Wound Infections in Post-bariatric Patients undergoing Body Contouring Abdominoplasty: the Role of Smoking

Background In this prospective study, we followed patients after laparoscopic adjustable gastric banding for morbid obesity who underwent abdominoplasty for body contouring. Our purposes were: 1) to determine if a significant relationship between cigarette smoking and postoperative wound infections existed, 2) the relative risk conferred by cigarettes and 3) a cut-off value for the increased risk. Methods Patients scheduled for body contouring abdominoplasty were considered eligible. We excluded those with ongoing clinical infections, recent antibiotic administration, those within 1 year from their bariatric surgery and those with systemic diseases. Smokers were asked to stop smoking at least 4 weeks before surgery. Results Since November 2004, we recruited 60 patients. Postoperative infections were present in 25% (n = 15) of patients and 86.7% of these (n = 13) were superficial. All except one occurred in smokers (P = 0.0001): 47% of smokers and 3% of nonsmokers developed infections. Significant differences between infections vs infection-free patients were present for the number of cigarettes smoked per day (P < 0.001), years of smoking (P < 0.001), overall estimated cigarettes smoked and the number of pack years (P = 0.001). A cut-off value of ∼62,000 overall estimated cigarettes (8.5 pack years) distinguished between infections vs infection-free patients (6.2% false positives and 7.1% false negatives). Relative risk conferred by smoking was 14 (95% confidence intervals 13.3–16.7). Conclusions The incidence of infections in postbariatric patients undergoing body contouring abdominoplasties is 25%. The relative risk conferred by smoking was 14 and the cut-off value was 62,000 overall cigarettes (8.5 pack years).     

IBD care in Europe: A comparative audit of the inpatient management of Crohn's disease and ulcerative colitis using the national UK IBD audit tool

Background and aimsThe National UK IBD audit tool is an electronic database created to improve the quality and safety of care for IBD patients by auditing individual patient care, service resources and organisation against national standards. We used the National UK IBD audit tool to compare the organisation and process of IBD care between services in Oxford (UK) and Milan (Italy), as a pilot study to evaluate its application outside national boundaries.MethodsClinical and demographic data of patients with CD and UC, consecutively admitted during a 2 month period, were collected and compared between the centres, to each other and to the UK IBD standards obtained by previous audit analyses performed in Oxford in 2006.Results20 and 26 patients with UC were admitted in Oxford and Milan, as well as 21 and 20 patients with CD, respectively. Most admissions in Milan were planned admissions for moderately active treatment-refractory disease. No patient died. Oxford had a higher surgery rate. Endoscopy for UC consisted mainly of colonoscopy in Milan (92%) and flexible sigmoidoscopy in Oxford (64%). In CD, Oxford data revealed a higher use of immununomodulators and CT scan, compared with higher use of bowel ultrasound in Milan. CRP was the preferred biomarker of disease activity. The following areas did not reach the standards set for the 2006 UK IBD Audit: the lack in Milan of IBD specialist nurses and few dietitian visits, as well as little attention to heparin prophylaxis and abdominal radiography in UC. Both sites paid little attention to stool cultures and revealed a high rate of active smokers in CD and little attention to bone protection in steroids users. Since the 2006 audit in Oxford, improvements include IBD specialist nurse visits, dietitian visits, number of active smokers, stool samples, prophylactic heparin, bone protection and nutritional assessment.ConclusionsConsistent procedural differences between Oxford and Milan identified by audits of both UC and CD could be resolved by organisational change, with an improvement in the service. The UK IBD audit tool is an easy instrument to assess the processes and outcomes of care delivery in IBD and can be applied also outside UK.     

Gender-related differences of diabetic patients undergoing percutaneous coronary intervention with drug-eluting stents: A real-life multicenter experience

Background

Gender-based differences in diabetic patients are understudied in the field of percutaneous coronary intervention (PCI) with drug-eluting stents.

Methods

Data were obtained from a multicenter registry of 2420 consecutive patients with diabetes mellitus (DM) who underwent PCI with paclitaxel- or sirolimus-eluting stents between 2003 and 2009. Among them, 679 (28.1%) women were compared to 1741 (71.9%) men in terms of clinical aspects and major adverse cardiac events (MACE), including all-cause death, myocardial infarction (MI) and target lesion revascularization (TLR). Target vessel revascularization (TVR) and any revascularization were also reported.

Results

Women were less numerous, older, used more insulin and showed more tortuous coronary arteries, while men were more frequently smokers and received larger stents. At the median follow-up of 24.3 months (interquartile range 12.3–39.7), MACE, TVR and any revascularization did not significantly differ between females and males (19.9% vs 18.7%, 12.2% vs 13.4%, 14.1% vs 15.1%, respectively). At multivariable analysis of the overall cohort, female gender was not a predictor of MACE (hazard ratio [HR] 1.02, 95% confidence interval [CI] 0.92–2.36, p = 0.11), death (HR 1.04, 95% CI 0.84–1.24, p = 0.86), MI (HR 1.48, 95% CI 0.92–2.36, p = 0.11), and TLR (HR 1.14, 95% CI 0.85–1.52, p = 0.38).

