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Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge.The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level.A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit.Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.Los adultos mayores sometidos a cirugía abdominal de urgencia tienen resultados significativamente peores que los adultos jóvenes. Para aquellos pacientes que sobreviven, el nivel de atención que requieren tras el alta hospitalaria se desconoce y esta información podría servir de guía en la toma de decisiones. El estudio ELF (Emergency Laparotomy and Frailty) tenía como objetivo determinar si la fragilidad preoperatoria en adultos mayores se asociaba con un aumento de la dependencia en el momento del alta. MÉTODOS: El estudio ELF era un estudio multicéntrico extenso efectuado en el Reino Unido (n = 49) que incluyó una cohorte prospectiva de 934 pacientes mayores ( 65 años) sometidos a laparotomía de urgencia durante marzo-junio de 2017. El objetivo fue establecer si la fragilidad preoperatoria aumentaba el nivel de asistencia en el momento del alta en comparación con el nivel de asistencia preoperatorio. Para el análisis se utilizó una regresión logística multinivel ajustada a características previas al ingreso: fragilidad, edad del paciente, género, y nivel de asistencia.La edad media de los pacientes fue 76,2 años (DE = 6,83), con un 57% de mujeres, un 20,2% de pacientes frágiles y un 37,4% de adultos mayores que presentaron un aumento en el nivel de asistencia en el momento del alta. Un aumento de la fragilidad se asoció con un incremento en el nivel de asistencia en el momento del alta (y mayor poder predictivo que la edad). La razón de oportunidades (odds ratio, OR) ajustada por el aumento del nivel de asistencia fue 4,48 (i.c. del 95% 2,03-9,91) para pacientes aparentemente vulnerables (Clinical Frailty Scale, CFS 4); 5,94 (i.c. del 95% 2,54-13,90) para aquellos ligeramente frágiles (CFS 5); y 7,88 (i.c. del 95% 2,97-20,79) para aquellos con fragilidad moderada o grave (CFS 6 and 7) en comparación con pacientes en buenas condiciones. CONCLUSIÓN: Este es el primer estudio que documenta que más del 37% de adultos mayores sometidos a laparotomía de urgencia precisaron un aumento en el nivel de asistencia en el momento del alta. La evaluación de la fragilidad debería integrarse en todas las unidades quirúrgicas de agudos para ayudar a compartir la toma de decisiones y los planes de tratamiento.

IntroductionThis protocol describes an observational study which set out to assess whether frailty and/or multimorbidity correlates with short-term and medium-term outcomes in patients diagnosed with COVID-19 in a European, multicentre setting.Methods and analysisOver a 3-month period we aim to recruit a minimum of 500 patients across 10 hospital sites, collecting baseline data including: patient demographics; presence of comorbidities; relevant blood tests on admission; prescription of ACE inhibitors/angiotensin receptor blockers/non-steroidal anti-inflammatory drugs/immunosuppressants; smoking status; Clinical Frailty Score (CFS); length of hospital stay; mortality and readmission. All patients receiving inpatient hospital care >18 years who receive a diagnosis of COVID-19 are eligible for inclusion. Long-term follow-up at 6 and 12 months is planned. This will assess frailty, quality of life and medical complications.Our primary analysis will be short-term and long-term mortality by CFS, adjusted for age (18–64, 65–80 and >80) and gender. We will carry out a secondary analysis of the primary outcome by including additional clinical mediators which are determined statistically important using a likelihood ratio test. All analyses will be presented as crude and adjusted HR and OR with associated 95% CIs and p values.Ethics and disseminationThis study has been registered, reviewed and approved by the following: Health Research Authority (20/HRA1898); Ethics Committee of Hospital Policlinico Modena, Italy (369/2020/OSS/AOUMO); Health and Care Research Permissions Service, Wales; and NHS Research Scotland Permissions Co-ordinating Centre, Scotland. All participating units obtained approval from their local Research and Development department consistent with the guidance from their relevant national organisation.Data will be reported as a whole cohort. This project will be submitted for presentation at a national or international surgical and geriatric conference. Manuscript(s) will be prepared following the close of the project.

