NITES, a nocturnal bladder score to aid diagnosis during the transition to older age care.

BACKGROUND: As adults transition to older age, bothersome nocturnal lower urinary tract symptoms (LUTS) become common. There is need for a reliable assessment metric to detect and measure specific symptoms. OBJECTIVE: To subject the nocturnal LUTS score for older individuals, Nocturia, Incontinence, Toileting and Enuresis Symptom Score (NITES), to psychometric analysis. MATERIAL AND METHODS: Factor analysis of the metric was conducted with completed questionnaires from 151 older individuals who were either admitted to a tertiary hospital or attending an outpatient continence clinic. Test re-test reliability involved 18 older community dwelling individuals attending a Geriatrician clinic completing the metric at two timepoints separated by at least 1 week. Intra-class correlation coefficients were determined for reliability of each factor and item. RESULTS: The NITES metric was completed by 98 hospitalized older individuals and 53 attending a continence clinic (mean age 83.2 years [SD 7.0]). Factor analysis demonstrated that one item had a floor effect and two items had poor endorsement. After test re-test reliability analysis, a further three items were removed: one due to poor correlation between timepoints and two demonstrating inadequate internal consistency. The final NITES metric is comprised of three factors: Sleep 4-items, Incontinence 4-items, and Personal Bother 2-items. A 4-item short form for symptom screening was extracted from the longer measure. CONCLUSION: The final NITES metric is a 10-item questionnaire with an embedded 4-item short symptom screen. It has utility utilized to detect nocturnal bladder symptoms in both community dwelling and hospitalized older adults.

Characteristics of geriatric rehabilitation inpatients with nocturia: RESORT.

INTRODUCTION: Nocturnal lower urinary tract symptoms (nLUTS) are common in geriatric rehabiliation inpatients but have not been well described. The aim of this study was to compare patient characteristics stratified by self-reported nocturia severity in geriatric rehabilitation inpatients. METHODS: The REStORing health of acutely unwell adulTs (RESORT) is an observational, longitudinal, prospective inception cohort of geriatric rehabilitation inpatients who underwent a Comprehensive Geriatric Assessment (CGA) at admission and discharge. Nocturia was captured by item 7 of the American Urology Association Symptom Score (AUASS) and dichotomised as ≤1 void and >1 void at night as per the International Continence Society definition. Differences in demographic, functional and medical characteristics of the inpatients with and without nocturia >1 were compared. RESULTS: Overall, 641 inpatients completed the nocturia item (mean age 82.6 (SD 7.7) years, 59.9% female). Nocturia occurred > once per night in 57.4%; mean number of episodes was 1.96 (SD 1.38), ranging from 0-5. There was no change in nocturia severity between admission and discharge. Daily urinary incontinence, urinary urgency and comorbid illness were independently associated with multiple nocturia episodes. A history of falls within the last year, difficulty climbing stairs pre-admission, higher faecal incontinence score, impaired quality of life domains, higher levels of anxiety and depression were significantly more common in inpatients with multiple episodes of nocturia compared to no or only one episode of nocturia Conclusion: Bladder symptoms, poor functional status and frailty markers were associated with repeated episodes of nocturia. Targeted intervention may reduce the severity of nocturia, with potential to improve sleep quality, impact therapeutic gains and influence discharge destination.

The Bladder at Night during Hospitalisation: Towards optimal care for elderly patients with nocturia.

OBJECTIVE: This study aimed to describe the characteristics of nocturia in older hospitalised patients and to explore knowledge, beliefs and experiences associated with night toileting while in hospital in order to identify unmet care needs. METHODS: A multisite mixed methods cross-sectional study of older hospitalised adults who were admitted for ≥2 days was conducted using a standardised researcher-administered questionnaire. An additional cohort 16 older hospitalised adults with nocturia >twice per night were interviewed to understand the experience and impact of nocturia during hospitalisation. RESULTS: Nocturia was experienced by 260 out of 308 participants. In-hospital nocturia was significantly correlated with nocturia in the month preceding admission, high diurnal voiding frequency and nocturnal urinary urgency. Bother was attributed to multiple nocturia episodes. Participants had poor knowledge and understanding of nocturia and believed the symptom to be a normal occurrence; only 20% had discussed management with staff. Disrupted sleep and fear of falling were common in older immobile participants with nocturia. CONCLUSION: Nocturia is highly prevalent in hospitalised older people. Toileting multiple times at night bothers patients, disrupts sleep, heightens a fear of falling yet is rarely addressed in ward management plans. A screening process to identify, assess, provide education and intervene for nocturia has the potential to improve wellbeing, safety at night and to address risk factors.

