The Cholecystectomy As A Day Case (CAAD) Score: A Validated Score of Preoperative Predictors of Successful Day-Case Cholecystectomy Using the CholeS Data Set

Background Day-case surgery is associated with significant patient and cost benefits. However, only 43% of cholecystectomy patients are discharged home the same day. One hypothesis is day-case cholecystectomy rates, defined as patients discharged the same day as their operation, may be improved by better assessment of patients using standard preoperative variables. Methods Data were extracted from a prospectively collected data set of cholecystectomy patients from 166 UK and Irish hospitals (CholeS). Cholecystectomies performed as elective procedures were divided into main (75%) and validation (25%) data sets. Preoperative predictors were identified, and a risk score of failed day case was devised using multivariate logistic regression. Receiver operating curve analysis was used to validate the score in the validation data set. Results Of the 7426 elective cholecystectomies performed, 49% of these were discharged home the same day. Same-day discharge following cholecystectomy was less likely with older patients (OR 0.18, 95% CI 0.15–0.23), higher ASA scores (OR 0.19, 95% CI 0.15–0.23), complicated cholelithiasis (OR 0.38, 95% CI 0.31 to 0.48), male gender (OR 0.66, 95% CI 0.58–0.74), previous acute gallstone-related admissions (OR 0.54, 95% CI 0.48–0.60) and preoperative endoscopic intervention (OR 0.40, 95% CI 0.34–0.47). The CAAD score was developed using these variables. When applied to the validation subgroup, a CAAD score of ≤5 was associated with 80.8% successful day-case cholecystectomy compared with 19.2% associated with a CAAD score >5 (p < 0.001). Conclusions The CAAD score which utilises data readily available from clinic letters and electronic sources can predict same-day discharges following cholecystectomy

The anatomy of an early Dinantian terraced floodplain: palaeoenvironment and early diagenesis

The lowermost Carboniferous rocks in the Cockburnspath area of east Berwickshire (southern Scotland) are interpreted as coastal floodplain sediments. A lower mudstone-dominated unit is composed of silty mudstones and shales with subordinate sandstones and argillaceous ferroan dolomites (cementstones). These are interpreted as distal floodplain sediments with periodic crevasse-splay deposition. The dark grey colour of the mudrocks suggests deposition in reducing conditions, probably in floodplain lakes. Most of the cementstones are concretionary, some with septarian cracks, suggesting an early diagenetic origin. An immature palaeosol suggests periodic pedogenesis under improved drainage. A synsedimentary erosion surface indicates incision of a valley into the floodplain, presumably in response to base-level lowering. An upper sandstone-dominated unit starts with fine-grained rippled sandstones, cut by small channel sandstones. These are interpreted as floodplain lake deposits fed by crevasse channels. A distinctive conglomerate with cementstone clasts, wood fragments and fish remains is interpreted as a major overbank deposit, dumped into a pre-existing floodplain lake. A bivalve fauna was established in the overlying mudstones, followed by a thin limestone with a restricted marine fossil assemblage, showing that seawater flooding of the lakes occurred at times. Mudrocks throughout the sequence contain no pyrite, except for the marine band which has an organic-carbon/sulphur ratio and degree of pyritization value typical of marine sediments. The concretionary cementstones have d13C values around —4 to —6%0/00 PDB which are interpreted as indicative of anaerobic oxidation of organic matter. The combined geochemical data suggest a significant involvement of iron reduction in cementstone formation, although the d13C values are ambiguous in assessing the relative involvement of methanogenesis and methane oxidation. Limited seawater inundation of the floodplains might have supplied magnesium and calcium ions for dolomite formation assuming that any H2S derived as a result of sulphate reduction was oxidized by iron reduction. Alternatively a weathering source for solutes might have been involved

Economic burden of environmental tobacco smoke on Hong Kong families: scale and impact

STUDY OBJECTIVE: To examine the financial cost of doctor consultations for cough, phlegm, and wheeze in children living in a home where family members smoke compared with those not exposed to environmental tobacco smoke. To model these costs to provide the Territory of Hong Kong with estimates of potentially avoidable health care resource use. DESIGN: Cross sectional questionnaire survey. SUBJECTS AND SETTING: All children (10,615) in classes primary 3 to 6 (aged 8-13 years) attending 27 schools in two districts of Hong Kong in 1992 and their parents. MEASUREMENTS AND MAIN RESULTS: Doctor consultations during the previous three months for symptoms of either cough, phlegm or wheeze were higher in younger children, ranging from 22.9% in 8 year olds to 8.4% in those aged 12 or over. For those children living in homes with one, or more than one, smoker category (there were four categories of smokers: father, mother, siblings, others), the adjusted odds ratios (95% confidence intervals) for a doctor consultation for any of these symptoms were 1.15 (1.01, 1.31) and 1.38 (1.14, 1.67) respectively. Using US$15 as the minimum cost incurred per consultation, the expected direct cost per annum per child of doctor consultations was 14$338,042 to US$991,591. CONCLUSIONS: Exposure to environmental tobacco smoke not only provides a respiratory health risk for children but also an avoidable excess cost to the family's financial resources and health service providers.