Background: The COVID-19 pandemic has placed unprecedented strain on health-care systems. Frailty is being used in clinical decision making for patients with COVID-19, yet the prevalence and effect of frailty in people with COVID-19 is not known. In the COVID-19 in Older PEople (COPE) study we aimed to establish the prevalence of frailty in patients with COVID-19 who were admitted to hospital and investigate its association with mortality and duration of hospital stay. Methods: This was an observational cohort study conducted at ten hospitals in the UK and one in Italy. All adults (≥18 years) admitted to participating hospitals with COVID-19 were included. Patients with incomplete hospital records were excluded. The study analysed routinely generated hospital data for patients with COVID-19. Frailty was assessed by specialist COVID-19 teams using the clinical frailty scale (CFS) and patients were grouped according to their score (1–2=fit; 3–4=vulnerable, but not frail; 5–6=initial signs of frailty but with some degree of independence; and 7–9=severe or very severe frailty). The primary outcome was in-hospital mortality (time from hospital admission to mortality and day-7 mortality). Findings: Between Feb 27, and April 28, 2020, we enrolled 1564 patients with COVID-19. The median age was 74 years (IQR 61–83); 903 (57·7%) were men and 661 (42·3%) were women; 425 (27·2%) had died at data cutoff (April 28, 2020). 772 (49·4%) were classed as frail (CFS 5–8) and 27 (1·7%) were classed as terminally ill (CFS 9). Compared with CFS 1–2, the adjusted hazard ratios for time from hospital admission to death were 1·55 (95% CI 1·00–2·41) for CFS 3–4, 1·83 (1·15–2·91) for CFS 5–6, and 2·39 (1·50–3·81) for CFS 7–9, and adjusted odds ratios for day-7 mortality were 1·22 (95% CI 0·63–2·38) for CFS 3–4, 1·62 (0·81–3·26) for CFS 5–6, and 3·12 (1·56–6·24) for CFS 7–9. Interpretation: In a large population of patients admitted to hospital with COVID-19, disease outcomes were better predicted by frailty than either age or comorbidity. Our results support the use of CFS to inform decision making about medical care in adult patients admitted to hospital with COVID-19. Funding: None.

Aim The determinants of cognitive impairment and delirium during acute illness are poorly understood, despite being common among older people. Anemia is common in older people, and there is ongoing debate regarding the association between anemia, cognitive impairment and delirium, primarily in non‐surgical patients. Methods Using data from the Older Persons Surgical Outcomes Collaboration 2013 and 2014 audit cycles, we examined the association between anemia and cognitive outcomes in patients aged ≥65 years admitted to five UK acute surgical units. On admission, the Confusion Assessment Method was carried out to detect delirium. Cognition was assessed using the Montreal Cognitive Assessment, and two levels of impairment were defined as Montreal Cognitive Assessment

Objective: This study aimed to document the prevalence of frailty in older adults undergoing emergency laparotomy and to explore relationships between frailty and postoperative morbidity and mortality. Summary Background Data: The majority of adults undergoing emergency laparotomy are older adults (≥65 y) that carry the highest mortality. Improved understanding is urgently needed to allow development of targeted interventions. Methods: An observational multicenter (n=49) UK study was performed (March–June 2017). All older adults undergoing emergency laparotomy were included. Preoperative frailty score was calculated using the progressive Clinical Frailty Score (CFS): 1 (very fit) to 7 (severely frail). Primary outcome measures were the prevalence of frailty (CFS 5–7) and its association to mortality at 90 days postoperative. Secondary outcomes included 30-day mortality and morbidity, length of critical care, and overall hospital stay. Results: A total of 937 older adults underwent emergency laparotomy: frailty was present in 20%. Ninety-day mortality was 19.5%. After age and sex adjustment, the risk of 90-day mortality was directly associated with frailty: CFS 5 adjusted odds ratio (aOR) 3.18 [95% confidence interval (CI), 1.24–8.14] and CFS 6/7 aOR 6·10 (95% CI, 2.26–16.45) compared with CFS 1. Similar associations were found for 30-day mortality. Increasing frailty was also associated with increased risk of complications, length of Intensive Care Unit, and overall hospital stay. Conclusions: A fifth of older adults undergoing emergency laparotomy are frail. The presence of frailty is associated with greater risks of postoperative mortality and morbidity and is independent of age. Frailty scoring should be integrated into acute surgical assessment practice to aid decision-making and development of novel postoperative strategies.

