Diabetes mellitus as a risk factor for recurrence of Clostridium difficile infection in the acute care hospital setting.

BACKGROUND: Clostridium difficile-associated diarrhea (CDAD) is increasingly encountered in the acute care setting with rates of infection increasing dramatically since 2001. Reoccurring episodes are being seen with increasing frequency. The purpose of this study was to examine risk factors specifically associated with CDAD recurrence in an urban medical center. METHODS: This study was conducted in a 651-bed, acute care teaching hospital in an urban community in northeastern New Jersey. We examined the medical records of subjects discharged from the institution with a diagnosis of CDAD over the 6-year period January 1, 2003, to December 31, 2008. Inclusion in the study required clinical signs and symptoms of CDAD and the presence of C difficile toxins A/B. This cohort of 247 subjects was divided into 2 groups: those who were not readmitted with CDAD within 6 months (n = 171) and those who required readmission for CDAD within 6 months of discharge from their last admission (n = 76). RESULTS: Both hypoalbuminemia (odds ration [OR], 1.74, 95% confidence interval [CI]: 1.10-2.77; P = .02) and diabetes (P < .0001; OR, 3.04; 95% CI: 1.84-5.03; P < .0001) were considered as independent risk factors. After adjustment for potential confounders, hypoalbuminemia was found to be race dependent (OR, adjusted for black race: 1.62; 95% CI: 0.93-2.82; P = .09); however, diabetes was found to be a significant independent risk factor for CDAD recurrence (adjusted OR ranged from 3.79 to 5.46, minimum lower 95% confidence level: 2.01, all P values <.0001). CONCLUSION: We have demonstrated that diabetes is an important risk factor for recurrence of CDAD. Although previous have concluded that hypoalbuminemia is associated with CDAD recurrence, our data suggest that this association may have some dependence on race or ethnicity.

Demand and capacity planning in the emergency department: how to do it.

BACKGROUND: Unless emergency departments have adequate capacity to meet demand, they will fail to meet clinical and performance standards and will be operating in the 'coping zone'. This carries risks both for staff and patients. METHODS: As part of a quality improvement programme, the authors undertook an in-depth analysis of demand and capacity for an emergency department in the UK. The paper describes this rigorous approach to capacity planning, which draws on techniques from other industries. DISCUSSION AND CONCLUSIONS: Proper capacity planning is vital, but is often poorly done. Planning using aggregated data will lead to inadequate capacity. Understanding demand, and particularly the variation in that demand, is critical to success. Analysis of emergency department demand and capacity is the first step towards effective workforce planning and process redesign.

A randomised controlled trial comparing fixation of mandibular angle fractures with a single miniplate placed either transbuccally and intra-orally, or intra-orally alone.

This study compared fixation of simple mandibular angle fractures with a single miniplate either placed from a combined transbuccal and intra-oral approach, or intra-orally alone. 140 consecutive patients were randomly allocated to the two treatment groups. Complications were noted and compared. An email questionnaire to all the participating surgeons examined their personal preferences between the two methods. 20% of plates needed to be removed during the 3 month study period in the combined transbuccal/intra-oral group compared with 36% in the intra-oral alone group (p

Maintaining a high level of suspicion for recurrent malignant disease: report of a case with periapical involvement.

AIM: To report the unusual endodontic presentation and radiographic features of a subgroup of pleomorphic adenoma called carcinoma ex pleomorphic adenoma and to stress the importance of maintaining a high level of suspicion in cases where primary or recurrent neoplasia is included in the differential diagnosis. SUMMARY: This paper describes a case in which a patient with a previous history of malignant neoplasm presented with signs and symptoms similar to a dental infection. The pathology report however confirmed recurrence of the previous tumour in a malignant fashion. The importance of maintaining a high level of suspicion in early management of such disease is highlighted. KEY LEARNING POINTS: *Pleomorphic adenomas, also known as benign mixed tumours, are common salivary gland tumours, which infrequently undergo malignant transformation, with potentially devastating consequences. *Malignant salivary gland tumours can present as dental swelling, dental pain and sudden loss of vitality of teeth so both general practitioners and specialists have the responsibility to evaluate such patients with a broad vision. *Radiographic differential diagnosis of periapical radiolucency should also include malignant salivary gland tumours. *This case highlights the need of vigilance at all times and emphasizes the benefits of biopsy and histological examination in the diagnosis of recurrent malignant salivary gland tumours.

