Chest CT findings in asymptomatic cases with COVID-19: a systematic review and meta-analysis.

AIM: To determine the overall rate of chest imaging findings in asymptomatic cases, describe the most common patterns found, and determine the rate of later symptom development in these initially asymptomatic cases. MATERIALS AND METHODS: The PubMed and EMBASE databases were searched until 1 May 2020, for studies examining the proportion of positive chest imaging findings in asymptomatic cases diagnosed with COVID-19 and a random-effects meta-analysis of proportions was performed. Heterogeneity was assessed using the I2 statistic. RESULTS: Among 858 non-duplicate studies, seven studies with a total of 231 asymptomatic cases met the inclusion criteria. In the primary analysis, the pooled estimate of the overall rate of positive chest computed tomography (CT) findings among asymptomatic cases was 63% (95% confidence interval [CI]: 44-78%). Among 155/231 cases that were followed up for later symptom development, 90/155 remained asymptomatic and 65/155 developed symptoms during the study period (that ranged between seven and 30 days of follow-up). The pooled estimate of the rate of positive chest CT findings was 62% (95% CI: 38-81%) in cases that remained asymptomatic, while it was 90% (95% CI: 49-99%) in cases that developed symptoms. Among CT findings, the pooled estimate of the overall rate of ground-glass opacities (GGO) at CT alone was 71% (95% CI: 50-86%). Among other CT findings reported, 22/231 patients had GGO with consolidation, 7/231 patients had stripe shadows with or without GGO, and 8/231 patients had GGO with interlobular septal thickening. Among initially asymptomatic cases with positive CT findings, the pooled estimate of the overall rate of later symptom development was 26% (95% CI: 14-43%). CONCLUSION: In COVID-19, asymptomatic cases can have positive chest CT findings, and COVID-19 should be considered among cases with CT abnormalities even when there are no other symptoms. There is a need for close clinical monitoring of asymptomatic cases with radiographic findings as a significant percentage will develop symptoms.

Cinnamyl Schiff bases: synthesis, cytotoxic effects and antifungal activity of clinical interest.

The aim of this study was to synthesize and investigate the in vitro antifungal properties of 23 cinnamyl Schiff bases. In addition, cytotoxic effects of such cinnamyl Schiff bases against human lung, kidney or red blood cells were also checked. The compounds were synthesized in a single-step, 2 min of reaction under microwave irradiation produced up to 97% yield. Six of the 23 cinnamyl Schiff bases possessed antifungal activities against strains of Candida, Aspergillus, Fonsecaea and, particularly, Cryptococcus species. Indeed, cinnamyl Schiff bases 1 and 23 exhibited minimum inhibitory concentration (MIC) values more than twofold lower than fluconazole (FCZ) against all the Cryptococcus neoformans strains (MIC = 1·33, 1·4 and 5·2 µg ml-1 , respectively) and Cryptococcus gattii strains (MIC = 5·3, 2·8 and 9·2 µg ml-1 , respectively) (12 strains of each species) while cinnamyl Schiff base 11 was as potent as FCZ against all strains from both Cryptococcus species. No significant cytotoxic effects were observed for Schiff bases against human lung, kidney or red blood cells, all presenting selective indexes higher than 10. In conclusion, this study revealed cinnamyl Schiff bases, especially 1 and 23, as new lead anticryptococcal agents for the discovery of novel antifungal drugs. SIGNIFICANCE AND IMPACT OF THE STUDY: The occurrence and severity of fungal infections have increased in recent decades due to resistance to available antifungal drugs and the appearance of new emerging pathogens. Thus, the search for new antifungal agents is mandatory. From a series of 23 cinnamyl Schiff bases, two compounds (1 and 23) were interrogated as new anticryptococcal agents without significant cytotoxicity against human lung, kidney or red blood cells. In turns, these new Schiff bases are lead compounds for the discovery of novel antifungal drugs.

ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Soluble immune effector molecules [I]: anti-tumor necrosis factor-α agents).