Ultrasound and Tc99mMIBI scans are used to localise parathyroid tumours in sporadic primary hyperparathyroidism (pHPT). Intra-operative PTH (ioPTH) assay facilitates unilateral neck exploration (UNE). When both ultrasound and MIBI are negative, it is our policy to explore the left side of the neck and only proceed to bilateral neck exploration (BNE) when either a tumour is not found or when ioPTH does not fall to >50% of the highest pre-excision value. The aim of this study was to investigate the outcome of our approach to ‘double negative’ patients. A retrospective analysis of patients undergoing primary parathyroidectomy for pHPT. Data were obtained from a prospective surgical database and the hospital electronic patient record. Between January 2004 and November 2014, 746 patients underwent a parathyroidectomy for pHPT. Those who did not have both pre-operative scans, ioPTH or a minimum of 6-month follow-up were excluded. Of 552 patients, 111 (20%) had double negative scans (group A), and in 441, either one or both scans were positive (group B). Median age was 61.5 years (range 10–88). Pre-operative PTH level was significantly lower in group A: 11.8 pmol/l (range 3.1–38.8) versus 14.9 pmol/l (range 2.8–101.6; P

Background\ud\udLow albumin is a prognostic factor associated with poor surgical outcomes. We aimed to examine the predicative ability of easily obtainable point-of-care variables in combination, to derive a practical risk scale for predicting older adults at risk of poor outcomes on admission to the emergency general surgical setting.\ud\ud\udMethods\ud\udThis is an international multi-center prospective cohort study conducted as part of the Older Persons Surgical Outcomes Collaboration (www.OPSOC.eu). The effect of having hypoalbuminemia (defined as albumin ≤3.5 g/dL) on selected outcomes was examined using fully adjusted multivariable models. In a subgroup of patients with hypoalbuminemia, we observed four risk characteristics (Male, Anemia, Low albumin, Eighty-five and over [MALE]). Subsequently, the impact of incremental increase in MALE score (each characteristic scoring 1 point (maximum score 4) on measured outcomes was assessed.\ud\ud\udResults\ud\udThe cohort consisted of 1406 older patients with median (IQR) age of 76 (70–83) years. In fully adjusted models, hypoalbuminemia was significantly associated with undergoing emergency surgery (1.32 (95%CI 1.03–1.70); p = 0.03), 30-day mortality (4.23 (2.22–8.08); p

Post-operative acute kidney injury (AKI) is a common and independent mortality risk factor carrying high clinical and economic cost. This study aimed to establish the incidence of AKI in patients undergoing emergency laparotomy (EL), to determine patients’ risk profile and consequent mortality. Consecutive 239 patients of median age 68 (IQR 51–76) years, undergoing EL in a UK tertiary hospital, were studied. Primary outcome measure was AKI and in-hospital operative mortality. Ninety-five patients (39.7%) developed AKI, which was associated with in-hospital mortality in 32 patients (33.7%) compared with 7 patients (4.9%) without AKI. AKI occurred in 81.1% of all mortalities, but none occurred when AKI resolved within 48 h of EL. AKI was associated with chronic kidney disease, age, serum lactate, white cell count, pre-EL systolic blood pressure and tachycardia (p

\ud \ud \ud \ud Background\ud \ud frail patients in any age group are more likely to die than those that are not frail. We aimed to evaluate the impact of frailty on clinical mortality, readmission rate and length of stay for emergency surgical patients of all ages.\ud \ud \ud Methods\ud \ud a multi-centre prospective cohort study was conducted on adult admissions to acute surgical units. Every patient presenting as a surgical emergency to secondary care, regardless of whether they ultimately underwent a surgical procedure was included. The study was carried out during 2015 and 2016.\ud \ud Frailty was defined using the 7-point Clinical Frailty Scale. The primary outcome was mortality at Day 90. Secondary outcomes included: mortality at Day 30, length of stay and readmission within a Day 30 period.\ud \ud \ud Results\ud \ud the cohort included 2,279 patients (median age 54 years [IQR 36–72]; 56% female). Frailty was documented in patients of all ages: 1% in the under 40’s to 45% of those aged 80+. We found that each incremental step of worsening frailty was associated with an 80% increase in mortality at Day 90 (OR 1.80, 95% CI: 1.61–2.01) supporting a linear dose–response relationship. In addition, the most frail patients were increasingly likely to stay in hospital longer, be readmitted within 30 days, and die within 30 days.\ud \ud \ud Conclusions\ud \ud worsening frailty at any age is associated with significantly poorer patient outcomes, including mortality in unselected acute surgical admissions. Assessment of frailty should be integrated into emergency surgical practice to allow prognostication and implementation of strategies to improve outcomes.

