No abstract

This paper reviews the pathogenesis and management of Clostridium difficile diarrhoea, in particular the management of recurrent episodes.

In clinical medicine, a balance needs to be struck between reductionism (the view that a system can be fully understood in terms of its isolated parts) and holistic complexity appreciation (the view that the whole may not be discernible from knowledge of its parts). Reductionism, which currently is associated with renaming of old well-established ideas, minimizes the reality of complexity in patients with several diagnoses. Holistic complexity appreciation on the other hand may encourage unscientific assessments. A balance between the two needs to be maintained if the needs of students and patients are to coincide.

SUMMARY The gut hormone response to a breakfast meal was studied in 12 subjects hospitalised for an episode of acute diarrhoea (presumed infective) who were otherwise well and in 13 healthy control subjects. Fasting blood glucose concentrations were low but basal insulin concentrations were raised. Basal concentrations of pancreatic polypeptide and both basal and postprandial responses of motilin, enteroglucagon, and vasoactive intestinal polypeptide (VIP) were also significantly greater than controls. No abnormalities in plasma concentrations of gastrin, gastric inhibitory polypeptide (GIP) or pancreatic glucagon were found. The suggested physiological actions of the raised hormones may be relevant to the pathophysiology of diarrhoea.The acute, spontaneous onset of diarrhoea in a previously healthy individual is generally considered to be the result of an enteritis which may be caused by ingestion of a bacterial toxin, or by direct viral or bacterial infection.' Often the causative agent is not identified and treatment consists of supportive measures only and complete recovery follows within a short period of time.Major abnormalities in water and electrolyte transport exist in infectious diarrhoea owing to raised adenylcyclase and cAMP activity, diminished Na+, K+-ATPase activity, loss of epithelial integrity, rapid transit and disorders of intestinal motility.2 The relative importance of these mechanisms probably varies depending on the aetiology.A number of gut hormones are thought to affect intestinal secretion and motility. The jejunal hormone, motilin, has pronounced effects on gastrointestinal motility,3 affecting the interdigestive migrating complexes.4 Indirect evidence suggests that enteroglucagon is trophic to the mucosa of the small intestine and has the effect of slowing intestinal transit.5In order to ascertain whether motilin and enteroglucagon or any other gut peptide was altered in acute diarrhoea, we measured the plasma concentrations of these peptides in patients with an acute attack of severe transient diarrhoea.

Chickenpox in the United Kingdom, where vaccination is not undertaken, has had a stable epidemiology for decades and is a routine childhood illness. Because of vaccination, chickenpox is now a rarity in the USA. In the UK vaccination is not done because introduction of a routine childhood vaccination might drive up the age at which those who are non-immune get the illness (chickenpox tends to be more severe the older you are), and the incidence of shingles may increase. The United Kingdom is waiting to see what happens in countries where vaccination is routine.