William B. Greenough

PROTEIN-LOSING ENTEROPATHY ASSOCIATED WITH CLOSTRIDIUM DIFFICILE INFECTION

A commercially available radial immunodiffusion assay was used to measure serum alpha-1-antitrypsin levels in stool samples from subjects aged over 60 years as a marker of protein-losing enteropathy. alpha 1-antitrypsin was found in all of 12 patients with colonoscopy-confirmed pseudomembranous colitis, 6 of 14 (43%) patients with Clostridium difficile diarrhoea without pseudomembranes, 6 of 12 (50%) nursing-home patients culture-positive for Cl difficile but negative for its cytotoxin, and none of 15 healthy control subjects. It is concluded that serum protein loss into the gastrointestinal tract can occur as a result of Cl difficile infection, that its presence correlates with the severity of disease, and that it may occur even in the absence of diarrhoea. The diagnosis of protein-losing enteropathy should be considered for all patients with Cl difficile infection, particularly elderly nursing-home patients, in whom the risk of Cl difficile disease and the frequency of severe malnutrition are high.

Home Hospital Program: A Pilot Study

OBJECTIVE: To evaluate the basic safety and feasibility of hospital care at home (Home Hospital (HH)) for treating acutely ill older persons requiring hospitalization.

Prospective evaluation of clinical criteria to select older persons with acute medical illness for care in a hypothetical home hospital

OBJECTIVE: To evaluate criteria to select older persons who need hospitalization for common acute medical illnesses for care in a hypothetical home hospital.

Clinical features in enteritis due to vibrio parahemolyticus

Abstract Clinical features of a case of enteritis due to Vibrio parahemolyticus are presented. Superficial ulcerations of colonic mucosa were observed directly by sigmoidoscopy. Previously such damage had not been documented but inferred from the presence of red cells and leukocytes in the stools. The literature pertinent to V. parahemolyticus and its recent presence in the United States is reviewed.

Low Airloss Hydrotherapy Versus Standard Care for Incontinent Hospitalized Patients

OBJECTIVE: To determine whether low airloss hydrotherapy reduces the incidence of new skin lesions associated with incontinence in hospitalized patients and results in more rapid healing of existing pressure sores compared with standard care. To assess subjectively patient and nursing satisfaction related to using low airloss hydrotherapy beds.

Correction of hyperaldosteronism and of massive fluid retention of unknown cause by sympathomimetic agents

Abstract A detailed study is reported of a thirty-nine year old woman with long-standing postural hypotension and recurrent episodes of massive anasarca. Later, periods of edema formation alternated with bouts of dehydration, azotemia and potassium depletion, and evidences of impaired renal function appeared. The episodes of sodium retention and edema formation were demonstrated to be associated with a marked increase in the adrenal secretory rate of aldosterone. The increased secretion of aldosterone was paradoxic because it occurred despite a relatively high sodium intake. Sustained diuresis was induced by a spirolactone dldosterone antagonist, providing evidence that aldosterone oversecretion was important in causation of the edematous state. Complete correction of the disorder during a prolonged period of observation was finally achieved by oral administration of sympathomimetic agents. Administration of these pressor agents produced a fall in the rate of secretion of aldosterone to normal values and a marked sodium diuresis. Potassium excretion did not increase. The nature of the disorder has not been elucidated. However, the patient was found to have hypervolemia and a markedly reduced glomerular filtration rate. It has been suggested that her arterial hypotension might be a result of venous pooling. The beneficial effects of the sympathomimetic drugs are viewed as a consequence of a direct or indirect action to improve the renal circulation, leading to suppression of the generation of an aldosterone stimulating factor (? angiotensin).