Parathyroid hormone (PTH) has a short half-life and is cleared by the liver and kidneys. This study examined whether declining estimated glomerular filtration rate (eGFR) affects application of the Miami criterion for intraoperative PTH (ioPTH) decline during parathyroidectomy for primary hyperparathyroidism (pHPT). A retrospective review of consecutive patients undergoes parathyroidectomy for pHPT. Patients with multi-gland disease, without ioPTH, failure-to-cure and those

Introduction: Guidelines suggest that all patients with choledocholithiasis should have a coagulation screen prior to endoscopic retrograde cholangiopancreatography (ERCP). This study aims to establish the incidence of deranged coagulation in such patients and its relationship with bleeding complications. Methods: Analysis of consecutive patients undergoing ERCP procedures at two NHS sites was undertaken. Exclusion criteria were anti-coagulation use, bleeding disorders or incomplete data. Demographic data, pre-procedure bilirubin and prothrombin time (PT), ERCP procedural information, and bleeding complications were recorded for each. The cohort was divided into jaundice and non-jaundiced groups. Statistical analysis was performed using the student's t-test, Chi-squared test and Fisher's exact test. Results: 793 patients (419 jaundiced; 374 non-jaundiced) were included. PT was significantly higher in the jaundiced group (greater by 2 (1.35–2.64) seconds; p 16.8 s 5.9 per cent of the non-jaundiced group had prolonged PT, with 1 patient having a PT >16.8 s. There were 5 major, and 32 minor bleeding complications with no differences between groups. In those with abnormal coagulation, only 1 minor bleeding complication occurred in a jaundiced patient. Discussion: Normal pre-ERCP bilirubin was 99.7% (98.5–100) sensitive to predict a PT

CONTEXT: Genetic abnormalities, such as those of multiple endocrine neoplasia type 1 (MEN1) and Cyclin D1 (CCND1) genes, occur in

Physiological studies of mice are facilitated by normal plasma and 24-hour urinary reference ranges, but variability of these parameters may increase due to stress that is induced by housing in metabolic cages. We assessed daily weight, food and water intake, urine volume and final day measurements of the following: plasma sodium, potassium, chloride, urea, creatinine, calcium, phosphate, alkaline phosphatase, albumin, cholesterol and glucose; and urinary sodium, potassium, calcium, phosphate, glucose and protein in 24- to 30-week-old C3H/HeH, BALB/cAnNCrl and C57BL/6J mice. Between 15 and 20 mice of each sex from all three strains were individually housed in metabolic cages with ad libitum feeding for up to seven days. Acclimatization was evaluated using general linear modelling for repeated measures and comparison of biochemical data was by unpaired t-test and analysis of variance (SPSS version 12.0.1). Following an initial 5–10% fall in body weight, daily dietary intake, urinary output and weight in all three strains reached stable values after 3–4 days of confinement. Significant differences in plasma glucose, cholesterol, urea, chloride, calcium and albumin, and urinary glucose, sodium, phosphate, calcium and protein were observed between strains and genders. Thus, these results provide normal reference values for plasma and urinary biochemistry in three strains housed in metabolic cages and demonstrate that 3–4 days are required to reach equilibrium in metabolic cage studies. These variations due to strain and gender have significant implications for selecting the appropriate strain upon which to breed genetically-altered models of metabolic and renal disease.

