Since publication of the Society for Healthcare Epidemiology of America position paper on Clostridium difficile infection in 1995, significant changes have occurred in the epidemiology and treatment of this infection. C. difficile remains the most important cause of healthcareassociated diarrhea and is increasingly important as a community pathogen. A more virulent strain of C. difficile has been identified and has been responsible for more-severe cases of disease worldwide. Data reporting the decreased effectiveness of metronidazole in the treatment of severe disease have been published. Despite the increasing quantity of data available, areas of controversy still exist. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, and infection control and environmental management.

/pdf/clinical-practice-guidelines-for-clostridium-difficile-meg93r15my.pdf

Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)

Background Zygomycosis is an increasingly emerging life-threatening infection. There is no single comprehensive literature review that describes the epidemiology and outcome of this disease. Methods We reviewed reports of zygomycosis in the English-language literature since 1885 and analyzed 929 eligible cases. We included in the database only those cases for which the underlying condition, the pattern of infection, the surgical and antifungal treatments, and survival were described. Results The mean age of patients was 38.8 years; 65% were male. The prevalence and overall mortality were 36% and 44%, respectively, for diabetes; 19% and 35%, respectively, for no underlying condition; and 17% and 66%, respectively, for malignancy. The most common types of infection were sinus (39%), pulmonary (24%), and cutaneous (19%). Dissemination developed in 23% of cases. Mortality varied with the site of infection: 96% of patients with disseminated disease died, 85% with gastrointestinal infection died, and 76% with pulmonary infection died. The majority of patients with malignancy (92 [60%] of 154) had pulmonary disease, whereas the majority of patients with diabetes (222 [66%] of 337) had sinus disease. Rhinocerebral disease was seen more frequently in patients with diabetes (145 [33%] of 337), compared with patients with malignancy (6 [4%] of 154). Hematogenous dissemination to skin was rare; however, 78 (44%) of 176 cutaneous infections were complicated by deep extension or dissemination. Survival was 3% (8 of 241 patients) for cases that were not treated, 61% (324 of 532) for cases treated with amphotericin B deoxycholate, 57% (51 of 90) for cases treated with surgery alone, and 70% (328 of 470) for cases treated with antifungal therapy and surgery. By multivariate analysis, infection due to Cunninghamella species and disseminated disease were independently associated with increased rates of death (odds ratios, 2.78 and 11.2, respectively). Conclusions Outcome from zygomycosis varies as a function of the underlying condition, site of infection, and use of antifungal therapy.

/pdf/epidemiology-and-outcome-of-zygomycosis-a-review-of-929-5d2xmysi26.pdf

Epidemiology and Outcome of Zygomycosis: A Review of 929 Reported Cases

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.

/pdf/clinical-practice-guidelines-for-clostridium-difficile-4hs0j01jnf.pdf

Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)

Once a rarely used subset of medical treatments, protein therapeutics have increased dramatically in number and frequency of use since the introduction of the first recombinant protein therapeutic--human insulin--25 years ago. Protein therapeutics already have a significant role in almost every field of medicine, but this role is still only in its infancy. This article overviews some of the key characteristics of protein therapeutics, summarizes the more than 130 protein therapeutics used currently and suggests a new classification of these proteins according to their pharmacological action.

Protein therapeutics: a summary and pharmacological classification

This article reviews the pathogenesis, epidemiology, diagnosis, and treatment of this nosocomial and potentially fatal infectious diarrhea, as well as the associated risk factors New treatments include fecal microbiota transplantation for disease that is resistant to vancomycin

