BACKGROUND Clostridium difficile infection (CDI) occurs due to a dysbiosis in the colon. The appendix is considered a ‘safe house’ for gut microbiota and may help repopulate gut flora of patients with CDI. AIM To study the impact of prior appendectomy on the severity and outcomes of CDI. METHODS We retrospectively reviewed data of 1580 patients with CDI, admitted to our hospital between 2008 to 2018. Patients were grouped based on the presence or absence of the appendix. The primary aim was to (1) assess all-cause mortality and (2) the severity of CDI. Severity was defined as per the Infectious Diseases Society of America criteria. Logistic regression, and propensity score analysis using inverse probability of treatment weights (IPTW) was performed. RESULTS Of the 1580 patients, 12.5% had a history of appendectomy. There was no statistical difference in mortality between patients with a prior appendectomy or without (13.7% vs 14%, P = 0.877). However, a history of appendectomy affected the severity of CDI [odds ratio (OR) = 1.32, 95% confidence interval: 1.01-1.75]. On IPTW, this association remained significant (OR = 1.59, P < 0.05). On multivariable analysis of secondary outcomes, prior appendectomy was also associated with toxic megacolon (OR = 5.37, P < 0.05) and colectomy (OR = 2.77, P < 0.05). CONCLUSION Prior appendectomy may affect the severity of CDI, development of toxic megacolon and the eventual need for colectomy. Since treatment of CDI is governed by its severity, stronger antibiotic regimens or earlier use of fecal microbiota transplant may be a viable option for patients with prior appendectomy.

Background: Hyperemesis gravidarum (HG) is the severe form of the nausea & vomiting in pregnancy and is associated with weight loss, ketonemia ,ketonuria ,electrolyte imbalances and profound volume depletion. Increased accumulation of fluid caused by elevated steroid hormones in pregnancy, a shift in pH and change of pH in the gastrointestinal tract could result in the manifestation of subclinical Helicobacter pylori (H. Pylori) infection. We therefore examined whether seropositivity for IgG antibodies to H. Pylori may be related to hyperemesis graviderum. Objective: To determine the association of H-pylori infection in hyperemesis graviderum patients. Methodology: A cross sectional study was conducted in the department of obstetrics and gynaecology, Dhaka medical college hospital from January 2007 to December 2008. Total 82 pregnant patients, 40 were hyperemesis gravidarum patients (Cases, group A) and 42 were normal pregnancy without hyperemesis graviderum (Control, group B) for admission and attending for routine ANC in OPD were selected. Purposive sampling method was followed as per inclusion and exclusion criteria. Evaluation of the patients was based on history, physical examination and investigation. Serum IgG antibody response to H.pylori antigen by ELISA were measured from every patients and analysed for its association with HG.

Background: Denosumab can lead to severe hypocalcemia in patients with underlying risk factors such as vitamin D deficiency, low PTH, hypomagnesemia, and CKD. Denosumab is a monoclonal antibody against RANKL, reducing the activity of osteoclasts and thus reducing the release of calcium in the bloodstream causing hypocalcemia. Hypocalcemia can range from mild to severe symptoms requiring prolonged hospitalization. Medications such as zoledronic acid and Denosumab are known to reduce the occurrence of Skeletal related events (pathological fracture, spinal cord compression, and radiation to bone). For metastatic prostate cancer, about 90% can develop bone metastasis with significant morbidity and mortality [1]. Our patient presented with severe hypocalcemia after denosumab use without any above risk factors. Clinical Case: A 66-year-old male with a medical history of Prostate cancer with Metastasis to chest and bone presented to ER with syncope. Patient-reported poor oral intake, nausea, and vomiting for the last few days. In the ER, the patient was found afebrile, bp 116/76, HR 92, saturating 100% on room air. On examination, the patient was found lethargic, malnourished, foley in place due to chronic urinary retention. The abdomen was soft and non-tender. Laboratory findings were significant for Hb 9.1, Na 133, K3.6, bicarb 21, total calcium (Ca) 4.2, ionized Ca 0.63 and corrected Ca 5.4, magnesium 1.6, phosphorus 2.1, albumin 3.3, ALT 218, AST 229, ALP 1607. Lipase 82, Total bilirubin 1.5, direct bilirubin 0.8. Spot Urinary Ca 0.7, Vitamin D 25 OH 36.9, serum PTH 225 pg/mL. Serum cortisol AM 20.9, BUN 16, and serum Creatinine 1.0. The patient was started on 11g calcium gluconate in 1L dextrose @ 50c/hr and calcitriol 0.25mcg twice daily. Serum Ca level was monitored every 6 hours and reached 6.7. Later was started on Ca carbonate 1250 TID with meals. Finally, after electrolyte correction, the patient clinically improved and was discharged with the plan to follow Calcium at the outpatient clinic. On review of previous labs at the oncology clinic, the patient received Denosumab at his oncologist’s clinic 10 days before this hospital admission, last Ca level from 6 months ago 8.6, the patient was not any vitamin D or Ca supplement. Conclusion: Many case reports have been published on severe hypocalcemia after denosumab usage. Several patients had underlying risk factors such as vitamin D deficiency, osteoblastic lesion, and AKI leading to an additional cause of hypocalcemia. We emphasize careful monitoring of serum Ca levels particularly in the first few weeks of treatment even without significant risk factors for hypocalcemia. References: [1] Metastatic patterns of prostate cancer: an autopsy study of 1,589 patients. Bubendorf L, Schöpfer A, Wagner U, Sauter G, Moch H, Willi N, Gasser TC, Mihatsch MJ. . Hum Pathol. 2000 May; 31(5):578–83

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