BACKGROUND: Concordant parathyroid localization with sestamibi and ultrasound scans allows minimally invasive parathyroidectomy (MIP) to be performed in patients with non-familial primary hyperparathyroidism (PHPT). AIM: To investigate the financial implications of scan-directed parathyroid surgery. METHODS: Analysis of hospital records for a cohort of consecutive unselected patients treated in a tertiary referral centre. RESULTS: Two hundred patients (138F:62M, age 18-91years) were operated for non-familial PHPT between Jan 2003 and Oct 2007. MIP was performed in 129 patients, with a mean operative time was 35 +/- 18min. Some 75 patients were discharged the same day and the others had a total of 72 in-patient days. Bilateral neck exploration (BNE) was performed in 71 patients with negative/non-concordant scans. Mean operative time was 58 +/- 25min. Only nine patients were discharged the same day and a total of 93 in-patient days were used ( approximately 1.3days/patient). The estimated total costs incurred were pound215,035 ( approximately 290,000). These costs would have been covered by the National Tariff ( pound2,170 per parathyroidectomy) but were higher than those possibly incurred if all 200 patients would have undergone BNE without any radiological investigations ( pound166,000 approximately 224,100euro). CONCLUSION: Shorter operative time and day-case admission for MIP generate costs savings that compensate only partially for the additional costs associated with parathyroid imaging studies.

Major surgery is associated with acute kidney injury (AKI). This study examines associations between elective parathyroid surgery and post-operative renal impairment.Consecutive patients undergoing elective parathyroidectomy were evaluated, and demographic data and relevant blood parameters collected. A renal risk score was calculated for each patient based on locally agreed criteria.62 patients were evaluated. Mean ± standard deviation creatinine increased between pre-operative and day 1 post-operative (72 ± 19 vs. 76 ± 20 μmol/L; p 0.010). Mean eGFR reduced between baseline and day 1 (78 ± 15 vs. 75 ± 16; p 0.010) and baseline and follow-up (78 ± 15 vs. 73 ± 17; p 0.050). 19 patients (30.7%) had a creatinine increase of ≥10% on day 1 post-operatively and 7 (11.3%) a rise of20%. At follow-up, 14 (30.4% of 46 patients with follow up creatinine measurements) and 5 (10.9%) patients had a creatinine of10% and20% higher than pre-operative or day 1 values respectively. Those with an increase in serum creatinine of ≥10% (at any time point) had a greater renal risk score [median 2 (inter-quartile range, IQR 0-3) vs. 1 (0-2); p = 0.040].A significant minority of patients undergoing elective parathyroid surgery demonstrate worsening renal function post-operatively. A pre-operative risk stratification tool may identify those at risk in the clinical setting.

Introduction Since the late 1990s, a number of factors have reduced the threshold for parathyroidectomy in patients with primary hyperparathyroidism. This study examined whether this has translated into increased numbers of parathyroid operations over the last decade. Methods A retrospective analysis was performed of the Patient Episode Database for Wales and English Hospital Episode Statistics annual data from 2000 to 2010 for parathyroidectomy admissions per 100,000 population. Statistical analysis was by linear regression. Results Between 2000 and 2010 there were 24,247 parathyroid operations in England and Wales (0.005% of the population), with 3 times as many women treated as men. Overall, incidence of parathyroidectomy rose from 3.3/100,000 population in 2000 to 5.8/100,000 in 2010 (p75 years nearly doubled over the decade (pConclusions The incidence of parathyroidectomy in adults has increased significantly in the last decade in England and Wales. This likely reflects changes in population demography, available guidelines, lower threshold for referral, changing surgical approach and the realisation that surgical morbidity is now infrequent.

Introduction: Early postoperative renal transplant vein thrombosis results in graft loss. We evaluate the effect of administering aspirin 75 mg daily for 28 days following transplantation. Methods: Prospectively collected data on the outcome of all transplants undertaken in our unit in the five-year period from January 1997 to January 2002 were reviewed, and in cases of graft failure before three months the cause was defined. Results: In the study period, a total of 401 transplants were undertaken (311 cadaveric and 90 living related). There was one case of renal transplant vein thrombosis (0.25%). This represents a significant reduction on the unit's historical incidence of 5.8%, P Conclusion: Aspirin 75 mg daily is adequate to virtually abolish renal transplant vein thrombosis and has a role in thromboprophylaxis in other situations where heparin is contraindicated.