Mitochondrial DNA mutations in oral squamous cell carcinoma.

It has previously been demonstrated that mitochondrial DNA (mtDNA) mutations within the ND2 gene of histologically normal parotid salivary gland tissue of smokers may be molecular biomarkers for smoking-induced mtDNA damage. Oral squamous cell carcinoma (SCC) is strongly related to cigarette smoking; therefore, we used PCR and direct sequencing to establish whether mtDNA mutations were also present in oral SCC which could be used as additional biomarkers for smoking-associated DNA damage. In addition to searching for mutations in the ND2 gene, the mitochondrial D-Loop was also analysed. Three mutation hotspots were observed in the D-Loop at nt 146, 152 and 186, two of which (nt 146 and 152) have also been implicated in oesophageal SCC, another smoking-related cancer. The mutation hotspot observed at nt 186 has not previously been reported in other tumours. Furthermore, we show that the mutations previously reported within the ND2 gene in normal parotid tissue of smokers were not evident in these samples, but that a mutation hotspot occurs at nucleotide 4917 in oral SCC. We also show that D-Loop mutations occur predominantly in male smokers and female non-smokers and that this association with gender is statistically significant (P = 0.003). We conclude that the mtDNA mutation hotspots found in this study, in particular nt 186, are potential biomarkers for oral SCC. However, owing to gender-specific differences in occurrence in smokers and non-smokers, and a lack of environmental smoking history, in general, it is difficult to associate these mutations with mtDNA damage induced by smoking. If the mutations observed in the subset of male patients are smoking induced, given our previous findings, mutation hotspots in the ND2 gene may be tissue specific suggesting the causative mutagens for mtDNA damage within these tissues are likely to be different.

Use of interventional radiology in the management of mediastinitis of odontogenic origin.

Descending necrotising mediastinitis is a rare complication of odontogenic infection. The key to diagnosis is to maintain a high index of suspicion when antibiotics and adequate surgical drainage do not lead to resolution of symptoms. Open thoracic operation to drain mediastinal collections is potentially lethal and interventional radiological techniques are thought to reduce mortality. We report the use of interventional radiology in the diagnosis, monitoring and treatment of this condition and illustrate our experience with three case reports.

Ultrasound and fine needle aspiration cytology in the staging of neck lymph nodes in oral squamous cell carcinoma.

We prospectively studied 49 patients with oral squamous cell carcinoma (SCC) who had their cervical regional lymph nodes examined by ultrasound (US), with or without fine needle aspiration cytology (FNAC), for the detection of metastatic spread. They were screened over a two-year period (1993-1995) by computed tomography (CT) and magnetic resonance imaging (MRI) or both to measure the primary tumour. US, with or without FNAC, was used to stage the neck. All tumours were biopsied preoperatively and the diagnosis of SCC conformed by histological examination. Management of the neck was based on US staging. Thirty-five patients had neck dissections and 14 were managed conservatively. Mean follow-up was 30 months (range 24-48). All patients were alive at one year, but one died at 14 months from recurrence of disease in the neck. There were 3 false negatives (6%). We find that US, with or without FNAC, is an accurate (86%), sensitive (92%) and specific (83%) technique for the preoperative assessment of lymph node metastases in patients with SCC.

Cocaine self-administration in monkeys: effects on the acquisition and performance of response sequences.

A three-component multiple schedule of intravenous cocaine self-administration (0.01-0.3 mg/kg), repeated acquisition and performance was used to examine the effects of self-administered cocaine on learning in rhesus monkeys. A 0.03 mg/kg infusion of cocaine maintained reliable self-administration without markedly decreasing overall response rate or increasing the percentage of errors in the acquisition and performance components in which food was presented. When saline was substituted for 0.03 mg/kg of cocaine, there was little or no effect on responding in the acquisition or performance components while the number of infusions and response rate in the self-administration component decreased. These effects occurred to a greater extent under a FR 90 schedule (Experiment 2) as compared to a FR 30 schedule (Experiment 1) of cocaine self administration. Substitution of higher infusion doses of cocaine also decreased response rate and the number of infusions in the self-administration components, and substantially decreased responding in the acquisition components; decreases in overall accuracy of responding were evident when responding in this schedule component occurred. Taken together, these data indicate that learning is generally more sensitive than performance to the disruptive effects of self-administered cocaine.

Quantitation of DNA from exfoliated colonocytes isolated from human stool surface as a novel noninvasive screening test for colorectal cancer.

