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To define ranges of plasma specific gravity useful for identifying volume depletion in older adults, plasma specific gravity was measured in 170 young adults (mean age 28 years) and 100 retirees (mean age 81 years), and ranges of values likely to be associated with volume depletion were defined. Subsequently, measurements of plasma specific gravity were made in 68 older emergency room (ER) patients (mean age 74 years), a few of whom had obvious reasons for being hypovolaemic, e.g. dehydrating diarrhoea, and these results were compared to those for the control groups. Ranges for plasma specific gravity useful for identifying volume depletion were designated as possible hypovolaemia (1.0265-1.0279), probable hypovolaemia (1.0280-1.0294), and hypovolaemia (> or = 1.0295). Using these definitions, there were more older ER patients compared to both young and old control group subjects, respectively, with probable hypovolaemia (21% vs. 5% and 8%; p < 0.03) and hypovolaemia (16% vs. 0% and 0%; p < 0.03). This study establishes ranges for plasma specific gravity for young and old adults likely to be associated with hypovolaemia, and shows that based upon measurement of plasma specific gravity, older ER patients may often be hypovolemic even in the absence of obvious fluid-wasting illnesses. Future studies are needed to identify the risk factors for hypovolaemia in ER patients, and more vigorously substantiate the findings of this study.

The insulin-degrading enzyme (IDE) and the multicatalytic proteinase (MCP) can be isolated as components of a cytosolic proteolytic complex. IDE is the primary enzyme involved in cellular degradation of insulin, and insulin has been shown to interact with cytosolic IDE. MCP is believed to be important in non-ubiquitin pathways of cellular protein degradation. Insulin has a dose- and time-dependent inhibitory effect on MCP degradation of N-succinyl-Leu-Leu-Val-Tyr 7-amino-4-methylcoumarin (LLVY), a substrate for MCP. Proinsulin also inhibits LLVY degradation in a dose-dependent manner. The effect of insulin is immediate as measured in a continuously monitored assay of LLVY degradation. Purification of the IDE-MCP complex using a variety of approaches, including affinity and conventional chromatography, retains the insulin effect on LLVY degradation as long as the complex remains intact. After ion-exchange chromatography, which separates IDE and MCP, insulin no longer has an inhibitory effect. Recombination of purified IDE and MCP does not restore the effect of insulin, but inclusion of additional components from the ion-exchange column does. These results support the existence of a functional cytosolic complex that contains IDE and MCP. Insulin interacts with IDE and alters the activity of MCP, suggesting a functional relationship between these two components and a mechanism for an intracellular action of insulin.

The insulin degrading enzyme (IDE) is the first recognized member of a new class of metalloproteinases. Studies on the purification and the properties of this enzyme have led to divergent results and conclusions from different laboratories. The present manuscript suggests that many of the divergent results may be due to the interaction of this enzyme with other proteins as part of a proteolytic complex. IDE co-isolates with the multicatalytic proteinase (MCP) during a wide variety of purification approaches including affinity chromatography and conventional purification approaches. Ion exchange chromatography will partially or completely separate IDE and MCP. The SDS-PAGE protein bands at various purification steps suggest the presence of a cytosolic proteolytic complex containing IDE, MCP and other unidentified components and raise the possibility of a functional interaction among these proteins.

Using a simple and inexpensive intervention, improvement in dryness was apparent by the first week of the study. More importantly, results were achieved by changing staff behavior, rather than residents' behavior.

Background: Occasionally after a rhombic flap has been designed, cut, and undermined, it fails to transpose into the recipient wound as easily as had been anticipated. This problem may have occurred because of unexpected skin tension due to previous surgery near the operative site or improper orientation of the rhombic flap., Objective: The purpose of this work is to show how unexpected restriction in rhombic flap movement can be overcome by using a double Z-plasty to increase tissue length., Methods: A double Z-plasty was incorporated into the rhombic flap design in one patient. The biomechanics of the flap were analyzed, and the modified flap was used in three other patients., Results: The addition of a double Z-plasty increased the movement of the rhombic flap in a predictable fashion in four patients., Conclusion: A double Z-plasty is useful to enhance rhombic flap mobility in certain uncommon situations.

