General hospital resources consumed by an elderly population awaiting long-term care

The provision of extended care facilities in urban Ireland has lagged behind the growth in the numbers of older people. A final pathway for placement is often through the general hospital and the attendant delay results in a diversion of resources. We developed a database of the long-term care waiting lists for the years 1994-present and this was analysed for the six years 1994-1999. We calculated the number of bed-days consumed by elderly patients awaiting placement in long-term care facilities and thus the hospital resources consumed during these periods. The total number of bed-days consumed over the study period was 51,923, the mean being 8653.8 days. Approximately 23.9% of patients die in hospital while awaiting long-term placement. Translating these bed-days into opportunity cost losses in areas relevant to the general hospital we found that 560 extra elective orthopaedic procedures and 1,212 extra transurethral prostatectomies could have been performed per year. The problem of overnight stays in casualty could have been totally abolished if only 65% of these beds were free. Elective theatre is often cancelled with one of the primary reasons being lack of beds. If even a proportion of these beds could be freed up few if any theatre sessions would have to be cancelled, assuming bed availability to be the only factor. This study confirms that the lack of appropriate accommodation for older people requiring extended care is consuming a significant proportion of health care resources. An accelerated program of building of publicly funded long-term placement facilities is urgently required to ameliorate this problem, especially in the greater Dublin area. Further study is required to determine whether this problem exists in other health board areas and if so whether it exists to the same extent.

Digital radiology equipment acquisition and installation procedures: a team approach at Mayo Clinic, Rochester, MN

Digital imaging system integration is a complex process. A project team and a defined process for system planning, evaluation, and implementation can improve the chance for success. In this presentation, our project team relates their experiences.

The effects of age on accident severity and outcome in Irish road traffic accident patients

Road traffic accidents (RTA's) are the leading cause of fatal trauma in Ireland. Although older drivers are the safest group of drivers in the population, once involved in a crash they are more likely to sustain a severe injury or death. The experiences of Irish elderly RTA victims has not been previously documented. We studied older RTA patients admitted to two Irish trauma centres in 1995. Of 525 patients, 39 (7%) were aged over 65. We compared 38 patients aged 16-64 years for comparison and reviewed the notes in detail. Elderly patients were mostly pedestrians (23/38 - 61%) though 21% (8/38) were drivers with 8% (3/38) on public transport. Younger patients were mostly drivers (14/37 - 38%), cyclists (9/37 - 24%) or motorcyclists (7/37 - 19%). Older patients had a higher median Injury Severity Score, p < 0.05, were more likely to be female (p<0.01), involved in RTA's between 9am-5pm (p<0.05) and have pre-existing medical conditions (p<0.01). The following were significantly increased in older patients (p values): surgical (<0.01), medical (<0.01) and therapist workload (p<0.05), complications (<0.0001), length of stay (<0.01). Less elderly were discharged directly to home (p<0.001). Strategies to reduce the mortality and morbidity associated with RTA in the elderly should emphasise a) older pedestrians during daytime hours, b) attention to safety in public transport. Treatment must ensure adequate medical and therapist input to anticipate higher complication rates.

Isolated juvenile xanthogranuloma of the subglottis: case report

BACKGROUND

Juvenile xanthogranulomatosis (JXG) is a relatively rare macrophage proliferative disorder. It usually presents as a localized cutaneous lesion but may affect other organs. Until now it has never been described in the subglottic region of the larynx.

METHODS

We report the first case of juvenile xanthogranulomatosis (JXG) in the subglottis in a 3 year old child.

RESULTS

The localization in the subglottis caused airway obstruction requiring tracheostomy to secure the airway. On the basis that most cutaneous lesions regress spontaneously the lesion was managed expectantly and regressed over a period of 28 months allowing decannulation of the child.

CONCLUSION

JXG should be considered in the differential diagnosis of subglottic lesions. Once the airway has been secured, JXG of the subglottis can be managed conservatively. Long-term follow-up is required because of the possibility of relapse at other sites.

