Emergent Management of Clostridium difficle Infection in a Patient With Chronic Inflammatory Bowel Disease.

Clostridium difficle (C. diff) is a well known cause of infectious diarrhea across hospitals in the developed world. An anaerobic, gram positive rod bacteria, C. diff is part of the normal flora of the human colon; however, alterations to the microbiome can promote proliferation leading to pathogenic behavior. Typical symptoms include watery diarrhea in excess of three or more times a day, for at least two days, and abdominal cramping. While most infections do not lead to long term complications, the two complications that are most deleterious to health are toxic megacolon and bowel perforation. Patients with an inflammatory bowel disease are at a higher risk of complications, and thus need to be managed appropriately. This case presents a 39-year-old male, with pertinent medical history of poorly controlled ulcerative colitis, who presented to general surgery with imaging suggesting rectal perforation secondary to a C. diff infection. Due to the free air visualized in the rectum, the patient was urgently transported to the operating room to undergo a total colectomy and end ileostomy surgery. This case discusses the well-known complication of bowel perforation, in order to raise awareness about the management and guidelines. This case is important and significant as it details the appropriate guidelines and structure to follow amongst this unique, and vulnerable to complications, population in order to manage a potentially devastating manifestation of C. diff.

Assessment of driving-related skills prediction of unsafe driving in older adults in the office setting.

OBJECTIVES: To examine the sensitivity and specificity of the Assessment of Driving-Related Skills (ADReS), a clinical tool recommended by the American Medical Association for identifying potentially unsafe older drivers that includes tests of vision, motor function, and cognition. DESIGN: Cross-sectional observation study. SETTING: Memory assessment outpatient clinic of a university hospital. PARTICIPANTS: Drivers with normal cognition (n = 47) and cognitive impairment (n = 75). MEASUREMENTS: A neurologist completed the ADReS during an office visit. Additional cognitive tests of executive, visuospatial, and visuomotor function were also performed. On a separate day, participants completed a standardized on-road test, assessed by a professional driving instructor using a global safety rating and a quantitative driving score. RESULTS: In this sample of currently active older drivers with and without cognitive impairment, measures of cognition-particularly the Trail-Making Test Part B-were more highly correlated with driving scores than other measures of function. Using recommended scoring procedures, the ADReS had a sensitivity of 0.81 for detecting impaired driving on the road test, with a specificity of 0.32 and an area under the receiver operating characteristic curve (AUC) of 0.57. A logistic regression model that incorporated computerized maze task and Mini-Mental State Examination scores improved overall classification accuracy, yielding a sensitivity of 0.61, a specificity of 0.84, and an AUC of 0.80. CONCLUSION: In its present form, the ADReS has limited utility as an office screen for individuals who should undergo formal driving assessment. Improved scoring methods and screening tests with greater diagnostic accuracy than the ADReS are needed for general office practice.

Road test and naturalistic driving performance in healthy and cognitively impaired older adults: does environment matter?

OBJECTIVES: To relate the standardized road test to video recordings of naturalistic driving in older adults with a range of cognitive impairment. DESIGN: Cross-sectional observational study. SETTING: Academic medical center memory disorders clinic. PARTICIPANTS: One hundred three older drivers (44 healthy, 59 with cognitive impairment) who passed a road test. MEASUREMENTS: Error rate and global ratings of safety (pass with and without recommendations, marginal with restrictions or training, or fail) made by a professional driving instructor. RESULTS: There was fair agreement between global ratings on the road test and naturalistic driving. More errors were detected in the naturalistic environment, but this did not affect global ratings. Error scores between settings were significantly correlated, and the types of errors made were similar. History of crashes corrected for miles driven per week was related to road test error scores but not naturalistic driving error scores. Global cognition (Mini-Mental State Examination) was correlated with road test and naturalistic driving errors. In healthy older adults, younger age was correlated with fewer errors on the road test and more errors in naturalistic driving. CONCLUSION: Road test performance is a reasonable proxy for estimating fitness to drive in older individuals' typical driving environments, but differences between performance assessed using these two methods remain poorly understood and deserve further study.