Background: Tissue expansion has become a widely used adjunct in reconstruction of the skin., Objective: To trace the history of the concept of tissue expansion from the ancient to the latest medical literature., Methods: We reviewed the technologic developments in the materials and methods of tissue expansion., Results: Tissue expansion is of clinical importance and can be understood by the biochemical, biomechanical, and histologic features of expanded skin., Conclusion: Tissue expansion is becoming widely used and accepted and its continued use under many circumstances is justified by the experimental and clinical results.

Diarrhea is a common problem among the elderly that can have catastrophic results. Atherosclerosis predisposes older adults to morbid sequelae from dehydration resulting from diarrhea. Deaths related to diarrheal illnesses are recognized among older adults living in the community as well as among those confined to nursing homes. Outbreaks have most often been associated with excess deaths from diarrhea among nursing-home patients. Although most cases of dehydration from diarrhea result from gastrointestinal infections, noninfectious causes of diarrhea related to prescription of laxatives, side effects of medications, and use of enteral feedings are common. Clostridium difficile infection is particularly common among older adults in hospitals and nursing homes, and relapsing disease in these groups may be more frequent than among younger adults. The approach to an elderly patient with diarrhea is to ensure proper hydration using available oral rehydration solutions, proceed with diagnostic tests likely to yield a positive result, avoid the use of harmful antiperistaltic drugs, and provide adequate follow-up of the nutritional state.

Diarrhea is a common problem among residents of long-term care facilities. Although the etiology of many cases of diarrhea will be noninfectious, the approach to managing all patients with diarrhea must include assuring the adequacy of hydration and controlling the spread of infection. The latter issue is especially critical in nursing homes where a large proportion of patients can became ill over a several-day period during an outbreak. Although most outbreaks of diarrhea are viral in origin, bacterial outbreaks can lead to hospitalization and even death. Increasing awareness among physicians and infection control practitioners of the correct approaches to investigating and managing cases of diarrhea among nursing home patients is necessary because the magnitude of this problem will grow as the number of individuals being cared for in long-term care facilities increases.

Background: A large proportion of our World War II patients with skin cancer had been stationed in the Pacific., Objective: Our purpose was to determine whether a statistically greater number of World War II servicemen with skin cancer were stationed in the Pacific than the number stationed in Europe., Methods: In a consecutive survey of 370 World War II servicemen with skin cancer who were stationed abroad, place of service, skin cancer types, skin type, ethnic background, and estimated average hours outdoors per day during their lifetime were determined. The number of veterans stationed in the Pacific and the number stationed in Europe with respect to these data were analyzed with the chi-square test., Results: A statistically significantly greater number of Pacific veterans than Europe veterans had basal cell or squamous cell carcinomas., Conclusion: A few months to a few years of prolonged sun exposure in a high-sun-intensity area may result in skin cancer development many years after exposure.

We describe four patients who developed basal cell carcinoma (BCC) among multiple facial trichoepitheliomas. The only clinical feature that distinguished the carcinomas from the trichoepitheliomas was their larger size in three of the four patients. None of the lesions ulcerated. Whether the BCCs developed independently or by transformation from a trichoepithelioma is uncertain. Mohs micrographic surgery was helpful in revealing the transition from one tumor type to the other so that as much normal tissue as possible could be saved. The literature on the relationship between multiple hereditary trichoepitheliomas and BCCs is reviewed.

Malignancies of the nail unit are relatively uncommon, with squamous cell carcinoma (SCC) representing most of the reported cases. Squamous cell carcinoma of the nail unit, although commonly considered to be a curable malignancy, can and does kill. Review of the literature as well as a personal series confirm that Mohs micrographic surgery is an ideal treatment for periungual and subungual SCCs without osseous involvement. In addition, the anatomy and histology of nail unit SCC, as well as prognostic factors and perioperative evaluation as they relate to performing Mohs micrographic surgery, are reviewed.

Stool specimens obtained from 77 residents of a nursing home were analysed to determine the relationship between colonisation with digoxin-reducing strains of Eubacterium lentum and infection with Clostridium difficile. Patients were categorised according to previous antibiotic treatment, prescription of enteral feedings, and pattern of bowel habits. Colonisation with digoxin-reducing E. lentum was less common in subjects infected with C. difficile, in those treated with antibiotics previously, and in those prescribed enteral feedings. Normal bowel habits were more common in those without C. difficile. The lowest incidence of diarrhoea was seen in patients without C. difficile who were colonised with digoxin-reducing species. This study establishes an inverse relationship between the presence of C. difficile and E. lentum that reduce digoxin which is related to previous treatment with antibiotics and prescription of enteral feedings. Bacterial markers may prove to be a useful tool for predicting clinical disturbances in bowel function.