Nocturnal voiding frequency does not describe nocturia-related bother.

AIM: Nocturia frequency has been used as a measure of treatment efficacy for nocturia even though fluctuation of the symptom over time has been well described in the literature. Additionally, given the multifactorial causal pathway and clinically relevant comorbidities, frequency alone may be an insufficient marker of treatment direction. The aim of this study was to investigate factors associated with nocturia-related bother to identify additional variables that may capture the impact of nocturia, direct clinical care and have potential to quantify treatment outcome. METHODS: Prospective data from tertiary hospital Urology and Continence cohorts were matched for identical variables to generate a sample of 204 datasets. Descriptive statistics were obtained to describe the two cohorts. Characteristics of patients were evaluated across levels of nocturia frequency and nocturia-related bother using nonparametric methods; statistically significant differences between groups in each cohort were established. RESULTS: Nocturia frequency alone does not comprehensively reflect attributable bother. Five sleep variables (poor quality sleep, short time to first awakening to void, less than 7 hours of total sleep, primary sleep latency, and daytime sleepiness) and daily urinary urgency were significantly associated with high nocturia-related bother. Attributable bother, despite high-frequency nocturia, was minimized by male gender, lack of daily urinary urgency and good sleep quality. Poor health status, urinary urgency and sleep latency were associated with nocturia frequency. CONCLUSIONS: Items of importance to individuals with nocturia have been identified from patient data. These variables have the potential to sit alongside change in nocturia frequency as potential markers of treatment response.

TANGO - a screening tool to identify comorbidities on the causal pathway of nocturia.

OBJECTIVES: To develop a robust screening metric for use in identifying non-lower urinary tract comorbidities pertinent to the multidisciplinary assessment of patients with nocturia. METHODS: Variables having a significant risk association with nocturia of greater than once per night were identified. Discriminating items from validated and reliable tools measuring these comorbidities were identified. A self-completed 57-item questionnaire was developed and a medical checklist and pertinent clinical measures added. Pre-determined criteria were applied to retain or remove items in the development of the Short-Form (SF) screening tool. The tool was administered to 252 individuals with nocturia who were attending either a tertiary level Sleep, Continence, Falls or Rehabilitation service for routine care. Data collected were subjected to descriptive analysis; criteria were applied to reduce the number of items. Using pre-determined domains, a nocturia screening metric, entitled TANGO, was generated. The acronym TANGO stands for Targeting the individual's Aetiology of Nocturia to Guide Outcomes. RESULTS: The demographic characteristics of the sample are described, along with item endorsement levels. The statistical and structural framework to justify deleting or retaining of items from the TANGO Long-Form to the SF is presented. The resultant TANGO-SF patient-completed nocturia screening tool is reported. CONCLUSIONS: A novel all-cause diagnostic metric for identifying co-existing morbidities of clinical relevance to nocturia in patients who present across disciplines and medical specialties has been developed. TANGO has the potential to improve practice and smooth inequalities associated with a siloed approach to assessment and subsequent care of patients with nocturia.

Nocturia as a marker of poor health: Causal associations to inform care.

AIMS: Nocturia is a common symptom of many conditions and is encountered in patients presenting to services across different medical specialities and health disciplines. The causal pathway of nocturia is multi-factorial and differs between patients. There is currently no symptom-specific clinical algorithm for all-cause diagnosis of nocturia. The aim of this study was to investigate the interrelationships between causes of nocturia in order to inform the development of a comprehensive multidisciplinary assessment metric. METHODS: A PubMed search that identified studies reporting relationships between nocturia and a priori aetiological factors was conducted by cross referencing the term "nocturia" with "polyuria, postural hypotension, hypertension, cardiac function, heart failure, depression, anxiety, polypharmacy, sleep disturbance, sleep disorder, apnoea, and lower urinary tract symptoms." Directed acyclic graphs (DAGS) were constructed to visually represent causal assumptions and to identify underlying relationships. RESULTS: This study confirmed that causality of nocturia can be expressed in a directed acyclic graph, with the key variables being cardiovascular dysfunction, polyuria, sleep disturbance, mental health, metabolic and inflammatory changes, health status and lower urinary tract symptoms. None of the variables were independently a sufficient or necessary direct cause of nocturia and multiple backdoor pathways exist to nocturnal voiding. Polypharmacy, increasing age and BMI all have confounding effects. CONCLUSIONS: There are significant interactions between voiding at night and metabolic, cardiovascular, hormonal, mental health, sleep and inflammatory changes that flag nocturia as a likely marker of co-morbid poor health. Patients should be comprehensively evaluated for all-causes of nocturia since multiple aetiologies commonly co-exist. Neurourol. Urodynam. 36:697-705, 2017. © 2016 Wiley Periodicals, Inc.

