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Background C-reactive protein (CRP) is a non-specific acute phase reactant elevated in infection or inflammation. Higher levels indicate more severe infection and have been used as an indicator of COVID-19 disease severity. However, the evidence for CRP as a prognostic marker is yet to be determined. The aim of this study is to examine the CRP response in patients hospitalized with COVID-19 and to determine the utility of CRP on admission for predicting inpatient mortality. Methods Data were collected between 27 February and 10 June 2020, incorporating two cohorts: the COPE (COVID-19 in Older People) study of 1564 adult patients with a diagnosis of COVID-19 admitted to 11 hospital sites (test cohort) and a later validation cohort of 271 patients. Admission CRP was investigated, and finite mixture models were fit to assess the likely underlying distribution. Further, different prognostic thresholds of CRP were analysed in a time-to-mortality Cox regression to determine a cut-off. Bootstrapping was used to compare model performance [Harrell’s C statistic and Akaike information criterion (AIC)]. Results The test and validation cohort distribution of CRP was not affected by age, and mixture models indicated a bimodal distribution. A threshold cut-off of CRP ≥40 mg/L performed well to predict mortality (and performed similarly to treating CRP as a linear variable). Conclusions The distributional characteristics of CRP indicated an optimal cut-off of ≥40 mg/L was associated with mortality. This threshold may assist clinicians in using CRP as an early trigger for enhanced observation, treatment decisions and advanced care planning.

Thyroid nodules are common and a frequent reason for referral to secondary care. Clinical assessment and investigation should aim to address the possibility of malignancy, functional status of the thyroid and compressive symptoms. A combination of neck ultrasound and fine needle aspiration cytology (FNAC) can usually help establish a plan of management, allowing conservative management of most patients, and surgical treatment for those with suspected or confirmed thyroid cancer. The limitations of FNAC include a relatively high rate of inadequate/non-diagnostic samples, and the inability of cytology to distinguish between benign and malignant follicular neoplasms. Surgery may therefore be required to establish the diagnosis in patients with indeterminate nodules, in addition to its role in treatment for compressive symptoms or thyrotoxicosis.

Background Phaeochromocytomas (PCC) and paragangliomas (PGL) are rare neuroendocrine tumours of chromaffin cells that secrete catecholamines. The understanding of their aetiology and management is evolving. This study aimed to examine aspects in the management of PCC and PGL over the last decade. Methods Patients undergoing surgery for PCC/PGL over an eleven-year period were studied using a prospectively maintained database and electronic hospital clinical portal. Appropriate statistics were then employed. Results Sixty-nine patients underwent surgery (35 female, median age 52 years (12–82) to treat 57 PCC (inc. 2 bilateral) and 14 PGLs (inc. 2 recurrences). Although PCC and PGL patients were matched for gender and tumour-size, those with PGL were younger (median 40 (12–75) versus 54 (23–82), p = 0.044). PGL patients were also more likely to have a genetic abnormality identified (58.3% versus 16.1%, p = 0.002) and to have a malignant tumour (38.5% vs 6.8%, p = 0.002). Peri-operative blockade regimes were similar, but PGLs more frequently had an open procedure (42.9% vs 5.3% p Conclusions PGLs represent an even rarer subset of an already rare tumour-type. Access to multi-disciplinary specialists and appropriate decision-making are critical. High incidence of inherited disease, increased malignancy and recurrence rates along with the increased operative complexity favour greater use of open surgery and specialised follow-up to ascertain recurrence, as well as access to high quality genetic counselling services.

Post-operative complications following emergency abdominal surgery are associated with significant morbidity and mortality. Despite the knowledge of prognostic factors associated with poor surgical outcomes; few have described risks of poor outcomes based on admission information in acute surgical setting. We aimed to derive a simple, point-of-care risk scale that predicts adults with increased risk of poor outcomes.We used data from an international multi-centre prospective cohort study. The effect of characteristics; age, hypoalbuminaemia, anaemia, renal insufficiency and polypharmacy on 90-day mortality was examined using fully adjusted multivariable models. For our secondary outcome we aimed to test whether these characteristics could be combined to predict poor outcomes in adults undergoing emergency general surgery. Subsequently, the impact of incremental increase in derived SHARP score on outcomes was assessed.The cohort consisted of 419 adult patients between the ages of 16-94 years (median 52; IQR(39) consecutively admitted to five emergency general surgical units across the United Kingdom and one in Ghent, Belgium. In fully adjusted models the aforementioned characteristics; were associated with 90-day mortality. SHARP score was associated with higher odds of mortality in adults who underwent emergency general surgery, with a SHARP score of five also being associated with an increased length of hospital stay.SHARP risk score is a simple prognostic tool, using point-of-care information to predict poor outcomes in patients undergoing emergency general surgery. This information may be used to improve management plans and aid clinicians in delivering more person-centred care. Further validation studies are required to prove its utility.