BACKGROUND: The present review is part of the ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies. AIMS: To review, from an Infectious Diseases perspective, the safety profile of agents targeting tumour necrosis factor-α (TNF-α) and to suggest preventive recommendations. SOURCES: Computer-based MEDLINE searches with MeSH terms pertaining to each agent or therapeutic family. CONTENT: Preclinical and clinical evidence indicate that anti-TNF-α therapy (infliximab, adalimumab, golimumab, certolizumab pegol and etanercept) is associated with a two-to four-fold increase in the risk of active tuberculosis and other granulomatous conditions (mostly resulting from the reactivation of a latent infection). In addition, it may lead to the occurrence of other serious infections (bacterial, fungal, opportunistic and certain viral infections). These associated risks seem to be lower for etanercept than other agents. Screening for latent tuberculosis infection should be performed before starting anti-TNF-α therapy, followed by anti-tuberculosis therapy if appropriate. Screening for chronic hepatitis B virus (HBV) infection is also recommended, and antiviral prophylaxis may be warranted for hepatitis B surface antigen-positive individuals. No benefit is expected from the use of antibacterial, anti-Pneumocystis or antifungal prophylaxis. Pneumococcal and age-appropriate antiviral vaccinations (i.e. influenza) should be administered. Live-virus vaccines (i.e. varicella-zoster virus or measles-mumps-rubella) may be contraindicated in people receiving anti-TNF-α therapy, although additional data are needed before definitive recommendations can be made. IMPLICATIONS: Prevention measures should be implemented to reduce the risk of latent tuberculosis or HBV reactivation among individuals receiving anti-TNF-α therapy.

Risk factors for meticillin-resistant Staphylococcus aureus colonization in dialysis patients: a meta-analysis.

BACKGROUND: Patients on dialysis are particularly vulnerable to meticillin-resistant Staphylococcus aureus (MRSA) infections and MRSA colonization is associated with increased risk for severe infections in this population. AIM: Determination of risk factors for MRSA colonization among dialysis patients. METHODS: This is a systematic review and meta-analysis of studies reporting risk factors of MRSA colonization. We performed a PubMed and EMBASE literature search to identify all studies on risk factors for MRSA colonization among patients undergoing dialysis treatment. Previous hospitalization, type of dialysis access, comorbid conditions, dialysis vintage, gender, length of time on dialysis, and previous antibiotic use were extracted and assessed for possible association with MRSA colonization in this population. FINDINGS: Ten out of 8252 articles, presenting data on 2364 dialysis patients, were included. We found that hospitalization within the previous 12 months [odds ratio (OR): 1.93; 95% confidence interval (CI): 1.04-3.58] and the use of temporary dialysis access (relative risk: 1.66; 95% CI: 1.06-2.60) were associated with a significantly higher risk of MRSA colonization. MRSA carriage was associated with lower serum albumin levels compared to non-carriage (OR: 0.8; 95% CI: 0.68-0.95) and was higher among patients with chronic lung disease (OR: 2.16; 95% CI: 1.04-4.51). There were no data on patients undergoing peritoneal dialysis. CONCLUSION: Active surveillance approaches, including potential decolonization strategies, are suggested to focus on these subgroups of haemodialysis patients with hospitalization within the previous year, temporary dialysis access, lower serum albumin levels, and chronic lung disease comorbidity.

MRSA and VRE colonization in solid organ transplantation: a meta-analysis of published studies.

The burden of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) colonization among the increasing number of solid organ transplant patients has not been systematically explored. We searched PubMed and EMBASE for pertinent articles, performed a meta-analysis of prevalence across eligible studies and estimated the risk of ensuing MRSA or VRE infections relative to colonization status. We stratified effects in the pretransplant and posttransplant period. Twenty-three studies were considered eligible. Seventeen out of 23 (74%) referred to liver transplants. Before transplantation, the pooled prevalence estimate for MRSA and VRE was 8.5% (95% confidence interval [CI] 3.2­15.8) and 11.9% (95% CI 6.8­18.2), respectively. MRSA estimate was influenced by small studies and was lower (4.0%; 95% CI 0.4­10.2) across large studies (>200 patients). After transplantation, the prevalence estimates were 9.4% (95% CI 3.0­18.5) for MRSA and 16.2% (95% CI 10.7­22.6) for VRE. Pretransplant as well as posttransplant MRSA colonization significantly increased the risk for MRSA infections (pooled risk ratio [RR] 5.51; 95% CI 2.36­12.90 and RR 10.56; 95% CI 5.58­19.95, respectively). Pretransplant and posttransplant VRE colonization were also associated with significant risk of VRE infection (RR 6.65; 95% CI 2.54­17.41 and RR 7.93; 95% CI 2.36­26.67, respectively). Solid organ transplantation is a high-risk setting for MRSA and VRE colonization, and carrier state is associated with infection. Upgraded focus in prevention and eradication strategies is warranted.

