Using the STOPBANG questionnaire and other pre-test probability tools to predict OSA in younger, thinner patients referred to a sleep medicine clinic.

BACKGROUND: The STOPBANG questionnaire is used to predict the presence of obstructive sleep apnea (OSA). We sought to assess the performance of the STOPBANG questionnaire in younger, thinner patients referred to a sleep medicine clinic. METHODS: We applied the STOPBANG questionnaire to patients referred for level I polysomnography (PSG) at our sleep center. We calculated likelihood ratios and area under the receiver operator characteristic (AUROC) curve and performed sensitivity analyses. RESULTS: We performed our analysis on 338 patients referred for PSG. Only 17.2% (n = 58) were above age 50 years, and 30.5 and 6.8% had a BMI above 30 and 35 years, respectively. The mean apnea-hypopnea index (AHI) was 12.9 ± 16.4 and 63.9% had an AHI ≥5. The STOPBANG (threshold ≥3) identified 83.1% of patients as high risk for an AHI ≥5, and sensitivity, specificity, positive (PPV), and negative predictive values (NPV) were 83.8, 18.0, 64.4, and 38.0%, respectively. Positive and negative likelihood ratios were poor at 1.02-1.11 and 0.55-0.90, respectively, across AHI thresholds (AHI ≥5, AHI ≥15 and AHI ≥30), and AUROCs were 0.52 (AHI ≥5) and 0.56 (AHI ≥15). Sensitivity analyses adjusting for insomnia, combat deployment, traumatic brain injury, post-traumatic stress disorder, clinically significant OSA (ESS >10 and/or co-morbid disease), and obesity did not significantly alter STOPBANG performance. CONCLUSIONS: In a younger, thinner population with predominantly mild-to-moderate OSA, the STOPBANG Score does not accurately predict the presence of obstructive sleep apnea.

Guillain-Barre Syndrome Associated With COVID-19 Pneumonia-The First Documented Case in a U.S. Military Intensive Care Unit.

Coronavirus disease 2019 (COVID-19) is a significant cause for intensive care unit (ICU) admission worldwide. Most COVID-19 infections are associated with lower respiratory abnormalities but it has been increasingly associated with extra-pulmonary manifestations. Guillain-Barre syndrome (GBS) is a rarely diagnosed but severe disease associated with COVID-19 infection. We describe the diagnostic process behind diagnosing GBS in an elderly male who developed acute-onset quadriparesis and respiratory muscle failure associated with severe COVID-19 pneumonia in a military ICU. A 69-year-old male was admitted to the ICU for acute hypoxemic respiratory failure due to COVID-19 pneumonia. He was subsequently intubated and treated with dexamethasone and remdesivir with improvement. On hospital day 32, the patient was extubated. Three days later, he developed acute, symmetric limb quadriparesis and respiratory muscle failure requiring reintubation. Analysis of his cerebrospinal fluid showed a cytoalbuminologic dissociation, and electromyography/nerve conduction study showed slowed nerve conduction velocity. These findings are consistent with GBS. Blood cultures, serum polymerase chain reaction testing, and clinical symptoms were not suggestive of other common pathogens causing his GBS. The patient's acute GBS in the setting of recent severe COVID-19 infection strongly suggests association between the two entities, as supported by a growing body of case literature. The patient was subjected to intravenous immunoglobulin treatment and was discharged with greatly improved strength in the upper and lower extremities. Our goal in describing this case is to highlight the need for providers to consider, accurately diagnose, and treat GBS as a consequence of severe COVID-19 infection.

Chronic pancreatitis.

Chronic pancreatitis is a progressive fibroinflammatory disease that exists in large-duct (often with intraductal calculi) or small-duct form. In many patients this disease results from a complex mix of environmental (eg, alcohol, cigarettes, and occupational chemicals) and genetic factors (eg, mutation in a trypsin-controlling gene or the cystic fibrosis transmembrane conductance regulator); a few patients have hereditary or autoimmune disease. Pain in the form of recurrent attacks of pancreatitis (representing paralysis of apical exocytosis in acinar cells) or constant and disabling pain is usually the main symptom. Management of the pain is mainly empirical, involving potent analgesics, duct drainage by endoscopic or surgical means, and partial or total pancreatectomy. However, steroids rapidly reduce symptoms in patients with autoimmune pancreatitis, and micronutrient therapy to correct electrophilic stress is emerging as a promising treatment in the other patients. Steatorrhoea, diabetes, local complications, and psychosocial issues associated with the disease are additional therapeutic challenges.

