Clostridium Difficile-Associated Diarrhea: A Review.

Clostridium difficile–associated diarrhea (CDAD) has become a major public health problem. The offending pathogen is acquired by the fecal-oral route from an environmental source or by contact with an infected person or health care worker who serves as a vector. Alteration of the intestinal microflora, frequently by antibiotics, generates a favorable environment results in the proliferation of C. difficile. The pathogen is not invasive but produces two toxins, A and B, that lead to severe inflammation of the colonic mucosa manifested as profound diarrhea, fever, abdominal pain, and leukocytosis. A new hypervirulent strain of C. difficile has become prevalent in the United States, Canada, and the United Kingdom. Identified by pulsed-field gel electrophoresis (PFGE), this strain is called North America PFGE type 1, abbreviated as NAP-1, and characteristically generates large amounts of toxins A and B, in addition to a binary toxin, and is associated with higher morbidity and failure of antibiotic therapy. Mild cases of CDAD may respond to withdrawal of antibiotic therapy, however the majority of patients require C. difficile-specific antimicrobial therapy. The US FDA has approved oral vancomycin for treatment of CDAD, but reluctance to use this antibiotic due to the fear of developing vancomycinresistant organisms in the hospital setting has made metronidazole the recommended first-line therapy for mild to moderate disease. Some newer studies show a high rate of failure, due to infection by NAP-1 or to the presence, in hospitals, of geriatric patients with more concurrent illnesses who may also have been treated with many broad-spectrum antibiotics. The recurrence rate after initial successful treatment can be as high as 20-30%, depending on the initial treatment. A more C. difficile-targeted non-absorbable bacterial RNA polymerase inhibitor, fidaxomicin (also known as OPT-80 and PAR-101), has recently been approved in the US with initial efficacy similar to vancomycin and a lower recurrence rate. Some additional agents that have shown efficacy in humans are nitazoxanide, bacitracin, teicoplanin, and fusidic acid. Rifaximin, polymers that bind C. difficile toxin, monoclonal antibodies to toxins, and preventive measures such as toxoid vaccines are under investigation. Interventions for treatment of recurrences include repeated vancomycin or fidaxomicin courses, probiotics, rifaximin, intravenous immunoglobulin and fecal transplants. Measures for preventing the spread of the pathogen, appropriate diagnostic testing, and treatment may avert morbidity and mortality due to CDAD.

Thoraco-abdominal mature teratoma in a left diaphragmatic hernia.

This case describes a contiguous mediastinal and retroperitoneal mature teratoma in a congenital diaphragmatic defect, a combination that is hitherto unreported in literature. It substantiates embryological chronology of events during the cephalad migration of the primordial germ cells through the developing diaphragm, prior to its closure.

Thoracoscopic thymectomy for juvenile myasthenia gravis.

Thoracoscopic thymectomy is feasible in adolescents with myasthenia gravis. It allows complete resection of the gland with less morbidity, shorter ICU and hospital stay and far superior cosmetic result as compared to trans-sternal thymectomy. Our experience with this procedure in 9 adolescents with myasthenia gravis is presented along with review of the relevant literature.

Efficacy and safety of losartan-amplodipine combination--an Indian postmarketing surveillance experience.

The present study was conducted among 719 patients enrolled by 109 doctors to evaluate the efficacy and tolerability of the combination of losartan potassium and amlodipine besylate in Indian patients with mild to moderate hypertension. Out of them 11 patients were dropped out. Of these 708 patients 643 patients received once daily dosage of the combination whereas 10 patients received 1/2 daily, 13 patients received 1 1/2 daily and 42 patients received 1 twice daily dosage of the combination. The mean SBP in the study was 172.89 +/- 19.18 mm Hg baseline. After the 10-day treatment, the mean SBP had significant reduction ie, 13.1% from basal and at the end of day 20 of the treatment, the reduction was 19.13% from the baseline which was significant. Similarly mean DBP was 105.42 +/- 10.85 mm Hg at baseline. After treatment, the mean DBP had significant reduction. After 10- day treatment, there was 12.7% reduction from the baseline and at the end of the treatment ie, after day 20, the reduction was 17.70% from basal, which was significant. Global evaluation of efficacy was done by the physicians; 93.8% of the cases had excellent to good response and 4.9% patients had fair response. Details of any adverse event reported or noted during the treatment with the combination were recorded in the appropriate section of the case record form, whether considered treatment related or not, as reported by the patients. The severity of an adverse event was graded on a 3-point scale as mild, moderate and severe. The most common side-effects reported were oedema of feet (5.08%), ankle oedema (1.98%). Remaining adverse events included some cardiovascular events such as palpitations, gastro-intestinal events such as constipation, miscellaneous events, muscular pain, weakness, generalised swelling, etc. CNS events included giddiness, headache, insomnia, etc.