The bacterial signalling molecule indole attenuates the virulence of the fungal pathogen Candida albicans.

AIMS: Indole is a signalling molecule, produced by a number of Gram-positive and Gram-negative bacteria both in nature as well as clinical environments. Here, we explored the effect of bacterial indole and one of its main derivatives on the virulence of the fungal pathogen Candida albicans. METHODS AND RESULTS: We found that indole and its derivate indole-3-acetonitrile (IAN) did not affect the viability of C. albicans. Interestingly, indole and IAN repressed C. albicans biofilm formation as well as the attachment of C. albicans to intestinal epithelial HT-29 cells and inhibited the ability of the yeast to make filaments that are the main virulence factor of C. albicans. In addition, we used the heterologous model host Caenorhabditis elegans to demonstrate in vivo that the presence of indole or IAN attenuates C. albicans infection (P = 0.0188 and P < 0.0001 for indole and IAN, respectively, compared to worms exposed to C. albicans DAY185 alone) and decreases fungal colonization in the nematode gut. Importantly, quantitative real-time polymerase chain reaction (qRT-PCR) results showed that in C. albicans, indole and IAN strongly stimulated the transcription of NRG1. CONCLUSIONS: Indole and IAN attenuates fungal virulence by regulating the transcription of NRG1, a transcriptional factor that influences filamentation and biofilm formation in C. albicans. SIGNIFICANCE AND IMPACT OF THE STUDY: Our findings indicate that the bacterial signalling molecules indole and its derivatives play an inter-kingdom role in dynamic network of microbiota and directly modulate the virulence of fungal C. albicans via NRG1.

Antifungal drug discovery through the study of invertebrate model hosts.

There is an urgent need for new antifungal agents that are both effective and non-toxic in the therapy of systemic mycoses. The model nematode Caenorhabditis elegans has been used both to elucidate evolutionarily conserved components of host-pathogen interactions and to screen large chemical libraries for novel antimicrobial compounds. Here we review the use of C. elegans models in drug discovery and discuss caffeic acid phenethyl ester, a novel antifungal agent identified using an in vivo screening system. C. elegans bioassays allow high-throughput screens of chemical libraries in vivo. This whole-animal system may enable the identification of compounds that modulate immune responses or affect fungal virulence factors that are only expressed during infection. In addition, compounds can be simultaneously screened for antifungal efficacy and toxicity, which may overcome one of the main obstacles in current antimicrobial discovery. A pilot screen for antifungal compounds using this novel C. elegans system identified 15 compounds that prolonged survival of nematodes infected with the medically important human pathogen Candida albicans. One of these compounds, caffeic acid phenethyl ester (CAPE), was an effective antifungal agent in a murine model of systemic candidiasis and had in vitro activity against several fungal species. Interestingly, CAPE is a potent immunomodulator in mammals with several distinct mechanisms of action. The identification of CAPE in a C. elegans screen supports the hypothesis that this model can identify compounds with both antifungal and host immunomodulatory activity.

BK virus in solid organ transplant recipients: an emerging syndrome.

BK virus is a human polyomavirus associated with a range of clinical presentations from asymptomatic viruria with pyuria to ureteral ulceration with ureteral stenosis in renal transplant patients or hemorrhagic cystitis in bone marrow transplant recipients. Infection of renal allografts has been associated with diminished graft function in some individuals. Fortunately, however, the majority of patients with BK virus infections are asymptomatic. The type, duration, and intensity of immunosuppression are major contributors to susceptibility to the activation of BK virus infection. Histopathology is required for the demonstration of renal parenchymal involvement; urine cytology and viral polymerase chain reaction methods are useful adjunctive diagnostic tools. Current, treatment of immunosuppressed patients with polyomavirus viruria is largely supportive and directed toward minimizing immunosuppression. Improved diagnostic tools and antiviral therapies are needed for polyomavirus infections.

A simple model host for identifying Gram-positive virulence factors.

