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Thirty-year-old observations report frequent asymptomatic Clostridium difficile carriage among cystic fibrosis (CF) patients. In this case-control study, we found more carriers among CF patients than controls (47% versus 11%), but most strains carried by CF patients were non-toxigenic (77% versus 17%). Among CF patients, carriers were younger, with more severe pulmonary disease than non-carriers. Strains belonged to multiple PCR-ribotypes, suggesting that these CF patients did not acquire strains from each other.

The objective of this study was to elucidate the relationship between outcomes from carotid endarterectomy (CEA) in patients with and without renal insufficiency. Carotid endarterectomy is one of the most commonly performed vascular procedures. The role of cardiac comorbidity in carotid endarterectomy has been extensively studied. The relationship between renal failure and surgical outcomes has also been studied for both coronary artery bypass grafting and lower extremity occlusive disease. However, the role of renal insufficiency in relationship to decision making regarding surgical intervention for carotid stenosis is not well defined. The authors hypothesized that the outcomes from CEA were negatively influenced by renal dysfunction. A retrospective review was made of consecutive CEAs performed at their institution from 1990 to 1995. Patients were grouped into 2 categories according to their renal function. Group A, 448 patients (90%) with creatinine level 1.8 mg/dL or less, and group B, 49 patients (10%) with creatinine levels more than 1.8 mg/dL. Data from patients on dialysis are presented but were excluded for the purpose of analysis. Included in the study were 497 patients with a mean age of 70 +/-8.9 and 74 +/-8.9 for groups A and B, respectively. Preoperative creatinine was 1.1 (+/-0.25) mg/dL for group A and 2.5 (+/-0.81) mg/dL for group B. Outcomes were as follows: perioperative cardiac events 5.4% vs 28.6%, stroke rates 2.7% vs 2.0%, and mortality rates 0.9% vs 8.2%, for groups A and B, respectively. At 60-month follow-up the stroke rates were 7.6% vs 6.1 %, and the mortality rates 22.8% vs 59.2%, for groups A and B, respectively. While patients with chronic renal insufficiency have no increased risk of perioperative or long-term neurologic events, perioperative and long-term mortality rates are significantly increased. This significant reduction in survival should prompt a more cautious application of CEA in patients with increased creatinine.

Management of the patient with diversion colitis is dependent upon both patient and disease-related factors. Patients in whom diversion is not permanent, who desire stoma closure, and who have an acceptable surgical risk should undergo re-establishment of intestinal continuity. Asymptomatic, high-risk surgical candidates need only undergo periodic, regular endoscopic surveillance of both the functional and nonfunctional large bowel according to currently accepted screening guidelines. Most symptomatic patients in whom the diversion is permanent can be treated successfully with steroid enemas, 5-aminosalicylic acid enemas or suppositories, or short-chain fatty acid enemas. If diversion is permanent, medical treatment is unsuccessful, and symptoms persist, acceptable surgical candidates should undergo resection of the excluded bowel.

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