Treatment of daytime urinary incontinence: A standardization document from the International Children's Continence Society.

PURPOSE: This article is a standardization document of the International Children's Continence Society (ICCS); it represent a consensus of ICCS on the management of pediatric daytime urine incontinence (DUI). MATERIALS AND METHODS: This document was designed and written by a multi-disciplinary core group of authors appointed by the ICCS' board. RESULTS: Based on evidence of studies and the experience of experts, the treatment guideline of DUI is assembled in this standardization document. Guidelines and the algorithm of management include non-pharmacological treatment (urotherapy), as well as the pharmacological therapy and other modalities that are presented for DUI in general, as along with recommendations for individual conditions. CONCLUSION: The final document is not a systematic literature review. It includes relevant research when available as well as experts' opinion on the current understanding of daytime incontinence in children. This document illustrates that specific treatment of DUI based on an exact diagnosis is effective. The mainstay of treatment is urotherapy, but a combination of treatment modalities is often necessary. Neurourol. Urodynam. 36:43-50, 2017. © 2015 Wiley Periodicals, Inc.

The transition of young adults with lifelong urological needs from pediatric to adult services: An international children's continence society position statement.

INTRODUCTION: Children with urinary tract disorders managed by teams, or individual pediatricians, urologists, nephrologists, gastroenterologists, neurologists, psychologists, and nurses at some point move from child-centered to adult-centered health systems. The actual physical change is referred to as the transfer whilst the process preceding this move constitutes transition of care. Our aims are twofold: to identify management and health-service problems related to children with congenital or acquired urological conditions who advance into adulthood and the clinical implications this has for long-term health and specialist care; and, to understand the issues facing both pediatric and adult-care clinicians and to develop a systems-approach model that meets the needs of young adults, their families and the clinicians working within adult services. METHODS: Information was gleaned from presentations at an International Children's Continence Society meeting with collaboration from the International Continence Society, that discussed problems of transfer and transitioning such children. Several specialists attending this conference finalized this document identifying issues and highlighting ways to ease this transition and transfer of care for both patients and practitioners. RESULTS: The consensus was, urological patients with congenital or other lifelong care needs, are now entering adulthood in larger numbers than previously, necessitating new planning processes for tailored transfer of management. Adult teams must become familiar with new clinical problems in multiple organ systems and anticipate issues provoked by adolescence and physical growth. During this period of transitional care the clinician or team assists young patients to build attitudes, skills and understanding of processes needed to maximize function of their urinary tract-thus taking responsibility for their own healthcare needs. Preparation must also address, negotiating adult health care systems, psychosocial, educational or vocational issues, and mental wellbeing. CONCLUSIONS: Transitioning and transfer of children with major congenital anomalies to clinicians potentially unfamiliar with their conditions requires improved education both for receiving doctors and children's families. Early initiation of the transition process should allow the transference to take place at appropriate times based on the child's development, and environmental and financial factors. Neurourol. Urodynam. 36:811-819, 2017. © 2016 Wiley Periodicals, Inc.

Previously healthy unvaccinated adults have significant functional limitations in the medium and long term after mild COVID-19.

BACKGROUND AND OBJECTIVES: Ongoing symptoms of COVID-19 can persist for weeks or months after the initial COVID-19 infection. The aim of this study was to identify persistent symptoms (fatigue, cognition, quality of life, anxiety, depression and physical measures) in unvaccinated community-managed patients following COVID-19 infection. METHOD: This was a prospective nested observational study of health and wellbeing measures determined seven and 13 months after COVID-19 infection, alongside physical abilities after 18 months. RESULTS: Data analyses were completed on 62 participants (60% female, median age 35 years). Severe fatigue was noted in 47% of participants at seven months and this had not improved significantly by 13 months (45%). Quality of life and mental health scores were significantly worse in individuals with severe fatigue. One-quarter of participants demonstrated mild cognitive impairment at seven months. After 18 months, walking and lung function were normal, but grip strength was reduced in 26% of participants. DISCUSSION: A significant proportion of unvaccinated COVID-19 patients had not returned to pre-illness levels of health and function after one year; screening functional ability and mental wellbeing is warranted in unvaccinated people with COVID-19.