We demonstrate the use of the nematode Caenorhabditis elegans as a facile and inexpensive model host for several Gram-positive human bacterial pathogens. Enterococcus faecalis, Streptococcus pneumoniae, and Staphylococcus aureus, but not Bacillus subtilis, Enterococcus faecium, or Streptococcus pyogenes, kill adult C. elegans. Focusing our studies on the enterococcal species, we found that both E. faecalis and E. faecium kill C. elegans eggs and hatchlings, although only E. faecalis kills the adults. In the case of adults, a low inoculum of E. faecalis grows to a high titer in the C. elegans intestine, resulting in a persistent infection that cannot be eradicated by prolonged feeding on E. faecium. Interestingly, a high titer of E. faecium also accumulates in the nematode gut, but does not affect the longevity of the worms. Two E. faecalis virulence-related factors that play an important role in mammalian models of infection, fsr, a putative quorum-sensing system, and cytolysin, are also important for nematode killing. We exploit the apparent parallels between Gram-positive infection in simple and more complex organisms by using the nematode to identify an E. faecalis virulence factor, ScrB, which is relevant to mammalian pathogenesis.

How does pouch construction for a final diagnosis of Crohn's disease compare with ileoproctostomy for established Crohn's proctocolitis?

PURPOSE: There is a difference of opinion concerning the role of ileal pouch-anal anastomosis in Crohn's disease, even in the absence of small-bowel or perianal disease. One view is that ileal pouch-anal anastomosis should never be entertained, the other is that ileal pouch-anal anastomosis, like ileoproctostomy, can be justified sometimes, because it allows young people a period of stoma-free life. The aim of this study was to examine the outcome of ileal pouch-anal anastomosis and to contrast it with ileoproctostomy in patients with Crohn's disease without small-bowel or perianal disease. METHODS: Ileal pouch-anal anastomosis was performed in 23 patients with Crohn's disease (12 of whom had evidence of Crohn's disease at the time of operation and 11 who were eventually found to have Crohn's disease as a result of complications) and ileoproctostomy in 35. Patients were matched for age, gender, follow-up, and medication, but all ileoproctostomy cases had relative rectal sparing. Thus, the groups were not comparable and the reasons for ileal pouch-anal anastomosis and ileoproctostomy were therefore quite different. RESULTS: The outcome in ileal pouch-anal anastomosis at a mean follow-up of 10.2 years was pouch excision, 11 (47.8 percent); proximal stoma, 1 (4.3 percent; patient preference); average small-bowel resection, 65 cm; persistent perineal sinus, 8 of 11 having pouch excision (73 percent); and mean time in hospital, 37 (range, 8-108) days. Of those in circuit having ileal pouch-anal anastomosis (n = 12), 24-hour bowel frequency was 6, with no incontinence or urgency, but 6 (50 percent) were on medication. When ileal pouch-anal anastomosis was done for Crohn's disease in the resection specimen, only 4 of 12 (33 percent) were excised compared with 7 of 11 (64 percent) in whom the diagnosis was made as a result of complications. The outcome in ileoproctostomy at a mean follow-up of 10.9 years was rectal excision in 3 (8 percent), proximal stoma in 1 (3 percent), average small-bowel resection was 15 cm, persistent perineal sinus in 1 (3 percent), and time in hospital was 21 (range, 8-36) days. Of those in circuit (n = 32), 24-hour bowel frequency was 5, 2 had incontinence, 3 had urgency, and 12 (36 percent) were taking medication. CONCLUSIONS: These results indicate that the overall outcome of ileal pouch-anal anastomosis is inferior to that of ileoproctostomy, especially if Crohn's disease was diagnosed as a result of complications. Nevertheless, the functional results of those with a successful outcome are comparable.

Diagnosis and treatment of androgen deficiency in human immunodeficiency virus-infected men and women.

Androgen deficiency is a common endocrine abnormality among men and women with human immunodeficiency virus (HIV) infection. Low testosterone concentrations are associated with lower CD4 cell count, advanced stage of illness, medication use, and weight loss. Signs and symptoms may be nonspecific. The most useful laboratory indicator is the serum bioavailable (free) testosterone concentration. A number of different testosterone preparations for treatment of androgen deficiency in HIV-infected men now exist. Administration of im testosterone significantly increases weight and lean body mass, energy, quality of life, and depression scores in HIV-infected men with low testosterone levels. Newer transdermal and gel preparations provide more-consistent steady-state dosing but are not as well tested, and sufficient testosterone concentrations may not be achieved with their use. Androgen deficiency is also common among HIV-infected women. Preliminary studies suggest that use of physiological testosterone administration, to achieve testosterone levels within the normal range, is of benefit in HIV-infected women, but further studies are necessary to define the therapeutic role of androgen therapy in this population.