Objective: To study the prevalence and risk factors for colonization with MRSA at a long-term-care facility., Design: Cross-sectional surveillance culture survey., Setting: A 233-bed university-affiliated long-term-care facility., Measurements: Surveillance cultures for MRSA were performed on patients of two adjacent nursing units and on new admissions to the entire facility over a 4-month period., Results: On the chronic medical unit, where patients known to be colonized had been cohorted, 20 of 38 (52.6%) were colonized vs 3 of 67 (4.5%) on the skilled/intermediate unit (P less than 0.001), suggesting that little intra-facility spread of MRSA occurs. Twenty-four of 55 (43.6%) chronic medical admissions were colonized vs 6 of 63 (9.5%) admitted to the other units (P less than 0.001). Thirteen of 30 (43.3%) admissions were not previously known to be colonized. By univariate analysis, colonized admissions were younger and more often male; had more listed diagnoses, including pressure sores, a previous positive MRSA culture, and urinary incontinence; were more often fed by feeding tube; and had longer durations of hospital stay prior to admission. Logistic regression analysis showed that the most powerful independent predictors of colonization at admission were: a prior positive culture for MRSA (OR 8.8, 95% CI 2.4, 32.4), male sex (OR 8.2, 95% CI 2.3, 29.7), urinary incontinence (OR 3.8, 95% CI 1.4, 10.4), and presence of pressure sores (OR 2.9, 95% CI 0.9, 9.2)., Conclusions: Unrecognized colonization of nursing home residents with MRSA is common, and nursing homes are unwittingly repositories for patients colonized with MRSA following acute hospitalization. Gloving and careful attention to handwashing may limit spread of MRSA within nursing homes, and identification of colonized patients may be facilitated by targeted surveillance cultures of the most debilitated patients at admission.

Insulin degrading enzyme (IDE) is a thiol-dependent metalloendoprotease that is responsible for initiation of cellular insulin degradation. However, its exact mode of action and the factors controlling it are poorly understood. Since IDE is a metal requiring enzyme, we have examined which metal(s) is(are) endogenously associated with it. Using neutron activation analysis, we studied the metal content of a partially purified enzyme from three different tissues: rat skeletal muscle, rat liver, and human placenta. Our results indicate that zinc and manganese are associated with the enzyme with approximately 10 times more zinc as manganese being present. These results suggest that one or both of these two metals are endogenously associated with this enzyme and are a means of controlling the enzyme's activity.

After surgery on the proximal nose, wearing eyeglasses can be difficult and uncomfortable. In addition, pressure on the skin underneath the eyeglass nose pads may modify wound healing. We describe simple techniques using readily available materials and optical devices that either reduce or remove pressure on the nose from eyeglasses.

The evolution of fresh-tissue Mohs micrographic surgery is presented in this article. Special emphasis is given to accepted indications for Mohs micrographic surgery. Reconstructive techniques and certification in Mohs micrographic surgery are discussed.

The association between cigarette smoking and necrosis of flaps and full-thickness grafts was analyzed in 220 patients. Review of a series of 916 flaps and full-thickness grafts revealed 44 patients in whom some degree of tissue necrosis occurred. These patients with necrosis were age and gender matched with 176 controls randomly selected from the remaining 872 patients. Current high-level smokers, that is those smoking one or more packs per day, had necrosis develop approximately three times more frequently than never smokers, low-level smokers (less than one pack per day), or former smokers (95% confidence interval, 1.2 to 8.2). Former smokers (relative risk, 1.4; 95% confidence interval, 0.6 to 3.2) and low-level smokers (relative risk, 1.1; 95% confidence interval, 0.2 to 6.1) were at a negligible increased risk for necrosis that was not significantly different from never smokers. Once tissue necrosis developed, the median percent of the visible flap or graft tissue that necrosed was approximately threefold greater among current smokers (regardless of the number of packs per day smoked) than never smokers.

The effect of training on an observer's ability to detect the misalignment of three points, a hyperacuity, and to resolve a six-line grating was studied in a transfer-of-training design with observers (4 in each of two experiments) who were experienced in making psychophysical judgments of other visual stimuli. The transfer-of-training design enabled us to look for any training-based improvement. Long periods of training produced no statistically significant improvement in performance under any condition. There were small practice-based improvements, but the primary patterns indicated threshold fluctuation rather than improvement. We interpret the results to indicate that the neural mechanisms underlying three-point alignment and grating discrimination, like those for gap bisection (Klein & Levi, 1985), are not malleable to any significant extent.