Prenatal diagnosis of fetal abdominal lymphangioma by ultrasonography

We present a case of abdominal lymphangioma in a fetus together with a review of the literature. Diagnosis was made at 20 weeks' gestation by antenatal ultrasonography. In keeping with other reports, the lesion was located on the left and serial ultrasonography demonstrated rapid growth with extension into the lower extremity.

Circulating leptin levels and weight loss in Alzheimer's disease patients

Weight loss is common in Alzheimer's disease (AD) and is predictive of mortality. Leptin, an adipocyte-derived peptide hormone is implicated in the regulation of satiety and energy expenditure. It acts on the hypothalamus to suppress appetite and increase energy expenditure. We undertook this study to determine if inappropriately elevated leptin levels play a role in AD-associated weight loss. Serum leptin levels of 8 patients in each of the following groups were determined: (1) AD, body mass index (BMI) >25; (2) AD, BMI <20; (3) non-Alzheimer's (vascular) dementia (VaD), BMI >25, and (4) VaD, BMI <20. Mean serum leptin levels were significantly lower in below-appropriate-weight patients (both AD and VaD) than in appropriate-weight controls. Below-appropriate-weight AD patients had a significantly lower mean serum leptin concentration than appropriate-weight VaD controls. Weight loss is a feature of AD. Inappropriately elevated leptin levels do not appear to be implicated. Indeed, we have shown that the afferent limb of the leptin feedback loop is intact in below-appropriate-weight AD patients and suggest hypothalamic dysfunction may underlie this feature.

The early experience of general practitioners using Green Prescription

AIM

Sedentary lifestyle is a significant risk factor for increased morbidity and mortality in many medical conditions. A Hillary Commission initiative, Green Prescription is a written exercise prescription given by general practitioners (GPs) to sedentary patients to encourage physical activity. Our aim was to establish the extent to which GPs in the North Health region in 1997 issued with Green Prescription packages had used them, the circumstances under which they were used, and barriers to their use.

METHODS

433 GPs issued with packs were faxed a one-page questionnaire for immediate completion, with follow-up of non-responders.

RESULTS

The response rate was 73%, with 65% of respondents having written Green Prescriptions. Their main reasons for use were patient need for more exercise and presence of high-risk medical conditions such as hypertension, cardiovascular disease, obesity and diabetes. Reasons for non-use were: GP already giving advice about physical activity; concern that Green Prescription was patronising and simplistic; compliance issues and time restraints. Some requested a computerised version.

CONCLUSION

Non-responders may be non-users, hence we estimate that 48-65% of targeted GPs used Green Prescription. Barriers identified by GPs have assisted in Green Prescription development, which is now nationwide and assessed by independent researchers tri-annually.

Prenatal diagnosis of congenital Wilms' tumor (nephroblastoma) presenting as fetal hydrops

We describe a case of congenital nephroblastoma (Wilms' tumor) presenting at 28 weeks of gestation with fetal hydrops and polyhydramnios. Prenatal diagnosis was made by biopsy. An emergency Cesarean section was performed due to deterioration in the cardiotocograph. A post-mortem examination confirmed the diagnosis of congenital nephroblastoma.

Health and relicensing policies for older drivers in the European union

BACKGROUND

The number of older drivers is increasing rapidly in the developed world. Many states of the European Union (EU) have initiated legislation to screen older drivers for age-related disease, despite evidence that screening may be harmful or have no positive effect.

METHODS

We reviewed the current situation in the EU by sending a questionnaire to the Driver and Vehicle Licensing Agency in each member state.

RESULTS

All fifteen countries replied. Regular medical screening occurs in ten. European Council Directive 91/439/EEC forms the basis for national guidelines on medical fitness to drive, but these are not specific for age-related illness, and interpretation of the directive varies between countries. Specific guidelines are not available in all countries for the age-related conditions of dementia, stroke, and Parkinson's disease. In nine countries a medical colleague is available for consultation in difficult cases. Drivers are required to report illness to the Driver and Vehicle Licensing Agency only in the United Kingdom. In six countries, there is mandatory reporting by physicians of conditions which may pose a risk to driving.