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.

Background In 2018, AJCC TNM staging changed for differentiated (DTC) and anaplastic (ATC) thyroid carcinoma. The impact of this change on mortality rates was investigated and compared with the MACIS prognostic score. Methods Analysis of a prospective database of DTC/ATC was undertaken. Patients were staged according to TNM7 and TNM8 criteria, and MACIS scores calculated. Five‐year disease‐specific mortality rates were determined. Proportions were compared with Fisher's exact and χ2 goodness‐of‐fit tests. Results Between August 2002 and December 2016, 310 patients had primary surgery for thyroid cancer. After exclusions, 159 patients (154 DTC, 5 ATC) remained to be studied. The MACIS score was less than 6 in 105 patients (66·0 per cent), 6–6·99 in 19 (11·9 per cent), 7–7·99 in 14 (8·8 per cent) and 8 or more in 21 (13·2 per cent), with corresponding disease‐specific 5‐year mortality rates of 0, 5, 14 and 86 per cent. For TNM7 the distribution was stage I in 53·5 per cent (85 patients), stage II in 10·1 per cent (16), stage III in 14·5 per cent (23) and stage IV in 22·0 per cent (35), and differed from that for TNM8: 76·7 per cent (122), 10·7 per cent (17), 4·4 per cent (7) and 8·2 per cent (13) respectively (P

There has been a paradigm shift in the approach to primary hyperparathyroidism (PHPT), from bilateral cervical exploration (BCE) to focused parathyroidectomy facilitated by preoperative localization scans. This has resulted in fewer four-gland explorations. Conversely, patients with negative localization are more likely to have smaller parathyroid tumors and, more often, have multiple gland disease (MGD). The diagnosis of mild or normocalcemic PHPT means that such patients now account for one-fifth of patients referred with PHPT. Nonlocalized disease may be associated with a 13% negative exploration rate and a surgical failure rate that is as high as 18%. Parathyroidectomy for MGD is, therefore, complex and associated with a higher operative failure compared with single-gland disease. Surgery in this setting poses several challenges; the diagnosis is often not clear until well into the neck exploration, as preoperative localization is rarely helpful. Furthermore, hyperplastic glands are typically much smaller than solitary parathyroid adenomas; therefore they are more difficult to identify. At times, it can be difficult to distinguish a small hyperplastic gland from a normal parathyroid. Finally, subtotal resection with or without thymectomy requires more surgical experience and judgment compared with excision of a solitary adenoma. For these reasons, consideration should be given toward centralizing the management both of patients predicted to have MGD, and those with negative preoperative localization, to high-volume centers. This chapter focuses on the pathology and etiology of sporadic multiglandular parathyroid disease and the rationale for the different surgical approaches used in the management of this challenging condition.

Highlights • Mortality from COVID-19 is not affected by prescription of ACEi and / or ARBs. • Hospital length of stay is reduced in patients prescribed ACEi or ARB when diagnosed with COVID-19. • This study should provide reassurance to patients and clinicians that continuation of ACEi or ARBs is not harmful, and maybe even confer benefit in COVID-19., Objective During the COVID-19 pandemic the continuation or cessation of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) has been contentious. Mechanisms have been proposed for both beneficial and detrimental effects. Recent studies have focused on mortality with no literature having examined length of hospital stay. The aim of this study was to determine the influence of ACEi and ARBs on COVID-19 mortality and length of hospital stay. Methods COPE (COVID-19 in Older People) is a multicenter observational study including adults of all ages admitted with either laboratory or clinically confirmed COVID-19. Routinely generated hospital data were collected. Primary outcome: mortality; secondary outcomes: Day-7 mortality and length of hospital stay. A mixed-effects multivariable Cox’s proportional baseline hazards model and logistic equivalent were used. Results 1371 patients were included from eleven centres between 27th February to 25th April 2020. Median age was 74 years [IQR 61-83]. 28.6% of patients were taking an ACEi or ARB. There was no effect of ACEi or ARB on inpatient mortality (aHR=0.85, 95%CI 0.65-1.11). For those prescribed an ACEi or ARB, hospital stay was significantly reduced (aHR=1.25, 95%CI 1.02-1.54, p=0.03) and in those with hypertension the effect was stronger (aHR=1.39, 95%CI 1.09-1.77, p=0.007). Conclusions Patients and clinicians can be reassured that prescription of an ACEi or ARB at the time of COVID-19 diagnosis is not harmful. The benefit of prescription of an ACEi or ARB in reducing hospital stay is a new finding.