Where do we go from here? A small scale observation of transfer results from chronic to skilled ventilator facilities ☆

PURPOSEnSkilled nursing facility ventilator units (SNF) are a recent attempt to reduce the costs of an increasing number of patients who are in acute intensive care units and are not able to be liberated from ventilators. Transfers of such patients from long-term care chronic vent units (LTCVs) to SNFs in Maryland began in 2006. The safety of these transfers needs to be assessed.nnnMETHODSnWe retrospectively followed up all patients designated as eligible by their insurance for transfer from our LTCV units to SNF from July 1, 2008 through June 30, 2010 looking only at survival. Those patients who refused transfer and appealed and remained in our LTCV were compared to those who were transferred to SNF ventilator units. The analysis was by Kaplan-Meier statistics.nnnRESULTSnThere was an increased mortality (P=.025) of those transferred to SNF ventilator facilities as compared to those remaining in the LTCV.nnnCONCLUSIONnWe recognize that bias may occur in patients choosing to remain in our LTCV compared to those accepting transfers, the magnitude of the difference in mortality indicates the need for more comprehensive well designed analysis investigating the outcome of all transfers occurring to and from LTCVs.

Inadvertent self-healing in desperate times

Correspondence to: Dr Sean X Leng, Johns Hopkins University School of Medicine, 5505 Hopkins Bayview Circle, Baltimore, MD 21224, USA sleng@jhmi.edu In February, 2007, a 47-year-old woman was admitted to our hospital, with stage IV pressure ulcers. She had become paraplegic in 1999, after a bullet damaged the spine at the level of the 9th thoracic vertebra. Pressure ulcers developed in 2006. In December, 2006, the patient devel oped a high fever and was found to have worsening pressure ulcers and meticillin-resistant Staphylococcus aureus bacteraemia. Her condition improved with intravenous vancomycin and wound debridement. Because she was doubly incontinent, a Foley catheter was inserted, and a colostomy was done to reduce wound contamination. The patient was transferred to a nursing home, but developed intermittent fever, anorexia, and severe left hip pain. After several weeks, she was transferred to our hospital. On admission, she was cachectic, at 48·2 kg, and had fi ve large stage IV pressure ulcers on the lower back and hips (fi gure). Her white-blood-cell count, and serum concentration of C-reactive protein (CRP) were 14·2×10 per L, and 167 mg/L, respectively. Her serum concentrations of haemoglobin and albumin were only 87 g/L and 19 g/L, respectively. We started to treat her with vancomycin. For wound care, we used an antimicrobial gel. CT showed erosion of the femoral head and neck, inferior pubic ramus, and acetabulum, with fl uid and air in the left hip joint. CT-guided aspiration yielded clear liquid, cultures of which were negative. Despite treatment, the patient’s condition worsened. The hip pain and fever continued; the white-blood-cell count and serum concentration of CRP rose as high as 18·5×10 per L and 257 mg/L, respectively; the serum albumin concen tration fell to 13 g/L, and the patient’s weight to 43·6 kg. 6 weeks after admission, radiography showed that the femoral head and neck were separated from the rest of the femur, and medially displaced. Hours later, a bone fragment fell out of a pressure sore, while the dressing was being changed. The patient’s condition then started to improve. The fever and pain ceased immediately, and the pressure ulcers began to heal. 8 weeks after the fragment fell out, the patient’s weight had increased to 58·2 kg; the serum concentrations of haemoglobin and albumin were 128 g/L and 32 g/L, respectively; the white-blood-cell count and serum concentration of CRP were 8·25×10 per L and 22 mg/L, respectively. At the end of August, 2007, the patient remained in hospital; she had no fever, her weight was stable at 59 kg, and her wounds continued to heal. Pressure ulcers are common in elderly people, and people with spinal-cord injuries. For several years after being shot, our patient had been cared for by relatives and had been able to live at home. When a close relative died, the standard of care provided by her family decreased substantially, and a fragmented health system did not fully meet her needs. We think that the osteomyelitis was caused by infection spreading from an ulcer, either directly or through the bloodstream. The infected proximal femur developed avascular necrosis. Because the blood supply to the proximal femur was so poor, intravenous antibiotics were largely ineff ective. Ordinarily, we would have done an excision arthroplasty, known as the Girdlestone procedure, to remove the infected bone. However, the patient was so ill that surgery was judged to be unaccept ably risky. Fortunately, the necrotic bone dropped off , eerily mimicking the Girdlestone procedure.