We describe a technique to rapidly and accurately construct the contact layer of a composite dressing. This technique is simple to perform and is suitable for any open wound. It is especially useful for moderately sized wounds created during extirpation of tumors by Mohs micrographic surgery.

Local skin flap repairs on the cheek are discussed. Anatomic and special considerations are reviewed. Advancement, rotation, and transposition flaps are described.

Clinical observations have suggested that wound healing may be altered in patients treated with systemic isotretinoin. In this study, we examined the effects of systemic isotretinoin on dermal wound healing and connective tissue metabolism in a rabbit ear model. Forty 6-mm punch-biopsy wounds were created in the ears of two control rabbits as well as two experimental animals fed isotretinoin, 4 mg/kg per day. Clinical inspection and histologic examination revealed no difference between the control and isotretinoin-treated rabbits in terms of the time required for complete wound healing or the appearance of the final scar. The tissue removed from the wound site at days 0, 7, 14, and 21 after wounding was subjected to analysis of a collagen production and collagen gene expression. Collagen production, determined by the synthesis of [3H]hydroxyproline after incubation of tissue slices with [3H]proline in vitro or by the measurement of the steady-state levels of types I and III procollagen mRNAs, was not significantly different between the two groups. The results indicate that systemic administration of isotretinoin does not affect collagen synthesis in the rabbit ear model of wound healing.

Fine-needle aspiration is a useful way to determine the presence of squamous-cell carcinoma in enlarged lymph nodes of patients at high risk for metastases. Advantages include a high degree of accuracy, outpatient as well as inpatient availability, and negligible potential for seeding of malignant cells. Cutaneous oncologists should consider using this technique in patients with lymphadenopathy and a previous history of cutaneous squamous cell carcinoma.

An original technique is presented for the closure of circular defects that cannot be closed primarily without undue tension. The technique involves the creation of dog-ear tissue, which is then fully utilized in the closure. The technique involves no sacrifice of normal tissue and results in a relatively short, cosmetically acceptable scar.

Clostridium difficile causes pseudomembranous colitis and is responsible for 20% to 25% of cases of postantibiotic diarrhea. In an earlier study, nursing-home patients with C. difficile infection were noted to have a high mortality rate. Because most of these infected patients had been treated with antibiotics, it was not clear whether this high mortality rate was associated with C. difficile infection or simply with antibiotic treatment. A prospective study was carried out to determine the rate of postantibiotic C. difficile colonization and risk factors for infection in patients in a 233-bed long-term care facility, as well as to determine whether C. difficile infection is associated with increased mortality. During a six-month period 150 courses of antibiotics were prescribed for 108 patients. Stool specimens were collected from 36 (33%) patients following the first course of antibiotic treatment, and 12 (33%) were infected with C. difficile. Risk factors for infection included ward location and stool incontinence. Age, body-mass index less than or equal to 18 kg/m2, and diagnoses of dementia and pressure scores tended to be associated with infection, but not significantly. Early mortality rates did not differ, but 12-month mortality for the infected patients was higher (83% vs 50%, P = .05). Therefore, we conclude that postantibiotic C. difficile infection serves as a marker of death in nursing-home patients, one that can be differentiated from the risk of antibiotic treatment alone. This increased death rate may be related in part to clinically unrecognized pseudomembranous colitis or, alternatively, to absorption of C. difficile toxins or even endotoxin from the gut lumen into the systemic circulation.

In an effort to define the pathological term surgical margins, 11 pathologists were interviewed regarding the meaning of the term margins. In addition, 25 plastic surgeons were queried regarding their decisions based on pathology reports of margins. We found nonuniformity of processing specimens and ambiguity in the use of the term close when describing specimen margins. Among the plastic surgeons there was also variability of opinion regarding handling of patients with pathology reports with close or involved margins and a lack of appreciation of the differences and the meanings of various methods of processing tissue.

