Background: Recent reports suggest that Clostridium difficile colitis may be evolving into a more severe disease. During the second half of 2002 we noted an increase in the number of patients with severe C. difficile-associated diarrhea (CDAD) in our institution. We describe cases of CDAD at our institution over a 13-year period and investigate changes in illness severity. Methods: We undertook a retrospective chart review of all cases of CDAD diagnosed at the Centre hospitalier universitaire de Sherbrooke from Jan. 1, 19911, , to Dec. 31, 2003. Because the hospital serves a well-defined population of Quebec, we were also able to calculate population-based incidence during this period. We abstracted data on individual patients from patient charts and from hospital and pharmacy computer databases. We defined cases of CDAD as having a positive C. difficile cytotoxicity assay result, or endoscopic or histopathological evidence of pseudomembranous colitis. A case was considered complicated if one or more of the following was observed: megacolon, perforation, colectomy, shock requiring vasopressor therapy, or death within 30 days after diagnosis. Results: A total of 1721 cases of CDAD were diagnosed during the study period. Interpretation: An epidemic of CDAD with an increased casefatality rate has had important consequences on the elderly population of our region. Our observational data suggest that the equivalence of vancomycin and metronidazole in the treatment of CDAD needs to be questioned. care facilities, which send their specimens to laboratories outside the region. The CHUS laboratory receives nearly all requests for C. difficile toxin assays for residents of Sherbrooke, and about 60% of those for residents in the Estrie region who live outside of Sherbrooke. The same C. difficile toxin B cytotoxin assay was used throughout the study period, using either Vero cells or MRC-5 cells, with readings after 24 and 48 hours of incubation and neutralization with C. difficile antitoxin (Bartels Inc., Issaquah, Wash.). Until mid-1996, the cytotoxin assay was routinely performed on all stool samples received for culture; afterward, it had to be specifically requested. Since the end of 1990, patient records at the CHUS, including those of patients at other institutions whose stool specimens were analyzed at the CHUS laboratory, have been entered into a computer database, with the exception of medical and nursing notes. We chose Jan. 1, 1991, as the start of the observation period because we could from then on identify nearly all cases (both inpatients and outpatients) with a positive cytotoxin assay result through the hospital computerized medical records. In addition, we searched the hospital discharge database for all patients who died or left the hospital with a recorded diagnosis of pseudomembranous colitis, antibiotic-associated colitis or C. difficile colitis.We defined cases of CDAD as those meeting at least one of the following criteria: a positive cytotoxin assay result; endoscopic evidence of pseudomem...

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This brief paper is a first attempt in contrasting La Ceppède's poems and the monstruous "commentaires"in the Théorèmes. Itis found that La Ceppède reverses the expected order of reading, since the commentaries are meant to précède the text itself, by narrowing the possible interprétations and controlling the formulation of meaning.