Background Ultravision™ is a new device that utilizes electrostatic precipitation to clear surgical smoke. The aim was to evaluate its performance during laparoscopic cholecystectomy. Methods Patients undergoing laparoscopic cholecystectomy were randomized into “active (device on)” or “control (device off).” Three operating surgeons scored the percentage effective visibility and three reviewers scored the percentage of the procedure where smoke was present. All assessors also used a 5-point scale (1 = imperceptible/excellent and 5 = very annoying/bad) to rate visual impairment. Secondary outcomes were the number of smoke-related pauses, camera cleaning, and pneumoperitoneum reductions. Mean results are presented with 95 % confidence intervals (CI). Results In 30 patients (active 13, control 17), the effective visibility was 89.2 % (83.3–95.0) for active cases and 71.2 % (65.7–76.7) for controls. The proportion of the procedure where smoke was present was 41.1 % (33.8–48.3) for active cases and 61.5 % (49.0–74.1) for controls. Operating surgeons rated the visual impairment as 2.2 (1.7–2.6) for active cases and 3.2 (2.8–3.5) for controls. Reviewers rated the visual impairment as 2.3 (2.0–2.5) for active cases and 3.2 (2.8–3.7) for controls. In the active group, 23 % of procedures were paused to allow smoke clearance compared to 94 % of control cases. Camera cleaning was not needed in 85 % of active procedures and 35 % of controls. The pneumoperitoneum was reduced in 0 % of active cases and 88 % of controls. Conclusions Ultravision™ improves visibility during laparoscopic surgery and reduces delays in surgery for smoke clearance and camera cleaning.

Background: Minimally invasive parathyroidectomy (MIP) is the choice of treatment in patients with sporadic adenomas localized on preoperative imaging. Currently there is no centre in the UK which performs this procedure under local anaesthesia. The aim of this study was to assess the efficacy and safety of MIP under local anaesthesia in patients with sporadic primary hyperparathyroidism (pHPT). Methods: This is a prospective, nonrandomized study of 86 patients with pHPT localized with Tc99m Sestamibi scan and ultrasound. MIPs were performed under local anaesthesia and sedation at the Oxford University Hospitals.Serum Ca and PTH were measured before discharge, at 6 weeks follow up, and at 6 months. Main outcome measures were cure at 6 months, complications with the procedure and operative time. Results: 86 patients (58 females: 28 males) with a mean age of 65 (range 24-87) underwent MIP under local anaesthesia and sedation. All patients (100%) were normocalcaemic at 6 months following surgery. There was no incidence of temporary or permanent recurrent laryngeal nerve palsy or persistent hypercalcaemia. Two patients had temporary hypocalcaemia that resolved in 6 weeks. In one patient the neck incision needed extension for bleeding, with no incidence of wound haematoma or infection. Conclusion: This study demonstrates that MIP (without ioPTH) can be safely performed under local anaesthesia for patients with sporadic primary hyperparathyroidism. © 2013 Surgical Associates Ltd.

Intraoperative parathyroid hormone (ioPTH) measurement has facilitated a move to minimally invasive parathyroidectomy. Patients are referred for surgery earlier with milder hypercalcaemia and smaller tumours. Whilst previous research has shown that glands size can affect ioPTH kinetics in patients with multiple gland disease, the dynamics of ioPTH in patients with mild hyperparathyroidism (HPT) has not been studied. We therefore investigated the relationship between biochemical parameters and parathyroid adenoma weight, and determined the dynamics and accuracy of ioPTH assay in patients with milder hypercalcaemia undergoing parathyroidectomy. Patients undergoing parathyroidectomy for single gland disease from January 2004 to March 2011 were divided prospectively into two groups according to preoperative serum calcium: patients with a preoperative calcium ≥2.85 mmol/L (11.4 mg/dL) and