Telangiectasias are thought to occur through the release or activation of vasoactive substances under a multitude of conditions. Patients seek therapy for telangiectasias principally because of the unsightly visual appearance. This paper discusses the etiology, histology, and treatment of telangiectasias, emphasizing microsclerotherapy. Specifically, the indication for sclerotherapy, mechanism of action of the various sclerosing agents, microinjection technic, and the advantages and disadvantages of the most commonly used sclerosants, sodium morrhuate, sodium tetradecyl sulfate (Sotradecol), hypertonic saline, hydroxypolyethoxydodecane (polidocanol; Aethoxysklerol), and, Sclerodex (a mixture of dextrose and sodium chloride) are reviewed.

A case is presented of a 31-year-old white man who developed a hemangiosarcoma in the very place where 30 years ago a hemangioma had been treated by radiotherapy. The rarity of such an occurrence is attested to by the fact that only two similar cases were found in the English medical literature.

Adaptation to stroboscopic motion affects the perceived temporal order of two adjacent stimuli presented along the same axis. The extent of shift appears to be independent of the duration of adaptation and under the conditions studied was 3-6 msec in a direction consistent with a cancellation of the motion aftereffect. There was no effect upon the locus of simultaneity when adapting stroboscopic motion was orthogonal to that of the test stimulus.

There are no large studies on long-term treatment of nursing home patients with pressure sores. A 4-year experience of treating 95 nursing home patients on air-fluidized beds was reviewed. Treated patients were elderly (median age 73 years) and neurologically impaired (79% with dementia, cerebral vascular accident, or anoxic encephalopathy). The index pressure sores (deepest truncal sore for each patient) were large (median surface area 35.3 cm2) and commonly located on the sacrum (41%) and trochanters (38%). Only 13 of 95 (14%) index sores healed completely, and only two small sores healed in less than 30 days. No others treated less than 30 days had greater than or equal to 50% reduction in sore surface area. Patients were grouped according to whether or not treatment was less than 30 days, and for those treated greater than or equal to 30 days, according to whether or not greater than or equal to 50% reduction in sore surface area occurred. None of the easily measured patient characteristics examined were associated with longer or more successful treatment. These results indicate that although air-fluidized beds can be used to treat pressure sores successfully, even in severely debilitated nursing home patients, no simple criteria can be used to predict which patients will benefit from this treatment. Because long periods of time are necessary for treatment [median trial length 79 days and 17 of 95 (18%) trials greater than 180 days], substantial patient-care expenditures result.(ABSTRACT TRUNCATED AT 250 WORDS)

Zinc chloride fixative (as described in fixed-tissue Mohs surgery) is useful as a chemical debridement method for osteomyelitic bone. We describe a case of an 86-year-old female with a 67-year history of an osteomyelitic ulcer of the anterior tibia. Previous attempts at surgical extirpation of the bone followed by immediate or delayed repair by orthopedic and plastic surgery services had eventuated in recurrence of the basic osteomyelitic process. Below-the-knee amputation was recommended as the only alternative to treatment. However, we chose to apply zinc chloride fixative which penetrated the full thickness of cortical bone and revealed a wider and deeper extent of the infectious process than previously recognized. Following removal of the fixed bone, a muscle flap repair followed by split-thickness skin grafting was done by plastic surgery. The patient remains ulcer and symptom free 31 months postoperatively. We feel zinc chloride fixative is useful as an adjunct to other surgical means of extirpation of bone as it is tissue sparing and more accurately determines the extent of involved bone when infected.

During the past decade, Mohs' surgery has been used increasingly, mostly by dermatologists, for the treatment of cutaneous neoplasms, usually basal cell or squamous cell carcinomas. This use has given rise to new developments, both in the technique itself and in basic tumor biology. As more tumors are delineated microscopically in both their histologic and growth patterns, certain concepts are emerging that are important for successful management of skin cancer.

The neck is not a common area for a skin cancer to occur. However, when it does occur and extends deeply, careful extirpation is necessary so that vital structures will be identified and, if possible, preserved. The Mohs surgeon can most accurately determine the true extent of malignancies in this area; the head and neck surgeon can best identify and protect important anatomic structures. Together both physicians can achieve the best chance of cure and lessen the complication rate for patients with selected invasive cutaneous tumors of the neck. Future collaborative efforts will undoubtedly be directed toward complete extirpation of deeper tumors of the neck, especially those of the pharynx, hypopharynx, and trachea.