CONCLUSIONS

There is considerable heterogeneity within the EU on the processes of older driver screening. This diversity may facilitate research into the effect of different policies on safe mobility of older people. If changes in the screening process are considered, further knowledge is needed on issues such as older driver exposure and valid measures of safe mobility for the EU. More evidence-based research is required to help policy makers frame future guidelines and legislation, so as to promote safe mobility of older people.

Do patient age and medical condition influence medical advice to stop smoking?

OBJECTIVE

to determine whether the age and medical condition of a patient influences hospital-based doctors' decision making when advising patients to stop smoking cigarettes.

METHODS

we presented 142 doctors from four grades (consultant, registrar, senior house officer and house officer) and four specialities (medicine, surgery, psychiatry and anaesthetics), based in a Dublin teaching hospital, with 20 clinical vignettes. Each vignette described a patient from one of five age groups with one of four levels of health. The vignettes were randomly mixed. We asked doctors to say whether they would advise the patient in each case to quit smoking.

RESULTS

hospital-based doctors are significantly less likely to advise patients aged over 65 years than younger patients of the hazards of cigarette smoking, irrespective of the person's physical or mental health (P < 0.001).

CONCLUSION

the advice given to patients about their cigarette smoking habits by hospital doctors is strongly influenced not only by the patient's health, but also by the patient's chronological age.

Identification of a key target sequence to block human immunodeficiency virus type 1 replication within the gag-pol transframe domain

Although the full sequence of the human immunodeficiency virus type 1 (HIV-1) genome has been known for more than a decade, effective genetic antivirals have yet to be developed. Here we show that, of 22 regions examined, one highly conserved sequence (ACTCTTTGGCAACGA) near the 3' end of the HIV-1 gag-pol transframe region, encoding viral protease residues 4 to 8 and a C-terminal Vpr-binding motif of p6(Gag) protein in two different reading frames, can be successfully targeted by an antisense peptide nucleic acid oligomer named PNA(PR2). A disrupted translation of gag-pol mRNA induced at the PNA(PR2)-annealing site resulted in a decreased synthesis of Pr160(Gag-Pol) polyprotein, hence the viral protease, a predominant expression of Pr55(Gag) devoid of a fully functional p6(Gag) protein, and the excessive intracellular cleavage of Gag precursor proteins, hindering the processes of virion assembly. Treatment with PNA(PR2) abolished virion production by up to 99% in chronically HIV-1-infected H9 cells and in peripheral blood mononuclear cells infected with clinical HIV-1 isolates with the multidrug-resistant phenotype. This particular segment of the gag-pol transframe gene appears to offer a distinctive advantage over other regions in invading viral structural genes and restraining HIV-1 replication in infected cells and may potentially be exploited as a novel antiviral genetic target.

An acute stroke service: potential to improve patient outcome without increasing length of stay

Acute stroke is associated with a high morbidity and mortality: up to 24% of patients may not survive their hospital admission. Stroke unit care has been shown in a meta-analysis to reduce this morbidity and mortality. We present a three-year audit of the first acute stroke service in an Irish teaching hospital. The audit was carried out prospectively on 193 patients admitted to the acute stroke service, from July 1996 to end of June 1999. Details regarding patients, type and severity of stroke, length of stay and outcome were collected prospectively on a standard pro-forma. We observed a reduction in mortality from 19% to 15% to 9%, and an increasing percentage of patients discharged home from 55% to 64% to 68%, in year 1, year 2 and year 3 respectively. A trend towards a greater number of patients, younger age and improved outcome with lower mortality was observed from year to year, without significant change in length of stay. This study confirms the value to patients of organised stroke care in terms of reduction in mortality and morbidity without increasing length of stay or disability. We suggest that every acute hospital should have organised stroke care.

Clinical assessment of rehabilitation potential of the older patient: a pilot study

Clinical assessment of 'rehabilitation potential' is an everyday occurrence in hospitals, where scarcity of dedicated rehabilitation facilities require clinicians to decide who is most likely to benefit from extended rehabilitation. We examined the reliability of this judgement by different interdisciplinary team members in 27 consecutive admissions to a geriatric rehabilitation ward. The reliability of a clinical judgement was in general quite poor (kappa = 0.21). A more reliable means of determining patient 'rehabilitation potential' is needed.