When to suspect and how to monitor babesiosis.

In the past decade, cases of babesiosis in humans have been reported with increasing frequency, especially in the northeastern United States. Babesia microti (in the United States) and bovine strains (in Europe) cause most infections in humans. Most cases are tick-borne, although cases of transfusion-associated and transplacental/perinatal transmission have also been reported. Factors associated with more severe disease include advanced age, previous splenectomy and immunodeficient states. Symptoms include high fever, chills, diaphoresis, weakness, anorexia and headache. Later in the course of the illness, the patient may develop jaundice. Congestive heart failure, renal failure and acute respiratory distress syndrome are the most common complications. Therapy using the combination of quinine sulfate and clindamycin was the most commonly used treatment; however, atovaquone suspension plus azithromycin was recently reported an equally effective and less toxic therapy. Exchange transfusion, together with antibabesial chemotherapy, may be necessary in critically ill patients.

Omentoplasty for persistent perineal sinus after proctectomy for Crohn's disease.

Persistent perineal sinus is a common and serious cause of morbidity after proctectomy for Crohn's disease. Recently we have performed excision and omentoplasty on 6 patients with persistent perineal sinus. The perineal sinus was completely excised and communication was established with the pelvis. In 4 patients, the left gastroepiploic vessels were divided close to their origins and in 2 other patients the right gastroepiploic vessels were divided. The omentum was brought down to the perineum and it was lightly sutured to the perineal skin. After a median follow-up of 28 months, the perineal sinus had healed in 5 patients. In 1 patient the omentum became necrotic and infected 1 month after omentoplasty, and this patient still has a complex sinus. Although the number of patients is small, omentoplasty may be an effective procedure for the treatment of persistent perineal sinus after proctectomy for Crohn's disease.

Cutaneous leucocytoclastic vasculitis associated with oxacillin.

A 67-year-old man who was treated with oxacillin for one week because of Staphylococcus aureus bacteremia, developed renal failure and diffuse, symmetric, palpable purpuric lesions on his feet. Necrotic blisters were noted on his fingers. Skin biopsies showed findings diagnostic of leucocytoclastic vasculitis. Oxacillin was discontinued and patient was treated with corticosteroids. The rash disappeared after three weeks and renal function returned to normal. Leucocytoclastic vasculitis presents as palpable purpura of the lower extremities often accompanied by abdominal pain, arthralgia, and renal involvement. Etiologic factors or associated disorders include infections, medications, collagen vascular disease and neoplasia. However, in half of the cases no etiologic factor is identified. Usually it is a self-limited disorder, but corticosteroid therapy may be needed in life-threatening cases since early treatment with corticosteroids in severe cases can prevent complications. Oxacillin should be included among the drugs that can cause leucocytoclastic vasculitis.

Clostridium difficile--Associated diarrhea: A review.

Clostridium difficile causes 300 000 to 3 000 000 cases of diarrhea and colitis in the United States every year. Antibiotics most frequently associated with the infection are clindamycin, ampicillin, amoxicillin, and cephalosporins, but all antibiotics may predispose patients to C difficile infection. The clinical presentation varies from asymptomatic colonization to mild diarrhea to severe debilitating disease, with high fever, severe abdominal pain, paralytic ileus, colonic dilation (or megacolon), or even perforation. The most sensitive and specific test available for diagnosis of C difficile infection is a tissue culture assay for the cytotoxicity of toxin B. However, this test takes 1 to 3 days to complete and requires tissue culture facilities. Detection of C difficile toxin by means of enzyme-linked immunoassay is more rapid and inexpensive. A minority of patients may require more than 1 stool assay to detect toxin. Oral metronidazole or oral vancomycin hydrochloride for 10 to 14 days are equally effective at resolving clinical symptoms; oral metronidazole is preferred in most cases because of lowered cost and less selective pressure for vancomycin-resistant organisms. Approximately 15% of patients experience relapse after initial therapy and require retreatment, sometimes with an extended, tapering regimen. Immunity appears to be incomplete and predominantly mediated by serum IgG to toxin A. Measures for preventing the spread of the pathogen, appropriate diagnostic testing, and treatment may avert morbidity and mortality due to C difficile-associated diarrhea.

