Introduction: Current guidelines strongly advise against testing for cure for recurrent C. diff infection based upon high (15%) false positive rate at 30 days following metronidazole and vancomycin therapy. Post FMT data on C. diff PCR testing is lacking. We aimed to assess the predictive value of early C. diff PCR testing for successful FMT. Methods: All patients undergoing FMT for recurrent or refractory CDI were asked to submit stool for C. diff PCR testing at week 1 and 4, or at any time, if diarrhea reoccurred. Baseline characteristics including age, gender, diagnosis of IBD or IBS, symptom resolution at week 1, 4, and 8, post FMT were recorded. Success of FMT was defined as complete symptom resolution or negative PCR when diarrhea persisted at week 8 without the need of further anti-CDI antibiotic or repeat FMT. Accuracy of C. diff PCR and symptom resolution at week 1 and 4 in predicting FMT success was calculated. Results: Of 99 patients, 72 were females, mean age was 58.2±19.5 years, 19 had IBD, and 6 had IBS. PCR test results were available for 77 patients at week 1 and for 65 patients at week 4. FMT success rate was 85% (n=84). Of these, 80 patients had complete symptom resolution and4 had negative PCR at week 8 while having ongoing diarrhea (2 with IBD and 2 with IBS). Of the 84 FMT successes, 4 were PCR positive and symptom positive at week 1 but subsequently tested negative at week 4. Of 15 FMT failures 11 had positive PCR at week 1 and symptoms that persisted beyond week 1, while 4 were PCR negative and asymptomatic at week 1 but developed diarrhea and tested positive at week 4. The positive and negative predictive value of PCR testing at week 1 was 94% and 64%, and at week 4 was 100% and 70%, respectively. Sub-group analysis of IBD and non-IBD patients is shown in the Table. The rate of positive PCR testing among asymptomatic patients was 0% at week 1 (all 65 patients with symptom resolution at week 1 tested negative; 95% CI: 0%-5.5%) and 0% at week 4 (all 49 patients with symptom resolution at week 4 tested negative; 95% CI: 0%-7.3%). Conclusion:C diff PCR testing at week 4 post FMT provides best accuracy in predicting FMT success Patients with persistent diarrhea beyond week 1 post FMT should undergo PCR testing and if positive, treated with antibiotics or FMT.Figure 1

This consensus statement from the members of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine recommends a standardized method for measuring gastric emptying (GE) by scintigraphy. A low-fat, egg-white meal with imaging at 0, 1, 2, and 4 h after meal ingestion, as described by a published multicenter protocol, provides standardized information about normal and delayed GE. Adoption of this standardized protocol will resolve the lack of uniformity of testing, add reliability and credibility to the results, and improve the clinical utility of the GE test.

Percutaneous endoscopic gastrostomy (PEG) has become the preferred method to provide enteral tube feeding to older adults who have difficulty eating, but the impact of PEG on patient outcomes is poorly understood. The objective of this study was to describe changes in nutrition, functional status, and health-related quality of life among older adults receiving PEG. A prospective cohort study. A small community of approximately 60,000 residents served by two hospital systems. One hundred fifty patients aged 60 and older receiving PEG from one of the four gastroenterologists practicing in the targeted community. Patients were assessed at baseline and every 2 months for 1 year to obtain clinical characteristics, process of care data, physical and cognitive function, subjective health status, nutritional status, complications, and mortality. Over a 14-month period, 150 patients received PEG tubes in the targeted community; the mean age was 78.9. The most frequent indications for the PEG were stroke (40.7%), neurodegenerative disorders (34.7%), and cancer (13.3%). All measures of functional status, cognitive status, severity of illness, comorbidity, and quality of life demonstrated profound and life-threatening impairment; 30-day mortality was 22% and 1-year mortality was 50%. Among patients surviving 60 days or more, at least 70% had no significant improvement in functional, nutritional, or subjective health status. Serious complications were rare, but most patients experienced symptomatic problems that they attributed to the enteral tube feeding. PEG tube feeding in severely and chronically ill older adults can be accomplished safely. However, there are important patient burdens associated with the PEG and there was limited evidence that the procedure improves functional, nutritional, or subjective health status in this cohort of older adults. The issues raised in this descriptive study provide impetus for a randomized trial of PEG tube feeding compared with alternative methods of patient care for older adults with difficulty eating.

