Clostridium difficile colitis in the critically Ill

Morbidity and treatment of Clostridium difficile colitis (CDC) continue to be controversial. Some claim minimum morbidity, which may be a function of differences in patient population and/or bacterial virulence. METHODS: To evaluate the effect of CDC in the critically ill, we retrospectively reviewed the records of 59 intensive care unit patients with CDC who were diagnosed by fecal toxin assays or clinical evidence of pseudomembranous colitis from January 1991 to October 1994. Symptoms, signs, antibiotic regimens, diagnostic tests, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, morbidity, and mortality were analyzed, and results of surgical treatment were compared with the literature. RESULTS: Mean age was 66.4 (17–95) years, with a male to female ratio of 1.81. First treatment was metronidazole by mouth in 15 patients (25.4 percent), vancomycin by mouth in 30 patients (50.8 percent), sequential by mouth vancomycin/metronidazole in 3 patients (5.1 percent), and intravenous metronidazole in 5 patients (8.5 percent). Six patients had no medical therapy before surgery or discharge. Ten patients (17 percent) had recurrence and 12 (20.3 percent) required surgery for progressive toxicity or peritonitis. Of three patients who were initially treated by diverting stomas, one died and two required total colectomy (TAC). Two underwent partial resection (1 that was nearly a total colectomy), and seven others had a TAC. Surgical patients had worse mean APACHE II scores at diagnosis (24.4 vs. 199;P<0.001). Thirty-day mortality in surgical patients was 41.7 vs. 14.7 percent in medical patients (P<0.5).CONLUSION: Twenty percent of critically ill patients with CDC required operation. TAC and diversion appeared to be more effective surgical treatments than diversion alone.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

A thermoluminescent dosimetry intercomparison in operational power station fields.

A dosimetry intercomparison was held among the five agencies in Canada that are recognized by the Atomic Energy Control Board as competent to perform external dosimetry. Exposures of thermoluminescent dosimeter badges were made under operational conditions to radiation fields in Candu nuclear generating stations. Details of the method are described including the large, block-type phantoms (with a rotating front face so that all badges were equally exposed) and a small device to measure the depth-dose distribution. Thirty-six exposures (or "runs") were made, exposing 522 badges for periods of 1 h-2 d. Normalization between the runs was based on the absorbed dose at 1,000 mg cm-2 for each run, as measured by the depth-dose device. Using this method, the average relative readings for the five participants ranged from 1.01-1.40 (dimensionless).     

Interstitial cystitis. Observations on diagnosis and on treatment with anti-inflammatory drugs, particularly benzydamine.

Interstitial cystitis is often missed on "routine" cystoscopy. If the disease is suspected, the bladder must be observed twice during complete filling. An anti-inflammatory drug, Benzydamine, has given mixed results but in view of its low toxicity it is worth trying in any patient with severe symptoms.     

Fluoxetine for bulimia nervosa following poor response to psychotherapy

OBJECTIVE: This was an investigation of whether treatment with fluoxetine is useful for individuals with bulimia nervosa who do not respond to psychotherapy or relapse afterward. METHOD: Twenty-two patients with bulimia nervosa who had not responded to, or had relapsed following, a course of cognitive behavior therapy or interpersonal psychotherapy were randomly assigned to receive placebo (N=9) or fluoxetine (60 mg/day, N=13) for 8 weeks. RESULTS: The median frequency of binge eating in the previous 28 days declined from 22 to four episodes in the fluoxetine group but increased from 15 to 18 episodes in the placebo group. Similarly, purging frequency in the previous 28 days declined from 30 to six episodes in the fluoxetine group but increased from 15 to 38 episodes in the placebo group. CONCLUSIONS: Fluoxetine may be a useful intervention for patients with bulimia nervosa who have not responded adequately to psychological treatment.     

Caring for people with developmental disabilities: survey of nurses about their education and experience

Over 500 nurses in New Jersey responded to a survey on education and training in the area of developmental disabilities. Respondents provided information on their work experience, experience with patients who have developmental disabilities, and opportunities for continuing medical education. Results showed that although many nurses thought educational activities related to developmental disabilities were important, only about 10% said that they received "a lot" of training. Most respondents (almost 60%) said that they received little or no training in the area, and most received no specific training on developmental disabilities since receiving their licenses or in their current job. Implications of these findings in light of the movement of people with developmental disabilities into community-living and managed care plans are discussed.     

The search for an integral theory of consciousness

In summary, Miller has identified one of the key concerns of consciousness research. However, significant contributions to an integral theory of consciousness will need to be more clear and precise and to incorporate the relevant literature on current integral theories. If Miller's future writings do this, they may make the contributions we so desperately need.     

The conduct of in vitro and in vivo drug-drug interaction studies: a Pharmaceutical Research and Manufacturers of America (PhRMA) perspective.

Current regulatory guidances do not address specific study designs for in vitro and in vivo drug-drug interaction studies. There is a common desire by regulatory authorities and by industry sponsors to harmonize approaches, to allow for a better assessment of the significance of findings across different studies and drugs. There is also a growing consensus for the standardization of cytochrome P450 (P450) probe substrates, inhibitors and inducers and for the development of classification systems to improve the communication of risk to health care providers and to patients. While existing guidances cover mainly P450-mediated drug interactions, the importance of other mechanisms, such as transporters, has been recognized more recently, and should also be addressed. This article was prepared by the Pharmaceutical Research and Manufacturers of America (PhRMA) Drug Metabolism and Clinical Pharmacology Technical Working Groups and represents the current industry position. The intent is to define a minimal best practice for in vitro and in vivo pharmacokinetic drug-drug interaction studies targeted to development (not discovery support) and to define a data package that can be expected by regulatory agencies in compound registration dossiers.