HemT-3, an alternative transcript of mouse gene HemT specific to male germ cells

A number of genes are known to be expressed primarily in hematopoietic cells and testis and are thought to function in the control of both blood cell and male germ cell differentiation. We have recently identified a mouse gene, HemT, that encodes two alternatively spliced transcripts specific to hematopoietic cells (HemT-1 and HemT-2) and kidney (HemT-2). We have now isolated a third HemT transcript, HemT-3, that is found only in testis by Northern blot analysis and RT-PCR. HemT-3 is alternatively spliced and may be initiated differently from HemT-1 and HemT-2. RNA in-situ hybridization of testis from wild-type and germ-cell-deficient adult mice, as well as from mice at different developmental stages, indicates that HemT-3 is expressed only in early spermatocytes. HemT-3 cDNA has a major open reading frame related to a human glycosylphosphatidylinositol (GPI)-anchored protein, GML. Using an antibody generated against a peptide derived from the HemT-3 open reading frame, we have detected a testis-specific 22kDa protein by Western blot analysis.

The identification and assessment of undernutrition in patients admitted to the age related health care unit of an acute Dublin general hospital

OBJECTIVES

To profile those over 65 yr admitted to an acute geriatric medical service. To identify and assess their undernutrition risk and quantify the nutritional intervention they received.

METHODS

Forty-nine consecutive admissions were recruited, 23 various parameters were assessed. A diagnosis of undernutrition was made according to a specifically designed flow chart.

RESULTS

Eighty-four per cent of recruits were at risk of undernutrition on admission and 80 per cent were moderately to severely at risk. There was deterioration from baseline nutritional status in 29 per cent of previously well nourished patients with hospitalization. In the undernourished group, an improvement and/or stasis from baseline was achieved in 75 per cent, with intervention.

CONCLUSIONS

The risk of undernutrition on admission to hospital and during treatment is an indicator of the need for nutrition services and nutritional screening for all acute medical services for older people.

The association between demographic factors, disease severity and the duration of symptoms at clinical presentation in elderly people with dementia

OBJECTIVE

To determine the association between factors unrelated to the disease process, the duration of symptoms and the degree of cognitive or functional impairment in elderly patients presenting with dementia.

METHOD

The living situation, educational level, age, gender and diagnosis based on standardized criteria were recorded for 209 elderly patients presenting to a memory clinic with dementia. Cognitive and functional deficits were measured with the cognitive section of the Cambridge Mental Disorders of the Elderly Examination combined with the Mini-Mental State Examination and the abbreviated version of the Blessed dementia scale, respectively.

RESULTS

129 patients had a diagnosis of probable Alzheimer's disease, 19 had probable ischaemic vascular dementia and 61 had mixed dementia. There was no effect of diagnosis on duration of symptoms or dementia severity at the time of presentation. Patients living with a son or daughter were more functionally impaired than those living alone or with a spouse. Males had higher cognitive scores but did not have milder functional deficits. Patients with only a primary-school education had a trend towards lower cognitive scores at presentation but did not have more functional deficits.

CONCLUSIONS

The gender of the patient and the relationship to the carer are associated with cognitive and functional scores at the time of presentation in patients with dementia.

A novel mouse gene, HemT, encoding an hematopoietic cell-specific transcript

We performed differential display to identify hematopoietic cell-specific genes that are expressed differentially before and after mouse erythroleukemia cell (MELC) induction. In this study we report the identification, cloning, and characterization of one such mouse gene, HemT. Using Northern blot, RT-PCR and in situ hybridization, we show that HemT encodes three different transcripts. One of them, HemT-1, is hematopoietic-cell specific and may be erythroid cell-specific. Another, HemT-2, is expressed mainly in hematopoietic cells. HemT-1 and HemT-2 are alternative splicing products. A third type of HemT transcript is expressed only in testis. The erythroid transcript is expressed preferentially in uninduced MELC as compared to induced MELC, and is likely to be expressed in early erythroid cell populations.