Background The United Kingdom Registry of Endocrine and Thyroid Surgeons is a national database holding details on > 28,000 parathyroidectomies. Methods An extract (2004–2017) of the database was analysed to investigate the reported efficacy, safety and use of intra-operative surgical adjuncts in targeted parathyroidectomy (tPTx) and bilateral neck exploration (BNE) for adult, first-time primary hyperparathyroidism (PHPT). Results 50.9% of 21,738 cases underwent tPTx. Excellent short-term (median follow-up 35 days) post-operative normocalcaemia rates were reported overall (tPTx 96.6%, BNE 94.5%, p p p p p p p > 0.05), nor any difference in VC dysfunction when formally examined (4.9% vs 4.1%, p > 0.05). Conclusions In image-positive, first time, adult PHPT cases, tPTx is as safe and effective as BNE, with both achieving excellent short-term results with minimal complications.

Background: The impact of surgical operation on older people presenting as general surgical patients compared to non-surgical management is less well researched.Methods: We examined the association between management and adverse outcomes in a cohort of emergency general surgery patients aged>65 years. This multi-center study included 727 patients (mean+/-SD, 77.1±8.2 years, 54% female) admitted to five UK hospitals. Data were analyzed using multi-level crude and multivariable logistic regression. Outcomes included: mortality at Day 30 and 90, length of stay, and readmission within 30 days of discharge. Covariates assessed were management approach, age, sex, frailty, polypharmacy, anemia, and hypoalbuminemia.Results: Approximately 25% of participants (n=185) underwent emergency surgery. Frailty and albumin were associated with mortality at 30 (frailty OR=3.52 [95%CI 1.66-7.49], albumin OR=3.78 ([95%CI 1.53-9.31]), and 90 days post discharge (frailty OR=3.20 [95%CI 1.86-5.51], albumin OR=3.25 [95%CI 1.70-6.19]) and readmission (frailty OR=1.56 [[95%CI (1.04-2.35)]. Surgically managed patients and frailty had increased odds of prolonged hospitalization (surgery OR=5.69 [95%CI 3.67-8.80], frailty OR=2.17 [95%CI 1.46-3.23]).Conclusion: We found the impact of surgery on length of hospitalisation in older surgical patients is substantial. Whether early comprehensive geriatric assessment and post-op rehabilitation would improve this outcome require further evaluation.

Coronavirus disease 2019 (COVID-19) infection causes acute lung injury, resulting from aggressive inflammation initiated by viral replication. There has been much speculation about the potential role of non-steroidal inflammatory drugs (NSAIDs), which increase the expression of angiotensin-converting enzyme 2 (ACE2), a binding target for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to enter the host cell, which could lead to poorer outcomes in COVID-19 disease. The aim of this study was to examine the association between routine use of NSAIDs and outcomes in hospitalised patients with COVID-19. This was a multicentre, observational study, with data collected from adult patients with COVID-19 admitted to eight UK hospitals. Of 1222 patients eligible to be included, 54 (4.4%) were routinely prescribed NSAIDs prior to admission. Univariate results suggested a modest protective effect from the use of NSAIDs, but in the multivariable analysis, there was no association between prior NSAID use and time to mortality (adjusted HR (aHR) = 0.89, 95% CI 0.52&ndash, 1.53, p = 0.67) or length of stay (aHR 0.89, 95% CI 0.59&ndash, 1.35, p = 0.58). This study found no evidence that routine NSAID use was associated with higher COVID-19 mortality in hospitalised patients, therefore, patients should be advised to continue taking these medications until further evidence emerges. Our findings suggest that NSAID use might confer a modest benefit with regard to survival. However, as this finding was underpowered, further research is required.

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

Introduction The incidence of thyroid cancer has increased worldwide, whether a real or apparent increase is debated. Literature from the USA suggests greater diagnostic scrutiny, environmental and genetic factors may all play a part. This increase will result in a greater number of referrals for surgical assessment. This study examined the trend in incidence of thyroid cancer in England and Wales. Materials and Methods A retrospective study, using the HES database over the period 2000-2010. Data were extracted of all newly diagnosed thyroid cancers in England and Wales and the age at diagnosis. Data were examined for the change in incidence of thyroid cancer diagnosis dependent on the age group of the patient using the linear regression model. Results 45411 patients were identified. In England the incidence of thyroid cancer rose from 5.7/100,000 of the population in 2000 to 9.9/100,000 in 2010 and in Wales it rose from 3.5/100,000 in 2000 to 7.5/100,000. There was a statistical increase (P≤0.02) (t-stat >2) in the diagnosis of thyroid cancers across all age groups with exception of the 0-14 age group (P>0.5). Conclusion There has been a statistical increase in the incidence of thyroid cancer. This is likely to impact on hospitals and cancer service resources. An increase in surgical demand and the coinciding ageing population highlights the importance of further investigation into the etiology, use of imaging, patient demographics, histology and overall mortality of this patient group.

