Now let’s talk about what else could put you at increased risk for infection and we have a list of some preoperative conditions that can affect your outcome and so can you walk us through these we mentioned the I know you mentioned obesity briefly in your discussion but diabetes is also a big one it’s a big one it’s a source of a lot of concern higher average blood sugars increase the rate of tissue oxidation which means aging of tissues and bacterial of sugar so with diabetes the goal is to get optimal control before surgery and then to maintain optimal control after surgery now while you’re in the hospital that’s easy because I can use insulin and with insulin you can control sugar reliably but when patients leave the hospital it’s very important for them to maintain good blood sugar and sort of pay attention if they’re checking their blood sugar check it more often smoking is another you know easy one to discuss there’s been a multitude of articles talking about how smoking is a problem and how it just ruins surgical outcomes and not just infections really just there’s a problem with smoking on every level right hypoxia nicotine malnutrition so if I’m a patient that’s a smoker going into surgery what do you do that’s a tough question so I will deny them surgery you will deny them with one or two exceptions if the patient is at risk of being paralyzed which is rare very rare then the patient has to understand that they’re at an increased risk of an infection but in their situation you may have to take that risk for the most part I ask smokers to stop smoking for at least a month and then we’ll go to a surgery with a significantly improved risk profile okay now when you even have a weakened immune system though that’s a little difficult also for surgery another one but that’s something where the patient really can’t do anything so for example a lot played on patients that are very elderly or patients who have had a weakened immunity because of can sir or chemotherapy you have to really be objective with the risks and you have to discuss this with patients at length I believe in a consultant or a sort of model where the patient has to be aware of what they’re getting into but sometimes there’s no option