To describe clinical decision-making for percutaneous endoscopic gastrostomy from the perspective of patients, caregivers, and physicians. A prospective cohort study. All patients aged 60 and older receiving percutaneous endoscopic gastrostomies in a defined community over a 16-month period. Either patients or their surrogate decision-makers completed a semistructured face-to-face interview to map out the information gathering process, expectations, and discussants involved in the decision to proceed with gastrostomy feeding. Physicians completed a written questionnaire to determine their likelihood of recommending percutaneous endoscopic gastrostomy, their involvement in the decision-making and recommendation process, and sources of perceived pressure in the decision-making. We identified 100 patients who received percutaneous endoscopic gastrostomy during the study window and 82 primary care physicians who provided care in the defined community. The most common reasons for the procedure were stroke, neurologic disease, and cancer. Patients or their surrogate decision-makers reported multiple discussants, incomplete information, and considerable distress in arriving at the decision to proceed with artificial feeding. This distress was usually in the context of an acute and debilitating illness that often overshadowed the decision about artificial feeding. The decision for gastrostomy often appeared to be a "non-decision" in the sense that decision-makers perceived few alternatives. Physicians also reported considerable distress in arriving at recommendations to proceed with percutaneous endoscopic gastrostomy, including perceived pressures from families or other healthcare professionals. Physicians have clear patterns of triage for percutaneous endoscopic gastrostomy, but the assumptions underlying these patterns are not well supported by the medical literature. Patients, caregivers, and physicians are often compelled to make decisions about long-term enteral feeding under tragic circumstances and with incomplete information. Decision-makers typically do not perceive any acceptable alternatives. Because data on these patients' long-term functional outcomes are lacking, decision-makers appear to focus primarily on the short-term safety of the procedure and the potential for improved nutrition.

Ash. In Fraxinus peunsylvanica Marshall the essential structure of the embryonic leaf is revealed by a study of an unswollen leaf bu-id of late March. Each leaflet (fig. I, 2) consists of midrib and conduplicately folded wings. The wings are composed of a limiting layer of small, brick-shaped cells and a mesophyll region of cells of somewhat similar shape and rather indefinitely layered into 5-6 rows. Provascular areas are embedded at intervals in the middle rows. In figure 2 two provascular areas are recognizable. The area which is near the tip of the leaflet shows a cell of the middle mesophyll layer divided horizontally into 2 daughter cells; the other area shows a stage in which spiral protoxylem elements are present. The midrib of the leaflet is composed of a central stelar region containing primary xylem and phloem parenchyma areas, a cortical region, and a limiting epidermal layer. Basswood. In Tilia glabra Ventenat the young leaf throughout its period of development from May until the following February (fig. 3-II) is composed of 5 rows of brick-shaped, densely protoplasmic parenchymatous cells of unifornm size so closely packed together that no intercellular spaces are present. This regular stratified arrangement of cells is broken at intervals by provascular areas in varying degrees of development. Each of these provascular areas arises through the horizontal division of one or more contiguous cells of the middle layer of the mesophyll, thus cutting each mother cell into an upper and lower cell. Such a stage is seen between the first and second major lateral veins in figure io. This first division is followed by other divisions in the mother cells and in adjacent mesophyll cells until very definite areas of irregularly arranged cells are gradually built up. These progressively more complex stages in the development of veins are well illustrated by the provascular areas sketched in figures 6, 4, II (near tip), 7, and 1 Contribution from tlhe Osborn Botanical Laboratory, Yale University, Seessel Fellow. Awarded secondl place, Walker Prize Contest, Boston Society of Natural History