Posttraumatic Stress Disorder Is Associated With a Decrease in Anaerobic Threshold, Oxygen Pulse, and Maximal Oxygen Uptake.

BACKGROUND: Posttraumatic stress disorder (PTSD) has been linked to respiratory symptoms and functional limitations, but the mechanisms leading to this association are poorly defined. RESEARCH QUESTION: What is the relationship between PTSD, lung function, and the cardiopulmonary response to exercise in combat veterans presenting with chronic respiratory symptoms? STUDY DESIGN AND METHODS: This study prospectively enrolled military service members with respiratory symptoms following deployment to southwest Asia. All participants underwent a comprehensive evaluation that included pulmonary function testing and cardiopulmonary exercise testing. Pulmonary function test variables and cardiopulmonary response to exercise were compared in subjects with and without PTSD by using multivariable linear regression to adjust for confounders. RESULTS: A total of 303 participants were included (PTSD, n = 70; non-PTSD, n = 233). Those with PTSD had a greater frequency of current respiratory symptoms. There were no differences in measures for airway disease or lung volumes, but patients with PTSD had a reduction in diffusing capacity that was eliminated following adjustment for differences in hemoglobin levels. Participants with PTSD had a lower anaerobic threshold (23.9 vs 26.4 cc/kg per minute; P = .004), peak oxygen pulse (19.7 vs 18.5 cc/beat; P = .03), and peak oxygen uptake (34.5 vs 38.8 cc/kg per minute; P < .001). No significant difference was observed in gas exchange, respiratory reserve, or effort at peak exercise between participants with and without PTSD. INTERPRETATION: A diagnosis of PTSD was associated with a reduced anaerobic threshold, oxygen pulse, and peak oxygen uptake. This objective reduction in cardiopulmonary work is independent of baseline lung function, was not associated with abnormalities in gas exchange or respiratory reserve, and may be related to deconditioning.

Randomized clinical trial of torsional versus linear mode ultrasonically activated devices for laparoscopic cholecystectomy.

BACKGROUND: Conventional ultrasonically activated devices use linear mode vibration. Torsional mode ultrasonically activated device (TM) that oscillate around an arc have been recently introduced in the hope that the design may result in faster cutting and better hemostasis. METHODS: Patients undergoing elective laparoscopic cholecystectomy were randomized to TM or linear mode ultrasonically activated device (LM). Intraoperative events were recorded. Postoperatively, a sample of suction fluid was analyzed for hemoglobin concentration to calculate intraoperative blood loss. RESULTS: Seventy-five patients were randomized to TM and 76 patients to LM. Median blood loss was 5 (interquartile range (IQR), 1-19.7) ml with TM and 10.5 (IQR, 2.3-23) ml with LM (p = 0.105). The 95% confidence interval for the difference in median operative blood loss was -1.3 to +9.5 ml. Median gallbladder dissection time was similar in both groups (17 (IQR 11-29) minutes for TM vs. 21 (IQR, 12-29) minutes for LM; p = 0.248). Other modalities of hemostasis were required in 14 patients (19%) in the TM group compared with 21 patients (28%) in the LM group. One patient in the LM group developed postoperative hemoperitoneum and required urgent laparoscopic exploration. No patient required blood transfusion or suffered any other significant complication. CONCLUSION: TM has similar effectiveness to LM for laparoscopic cholecystectomy. REGISTRATION NUMBER: ISRCTN87527062 ( http://www.controlled-trials.com ).

The SPINK1 N34S variant is associated with acute pancreatitis.

OBJECTIVE: Acute pancreatitis (AP) is a disease whose pathogenesis remains largely obscure. Genetic research has focussed attention upon the role of the pancreatic protease/protease inhibitor system. The aim of this study was to investigate the prevalence of genetic variants of the trypsin inhibitor, SPINK1, in acute pancreatitis. METHODS: We genotyped 468 patients with AP and 1117 healthy controls for SPINK1 alterations by single-strand conformation polymorphism analysis and by melting curve analysis using fluorescence resonance energy transfer probes. RESULTS: The c.101A>G (p.N34S) variant was detected in 24/936 alleles of patients and in 18/2234 alleles of healthy controls (odds ratio=3.240; 95% confidence interval: 1.766-5.945; P<0.001). In the UK patients, the mean age of patients with N34S was 11.9 years younger compared with N34S negative patients (P=0.023), but this was not apparent in the German patients. Allele frequencies for the c.163C>T (p.P55S) variant did not differ between patients and controls. CONCLUSION: The SPINK1 N34S variant is associated with acute pancreatitis. This supports the importance of premature protease activation in the pathogenesis of AP and suggests that mutated SPINK1 may predispose certain individuals to develop this disease.