Bladder and bowel dysfunction and the resolution of urinary incontinence with successful management of bowel symptoms in children.

AIM: To investigate the effect of treating defecation problems on urinary incontinence in children suffering from combined urinary bladder and bowel dysfunction (BBD). METHODS: We established a clinical database from medical records of all children referred to the urinary incontinence and gastroenterology outpatient clinics with BBD. The following variables were extracted: symptoms of constipation, faecal incontinence, urinary incontinence, age at onset of symptoms, treatment, including duration and response. All children went through the same treatment protocol. Faecal disorders were treated primarily and once relieved, the daytime incontinence was managed and followed by intervention for nocturnal enuresis. RESULTS: In total, 73 children were included in the study. The treatment regimen resulted in resolution of the defecation disorder in 96% of the patients. Of the children with daytime urinary incontinence, 68% had at least a 50% reduction in number of daytime incontinence episodes by successful relief of bowel dysfunction and 27% became completely continent during daytime. Only 17% of the children suffering from enuresis had a significant reduction in number of wet nights after relief of their faecal problem. CONCLUSION: The empirical treatment approach of managing bowel symptoms before intervening for bladder dysfunction in children with BBD is found to be appropriate.

Pediatric incontinence questionnaire (PINQ): translation and transcultural adaptation to Brazilian Portuguese.

OBJECTIVE: Lower urinary tract symptoms (LUTS) affect approximately 10% of children worldwide and are related to psychosocial manifestations and compromised quality of life, both for children and their families. The assessment of emotional conditions of LUTS in children is recommended by International Children's Continence Society; however, there is no specific instrument in the Brazilian Portuguese language. Therefore, the aim of this study was to translate, culturally adapt and assess the internal consistency of the Brazilian Portuguese version of the Pediatric Incontinence Questionnaire (PINQ). MATERIAL AND METHODS: This cross-sectional study was performed at two referral centers for childhood voiding dysfunction. The 20-item PINQ was translated into Brazilian Portuguese and culturally adapted according to Beaton, 2000. His-standard methodology consists of 6 phases: translation, synthesis, back-translation, expert committee, and pre-test. The internal consistency was assessed using Cronbach's alpha. RESULTS: The PINQ-br version was developed, validated by a committee of experts, and pre-tested on 44 children diagnosed with lower urinary tract symptoms, 23 boys and 21 girls (mean age: 9.7 and 9.6 years old respectively), as well as on their parents. The internal consistency was considered satisfactory, reaching Cronbach's alpha coefficient of 0.74 when applied to children and 0.82 when applied to parents. CONCLUSIONS: The PINQ was translated and culturally adapted to Brazilian Portuguese to assess the impact of LUTS on the health-related quality of life in Brazilian children and adolescents.

Tailoring treatment of monosymptomatic nocturnal enuresis: the role of maximum voided capacity.

PURPOSE: We evaluated bladder reservoir function in children with monosymptomatic nocturnal enuresis with and without response to desmopressin, and assessed the importance of first morning voiding when defining maximum voided volume. MATERIALS AND METHODS: A total of 238 patients 5 to 15 years old with monosymptomatic nocturnal enuresis completed 2 weeks of enuresis recordings and 4 days of frequency-volume charts. Of the patients 186 completed subsequent home recordings during titration with desmopressin. Maximum voided volumes with and without the first morning void were calculated. Desmopressin response was defined as greater than 50% reduction in wet nights. Maximum voided volume with and without first morning voiding was evaluated as a prognostic factor for desmopressin response. RESULTS: Mean ± SD maximum voided volume without first morning void was comparable between desmopressin responders and nonresponders (230.5 ± 69.3 ml and 219.0 ± 84.8 ml, respectively, p = 0.391). Inclusion of the first morning void demonstrated responders to have significantly larger values than nonresponders (mean ± SD 296.0 ± 94.0 ml vs 233.5 ± 90.0 ml, p <0.001). When first morning void was included, desmopressin response was seen in 40% of patients with voided volumes of 65% expected volume for age vs 10% of patients with volumes less than 65% expected volume for age. CONCLUSIONS: Maximum voided volume can be used as a predictor of desmopressin response only if first morning voids are taken into consideration. All patients with monosymptomatic nocturnal enuresis should receive clear instructions to include this measure when completing frequency-volume charts.