Plasma viral load testing in the management of HIV infection.

The polymerase chain reaction assay, branched DNA assay and nucleic acid sequence-based amplification assay quantitate human immunodeficiency virus (HIV) RNA levels. Plasma viral load (PVL) testing has become a cornerstone of HIV disease management. Initiation of antiretroviral drug therapy is usually recommended when the PVL is 10,000 to 30,000 copies per mL or when CD4+ T-lymphocyte counts are less than 350 to 500 per mm3 (0.35 to 0.50 x 10(9) per L). PVL levels usually show a 1- to 2-log reduction within four to six weeks after therapy is started. The goal is no detectable virus in 16 to 24 weeks. Periodic monitoring of PVL is important to promptly identify treatment failure. When feasible, the same assay should be used for serial PVL testing in the individual patient. At least two PVL measurements usually should be performed before antiretroviral drug therapy is initiated or changed. PVL testing may be helpful in the rare instance of indeterminate HIV antibody testing, especially in a patient with recent infection.

Babesiosis.

A case of human babesiosis is presented. This case emphasizes the need to consider tick-borne disease in anyone who presents with prolonged and undulating fevers, chills, headache, myalgias, and arthralgias. This holds true particularly in areas endemic for tick-borne diseases, even in the absence of a history of tick bite. These symptoms, associated with signs of intravascular hemolysis, thrombocytopenia, and renal insufficiency in a patient who resides in, or with recent travel to, the Northeastern United States, strongly suggest a diagnosis of babesiosis.

Quality of life of patients after surgical treatment of anal fistula; the role of anal manometry.

OBJECTIVE: This study was undertaken to assess the quality of life of patients after surgical treatment of anal fistula and to investigate whether anal manometry (AM) can guide the choice of the proper surgical intervention in these patients in order to protect the sphincter mechanism. PATIENTS AND METHODS: One hundred patients with anal fistula (AF) were studied prospectively (78 men; mean age 45 years; range 11-78). Cleveland Incontinence Score (CIS) was record pre-operatively and 1 and 3 months postoperatively for each patient in order to specify their quality of life (QOL) before and after the surgical treatment. Also, anal manometry (AM) was performed pre-operatively and 1 month postoperatively. The pre-operative anal pressures and the type of fistula determined the kind of the surgical treatment. 55 patients had an intersphincteric fistula, 42 trans-sphincteric and 3 suprasphincteric. 65 patients underwent laying open of the fistulous track, 7 fistulectomy and 28 were treated by seton fistulotomy. RESULTS: Three patients had defective gas control and 6 reported some degree of soiling. 3 patients developed recurrent fistula. CIS was significantly impaired (P=0.02) at the first postoperative month in these patients who were treated for trans-sphincteric fistula by fistulotomy; AM revealed significant decrease of anal pressures in these patients (resting and squeeze; P=0.007 and 0.0001 respectively); CIS and AM in the remaining cases revealed no significant deterioration of QOL and fall of anal pressures respectively. CIS was normal in the vast majority of patients at 3-months postoperatively. CONCLUSIONS: QOL of patients after surgical treatment of AF is unalterable on the understanding that the AF is simple and the treatment is not associated by incontinence or recurrence. Pre-operative AM is important regarding the choice of the proper surgical procedure.

Life table analysis of hernia following end colostomy construction.

OBJECTIVE: To study the long-term hernia rate and risk factors after end colostomy construction. PATIENTS AND METHODS: 86 patients with a permanent end colostomy constructed over 5 years were examined and interviewed. There were 35 men and the mean age was 56.5 (28-87) years. Risk factors which were analysed included emergency operation, age over 60 years, obesity, steroids, cancer, infection at the stoma site, smoking and chronic obstructive airways disease. RESULTS: Para-colostomy hernia occurred in 12/86 cases (13.9%). The cumulative recurrence rose with duration of follow up. Overall 10/45 patients (22%) over 60 years developed hernia vs. 2/41 patients (4.8%) less than 60 years (P=0.02). There were no other risk factors that correlated with para-colostomy hernia. CONCLUSIONS: These data indicate that the incidence of colostomy related hernia increases with follow up and is significantly higher in patients over the age of 60. Other risk factors, particularly obesity and coexisting cardiorespiratory disease, have no impact.