz et al. (10), the MEC is the lowest concentration of drug that leads to the growth of small, rounded, compact hyphal forms compared to the hyphal growth visualized in the growth control well of a BMD panel.The echinocandins are an important class of antifungal agents for the empirical treatment of invasive aspergillosis. The BMD reference method is very cumbersome, which prevents many clinical laboratories from performing the test. The Etest (AB bioMerieux, Solna, Sweden) is an agar-based gradient endpoint susceptibility test that is much simpler to perform than BMD. Etest strips for the susceptibility testing of Candida to amphotericin B, fluconazole, voriconazole, posaconazole, and caspofungin (2,5,11,(14)(15)(16)(17)19), and Aspergillus to amphotericin B, voriconazole, and posaconazole (9,12,18), have demonstrated good correlation to the BMD.However, little has been published to verify the utility of echinocandin Etests for Aspergillus susceptibility testing (6).The objective of this study was to determine if the caspofungin Etest could accurately and reliably measure th...

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Aim:The Enhanced Recovery After Surgery (ERAS®) Society guidelines aim to standardize perioperative care in colorectal surgery via 25 principles. We aimed to assess the variation in uptake of these principles across an international network of colorectal units.Method: An online survey was circulated amongst European Society of Coloproctology members in 2019-2020. For each ERAS principle, respondents were asked to score how frequently the principle was implemented in their hospital, from 1 ('rarely') to 4 ('always'). Respondents were also asked to recall whether practice had changed since 2017.Subgroup analyses based on hospital characteristics were conducted.Results: Of hospitals approached, 58% responded to the survey (195/335), with 296 individual responses (multiple responses were received from some hospitals). The majority were European (163/195, 83.6%). Overall, respondents indicated they 'most often' or 'always' adhered to most individual ERAS principles (18/25, 72%). Variability in the uptake of principles was reported, with universal uptake of some principles (e.g., prophylactic antibiotics; early mobilization) and inconsistency from 'rarely' to 'always' in others (e.g., no nasogastric intubation; no preoperative fasting and carbohydrate drinks). In alignment with 2018 ERAS guideline updates, adherence to principles for prehabilitation, managing anaemia and postoperative nutrition appears to have increased since 2017.Conclusions: Uptake of ERAS principles varied across hospitals, and not all 25 principles were equally adhered to. Whilst some principles exhibited a high level of acceptance, others had a wide variability in uptake indicative of controversy or barriers to uptake. Further research into specific principles is required to improve ERAS implementation.

Thoracoscopic mobilization of the oesophagus during oesophagectomy has many advantages over the traditional open approach including less blood loss, reduced pulmonary complications and shorter hospital stay. Minimally invasive intrathoracic oesophagogastric anastomosis can be technically challenging, with several different techniques described in the literature. Here, we describe a nuanced technique to perform an intracorporeal anastomosis using a circular stapler.