Comparison of early outcomes for laparoscopic ventral hernia repair between nonobese and morbidly obese patient populations.

BACKGROUND: Obesity predisposes to incisional herniation and increased the incidence of recurrence after conventional open repair. Only sparse data on the safety and security of laparoscopic ventral hernia repair (LVHR) for morbidly obese patients are available. This study compared the incidence of perioperative complications and early recurrence after LVHR between morbidly obese and non-morbidly obese patients. METHODS: The case records of consecutive patients who underwent LVHR between December 2002 and August 2007 were reviewed. Patients with a body mass index (BMI) lower than 35 kg/m2 were compared with morbidly obesity patients who had a BMI of 35 kg/m2 or higher. RESULTS: The study included 168 patients (87 men) with a median age of 55 years (range, 24-92 years). Two conversions to open repair (1.2%) were performed, both for non-morbidly obese patients. Of the 168 patients, 42 (25%) were morbidly obese (BMI range, 35.0-58.0 kg/m2) and 126 (75%) were non-morbidly obese (BMI range, 15.5-34.9 kg/m2). The groups showed no significant differences in age, gender, number or size of fascial defects, operative time, length of hospital stay, or incidence of perioperative complications. At a median follow-up period of 19 months (range, 6-62 months), 20 patients (12%) had recurrent hernias. The incidence of recurrence was significantly associated with the size of the fascial defect and the size of the mesh, but not with morbid obesity. CONCLUSION: No significant difference in the incidence of perioperative complications or recurrence after LVHR was observed between the morbidly obese patients and the non-morbidly obese patients.

Comparison of torsional and linear mode ultrasonic coagulating shears for sealing veins.

BACKGROUND: Torsional mode ultrasonic coagulating shears are an alternative device to linear mode shears for hemostatic cutting. The aim of this study was to compare the vessel-sealing quality of torsional and linear mode ultrasonic coagulating shears on human veins. MATERIALS AND METHODS: Veins were harvested from 15 patients during varicose vein surgery. Each vessel was sealed and cut by both devices at different sites. The seals were either tested for burst pressure or examined microscopically to compare mural thickness, seal length, and extent of coagulation and lateral thermal effect. RESULTS: For veins 2.0-3.0 mm in diameter, the median burst pressure was higher on seals made with torsional mode shears (245, IQR 161-360 mm Hg vs. 133, IQR 101-165 mm Hg; P = 0.001). Similarly, for veins 3.5-4.5 mm in diameter, the median burst pressure was higher with torsional mode shears (149, IQR 118-212 mm Hg vs. 94, IQR 82-126 mm Hg; P = 0.001). There was no significant difference in the median burst pressure for veins 5.0-6.0 mm in diameter (82, IQR 61-132 mm Hg vs. 76, IQR 40-114 mm Hg; P = 0.268). Seals made with torsional mode shears showed significantly greater seal length (517 +/- 300 microm vs. 316 +/- 147 microm; P = 0.016), more tissue coagulation (467 +/- 197 microm vs. 335 +/- 128 microm; P = 0.015), and greater lateral thermal effect (1479 +/- 340 microm vs. 1116 +/- 253 mum; P < 0.001). CONCLUSION: Torsional mode ultrasonic shears produced more secure seals on veins up to 4.5 mm in diameter. This can be explained by the greater seal length produced by torsional mode shears.

Developing a Mobile Health Application to Assist With Clinic Flow, Documentation, Billing, and Research in a Specialty Clinic.

In specialty clinics, a staff physician is often required to direct patient flow through the clinic and performs all documentation for coding/billing. In response to the workload created by increased patient volume, many specialty clinics have implemented protocols for both disease treatment and coordination of clinic flow. In this article, we review the literature on using mobile technology to assist with patient care, clinic flow, disease treatment, and documentation/billing. We also describe the development and implementation of a mobile application in our pulmonary clinic designed to automate patient flow, assist the physician in documentation/billing, and gather research data including review of initial user data and lessons learned.