Conclusion

In this registry of diabetic patients treated by drug-eluting stents, women were less represented, older and needed more insulin compared to men who, on the other hand, received larger stents. Gender-related outcomes were similar and female sex did not predict MACE.     

Curative colorectal resections in patients aged 80 years and older: clinical characteristics, morbidity, mortality and risk factors

Background

The management of colorectal cancer in the elderly presents unique challenges. The objective of this study was to determine outcomes following curative colorectal resection in patients aged 80 years and older.

Patients and methods

Study design is retrospective. Data were extracted from the university hospital database and medical records of patients aged 80 years and older operated between April 2004 and December 2009. Intervention was curative colorectal resection. Main outcome measures include postoperative morbidity, mortality and individual risk factors associated with them.

Results

Three hundred fifty-eight patients (43.8 % males, age?=?84?±?3 years) were included; 72.6 % received elective surgery. A significantly higher complication rate and 30 day, 1 year and 4 year mortality were present for emergency operations compared to elective (p?<?0.001). One-year survival was 65.0 % for elective resections and 55.1 % for emergency. At 4 years of follow-up, survival was 49.2 % for the elective vs. 27.6 % for emergency. The American Society of Anesthesiologists (ASA) score is the only factor associated with the 30-day mortality at the multivariate analysis (p?<?0.01), Dukes staging with overall mortality (p?<?0.005), sex and mode of the operation with major complications (p?<?0.05). A limitation of the study is that is retrospective.

Conclusions

The highest mortality rates following colorectal surgery in the elderly are in the early postoperative period, especially for emergency operations and patients with significant comorbidities. However, the 1-year survival following elective curative resection for colorectal cancer approaches 65 %. ASA score and modality of the operation (elective vs. emergency) impacted on postoperative mortality and morbidity and could be used to select patients with more favourable outcomes.     

The risk of false-positive histology according to the reason for colposcopy referral in cervical cancer screening: a blind revision of all histologic lesions found in the NTCC trial

All cervical intraepithelial neoplasia (CIN) diagnoses identified during the New Technologies for Cervical Cancer trial (ISRCTN81678807) were blindly reviewed by 2 pathologists. Original diagnoses based on colposcopy-guided biopsies were compared with those made by the reviewers who had access to all clinical histologic samples (including postsurgical). Cases downgraded from CIN 2+ by the reviewers were considered indicative of unnecessary treatments. The analyses are presented according to the molecular (high-risk human papillomavirus [HPV]) and/or cytologic diagnosis used to refer the women for colposcopy.We reviewed 812 CIN 1 and 364 CIN 2 + diagnoses. The specificity of colposcopy-guided biopsy was 98% and the sensitivity, 84%. The probability of unnecessary treatment was 27% for women with atypical squamous cells of undetermined significance cytologic findings and 8% for women with low-grade squamous intraepithelial lesion or worse, 10% for HPV+ and positive cytologic findings, and 16% for HPV+ alone. The positive predictive value of the first-level screening test was inversely associated with probability of a histologic false-positive result (P = .015).In screening, a low positive predictive value of the colposcopy-referring test may result in unnecessary treatments.     

Isolated sagittal craniosynostosis: definition, classification, and surgical indications

Sagittal craniosynostosis (SC) remains the most common type of synostosis, accounting for about a half of all forms. It would result from a mesenchymal disorder involving the intramembranous ossification of the sagittal suture and leading to its early fusion. No specific data on the etiologic factors are currently available. The premature ossification of the sagittal suture can result in three main types of SC, according to the different segment prevalently involved: anterior, posterior, and complete SC. The diagnosis is easily obtained by clinical examination. However, a radiological work up (3D CT scan) may be necessary to rule out hidden venous or cranial anomalies possibly associated with most severe cases, or for the surgical planning. The most common indication for surgery is the improvement of the cosmetic appearance of the skull, since a cranial deformation may have a significant psychological impact on affected subjects. To relieve from raised intracranial pressure is a further indication to surgery. Although an increased intracranial pressure can be demonstrated in a minority of affected children at diagnosis, indeed, it can present later (usually after the second/third year of life) with chronic symptoms. The role of surgery in the preservation of cognitive functions in scaphocephalic patients does not seem to be relevant, since minor anomalies of the cerebral development associated with SC would occur independently from the cranial shape. On the other hand, the surgical correction may show a protective effect on some visual skills, like the ability to fix and follow, and the fixation shift.