http://unmhospitalist.pbworks.com/w/file/fetch/95983922/nejmra1403772.pdf

Clostridium difficile Infection

EDITOR,-We thank Dr Miller for his interest and commentary about our paper on pleomorphic adenomas of the lacrimal gland. We are unable to answer the question of whether the chances of spillage of tumour cells into surrounding tissues is less if the whole of the tumour is removed immediately after biopsy or after an interval of several days. Theoretically, biopsy with frozen section can reduce contact between normal tissue and the biopsy site. Biopsy will be trans-septal, however, whereas excision of lacrimal pleomorphic adenomas should use a lateral orbitotomy approach, so that there is potential for seeding of tumour cells during the surgical manoeuvres. Furthermore, the histopathological differential diagnosis of lacrimal gland lesions is more difficult with frozen section material than with appropriately stained paraffin sections. Thankfully the majority of pleomorphic adenomas can be correctly diagnosed using the clinical and radiological criteria outlined in our paper. In these cases there is no need for a biopsy and the tumour can be removed with an intact capsule. Our recommendation against biopsy of pleomorphic adenomas is based upon the landmark cinicopathological review of Font and Gamel'; a view strengthened by the high rate of recurrence in a large series ofChinese patients,2 many ofwhom were biopsied. With the current follow up intervals, our paper is unable to either confirm, or refute, this issue.

https://bjo.bmj.com/content/bjophthalmol/77/7/465.1.full.pdf

Cautery for lower lid entropion.

Two patients on total parenteral nutrition who developed endophthalmitis secondary to Candida albicans are described. Candidal endophthalmitis as a manifestation of systemic candidiasis is discussed and its early diagnosis by bedside fundal examination in patients at risk is stressed.

https://pmj.bmj.com/content/postgradmedj/63/741/563.full.pdf

Candidal endophthalmitis: a manifestation of systemic candidiasis.

Optical coherence tomography (OCT) is a noninvasive imaging technique that uses low-coherence interferometry to produce depth-resolved imaging. A beam of light is used to scan an area of the eye, say the retina or anterior eye, and interferometrical measurements are obtained by interfering with the backscatter or reflectance from ocular structures with the known reference path of traveling light. This modification of classic Michelson interferometry allows for the generation of structural images of anatomy when using OCT. OCT has become widely adopted in the field of ophthalmology since its introduction in 1991 and has since continually been improved. Until optical coherence tomography angiography (OCT-A), conventional structural OCT images predominantly provided visualization of anatomic changes with low contrast between small blood vessels and tissue within retinal layers. Thus, other imaging modalities such as fluorescein or indocyanine green angiography was generally used to evaluate retinal vasculature and choroidal vasculature, respectively.OCT-A uses the principle of diffractive particle movement of moving red blood cells to determine vessel location through various segments of the eye without the need of any intravascular dyes. OCT-A technology allows for the ability to image flow in the retinal, and choroidal vasculature can be displayed through en face, depth-encoded slabs. These slabs are presented alongside structural OCT B scans. Together, they provide detailed flow imaging of the deep retinal vascular plexus and choriocapillaris, which were not well visualized with previous imaging modalities.It is important to distinguish the differences between Doppler OCT and OCT-A. Although they both use phase information, Doppler OCT quantifies blood flow in larger vessels and measures total retinal blood flow using phase-shift while OCTA analyzes scatter from a static background tissue to create angiograms. History of the development of Ocular Coherence Tomography Optical coherence tomography is the optical equivalent of ultrasound to generate images using time delay and light echo magnitudes. The use of echoes of light to examine biological tissue was originally proposed by Michel Duguay at the ATT it was possible to "see inside biological tissues." The field of Femtosecond optics was further developed by Erich Ippen of the Massachusetts Institute of Technology in the mid-1970s. His group collaborated with Dr. Carmen Puliafito of the Massachusetts Eye and Ear Infirmary, and they studied femtosecond laser effects on the retina and the cornea. Together with S DeSilvestri of Milan, Italy, and R. Margolis and A. Oseroff from the Department of Dermatology at the Massachusetts General Hospital, they further developed Duguay's initial work to "see inside tissues." They initially used lasers at a 625-nm wavelength and later progressed to using longer 1300-nm wavelengths, which allowed the reduction of scattering. The first application of low-coherence interferometry, which was used to measure the axial length of the eye, was reported by Fercher et al. of the Medical University of Vienna, Austria, in 1988. An Electrical Engineering undergraduate, John Apostolopoulos, used low-coherence laser diodes in 1989 to describe the potential ophthalmic applications of this technology, although the sensitivity was limited. The breakthrough came after ongoing research into low-coherence interferometry by David Huang, an MD/Ph.D. student, in 1991. He showed the practical applicability of coherence interferometry using an 800-nm low-coherence laser diode. Higher sensitivities were achieved, which yielded information on eye structures such as the lens and the iris. The first OCT images were demonstrated by David Huang in Science in 1991. Unpublished concepts of a similar system were also demonstrated by Tanno et al. in Japan. Swanson et al. developed the first in vivo retinal images in 1993, and a similar retinal system was demonstrated by Fercher et al. of Vienna. Practical advances were then rapidly made by the MIT group working with Carmen Puliafito and Joel Schuman of the New England Eye Center of the Tufts University School of Medicine in Boston. OCT examination protocols for circumpapillary scanning for the assessment of glaucoma and to assess macular edema were developed by Michael Hee, an expert programmer who used the early Apple Macintosh computers. Michael Hee was largely responsible for the major development in the 1990s, publishing more than 30 papers during his doctorate. His 1997 doctorate thesis, "Optical coherence tomography of the eye," remains a seminal reference work on OCT in ophthalmology. The first OCT atlas was organized by Carmen Puliafito in 1996 (Optical Coherence Tomography of Ocular Diseases, Slack, 1995). The Advanced Ophthalmic Diagnostics (AOD) company set up by C Puliafito, E Swanson, and J Fujimoto in 1992, was acquired by Humphrey Zeiss two years later and went on to develop machines that were introduced into clinical use, the first machine being introduced in 1996. As with many new techniques, clinical adoption by the ophthalmic community was slow in the latter 1990s, with only 180 units in use until 2000. By 2004, the company had developed further machines that were faster and had better resolution images, and by 2004, more than 10 million OCT imaging procedures had been obtained worldwide. OCT has since become a standard of care in the ophthalmic community. OCT imaging is now used in ophthalmology, cardiovascular medicine, dermatology, neurology, gastroenterology, dentistry, otolaryngology, urology, pulmonology, gynecology, and other subspecialties with new applications being found every year.