The only widely used screening test for early detection of colorectal cancer, the fecal occult blood test, lacks both sensitivity and specificity because it relies upon incidental bleeding rather than the neoplastic process. With the purpose of developing a new noninvasive diagnostic approach, we quantified DNA extracted from cells isolated from the surface of human stools by a novel procedure. Stools collected from 28 healthy individuals, 17 colorectal cancer patients, and 11 colorectal polyp patients were analyzed. A stool DNA index (SDNAI), expressed as DNA amount in nanograms per gram of stool, had a remarkable 4.5-fold difference in mean values between colorectal cancer patients and healthy people of comparable age. SDNAI was 2133 +/- 407 in the cancer group versus 469 +/- 65 in healthy people of the older (> 50 years) age group (P = 0.0005). The difference was independent of tumor location and size. If 700 ng of DNA/g of stool was taken as a cutoff SDNAI value in discrimination between older healthy people and cancer patients, sensitivity and specificity values reached 1.00 and 0.81, respectively. Age dependence of SDNAI was demonstrated by substantially lower SDNAI values (mean, 227 +/- 41) in younger healthy individuals. Polyp patients sometimes displayed elevated SDNAI values, but considerable variation was observed (mean, 1215 +/- 548). These preliminary findings indicate that SDNAI provides a novel, simple, and powerful noninvasive test for colorectal cancer early detection and screening. The fundamental advantage of the SDNAI is that it directly characterizes colonic epithelium involved in carcinogenesis.

Sensitivity of a method for the analysis of facial mobility. I. Vector of displacement.

OBJECTIVE: (1) To determine which facial landmarks show the greatest movement during specific facial animations and (2) to determine the sensitivity of our instrument in using these landmarks to detect putatively abnormal facial movements. DESIGN: Movements of an array of skin-based landmarks on five healthy human subjects (2 men and 3 women; mean age, 27.6 years; range, 26 to 29 years) were observed during the execution of specific facial animations. To investigate the instrument sensitivity, we analyzed facial movements during maximal smile animations in six patients with different types of functional problems. In parallel, a panel was asked to view video recordings of the patients and to rate the degree of motor impairment. Comparisons were made between the panel scores and those of the measurement instrument. RESULTS: Specific regions of the face display movement that is representative of specific animations. During the smile animation, landmarks on the mid- and lower facial regions demonstrated the greatest movement. A similar pattern of movement was seen during the cheek puff animation, except that the infraorbital and chin regions demonstrated minimal movement. For the grimace and eye closure animations, the upper, mid-facial, and upper-lip regions exhibited the greatest movement. During eye opening, the upper and mid-facial regions, excluding the upper lip and cheek, moved the most, and during lip purse, markers on the mid- and lower face demonstrated the most movement. We used the smile-sensitive landmarks to evaluate individuals with functional impairment and found good agreement between instrument rankings based on the data from these landmarks and the panel rankings. CONCLUSION: The present method of three-dimensional tracking has the potential to detect and characterize a range of clinically significant functional deficits.

Effect of meat and resistant starch on fecal excretion of apparent N-nitroso compounds and ammonia from the human large bowel.

N-nitroso compounds are produced in the human large intestine, but little is known about the dietary modulation of their synthesis at this site. The effects of meat and resistant starch on the fecal excretion of N-nitroso compounds, measured as apparent total N-nitroso compounds (ATNC), were therefore investigated in a crossover study involving eight healthy men. Three controlled diets that differed in the amount of meat (40 or 600 g) and resistant starch (37 g added to 600 g meat diet) were fed in random order, and fecal ATNC, as well as fecal ammonia and parameters of bowel function, were measured after 19 days of dietary adaptation. Mean ATNC excretion during the high-meat period was 114 micrograms/day, three times that during the low-meat period of 35 micrograms/day (p = 0.02); ammonia excretion was twice that during the low-meat period: 2.9 vs. 1.4 mmol/day (p = 0.03). The fecal ATNC were dissolved in the fecal water, and 45% had a molecular weight < 3,000. The addition of readily fermentable resistant starch to the high-meat diet significantly increased stool output from 118 to 153 g/day and decreased fecal pH from 7.2 to 6.6 but had no significant effect on fecal ATNC (151 micrograms/day), ammonia (3.7 mmol/day), whole gut transit time, urinary nitrate, or plasma urea. ATNC produced in the large bowel in association with a high-meat intake could represent an important source of DNA-damaging alkylating agents in the human large bowel.