The allopurinol load test lacks specificity for primary urea cycle defects but may indicate unrecognized mitochondrial disease

Thirty-three children ranging from 2 weeks to 12 years of age were selected for allopurinol loading, 16 on the basis of an increased urinary ourotate excretion detected by routine organic acid analysis (group A), and 17 for clinical reasons suggesting a urea cycle defect (group B). The allopurinol load test proved positive in 13 of 16 patients from group A, mean peak orotate 64.0 mumol/mmol creatinine (upper limit of reference range, 13.2) and 11 of 17 patients from group B, mean peak orotate 41.0 mumol/mmol creatinine (upper limit of reference range, 13.2). Thorough investigation of these patients including urinary and plasma amino acid analysis and, in 17 cases, liver biopsy for histology and measurement of ornithine carbamyltransferase (OCT) and carbamyl-phosphate synthetase (CPS) activity failed to identify any evidence of a urea cycle disorder. However, muscle biopsies performed in 11 patients showed some evidence of mitochondrial disease in four cases, two defined on the basis of reduced respiratory chain enzyme activity and two on the basis of mtDNA abnormalities. These findings indicate that an increased excretion of orotate in sick children may not be uncommon and that a positive allopurinol load test result may not indicate a specific inherited urea cycle defect. In addition, these results raise the interesting possibility that defective ureagenesis may be a feature of mitochondrial disease in some individuals.

Unusual case of tracheal agenesis

We describe the clinical presentation and pathological features of an unusual case of tracheal agenesis. The axial derivatives of the primitive foregut between the larynx and stomach were represented by a single structure featuring sequential segmentation into regions showing exclusively tracheal or esophageal differentiation in a pattern that is not easily classified by existing nosologic systems nor explained by the conventional hypothesis of dysontogenesis.

Factors associated with prolonged symptoms and severe disease due to Clostridium difficile

OBJECTIVE

toxigenic Clostridium difficile is responsible for a spectrum of disease severity ranging from mild diarrhoea to fulminant colitis. This study attempts to determine the proportion of patients in each category of severity and evaluate the risk factors for a more prolonged and complicated course.

DESIGN

prospective cohort study.

SETTING

university teaching hospital.

SUBJECTS

all patients with symptomatic C. difficile infection during 4 months of an outbreak (January-April 1995); n=73; median age 74 years (range 17-91).

MEASUREMENTS

incidence of C. difficile-associated disease (CDAD); severity of disease; percentage of patients in each category of severity; risk factors for severe disease/prolonged symptoms (univariate and multivariable analyses).

RESULTS

the incidence of CDAD was 0.93%. Of the cases identified, 18 (24.7%) had mild, self-limiting disease; 26 (35.6%) had moderately severe disease; 23 (31.5%) had prolonged symptoms and six (8.2%) had a complicated course. Although CDAD was more common in older patients (P < 0.001), increasing age was not a risk factor for severity. Significant risk factors for severe CDAD included low Barthel and abbreviated mental test scores (P < 0.01, P < 0.001 respectively) and recent endoscopy (P=0.03). Logistic regression analysis revealed the following independent predictors of severe CDAD: endoscopy [odds ratios (OR) 4.0, P=0.03] and cognitive impairment (OR 11.0, P < 0.01). A trend towards significance was noted for nasogastric tube insertion (OR 3.1, P=0.08). Complications of infection included dehydration, malnutrition and faecal incontinence (which was statistically significantly associated with more severe disease; P < 0.01).

CONCLUSION

risk factors for severity of CDAD include functional disability, cognitive impairment, and recent endoscopy. Anticipation of severe CDAD may limit morbidity and mortality.