Optical Coherence Tomography Angiography

The authors report a case of a 72-year-old woman with unilateral, complete, reversible blindness (no light perception) immediately after uncomplicated repair of an orbital floor fracture. In this case, vision loss was reversed with prompt surgical intervention with removal of the orbital floor implant. The authors review the etiology of vision loss after orbital fracture repair and hypothesize as to the cause of blindness in this case. Given the frequency with which orbital fracture repair is performed by a variety of surgical subspecialists, it is imperative for surgeons to be familiar with the ophthalmic complications and be aware of the multiple causes of postoperative vision loss. The authors propose that immediate postoperative assessment of visual function be performed on all patients undergoing orbital fracture repair.

Reversible Blindness Following Orbital Fracture Repair.

Capillary hemangiomas of infancy are the most common benign orbital neoplasms in children. Historically, they have been referred to by many names such as infantile hemangiomas, juvenile hemangiomas, hemangioblastomas, or strawberry nevi. Currently, the universal vocabulary of capillary hemangioma is followed.Initially, these vascular anomalies were classified as angiomas by John Mulliken and Julie Glowacki, as early as 1982: they were thought to be proliferating lesions with an independent life cycle. However, these classifications have undergone several revisions. Capillary hemangiomas have been reclassified as benign vascular neoplasms as per the revised International Society for the study of vascular anomalies (ISSVA). According to this classification, hemangiomas are benign neoplasms which are true tumors that arise de novo and undergo clonal proliferation and growth out of proportion to the patient. These lesions have a predictable life cycle and most often do not require any treatment in the absence of complications. This is in contrast to the other category of vascular malformations which often present at birth, undergo slow growth, and persist into adult life.

Bhupendra C. Patel

Papers

Cautery for lower lid entropion.

Candidal endophthalmitis: a manifestation of systemic candidiasis.

Optical Coherence Tomography Angiography

Reversible Blindness Following Orbital Fracture Repair.

Capillary Infantile Hemangiomas