Charles E. Gessert

Fecal microbiome transplantation for recurrent Clostridium difficile infection: Report on a case series

BACKGROUND Clostridium difficile infection (CDI) continues to increase in incidence and severity, and was the most common nosocomial infection in the USA in 2010. Most cases of CDI respond to a standard course of antibiotics, but recurrent C. difficile infection (RCDI) has become increasingly frequent, and alternative treatments are needed. We examined the efficacy of fecal microbiota transplantation (FMT) instilled into the upper gastrointestinal tract for RCDI. MATERIALS AND METHODS The medical records for all patients treated with FMT during a 9-year period at a single institution in northern Minnesota were reviewed retrospectively. Eighty-nine FMT courses were provided by nasogastric tube to 87 patients, and demographic and clinical data were abstracted, including details of treatments prior to FMT, rate of FMT treatment success and clinical course during a 60-day post FMT follow up period. Fourteen FMT courses failed to meet criteria for inclusion. RESULTS Each patient served as his or her own control, having failed standard treatment. After exclusions, the case series included 75 FMT courses administered to 74 patients. Fifty-nine FMT courses resulted in clinical resolution of diarrhea for a primary cure rate of 79%. Diarrhea relapsed following 16 FMT courses; in 9 of these cases diarrhea subsequently resolved after a single course of vancomycin. No adverse events were noted. CONCLUSIONS Our findings parallel findings from other studies when FMT has been provided via the upper GI tract, and suggest that patients with recurrent CDI may resolve diarrhea by introducing stool from healthy donors into the upper GI tract via nasogastric tube.

Rural-urban differences in medical care for nursing home residents with severe dementia at the end of life.

OBJECTIVES: To identify factors associated with the use of selected medical services near the end of life in cognitively impaired residents of rural and urban nursing homes.

Treating alcohol withdrawal with oral baclofen: A randomized, double‐blind, placebo‐controlled trial

BACKGROUND Abrupt cessation of alcohol intake causes habituated drinkers to experience symptoms of alcohol withdrawal syndrome (AWS). OBJECTIVE To determine the effect of the gamma-aminobutyric acid (GABA)-B agonist baclofen on the course of acute symptomatic AWS. DESIGN Prospective, randomized, double-blind, placebo-controlled clinical study. SETTING Two tertiary-care hospitals in Duluth, Minnesota. PATIENTS Inpatient adults admitted for any reason (including AWS) judged to be at high risk for AWS. INTERVENTION Inpatients who developed symptoms of AWS received symptom-triggered benzodiazepine treatment using lorazepam by standard protocol, and were randomized to receive baclofen 10 mg or placebo, 3 times per day, orally. MEASUREMENTS AWS severity was assessed using the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar); lorazepam dose was monitored. RESULTS Seventy-nine subjects were enrolled. The 44 subjects who developed symptoms of AWS were randomized to baclofen or placebo. Thirty-one subjects (18 baclofen, 13 placebo) completed 72 hours of assessments, either entirely as inpatients or with outpatient follow-up. The need for high doses of benzodiazepines (20 mg or more of lorazepam over 72 hours) to control AWS was less likely in the baclofen treatment group (1 of 18) than in the placebo-treated group (7 of 13) (P = 0.004). CONCLUSIONS We found that the use of baclofen was associated with a significant reduction in the use of high doses of benzodiazepine (lorazepam) in the management of symptomatic AWS. The use of low-dose baclofen in the management of AWS deserves further study, as reduced dependence on high-dose benzodiazepines in AWS management could improve patient safety.

Dying of old age: An examination of death certificates of Minnesota centenarians

OBJECTIVES: To compare how causes of death are recorded on the death certificates of centenarians with those who die in their 70s, 80s, and 90s. We also examined direct and indirect acknowledgment of age as a cause of death.

Nursing homes and suffering: Part of the problem or part of the solution?

The quality of residents’ life is now widely recognized as a principle measure of the quality of care provided by nursing homes. This article is focused on the profound psychosocial and existential suffering that was experienced by many of the nursing home residents who were part of a larger study that examined end-of-life experiences in nursing homes. Data were collected using a case study approach, incorporating observations, interviews, and document review. Qualitative content analysis was used to analyze data. The narratives of two residents are used as exemplars. Through these narratives, specific examples of physical, psychosocial, and existential suffering are revealed. Suffering as an essential aspect of the human condition is explored within the context of nursing homes as systems of care for older adults. Attention to suffering is integral to quality of life, yet few nursing homes have integrated the diagnosis and relief of suffering into their routine work.