OBJECTIVE: Parathyroidectomy for primary hyperparathyroidism (PHPT) is curative in over 95% of cases. Although PHPT affects up to 2% of the elderly population, whose life expectancy may be a decade or more, such patients may be denied surgery because of perceived risk. This study investigates the outcomes of surgery for PHPT in the elderly. DESIGN AND PATIENTS: Consecutive patients with PHPT treated at a tertiary referral centre over 5 years. MEASUREMENTS: A prospective database recorded clinical, biochemical and pathological information. Pasieka's parathyroid symptom scores were obtained pre-operatively and post-operatively, from a recent subgroup of 70 consecutive patients. Deaths during follow-up were identified using the NHS Strategic Tracing Service. Statistical analysis was performed with spss v12.0. RESULTS: Between November 2002 and October 2007, 224 patients (17-89 years) underwent surgery for PHPT. In the subgroup comprising patients aged >75 years there was a significantly greater proportion of women (47/56 vs. 52/81, P < 0.05). Pre-operative indices of these patients were similar to younger patients, as were proportions undergoing minimally invasive parathyroidectomy (n = 134) or bilateral neck exploration (n = 90). Patients >75 years had a longer hospital stay (1.6 vs. 0.8 days, P = 0.003). Pasieka's symptom scores improved significantly at 3-6 months postoperatively in all age groups. During a minimum median follow-up of 22 months, there were seven patients with persistent/recurrent disease. Median 2-year survival of those aged 60-74 and those over 75 ranged from 85-90%. CONCLUSION: Parathyroidectomy is safe in the elderly and is associated with a significant improvement in symptoms. As survival after operation is similar to younger patients, surgery should be considered in all elderly patients with PHPT.

Objective Diagnostic laparoscopy is advocated in the management of patients with acute right iliac fossa pain. We asked consultant surgeons in the UK about their current use of this technique. Method A short anonymous questionnaire was sent to consultant surgeons from the ASGBI database. Information was sought on general surgical specialty, participation in the emergency surgical on-call rota, current practice regarding the use of diagnostic laparoscopy in patients with suspected acute appendicitis and on the management of an inflamed or noninflamed appendix. Statistical analysis was by means of χ2 test. Results There were 161 eligible returns from 250 questionnaires (64%) and the proportion of consultants replying from each subspecialty was similar to membership numbers of subspecialty organizations. Most consultants (68%) performed diagnostic laparoscopy in patients with suspected acute appendicitis. The majority (69%) reserved its use for women of reproductive age and 14% of respondents laparoscoped all patients with suspected appendicitis. Compared to nongastrointestinal (GI), GI surgeons were significantly more likely to perform diagnostic laparoscopy (75 vs 52%, P = 0.008). In the case of an overtly inflamed appendix, 81% of respondents would remove it laparoscopically with significantly more GI surgeons following this course than nonGI surgeons (P = 0.04). Conclusion Despite good evidence on the benefits of diagnostic laparoscopy in certain patients with suspected acute appendicitis, there is significant variation in its use. This difference appears to be based upon subspecialty and may be as a result of increasing subspecialization.

INTRODUCTION: Subintimal angioplasty has been proposed for the treatment of long segment occlusive disease and for patients with critical limb ischaemia (CLI) with significant co-morbidity. There is no consensus as to short- and long-term patency. We present our experience with this technique. METHODS: Between 1995 and 2000, 43 consecutive patients (48 limbs) underwent subintimal angioplasty for superficial femoral artery occlusions. Outcome measures were haemodynamic and/or symptomatic patency. RESULTS: Technical success was achieved in 14/17 limbs with CLI (82%) and 30/31 (97%) with intermittent claudication (IC). There were 7 complications (15%), 6 occurring in the claudicant group. The median occlusion length was 10 cm for CLI and 6 cm for IC. Patency at 12 and 36 months, on an intention-to-treat basis, was 69% and 58% for claudicants and 25% and 25% for patients with CLI (P = 0.0005 and P = 0.0044, respectively). Following only technically successful procedures, 12-month patency was 72% (IC) and 31% (CLI) (P = 0.009). Patients with occlusions > or = 10 cm were more likely to re-occlude than those < 10 cm (12-month patency 60% versus 25%;P = 0.037). CONCLUSIONS: In this series, short- and long-term patency in patients with CLI is poor. Subintimal angioplasty in the treatment of CLI should be reserved for those patients not fit for surgical bypass.