Effect of indomethacin on desmopressin resistant nocturnal polyuria and nocturnal enuresis.

PURPOSE: We evaluated the acute effect of indomethacin on renal water and solute handling in children with coexisting monosymptomatic nocturnal enuresis and desmopressin resistant nocturnal polyuria, and in healthy controls. MATERIALS AND METHODS: A total of 23 subjects were recruited, consisting of 12 children with monosymptomatic nocturnal enuresis and nocturnal polyuria with partial or no response to desmopressin, and 11 age matched controls. Children completed a 48-hour inpatient study protocol consisting of fractional urine collections and blood samples. Sodium and water intake were standardized. During the second night a dose of 50 mg indomethacin was administered orally before bedtime. Diuresis, urine osmolalities, clearances and fractional excretions were calculated for sodium, potassium, urea, osmoles and solute-free water. Renin, angiotensin II, aldosterone and atrial natriuretic peptide were measured in plasma. Prostaglandin E(2) was measured in urine. RESULTS: Indomethacin markedly decreased the nocturnal sodium, urea and osmotic excretion in children with enuresis and controls. The overall effect on nocturnal urine output was inconsistent in the group with enuresis. Subjects in whom nocturnal diuresis was decreased following administration of indomethacin remained dry. CONCLUSIONS: Prostaglandin inhibition leads to antidiuresis, reducing the amount of sodium, urea and osmotic excretion in children with monosymptomatic nocturnal enuresis and desmopressin resistant nocturnal polyuria. The sodium regulating hormones do not seem to mediate these processes. The overall effect in desmopressin nonresponders with nocturnal polyuria is variable. The extent to which indomethacin can be applied in the treatment of enuresis needs further evaluation.

Wake-up call: 4 out of 5 older hospitalised patients have nocturnal lower urinary tract symptoms.

OBJECTIVE: Nocturnal lower urinary tract symptoms (nLUTS) increase with age, frailty and comorbid systemic illness and affect many older people. The aim of this study was to describe the prevalence of nLUTS in a hospital aged-care sub-acute environment. METHODS: Prospective clinical audit based on semi-structured bedside interviews of older adult patients admitted to a tertiary hospital aged rehabilitation ward over a 7-month period. RESULTS: A total of 147 eligible patients were included in this clinical audit. The prevalence of nLUTS was 80% (76% nocturia; 54% nocturnal urgency; 32% nocturnal enuresis; 51% nocturnal incontinence). The incidence of any nLUTs was 37%. Half the sample reported daytime incontinence, which always co-existed with at least one nLUTS. CONCLUSION: Nocturnal lower urinary tract symptoms are a problem for four out of five older hospitalised patients. This highlights the need to screen for nLUTS early in the hospital admission and for implementation of a multidisciplinary team intervention to decrease morbidity and improve quality of life in this vulnerable population.

Endoscopic assessment of the nasopharynx: an objective score of abnormality to predict the likelihood of malignancy.

OBJECTIVES: We developed an objective endoscopic score of abnormality of the nasopharynx to predict the likelihood of malignancy. METHODS: A score sheet with 44 variables was developed to objectively quantify the bilateral endoscopic assessment of the nasopharynx. Patients scheduled to undergo nasopharyngeal biopsies were recruited. The nasopharynx was assessed endoscopically, photographed, and scored on 44 variables. The scores were compared to the biopsy results, and predictors of malignancy were modeled with regression analysis. The sensitivity and specificity of the novel scoring system were examined. RESULTS: Seventeen patients had carcinoma, and 60 had a benign lesion or no disease. Patients with a nasopharyngeal malignancy scored significantly higher than did patients with a benign lesion or no disease. No patient with a malignant lesion had a score of less than 12. With a receiver operating characteristic curve area of 0.917, the score demonstrated an excellent ability to discriminate between nasopharynges that were likely or unlikely to contain malignant disease. Independent predictors for both malignant disease and a score greater than 12 were modeled. CONCLUSIONS: A cutoff score above 12 on the novel objective endoscopic assessment of the nasopharynx measure was highly predictive of possible malignancy.

Toileting-related falls at night in hospitalised patients: The role of nocturia.

