The incidence and virulence of C. difficile infection are increasing. Antibiotic use and length of hospital stay correlate strongly with infection. Oral or intravenous metronidazole is the recommended first-line therapy, with discontinuation of systemic antibiotics if possible. Forty percent of patients may have a prolonged course and 20% will relapse despite adequate therapy. Fulminant colitis develops in 3-8% of patients; diagnosis can be difficult with diarrhea absent in 20% of the subgroup. Once diagnosed, subtotal colectomy with ileostomy is usually required. In patients with a marked leukocytosis or bandemia, surgery is advisable because the leukocytosis frequently precedes hypotension and the requirement for vasopressor therapy, which carries a poor prognosis.

While cellular therapy has shown promise in the management of traumatic brain injury (TBI), microenvironment interactions between the intracerebral milieu and therapeutic stem cells are poorly understood. We sought to characterize the acute, regional inflammatory response after TBI. Rats underwent a controlled cortical impact (CCI) injury or sham injury, were sacrificed at 6, 12, 24, 48, and 72 hours, and intracerebral fluid (IF) was isolated from the direct injury, penumbral, ipsilateral frontal, contralateral regions. Cortical and hippocampal areas were also isolated. Regional cytokine levels were measured. PMN oxidative burst and marker expression were assessed after incubation with the IF. Immunohistochemistry identified intracerebral CD68+ cells (microglia/macrophages). The pro-inflammatory cytokines IL-1α, IL-1β, IL-6, and TNF-α were significantly elevated after CCI in the injury and penumbral regions. Increases in the same cytokines were localized to the cortex and the hippocampus. Increased PMN expression of CD11b and L-selectin was identified after incubation with injury or penumbral area IF, without change in PMN oxidative burst. CD68+ cells were noted in the direct injury and penumbral areas. The local cerebral milieu in the first 48 hrs after TBI is highly pro-inflammatory. This response is most pronounced in areas at or proximal to the direct injury. The local, acute pro-inflammatory response after TBI may serve as a therapeutic target of early cell therapy or, conversely, may create an unfavorable local milieu, limiting the efficacy of early cellular therapy.

Optimal care of geriatric trauma patients will be based on the well established tenets of trauma resuscitation and injury repair, but with distinct elements that address the physiological and anatomical challenges presented by geriatric patients.

Background Trauma centers are caring for increased proportions of elderly patients. While age and ISS are independently associated with mortality, trauma centers were originally designed to care for seriously injured patients without age-specific guidelines. We hypothesized that elderly patients would have different complication patterns than their younger counterparts. Methods The trauma registry of an ACS-verified level I trauma center was queried for all patients > 14 years of age admitted between 1/2005 and 12/2008. Mechanism, mortality, and complications were evaluated after dividing patients into eight age groups. Results Of the 15,223 patients, 13% were elderly (≥ 65), and 86% were injured via a blunt mechanism. Increasing age correlated with fatality (all ISS scores), end-organ failure and thrombo-embolic complications (DVT and coagulopathy). Analysis revealed a significant breakpoint at 45 years of age for mortality, decubiti and renal failure (all p-values < 0.05). Infectious complications (sepsis, wound infection and abscess) all peaked between 45–65 years old, and then declined with increasing age. Conclusions We document that elderly trauma patients suffer the same complications as their younger counterparts, albeit at a different rate. More importantly, we identified a “breakpoint” of increased risk of complications and mortality at greater than 45 years of age. While the mechanisms behind these observations remain unknown, understanding their unique patterns may allow appropriate allocation of resources and focus research efforts on interventions that should improve outcomes.