Search

Recently, the incidence and severity of Clostridium difficile infection (CDI) has increased. In cases of fulminant infection, surgery is a viable therapeutic option but associated with high mortality. We sought to examine factors associated with mortality in a large sample of patients with severe CDI that underwent surgery. A retrospective study was conducted in patients with severe CDI undergoing colectomy. Demographics, risk factors, comorbidities, clinical and laboratory data, and time between admission/diagnosis of CDI and colectomy were collected. Conventional markers of severity were evaluated as predictors of mortality. Sixty-four cases were included for analysis. The overall observed mortality rate was 45.3 per cent. Few conventional markers of severity were significantly associated with mortality. Risk factors that correlated with postsurgical mortality were vasopressor use (odds ratio, 3.08; 95% confidence interval, 1.00 to 9.92) and shorter time between diagnosis and surgery (median time, 2 vs 3 days, P = 0.009). This study suggests that a delay in surgery after diagnosis of severe CDI may improve overall outcomes. The finding regarding timing of surgery is contrary to traditional teaching and may be the result of improved medical treatment and stabilization before surgery. Consideration should be given to the importance of timing of colectomy in fulminant CDI, whereas prospective studies should be conducted to elucidate causal relationships.

Background Our goal was to determine the need for a repeat head CT scan when the initial CT was negative. Study Design Data were collected from January 1, 2002 to December 31, 2008. There were 281 patients admitted to the trauma center with an initial negative head CT, who had a repeat CT during the same hospitalization. Repeat CTs were categorized into negative/negative (NNG) and negative/positive (NPG) groups. Results There were 281 patients who underwent a repeat head CT for changes in neurologic status, persistent symptoms, follow-up, decreased mental status, or suspected bleed. Of these, 241 patients remained negative (NNG) and new abnormal findings were noted in 40 patients (NPG). There were no differences in sex (NNG, 63% males vs NPG, 75% females; p=0.14) or average age (NNG, 51.6 ± 22.5 years vs NPG, 45.2 ± 24.6 years; p=0.07). There was no difference in positive toxicology (NNG, 29% vs NPG, 30%; p=0.94) or mechanism of injury (NNG, 51% motor vehicle crash [MVC] vs NPG, 62% MVC; p=0.18). There was a significant difference in Injury Severity Score (ISS) (NNG, 10.7 ± 8.1 vs NPG, 17.9 ± 11.0; p=0.0002) and initial Glasgow Coma Scale (GCS) (NNG, 12.7 ± 3.5 vs NPG, 10.9 ± 4.2; p=0.006). Patients with an ISS > 15 and who were intubated were associated with an increased odds of having a positive repeat CT scan (odds ratio [OR] 2.6; 95%CI 1.2, 5.5 and OR 3.5; 95% CI, 1.7, 7.3, respectively). Conclusions Patients with a high ISS score and/or those who are intubated have significantly higher odds of having a positive repeat head CT when repeated for follow-up or when clinically warranted.

This article involves the study of a patient with a rare benign schwannoma in the body of the pancreas. After reviewing 39 patient cases previously reported in the literature, a discussion of the schwannoma with regard to clinical presentation, diagnosis, and treatment is examined. A review of the patient's chart was performed along with a review of the literature using a Medline search. Translations were performed whenever necessary. There are 23 reports of 29 patient cases of pancreatic schwannomas in English and European literature and one report of 10 patient cases in the Japanese literature. The mean age was 57.75 years (range 32-89) and the male-to-female (M:F) ratio was 17:23. The mean reported size was 8.79 cm. The lesion was located in the head in 16 patients (40%), the body in 8 patients (20%), the body and tail in 8 patients (20%), the tail in 6 patients (15%), the head and body in 1 patient (2.5%), and the location was not specified in 1 patient (2.5%). Of the English and European patients, 11 out of 30 patients (36.7%) exhibited solid tumors and 14 out of 30 patients (46.7%) exhibited cystic tumors. The majority of the tumors (35 out of 40) were benign, but there were five reported malignancies. There were no deaths or recurrences reported with a follow-up of 18.68 months +/- 24.09 (range 3-108 months). Pancreatic schwannomas are rare, and the preoperative diagnosis is difficult. Intraoperative frozen section can confirm the diagnosis of a benign schwannoma. Enucleation of the tumor from the surrounding parenchyma is recommended, if possible. Patients undergoing resection indicate an excellent long-term prognosis.