Stool transplantation for older patients with clostridium difficile infection

DISCUSSION Short-term evidence-based CHF therapy in elderly patients with chronic cardiorenal syndrome was associated with improvement of clinical and hemodynamical parameters. At the same time, the therapy based on the renin-angiotensin-aldosterone system and sympatoadrenal system blockade was not associated with a significant decrease in kidney function in this group of patients with systolic CHF and moderate to severe renal insufficiency. Still, many questions on the care of elderly patients with heart failure and renal insufficiency remain unanswered. Future clinical trials in heart failure should include a representative number of elderly patients with renal insufficiency to improve the evidence base and outcomes in this vulnerable population.

Randomized, double-blind trial of 220 mg zinc sulfate twice daily in the treatment of rosacea.

A 2006 article published in the International Journal of Dermatology reported that oral zinc sulfate 100 mg three times daily was associated with improvement in the severity of facial rosacea (Sharquie et al. 2006; 45: 857–861). The current study was undertaken to further assess the role of zinc in the management of rosacea. This was a randomized, double‐blind trial of 220 mg of zinc sulfate twice daily for 90 days in patients with moderately severe facial rosacea at baseline. Subjects were recruited in the Upper Midwest USA between August 2006 and April 2008, and followed until July 2008. Forty‐four subjects completed the trial (22 in each arm). Rosacea improved in both groups. There were no differences in magnitude of improvement based on rosacea severity scores between subjects receiving zinc sulfate and subjects receiving placebo (P = 0.284). Serum zinc levels were higher in subjects receiving zinc (P < 0.001). Oral zinc sulfate was not associated with greater improvement in rosacea severity compared with placebo in this study. Additional studies are needed to determine what role oral zinc may have in the management of rosacea.

Rating the Importance of Nursing Home Residents' Quality of Life

Objectives: To assess how various stakeholders involved with nursing home care rate the importance of various quality‐of‐life (QoL) items for hypothetical residents with varying types of impairment.

Regional variation in care at the end of life: discontinuation of dialysis

BackgroundRegional variation in the intensity of end-of-life care contributes significantly to the overall cost of health care. The interpretation of patterns of regional variation hinges, in part, on appropriate adjustment for regional variation in demographic variables such as age, race, sex, and rural vs. urban residence. This study examined regional variation in discontinuation of dialysis prior to death in the US, after adjustment for key demographic variables.MethodsIn this retrospective cohort study of the 2009 United States Renal Data System (USRDS) database we examined discontinuation of dialysis prior to death among deceased adult patients with end-stage renal disease (ESRD) from the 50 states and the District of Columbia. The discontinuation of dialysis prior to death was ascertained from the Centers for Medicare & Medicaid Services form 2746 (ESRD Death Notification form). We used logistic regression to estimate the log-odds of discontinuation of dialysis with ESRD network as independent variable adjusted for urban–rural status, demographic and treatment variables.ResultsThe study cohort included 715,605 deceased ESRD patients; for 176,021 of whom (24.6%) dialysis was discontinued prior to death. Dialysis was discontinued at higher rates for women than for men (26.3% vs. 23.0%, p < 0.001) and for whites than for blacks (29.5% vs. 14.7%, p < 0.001). Significant regional variation in dialysis discontinuation prior to death was noted after adjustment for age, race and rural–urban status: rates of discontinuation in the Upper Midwest and Mountain regions were more than double the rates in Southern and Coastal regions. This pattern parallels the regional pattern of end-of-life health service utilization documented in the Dartmouth Atlas and other studies.ConclusionsDiscontinuation of dialysis prior to death was common in the US between 1995 and 2009. The deaths of nearly one quarter of chronic dialysis patients followed a decision to discontinue dialysis. Significant regional variation in discontinuation rates exists after adjusting for age, race, sex, and rural–urban status. Further research and analysis is needed on the cultural and economic factors that affect regional variation in health services utilization, especially in regard to the use of expensive medical services near the end of life.

Nursing home staff's perceived ability to influence quality of life

Nurses, certified nursing assistants, activity personnel, social workers, and physicians in 5 cities rated their ability to affect each of 17 quality of life (QoL) items for 2 hypothetical cases. Those closest to the residents feel the most empowered to make a difference. Overall, certified nursing assistants were consistently the most optimistic about their ability to influence QoL. Perceptions of ability to influence QoL were correlated with attitudes about nursing homes. These perceptions may be helpful in retaining such staff.