Ultrasound diagnosis of Clostridium difficile-associated diarrhea

Clostridium difficile colitis is diagnosed using an immunoassay or polymerase chain reaction (PCR) assay for toxins A/B. Since ultrasound is frequently used as a screening test for hospitalized patients suffering from different abdominal morbidities, we searched for sonographic indicators of C. difficile infection (CDI). In a prospective and blinded case-control study, abdominal ultrasound was performed on hospitalized patients for whom stool samples were sent for C. difficile toxin immunoassay. All patients with positive toxin were included as the case group and patients with negative toxin comprised the control group. Sonographic parameters of both groups were compared. Demographic variables of the 67 patients in the toxin-positive group were similar to those of the 71 patients in the toxin-negative group. The sonographic parameters which were found to be associated with CDI included colonic wall thickening, appearing in 61 (91%) patients of the toxin-positive group versus 15 (21%) patients of the toxin-negative group (p < 0.001), and also internal ring (24 versus 0%, p < 0.001), external ring (15 versus 0%, p < 0.001), ascites (24 versus 10%, p < 0.001), and diminution of large bowel content (16 versus 1%, p < 0.001). Bowel wall thickening had high positive and negative predictive values (0.80 and 0.90, respectively), while the other features had only high positive predictive values (0.7-1.0). Abdominal ultrasound may contribute to the diagnosis of C. difficile colitis in patients developing hospital-acquired diarrhea.

Vitamin D deficiency among physicians: a comparison between hospitalists and community-based physicians

Physicians are indoor workers with low sun exposure. The aim of this study was to compare serum 25-hydroxyvitamin D(25(OH)D) levels among hospitalists and community-based physicians. 25(OH)D levels among hospitalist physicians were significantly lower than those among community-based physicians. Hospitalist physicians should be considered for vitamin D deficiency screening and replacement.

INTRODUCTION

Vitamin D deficiency is now recognized as a widespread phenomenon, even in a sunny, Mediterranean country such as Israel. Physicians may be vulnerable to low vitamin D levels due to long work hours and lack of sun exposure.

METHODS

Forty-three physicians employed in a hospital and 38 physicians who work in the community in Jerusalem were enrolled. Their serum 25(OH)D levels were measured, and a questionnaire was filled to assess the risk of vitamin D deficiency.

RESULTS

Mean serum levels of 25(OH)D among hospitalist physicians were significantly lower than those among community-based physicians (15 ± 6 vs. 19.7 ± 6 ng/ml, respectively; p < 0.00 l). Arab physicians had a lower 25(OH)D level compared to Jewish physicians (18.2 ± 6.6 vs. 11.4 ± 2.7 ng/ml; p < 0.001). After exclusion of Arab physicians from the analysis, 25(OH)D levels remained higher in hospitalist compared to community-based physicians (15.9 ± 6 vs. 20.4 ± 6 ng/ml; p < 0.004). The variables that were significantly linked to low mean serum levels of 25(OH)D were as follows: age, night shifts, daily sun exposure, and ethnic origin.

CONCLUSION

Hospitalist physicians are at greater risk for low vitamin D levels than community-based physicians.

Severe hyponatraemia in elderly hospitalized patients: prevalence, aetiology and outcome

BACKGROUND

Hyponatraemia is the commonest electrolyte disorder in the elderly. Data on severe hyponatraemia and the prevalence of cerebral salt wasting syndrome (CSWS) in elderly hospitalized patients are lacking. We studied the incidence, frequency of various aetiologies, outcome and the possible role of CSWS in severe hyponatraemia in elderly medical patients.

METHODS

A prospective, observational, non-interventional study conducted over a 5-month period in medical wards. Eighty-six patients aged over 65 years with serum sodium levels < or =125 mEq/L were included. All patients were examined by one of the authors, who also evaluated potential contributing factors. Demographic, clinical and outcome data were extracted from the medical records.

