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A Pulmonologist-led disease management program integrating key elements of care is cost effective and significantly decreases severe exacerbations. Integrated programs should be encouraged for care of frequent exacerbators of asthma and COPD.

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Stoma creation in the obese patient presents technical challenges beyond the usual considerations that surround stoma creation. Both short-term and long-term stoma complication rates are higher in the obese patient. One must always strive to create a protruding well-vascularized stoma while maximizing the potential to restore bowel continuity in the future. This article will discuss the potential complications and difficulties associated with the creation of a stoma in the obese patient. It will also discuss the traditional techniques for creating the stoma and include modifications that may be required in the obese patient. It will cover technical tips that may help to avoid the complications and pitfalls of creating a stoma in the obese patient.KEYWORDS: Colostomy, ileostomy, obesity, parastomal hernia, stoma complication Objectives: On completion of this article, the reader should be able to: (1) summarize the need for colostomy or ileostomy and discuss the optimal construction of the stoma; and (2) summarize the stoma complications and methods for treating and avoiding these in the obese patient.During this time when obesity is at epidemic proportions in the United States and other developed countries, we are often faced with the challenge of creating a stoma in an obese patient. In 2009, the Centers for Disease Control and Prevention reported that only Colorado and the District of Columbia had obesity rates less than 20%. Thirty-three states had an obesity rate greater than 25% and, of these, nine states had an obesity rate greater than 30%.

The purpose of this study was to define clinical and radiographic variables associated with postoperative mortality after urgent colectomy for fulminant Clostridium difficile colitis. Data were obtained regarding patients undergoing colectomy for fulminant C. difficile colitis at two institutions (1997-2005). Univariate analysis of factors predicting 30-day mortality was performed using χ2 and Student's t tests. Multivariable logistic regression was done to include all variables whose P value was < 0.20. Clinical variables analyzed included: age, gender, recent operation, comorbidities, preoperative multisystem organ failure, vasopressors, symptom duration, time to surgery, serum albumin, change in serum albumin, serum creatinine, white blood cell count, and extent of colectomy. Computed tomography variables included: ascites, megacolon, and extent of colitis. Thirty-five patients (mean age 70 years, 46% male) underwent urgent colectomy for C. difficile colitis. The 30-day mortality rate was 45.7 per cent (16/35). The only clinical variable associated with mortality was preoperative multisystem organ failure (non-survivors 9/16 vs survivors: 4/19; P = 0.037). None of the three patients undergoing partial colectomy survived, although the difference in survival versus those undergoing subtotal colectomy was not significant. Patients with fulminant C. difficile colitis undergoing colectomy have a high mortality rate. Preoperative presence of multisystem organ failure was independently predictive of mortality.