Can radio-opaque markers be used to measure mouth-to-stoma transit time in ileostomates?

OBJECTIVE: To determine whether radio-opaque markers can be used to assess mouth-to-stoma transit time (MSTT) in ileostomates. DESIGN: Criterion standard. SETTING: Metabolic research unit. SUBJECTS: Five volunteer ileostomates. RESULTS: MSTT assessed by radio-opaque markers (11.3 to 12.5 h) was significantly longer (P < 0.5) than that calculated by ileal recovery of dietary starch (6.5 to 8.8 h), the criterion standard. CONCLUSION: Radio-opaque markers are unsuitable for measurement of MSTT in ileostomates.

Ileal recovery of starch from whole diets containing resistant starch measured in vitro and fermentation of ileal effluent.

Six subjects with ileostomies consumed five diets containing 61-164 g starch/d of which 0.4-34.8 g was resistant starch (RS). Ileal excretion of starch was 97% of that measured as dietary RS in vitro with no significant difference between RS fed and starch recovered on any of the test diets. Variation in starch excretion between subjects was partly due to differences in mouth-to-stoma transit time. In vitro fermentation of ileal effluent from RS-supplemented diets produced significantly more short-chain fatty acids, a higher molar proportion of butyrate (17% compared with 12%), and a lower concentration of ammonia compared with control subjects. These results indicate that the amount of starch that reaches the large intestine can be predicted from measurements in vitro for a wide range of RS intakes under normal eating conditions. They also support the hypothesis that RS, through fermentation, has distinctive influences on the colonic environment.

Does digestibility of meat protein help explain large bowel cancer risk?

An association between meat eating and large bowel cancer risk has been shown in a variety of epidemiologic studies. One reason could be that meat is less well digested than other protein foods and leads to greater amounts of protein entering the large bowel and being metabolized by colonic bacteria to potential carcinogens. To test this hypothesis, five subjects with ileostomies were fed, for five days, a basal diet to which were added test meals of cheese, a small or a large fried beef steak, and a large steak with resistant starch (RS). Ileal true nitrogen digestibility was similar for all five diets: control, 86.3%; cheese, 89.4%; low beef, 88.6%; high beef, 89.6%; and high beef + RS, 88.7%. Beef, at both low and high intake levels, was as well digested as cheese, suggesting that poor digestibility of meat does not explain the association between meat intake and large bowel cancer risk. Ileal starch output on the high beef + RS diet was 27% greater than expected on the basis of the measurement of dietary RS in vitro (p = 0.005 for linear trend), and this was confirmed by a meta analysis with eight other published studies. The relation between meat and large bowel cancer may reflect higher protein intakes in meat eaters or may be explained by other mechanisms.

Extradural haematoma after temporomandibular joint arthroscopy. A case report.

A case report of an extradural haematoma (EDH) after temporomandibular joint arthroscopy is presented. The possible cause of this unusual occurrence is discussed.

Early management of multiply injured patients with maxillofacial injuries transferred to hospital by helicopter.

It has been suggested that early intensive medical treatment will improve the outcome for trauma patients with severe injuries. A Helicopter Emergency Medical Service (HEMS) based in an urban area was inaugurated by The Royal London Hospital. Specially trained medical and paramedical personnel flew with the helicopter to accident scenes. On return to the hospital, multi-disciplinary teams, including maxillofacial, were called to manage the patients. Operations from its own helipad commenced from the end of August 1990. A retrospective study of 192 patients transferred by HEMS to the Royal London Hospital during 16 months was undertaken. 18% (34) patients had facial injuries recognised at primary and secondary surveys according to Advanced Trauma Life Support (ATLS) protocols. The problems of early management are described and routine techniques for the control of haemorrhage from the maxillofacial area were developed.

Neurilemmoma of the head and neck.

The neurilemmoma is an uncommon tumour of the oral cavity. In this present series of soft tissue neurilemmomas the majority occurred within or around the mouth. Initially these were provisionally diagnosed on clinical appearances and behaviour as commoner benign lesions, including the fibro-epithelial polyp, mucocele and papilloma. On sampling they were found to have the histological features of a neurilemmoma. This suggests that the solitary neurilemmoma occurs more frequently than previously reported and should be included in the differential diagnosis of these more frequent benign lesions occurring in and around the mouth.