RESULTS

The mean age of the patients was 82.1 + 8.7 years. The prevalence of hyponatraemia was 6.2% (8.1% women and 4.0% men (P < 0.001)). There was no increase in incidence of hyponatraemia with age. The leading cause of hyponatraemia was the syndrome of inappropriate antidiuretic hormone secretion (SIADH), whose aetiology could be determined in only 46% of cases. Aetiology was multifactorial in 51% of patients (1.7 aetiological factors per patient). All patients with thiazide-induced hyponatraemia had other contributing factors. Hyperglycaemia and hypoalbuminaemia were predictors of neurological manifestations of hyponatraemia. Overall in-hospital mortality was 19%. Only hypoalbuminaemia was found as an independent risk factor for death. In none of the patients was the hyponatraemia due to CSWS.

CONCLUSION

Severe hyponatraemia in elderly hospitalized medical patients is more frequent in women and of multifactorial aetiology in 50% of cases. It is most commonly caused by SIADH; CSWS is an unlikely cause.

Extreme leukocytosis in the emergency department

BACKGROUND

Extreme leukocytosis in the absence of haematological disease, is a topic about which little is known, although it may be associated with increased mortality among patients admitted to the intensive care department. The significance of extreme leukocytosis in patients presenting to hospital is uncertain.

AIM

To study the correlates and prognostic significance of extreme leukocytosis, in patients admitted to an emergency department.

DESIGN

Observational study.

METHODS

Consecutive adult patients with extreme leukocytosis (>25 x 10(9)/l, n=54) presenting to the emergency department of a university-affiliated hospital were compared to age-matched controls (+/-5 years) with moderate leukocytosis (12-25 x 10(9)/l, n=118) presenting to the same department. Data were collected on demographic features, emergency room findings and hospital course.

RESULTS

Patients with extreme leukocytosis were more likely to suffer from infectious disease (74% vs. 48%, p<0.01), to be hospitalized (100% vs. 80%, p<0.001), and to die (32.1% vs. 12.7%, p<0.01), and had a longer median length of stay (7.5 vs. 4.0 days, p<0.005). There was no significant difference in vital signs between the two groups.

DISCUSSION

In our patients, extreme leukocytosis appeared to be predominantly caused by infectious disease, and was associated with a high case fatality rate. The degree of leukocytosis may provide prognostic information beyond that reflected in traditional vital signs.

Acute liver failure as the sole manifestation of relapsing non-Hodgkin's lymphoma

Acute liver failure due to hepatic involvement by haematological malignancies is very rare, and usually has a rapidly fatal prognosis. We describe the case of a man who was treated for diffuse large B-cell lymphoma, and achieved a complete remission after eight courses of chemotherapy. He then presented with acute liver failure. Transjugular liver biopsy revealed massive infiltration by lymphomatous cells, with extensive necrosis. A CT scan did not show any evidence of extrahepatic lymphoma. The patient recovered from the liver failure following combined immuno-chemotherapy. Recurrence of the disease should be included in the differential diagnosis of patients with haematological malignancies and acute liver failure, even without evidence of extrahepatic involvement.

Increased warfarin sensitivity as an early manifestation of occult prostate cancer with chronic disseminated intravascular coagulation

Increased sensitivity to warfarin anticoagulation is usually attributed to liver disease, vitamin K deficiency, or drug interactions. We describe a patient with unexplained sensitivity to warfarin and mildly elevated prostate-specific antigen levels in whom subsequent developments indicated that warfarin sensitivity was the first manifestation of occult prostatic cancer. A review of all published cases of coagulopathy associated with cancer of the prostate shows that, unlike other solid tumors with secondary disseminated intravascular coagulation (DIC), in prostate cancer increased bleeding is more common than thrombotic phenomena. Chronic DIC due to occult prostate cancer should be included in the differential diagnosis of excessive prothrombin time prolongation in patients receiving anticoagulants.