BackgroundThere is currently conflicting evidence surrounding the effects of obesity on postoperative outcomes. Previous studies have found obesity to be associated with adverse events, but others have found no association. The aim of this study was to determine whether increasing body mass index (BMI) is an independent risk factor for development of major postoperative complications.MethodsThis was a multicentre prospective cohort study across the UK and Republic of Ireland. Consecutive patients undergoing elective or emergency gastrointestinal surgery over a 4‐month interval (October–December 2014) were eligible for inclusion. The primary outcome was the 30‐day major complication rate (Clavien–Dindo grade III–V). BMI was grouped according to the World Health Organization classification. Multilevel logistic regression models were used to adjust for patient, operative and hospital‐level effects, creating odds ratios (ORs) and 95 per cent confidence intervals (c.i.).ResultsOf 7965 patients, 2545 (32·0 per cent) were of normal weight, 2673 (33·6 per cent) were overweight and 2747 (34·5 per cent) were obese. Overall, 4925 (61·8 per cent) underwent elective and 3038 (38·1 per cent) emergency operations. The 30‐day major complication rate was 11·4 per cent (908 of 7965). In adjusted models, a significant interaction was found between BMI and diagnosis, with an association seen between BMI and major complications for patients with malignancy (overweight: OR 1·59, 95 per cent c.i. 1·12 to 2·29, P = 0·008; obese: OR 1·91, 1·31 to 2·83, P = 0·002; compared with normal weight) but not benign disease (overweight: OR 0·89, 0·71 to 1·12, P = 0·329; obese: OR 0·84, 0·66 to 1·06, P = 0·147).ConclusionOverweight and obese patients undergoing surgery for gastrointestinal malignancy are at increased risk of major postoperative complications compared with those of normal weight.
Staphylococcus schleiferi is a Gram-positive coccus bacterium first discovered in 1988 that is typically associated with skin and ear infections in dogs, cats and birds. It is infrequently described as a human pathogen. There are, however, emerging reports of S. schleiferi infections in diverse clinical scenarios in humans, particularly in patients with weakened immune systems. S. schleiferi may be underrecognised due to limitations in routine microbiology diagnostic protocols and mislabelling as other Staphylococcus sp. We present a rare case of S. schleiferi diabetic foot osteomyelitis with subsequent bacteraemia in an immunocompromised host.
Background: Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery. Methods: This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and intercentre variation in critical care admission after emergency laparotomy. Results: Of 4529 patients included, 37.8% (n¼1713) underwent planned critical care admissions from theatre. Some 3.1% (n¼86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n¼133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51e19.97) than planned admissions (OR: 2.32, 95% CI: 1.43e3.85). Some 26.7% of patients (n¼1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8e51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n¼10/145) of centres outside the 95% CI. Conclusions: After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.
IntroductionIndividuals with end stage renal disease (ESRD) undergoing renal replacement therapy (RRT) are at increased risk of tuberculosis (TB). Timely identification and treatment of latent TB infection (LTBI) reduces the risk of progression to active disease. Diagnosing LTBI is challenging in ESRD as standard tests, such as the tuberculin skin test (TST) and Interferon Gamma Release Assay (IGRA) are less reliable. Although TB guidelines exist for ESRD they acknowledge a lack of evidence base and are limited in their scope.This study aimed to establish the current LTBI screening and treatment practice in patients of RRT in a central London teaching hospital with the hypothesis that there would be a varied approach with overall low levels of screening.MethodsNew starters on haemodialysis (HD) in the year 2010 were identified from computerised renal databases and information collected on; demographics, renal diagnosis, co-morbidities, dialysis attributes, TB risk factors, screening methods and LTBI treatment. All patients were followed for a period of 5 years to establish the rate of active TB after commencing RRT. Screening was considered to have taken place if any of the following were performed irrespective of symptoms of active disease; TST, IGRA, radiography specifically to investigate for TB or documented risk stratification.ResultsOf the 331 eligible patients only 77 (23.2%) received screening. In those who were screened, 13 (16.9%) were diagnosed with active TB equating to an incidence of 3927/100,000, 37 (48.1%) with latent TB and 27 (35.1%) with neither. Risk factor stratification was the commonest modality of LTBI identification although there were a wide variety of approaches. Chemoprophylactic treatment regimes were non-standardised and often based on clinical experience rather than guidelines. Of those with active infection, disease developed most commonly within the first year of starting HD.ConclusionHigh rates of active TB occur mainly within the first year of RRT. There is a lack of a uniform approach to detecting and treating LTBI in this population currently. Risk stratification and the use of immunological tests may offer the most sensitive approach to screening ESRD and within the first year of RRT.
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