The effect of heparin in peripheral intravenous nutrition via a fine-bore midline: a randomised double-blind controlled trial.

BACKGROUND AND AIMS: Peripheral intravenous nutrition (PIVN) delivered via a finebore midline offers a viable alternative to central venous feeding. The major complication is the onset of peripheral vein thrombophlebitis (PVT). Feed additives such as heparin and hydrocortisone have been advocated in its prevention. Concern over the safety of heparin has prevented its widespread use; this study examines its true benefit. METHODS: A randomised, double-blind trial comparing the addition of either, Heparin 1500 units or hydrocortisone 15 mg or a combination of the two to full intravenous nutrition (IVN) (2500 ml, 13 g of nitrogen, 1190 m0sm/k) was performed. All feeds were delivered via a finebore midline inserted via an antecubital fossa vein. Feeding was terminated in the event of complication or cessation of intended nutritional support. RESULTS: One hundred and twenty-three episodes of feeding occurred in 110 patients. The incidence of peripheral vein thrombosis was similar in each group (Heparin 30% (12/41), hydrocortisone 33% (14/42), combination 31% (13/41) chi(2) test P>0.05). There was a significant difference in total catheter survival with the addition of heparin to the feeds, either alone (11 days (SEM 1.79) or in combination with hydrocortisone (11.7 days (SEM 1.39) compared with those receiving only hydrocortisone (6.9 days (SEM 0.73) P=0.002 and 0.030, respectively)). CONCLUSION: When intravenous feeds are delivered in to a peripheral vein via a fine-bore midline, the addition of heparin to the feed extends the total period of feeding attainable.

Reflective testing: what do patients think?

INTRODUCTION: Reflective testing refers to the practice of adding on tests by laboratory staff. Little is known about what patients think of this practice. METHODS: We surveyed patients attending a general practice surgery and patients attending hospital outpatient clinics. We sought their views about the practice of adding on tests and about the information they received from requesting clinicians about their investigations. RESULTS: In both groups of patients, large majorities favoured an approach in which relevant additional tests are performed without consulting the requesting clinician or patient first. Most patients also felt that the requesting clinicians had provided a satisfactory explanation about what tests were to be performed and why. CONCLUSION: Most patients are content to let NHS professionals add on relevant tests if this is felt to be in their interest.

Characterization of malignant pancreatic cystic lesions in the background of chronic pancreatitis.

CONTEXT: Cystic lesions of the pancreas in association with chronic pancreatitis are a diagnostic and therapeutic challenge. OBJECTIVE: The aim of the study was to study clinical and radiological features that may differentiate between benign and malignant cystic lesions of the pancreas and examine the indications for surgery in these patients. DESIGN: Retrospective case note study. PATIENTS: Patients with concomitant cystic lesions of the pancreas and chronic pancreatitis stated in radiology reports between 1995 and 2005. RESULTS: Thirty-one patients were identified with alcohol-related chronic pancreatitis with a median age of 53 years (range: 27-82 years). Eight patients (26%) had deranged liver function tests and four (13%) presented a raised CA 19.9. Radiological features of cystic lesions of the pancreas included median cyst size of 3 cm (range: 0.8-10 cm), solitary cyst in 28 patients (90%) and multi-loculated in 3 patients (10%). Dilatation of the main pancreatic duct was seen in seven cases (23%). Overall, 12 patients (39%) underwent surgery, 13 patients (42%) were managed with radiological follow-up, five patients (16%) were managed conservatively and one patient (3%) was treated with chemotherapy for advanced malignancy. Overall, three cases (10%) of this series had malignant cystic lesions of the pancreas. Malignant cystic lesions of the pancreas are associated with deranged liver function tests, elevated CA 19.9, and are larger solitary cysts on imaging. CONCLUSION: The differentiation between benign and malignant cystic lesions of the pancreas remains a diagnostic challenge, although malignant cysts tend to be solitary and larger. The high prevalence of malignancy merits an aggressive approach to follow-up and early surgical intervention.

Intestinal hypoperfusion contributes to gut barrier failure in severe acute pancreatitis.