Tissue-specific and developmental stage-specific DNA binding by a mammalian SWI/SNF complex associated with human fetal-to-adult globin gene switching

SWI/SNF complexes in yeast and higher eukaryotes are thought to facilitate gene activation and transcription factor binding by disrupting repressive chromatin structures. Little is known, however, about how these complexes target specific genes for activation. We now have purified a specialized SWI/SNF-related complex (PYR complex) from murine erythroleukemia (MEL) cell nuclear extract that binds pyrimidine-rich elements at the human and murine beta-globin loci. PYR complex DNA-binding activity is restricted to definitive hematopoietic cells and is both DNA sequence- and length-dependent. Mass spectrometric identification of purified peptides and antibody supershift assays indicate that PYR complex contains at least four known mammalian SWI/SNF subunits: BAF57, INI1, BAF60a, and BAF170. PYR complex broadly footprints a 250-bp pyrimidine-rich element between the human fetal and adult beta-globin genes. A short intergenic deletion that removes this element from a human globin locus cosmid construct results in delayed human fetal-to-adult globin gene switching in transgenic mice. Taken together, the data suggest that PYR complex may act through this intergenic element to facilitate human fetal-to-adult globin gene switching, presumably by opening the locus in the region of the adult genes to permit the binding of beta-globin transcriptional activators.

Potential for treatment with thrombolysis in an Irish stroke unit

Since the publication of the NINDS rt-PA trial in 1995, tissue plasminogen activator has been licensed for the treatment of acute cerebral infarction in the U.S. The demonstrated benefit was confirmed to patients presenting within three hours of symptom onset on adhering to study guidelines, which subsequently have formed the basis for a protocol for thrombolysis in acute stroke. The implementation of a thrombolysis programme in Ireland would require a restructuring of hospital facilities to manage acute stroke. We conducted a prospective study of 100 patients admitted to an acute stroke unit to assess the potential for intervention with t-PA under NINDS guidelines. Data was collected on stroke type. CT appearances, time of onset of stroke and laboratory parameters. Only 6% of all strokes assessed were eligible for thrombolysis and time to presentation was the major excluding factor. When time was removed as an exclusion criteria only 1/5 of all strokes were potential candidates in this best case scenario. Thrombolysis does improve outcome in cerebral infarction in a a strictly controlled setting but only 6% of our patients would currently be eligible for treatment. While this may improve with better public education regarding stroke and it's treatment, only a 1/5 of our patients would still be eligible were they all to present within 2 hours of symptoms onset.

Basolateral D-glucose transport activity along the crypt-villus axis in rat jejunum and upregulation induced by gastric inhibitory peptide and glucagon-like peptide-2

Phloridzin-insensitive D-glucose uptake into enterocytes isolated sequentially from along the crypt-villus axis showed the majority of transport activity to reside in cells from the upper third of the villus. In contrast, total postnuclear glucose transporter 2 (GLUT2) protein content of the cells was high even close to the crypt and was almost constant for the upper 80% of the villi. A 4 h lumenal perfusion in vivo with 100 mM D-glucose prior to harvesting the enterocytes produced a 2- to 3-fold increase in phloridzin-insensitive D-glucose uptake which extended down 70% of the villus. Vascular infusion in vivo with either 800 pM gastric inhibitory polypeptide (GIP) or glucagon-like peptide-2 (GLP-2) prior to harvesting enterocytes produced the same response as lumenal glucose, while glucagon like peptide-1 (GLP-1) had no effect. Inclusion of 30 microM brefeldin A (BFA), an inhibitor of protein trafficking, in the lumenal perfusate produced a small, but not significant, increase in the control uptake profile along the villus in isolated enterocytes. However, BFA significantly reduced the upregulation induced by lumenal glucose and vascular GIP and blocked the stimulation produced by vascular GLP-2. Biotinylation of surface proteins and isolation with protein A indicated that there was no change in the membrane abundance of GLUT2 after GLP-2 treatment. These results are discussed in relation to the role of gastrointestinal peptide hormones in controlling intestinal hexose transport and the possibility of protein trafficking being involved in mediating the upregulation of GLUT2 activity in the enterocyte basolateral membrane.