Sclerotherapy refers to the injection of a material for the purpose of obliterating a blood vessel. During this procedure a small quantity of sclerosing solution may be unintentionally injected into the tissues surrounding the vessel, either by missing the vessel or leakage of sclerosant upon withdrawal of the needle. Occasionally, the sclerosant may be intentionally injected into an extravascular site in the hope of reducing telangiectatic mats (best described as multiple, grouped, extremely fine telangiectatic vessels). The various sclerosants in use appear to vary in their potential to cause necrosis of perivascular tissues as a complication. This study examines the clinical and histologic effects of the intradermal injection of 0.1 ml of 0.25, 0.5, and 1.0% Aethoxysklerol (AES); 0.5% Sotradecol (SOT); and 23.4% hypertonic saline (HS) in rabbit skin. All three agents produced some clinical necrosis with intradermal injection. AES in all three concentrations produced the least clinical necrosis, no histologic necrosis, and resolved faster than SOT or HS.

The Culturette Brand Clostridium difficile test (CDT; Marion Laboratories, Inc., Kansas City, Mo.) is a latex agglutination test for C. difficile. The recent controversy involving the identity of antigens detected by CDT has made decisions on its use difficult. We compared the test results with those of selective culture and stool cytotoxin assays in investigations of two nursing home outbreaks of C. difficile-associated disease in order to formulate usage recommendations. Selective culture for C. difficile identified 27 (19%) of 142 subjects as carriers. CDT and the stool cytotoxin assay identified only 52 and 48% of these carriers, respectively. Compared with the stool cytotoxin assay, CDT had a high sensitivity (92%) and specificity (89%) for the detection of C. difficile disease, but the positive predictive value of the test was only 17% when the prevalence of disease was 2%. We conclude that the CDT should not be used to identify carriers but that it is a sufficiently sensitive and specific screening test for diagnosing C. difficile disease. However, since the positive predictive value of the CDT is low when the prevalence of disease is low, positive test results should be confirmed by the stool cytotoxin assay.

Different local anesthetics have different physicochemical properties that result in different biological effects. Etidocaine (Duranest) is said to be a long-acting anesthetic with a rapid onset of action, properties that are particularly useful in busy office practices in which lengthy operative procedures are performed. Clinical testing confirmed that this anesthetic does, indeed, work in this manner, which makes it a good addition to the varieties of local anesthetics available.

Selection of wound closure materials (sutures, needles, staples, and skin tapes) is presented. The characteristics of commonly used suture materials and needles are discussed as a background for their rational selection and usage. The attributes of staples and sutureless skin closures (skin tapes) are also given and contrasted with those of sutures.

A 63-year old man is presented who developed a ruptured extensor tendon of the hand 3 days following Mohs surgery (fresh tissue technique) for a recurrent squamous-cell carcinoma. Retrospective examination of this case led us to conclude that several different factors (partial tendon laceration, infection, and underlying medical problems) jointly contributed to this complication. These factors are discussed, along with recommendations for management of such cases.

An assessment of the occurrence rate of periungual hyperpigmentation with subungual melanoma (Hutchinson's sign) and periungual hyperpigmentation with other subungual lesions has not been published, although periungual hyperpigmentation with a pigmented streak or other pigmented lesion of the nail has been considered pathognomonic for subungual melanoma for a century. We report a case of minocycline hyperpigmentation presenting as a longitudinal pigmented streak of the nail associated with periungual hyperpigmentation. These pigmentary changes could be mistaken for Hutchinson's sign.

The repair of large defects resulting from ablation of a primary malignancy of the skin requires judicious decision. Failing reasonable surety of extirpation, permitting spontaneous healing, if feasible, is the best cours. Grafting or primary closure that does not require extensive undermining are usually second choices. Flap repair is least desirable, except in instances where immediate function is necessary.

A commercially available radial immunodiffusion assay was used to measure serum alpha-1-antitrypsin levels in stool samples from subjects aged over 60 years as a marker of protein-losing enteropathy. alpha 1-antitrypsin was found in all of 12 patients with colonoscopy-confirmed pseudomembranous colitis, 6 of 14 (43%) patients with Clostridium difficile diarrhoea without pseudomembranes, 6 of 12 (50%) nursing-home patients culture-positive for Cl difficile but negative for its cytotoxin, and none of 15 healthy control subjects. It is concluded that serum protein loss into the gastrointestinal tract can occur as a result of Cl difficile infection, that its presence correlates with the severity of disease, and that it may occur even in the absence of diarrhoea. The diagnosis of protein-losing enteropathy should be considered for all patients with Cl difficile infection, particularly elderly nursing-home patients, in whom the risk of Cl difficile disease and the frequency of severe malnutrition are high.