Intestinal barrier failure and subsequent bacterial translocation have been implicated in the development of organ dysfunction and septic complications associated with severe acute pancreatitis. Splanchnic hypoperfusion and ischemia/reperfusion injury have been postulated as a cause of increased intestinal permeability. The urinary concentration of intestinal fatty acid binding protein (IFABP) has been shown to be a sensitive marker of intestinal ischemia, with increased levels being associated with ischemia/reperfusion. The aim of the current study was to assess the relationship between excretion of IFABP in urine, gut mucosal barrier failure (intestinal hyperpermeability and systemic exposure to endotoxemia), and clinical severity. Patients with a clinical and biochemical diagnosis of acute pancreatitis were studied within 72 hours of onset of pain. Polyethylene glycol probes of 3350 kDa and 400 kDa were administered enterally, and the ratio of the percentage of retrieval of each probe after renal excretion was used as a measure of intestinal macromolecular permeability. Collected urine was also used to determine the IFABP concentration (IFABP-c) and total IFABP (IFABP-t) excreted over the 24-hour period, using an enzyme-linked immunosorbent assay technique. The systemic inflammatory response was estimated from peak 0 to 72-hour plasma C-reactive protein levels, and systemic exposure to endotoxins was measured using serum IgM endotoxin cytoplasmic antibody (EndoCAb) levels. The severity of the attack was assessed on the basis of the Atlanta criteria. Sixty-one patients with acute pancreatitis (severe in 19) and 12 healthy control subjects were studied. Compared to mild attacks, severe attacks were associated with significantly higher urinary IFABP-c (median 1092 pg/ml vs. 84 pg/ml; P < 0.001) and IFABP-t (median 1.14 microg vs. 0.21 microg; P = 0.003). Furthermore, the control group had significantly lower IFABP-c (median 37 pg/ml; P = 0.029) and IFABP-t (median 0.06 microg; P = 0.005) than patients with mild attacks. IFABP correlated positively with the polyethylene glycol 3350 percentage retrieval (r = 0.50; P < 0.001), CRP (r = 0.51; P < 0.001), and inversely with serum IgM EndoCAb levels (r = -0.32; P = 0.02). The results of this study support the hypothesis that splanchnic hypoperfusion contributes to the loss of intestinal mucosal integrity associated with a severe attack of pancreatitis.

The routine microbiological screening of central venous catheters in home parenteral nutrition patients.

BACKGROUND & AIMS: Catheter-related bloodstream infection (CRBSI) is a major complication for patients receiving home parenteral nutrition (HTPN). Endoluminal sampling techniques allow the diagnosis of CRBSI without catheter removal and may allow the screening of asymptomatic patients. METHODS: Over a 5-year period, patients receiving HTPN were offered screening on a 3 monthly basis. All patients had tunnelled cuffed Hickman lines. All were asymptomatic at the time of screening, which took the form of either endoluminal brushing or quantitative cultures on through-line blood. RESULTS: Thirty-two patients were suitable for inclusion within the study period (10 male, median age 51 (iqr 46-61)) years with 30 of these having a least one screening performed. Four had positive screening results and underwent appropriate treatment. Of the remainder, 12 presented with at least one clinical episode of CRBSI and 14 had neither clinical CRBSI nor a positive screening result. The combined clinical and screening CRBSI rate was 0.39 episodes per catheter year. CONCLUSION: Although routine microbiological catheter screening can detect subclinical infections in HTPN patients the positive rate is low with the majority of patients still presenting clinical. Identification of higher risk patients and appropriate alterations to screening frequency may improve its value further.

The use of a rapid in situ test in the detection of central venous catheter-related bloodstream infection: a prospective study.

BACKGROUND: Acridine orange leukocyte cytospin (AOLC) is a highly sensitive and specific test for the detection of catheter-related bloodstream infection (CRBSI). We evaluated the role of the AOLC test in early detection or exclusion of CRBSI and compared the cost of managing patients with suspected CRBSI. METHODS: On the day of clinical suspicion of CRBSI, blood samples were obtained from the catheters for the AOLC test, and peripheral blood samples were obtained for quantitative blood cultures. Catheters with positive AOLC results were immediately removed for culture and replaced if necessary. Catheters with negative AOLC tests were left in situ. We compared the catheter lifespan in patients with suspected CRBSI who had positive and negative AOLC tests and calculated the cost of using the AOLC test to prevent indiscriminate catheter removal. RESULTS: Fifty patients with suspected CRBSI were tested and prospectively followed up. Catheters were removed in 10 patients (20%) with a positive AOLC test, and CRBSI was confirmed in each case subsequently. Selective removal of catheters based on AOLC tests significantly extended the lifespan of catheters compared with an indiscriminate removal of catheters based on clinical suspicion of CRBSI (median, 24 versus 11 days; p < .0001). The cost of an AOLC test and selective catheter replacement strategy was significantly lower than the cost of routine removal and replacement of catheters (median, pounds sterling 9.53 versus pounds sterling 64.20; p < .0001). CONCLUSION: The AOLC test enables a rapid detection of CRBSI, avoids unnecessary removal of catheters, and provides a cost-efficient management approach in patients with suspected CRBSI.