Sensitization to human leukocyte antigen before and after the introduction of erythropoietin

INTRODUCTION

Antibodies directed against human leukocyte antigens (HLAs) impact adversely on renal transplantation. Measures aimed at preventing such antibody formation are thus important. The introduction of recombinant human erythropoietin (rHuEpo) has permitted the reduction of blood transfusion in patients with chronic renal failure. The impact of rHuEpo on the incidence of sensitization in patients awaiting transplantation was therefore studied.

METHODS

A retrospective analysis of the patients awaiting transplantation before (group A) and 4 years after (group B) the introduction of rHuEpo was performed in order to ascertain changing patterns in the use of blood transfusion and causes of sensitization.

RESULTS

The total number of transfusions administered to haemodialysis patients decreased by 34% during the study period. This was accompanied by a significant reduction in the ratio of blood transfusion to haemodialysis treatment episodes (0.095 in group A to 0.06 in group B, P = 0.001). The number of patients sensitized as a consequence of blood transfusion decreased from 63% in group A to 28% in group B (P = 0.0004). The overall incidence of sensitization decreased from 50% in group A to 36.5% in group B (P = 0.008). This decrement was associated with a significant reduction in the mean waiting time for transplantation (42.1 +/- 1.1 vs 15.4 +/- 2.4 months, P < 0.0001). The incidence of sensitization due to previous transplantation increased during the study period from 41% in group A to 77% in group B, (P = 0.0004). There was no change in the number of patients sensitized due to pregnancy.

CONCLUSION

The introduction of rHuEpo has resulted in a significant decrease in the requirements for blood transfusion among patients awaiting transplantation and is associated with a significant reduction in transfusion-related sensitization and mean waiting time for transplantation.

Community-acquired Clostridium difficile infection

Clostridium difficile-associated disease (CDAD) is primarily a nosocomial condition. Community-acquired disease has been reported but the incidence is felt to be low and the rate of disease resulting in hospitalization is reported as negligible. We recently experienced a 6-month outbreak of CDAD (January to June 1995): 139 patients were involved and four deaths were attributable to pseudomembranous colitis. Early in the outbreak period we were aware that many new admissions presented with C. difficile cytotoxin B positive diarrhoea: in some cases this was the sole reason for hospitalization. This observation forms the basis of this report.

Simultaneous outbreaks of two strains of toxigenic Clostridium difficile in a general hospital

We report an outbreak of Clostridium difficile-associated disease (CDAD) in a large Dublin hospital. From January to June 1995, inclusive, 139 patients were affected; the mean age of cases was 68.8 +/- 19 years. Clinical information is available for 73 cases identified during the first four months of the outbreak. The majority of patients presented with abrupt onset of watery diarrhoea; however, 19.2% presented with an unexplained pyrexia following a course of antimicrobial therapy and 5.5% presented with a surgical acute abdomen. Twenty patients (27.4%) experienced relapsing disease and seven (9.6%) patients died. Seventy-six percent of cases received a cephalosporin prior to the onset of disease, the highest relative risks occurring with third-generation agents; however, 9.6% of patients affected had not been exposed to antimicrobial therapy in the preceding eight weeks. Pyrolysis mass spectrometry identified two clusters of isolates, representing two strains of C. difficile. There was marked spatial clustering of these strains, with each confined to a separate area of the hospital. Infection control measures and an antibiotic policy were introduced. Throughout the outbreak period the use of the most frequently used cephalosporin in the hospital increased; this was accompanied paradoxically by a reduction in the number of new cases of CDAD.

Child fatality associated with pathological features of histiocytic necrotizing lymphadenitis (Kikuchi-Fujimoto disease)

We report a case of histiocytic necrotizing lymphadenitis without granulocytic infiltration (Kikuchi-Fujimoto disease), diagnosed at necropsy in a 19-month-old child dying unexpectedly after a febrile illness. This is the youngest case with this disease that has been thus far reported. It is one of only two reported cases in which the patient died during the acute phase of the illness. Histological findings not unlike those seen in the lymph nodes were present at extranodal sites; this is the first case in which this feature has been described. In keeping with many other reported cases, it was not possible to identify an underlying etiology that might explain the morphologic changes.