OBJECTIVE: The purpose of this study was to describe the prevalence and characteristics of toileting-related falls in hospitalised older people. METHODS: Retrospective analysis of falls related to night-time toileting in patients 60 years or over in a tertiary hospital during a one-year period. RESULTS: Overall 34% of falls were related to toileting with at least 44% of these falls occurring during the night. Toilet-related falls peaked between 11 pm and 1 am, a period that coincides with maximum supine-induced diuresis. Almost half of night falls occurred at the bedside. In 80% of night toileting-related falls, patients were mobilising without the recommended level of assistance. Half of all patients had no strategies for toileting documented in their care plan. CONCLUSION: Findings support screening for nocturia in older inpatients and implementation of strategies to reduce both the need for toileting at night and risk factors for falling.

The role of lower urinary tract symptoms in fall risk assessment tools in hospitals: a review.

A large number of falls in hospitals occur on the way to the toilet. Accordingly, a literature search was conducted in Web of Science, PubMed, Embase, and the Cochrane Library to identify fall risk screening and assessment metrics published between 1980 and 2019 and to study the inclusion of lower urinary tract symptoms (LUTS) and their related parameters in these screening tools. In addition, the literature was searched to explore the relationship between toilet-related falls and LUTS. In total, 23 fall risk scales were selected, from which 11 were applicable for in-hospital patients. In nine of the 11 scales for in-hospital patients, a LUTS or LUTS-related parameter was included. In the 12 risk assessment tools for community-dwelling older people, there were no LUTS included. Frequency, urinary incontinence, and nocturia were mostly reported in the literature as a potential fall risk parameter. It is recommended to create greater awareness of nocturia and other LUTS among caregivers of hospitalized patients to prevent falls.

Does successful treatment of overactive bladder improve co-morbidities in patients with nocturia?

OBJECTIVE: To investigate whether treatment of overactive bladder (OAB), one comorbidity of nocturia, could reduce waking to void and improve other co-existing symptoms. METHODS: A prospective cohort study was conducted at Royal Melbourne Hospital. Participants received 12 weeks of standard treatment, including lifestyle interventions and pharmacotherapy. Outcome measures were nocturia episodes, severity of urinary urgency/incontinence, sleep quality, daytime somnolence, anxiety and depression scores, quality of life and change in blood pressure. RESULTS: Twenty participants completed the study. Nocturia frequency improved by one void per night. Overactive Bladder Symptom Score, sleep quality, first uninterrupted sleep time and systolic blood pressures improved. There were no significant changes in daytime somnolence, mood or quality of life. CONCLUSIONS: In this pilot study, nocturia and other co-morbid dysfunctions appeared to improve when the severity of OAB was reduced. Treatment of OAB co-morbid with nocturia reduces urinary symptoms and may improve sleep parameters and positively impact return to health.

An audit of risk factors for wound infection in patients undergoing coronary artery bypass grafting or valve replacement.

OBJECTIVES: To investigate the epidemiology of surgical site infection in cardiac surgery patients operated on in 2006. DESIGN: Retrospective study of a case-control sample. SETTING: Cardiac surgery unit of a university teaching hospital in Hong Kong. PATIENTS: Cardiac surgery patients with surgical site infection were matched by procedure type, sex, and year of surgery with non-infected patients. MAIN OUTCOME MEASURES: Identification of risk factors for surgical site infection. RESULTS: The infected and non-infected cardiac surgery patients did not differ in age, sex, or smoking history; however, patients with surgical site infection were significantly heavier (mean body mass index, 26.6 vs 23.9 kg/m2, P < 0.046). Almost 41% of the subjects had a history of diabetes mellitus, there being a significantly greater proportion among infected than non-infected patients (53.1% vs 28.1%, P < 0.042). All 37 of the patients without a diagnosis of diabetes had normal (ie < 8 mmol/L) preoperative glucose levels, but 99% of them yielded evidence of subsequent glycaemic dysfunction during or after surgery. Overall, 50% of the patients had a blood transfusion during the operation, with infected patients significantly more likely to have been transfused than the non-infected ones (65.6% vs 34.4%, P < 0.008). CONCLUSIONS: There appears to be a relationship between surgical site infection in cardiac surgery patients and pre-existing (diagnosed and covert) diabetes mellitus and blood transfusion. Future studies should consider these factors in relation to surgical site infections, both in the wider surgical population and from a risk-minimisation perspective.