Long-term follow-up after laparoscopic sleeve gastrectomy: 8-9-year results.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has rapidly gained popularity as a definitive bariatric procedure despite the sparse long-term follow-up data. On the basis of extensive experience with the open Magenstrasse and Mill operation, we began practice of LSG in 2000. The objective of the present study was to analyze 8-9 years of our follow-up data for LSG at a university hospital in the United Kingdom. METHODS: From January 2000 to December 2001, 20 patients underwent LSG. A 32F bougie was used for calibration in all cases. RESULTS: The preoperative median body mass index was 45.8 kg/m(2) (range 35.8-63.7), and 9 patients (45%) were superobese (body mass index ≥ 50 kg/m(2)). For LSG as a definitive bariatric procedure, 8-9-year follow-up data were available for 13 patients. Of the remainder, 4 patients underwent revision surgery and 3 were lost to follow-up after 2 years. For the entire cohort, the median excess weight loss (EWL) was 73% (range 13-105%) at 1 year, 78% (range 22-98%) at 2 years, 73% (range 28-90%) at 3 years, and 68% (range 18-85%) at 8 or 9 years (P = .074). Of the 13 LSG-only patients with 8-9 years of follow-up, 11 (55% of the starting cohort) had >50% EWL at 8 or 9 years. No significant difference was found in the initial body mass index between the LSG-only patients with >50% EWL and others (45.9 kg/m(2), range 35.8-59.4 versus 45.7 kg/m(2), range 38.9-63.7, respectively; P = .70). The LSG-only patients with >50% EWL had a marginally significantly greater EWL at 1 year compared with the others (76%, range 48-103% versus 45%, range 13-99%, respectively; P = .058). CONCLUSION: At 8-9 years of follow-up, 55% of patients had >50% EWL from LSG as a definitive bariatric procedure.

Use of the obesity surgery mortality risk score to predict complications of laparoscopic bariatric surgery.

BACKGROUND: This study aimed to evaluate the role of the Obesity Surgery Mortality Risk Score (OS-MRS) to predict the risk of post-operative adverse events, in addition to death, from any laparoscopic bariatric procedure. METHODS: The OS-MRS was applied to consecutive patients at a single hospital during October 2008-September 2009. The composite end point comprised one or more of the following adverse events: mortality, re-intervention, re-admission to hospital, venous thromboemobolism, or blood transfusion. RESULTS: There were 381 patients (men, 19%). The median age was 43 years (range, 19-67 years), with 42% patients aged ≥45 years. The median weight was 126 kg (75-295 kg) and median BMI 46 kg/m(2) (30-84 kg/m(2)); 37% had BMI ≥50 kg/m(2). Twenty-seven percent of patients had hypertension and 3% had a past history of venous thromboembolism. The OS-MRS classes were A (60.1%), B (35.9%), or C (4.0%). Operations comprised adjustable gastric band (37%), Roux-en-Y gastric bypass (54%), sleeve gastrectomy (8%), or biliopancreatic diversion (1%). Of the operations, 1.6% were revisional procedures. An adverse outcome occurred in 19 patients, with distribution in 3.5% of class A patients, 5.8% of class B, and 20.0% of class C (A vs. B, P = 0.451; A vs. C, P = 0.002; B vs. C, P = 0.025). There was one death: OS-MRS class C. On multivariate analysis, OS-MRS (class C vs. A or B; Odds Ratio [OR], 4; P = 0.050) and type of operation (band vs. bypass or sleeve; OR, 9.2; P = 0.033) were independently predictive of the composite end point. CONCLUSION: OS-MRS and type of the bariatric operation are independently predictive of the risk of post-operative adverse events.