Background: With an ageing population, an increasing number of older adults are admitted for assessment to acute surgical units. Older adults have specific factors that may influence outcomes, one of which is delirium (acute cognitive impairment). Objectives: To establish the prevalence of delirium on admission in an older acute surgical population and its effect on mortality. Secondary outcomes investigated include hospital readmission and length of hospital stay. Method: This observational multi-centre study investigated consecutive patients, &ge, 65 years, admitted to the acute surgical units of five UK hospitals during an eight-week period. On admission the Confusion Assessment Method (CAM) score was performed to detect delirium. The effect of delirium on important clinical outcomes was investigated using tests of association and logistic regression models. Results: The cohort consisted of 411 patients with a mean age of 77.3 years (SD 8.1). The prevalence of admission delirium was 8.8% (95% CI 6.2&ndash, 11.9%) and cognitive impairment was 70.3% (95% CI 65.6&ndash, 74.7%). The delirious group were not more likely to die at 30 or 90 days (OR 1.1, 95% CI 0.2 to 5.1, p = 0.67, OR 1.4, 95% CI 0.4 to 4.1. p = 0.82) or to be readmitted within 30 days of discharge (OR 0.9, 95% CI 0.4 to 2.2, p = 0.89). Length of hospital stay was significantly longer in the delirious group (median 8 vs. 5 days respectively, p = 0.009). Conclusion: Admission delirium occurs in just under 10% of older people admitted to acute surgical units, resulting in significantly longer hospital stays.

BackgroundThis study investigated the indications, procedures and outcomes for adrenal surgery from the UK Registry of Endocrine and Thyroid Surgery database from 2005 to 2017, and compared outcomes between benign and malignant disease.MethodsData on adrenalectomies were extracted from a national surgeon‐reported registry. Preoperative diagnosis, surgical technique, length of hospital stay, morbidity and in‐hospital mortality were examined.ResultsSome 3994 adrenalectomies were registered among patients with a median age of 54 (i.q.r. 43–65) years (55·9 per cent female). Surgery was performed for benign disease in 81·5 per cent. Tumour size was significantly greater in malignant disease: 60 (i.q.r. 34–100) versus 40 (24–55) mm (P ConclusionAdrenalectomy is a safe procedure but the higher incidence of open surgery for malignant disease appears to influence postoperative outcomes.

BACKGROUND/PURPOSE A key measure to maintain and improve the quality of healthcare is the formal accreditation of provider units. The European Society of Endocrine Surgeons (ESES) therefore proposes a system of accreditation for endocrine surgical centers in Europe to supplement existing measures that promote high standards in the practice in endocrine surgery. METHODS A working group analyzed the current healthcare situation in the field of endocrine surgery in Europe. Two surveys were distributed to ESES members to acquire information about the structure, staffing, caseload, specifications, and technology available to endocrine surgery units. Further data were sought on tracer diagnoses for quality standards, training provision, and research activity. Existing accreditation models related to endocrine surgery were included in the analysis. RESULTS The analysis of existing accreditation models, available evidence, and survey results suggests that a majority of ESES members aspire to a two-level model (termed competence and reference centers), sub-divided into those providing neck endocrine surgery and those providing endocrine surgery. Criteria for minimum caseload, number and certification of staff, unit structure, on-site collaborating disciplines, research activities, and training capacity for competence center accreditation are proposed. Lastly, quality indicators for distinct tracer diagnoses are defined. CONCLUSIONS Differing healthcare structures, existing accreditation models, training models, and varied case volumes across Europe are barriers to the conception and implementation of a pan-European accreditation model. However, there is consensus on accepted standards required for accrediting an ESES competence center. These will serve as a basis for first-stage accreditation of endocrine surgery units.

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

Introduction Focused parathyroidectomy for primary hyperparathyroidism (pHPT) in patients with a single positive localizing scan may have an unacceptably high recurrence rate unless intraoperative parathyroid hormone (ioPTH) is used. The CaPTHUS score was previously developed to predict singlegland disease in such instances. We evaluated the accuracy of this model in a cohort of patients with pHPT in the UK. Materials and methods CaPTHUS scores were calculated from prospectively collected data on consecutive patients undergoing surgery for pHPT [(1 point each for: Preoperative calcium ≥3 mmol/L; PTH ≥2 times upper limit; ultrasound (1 point) and sestamibi (1 point) positive for single enlarged gland; concordant positive scans]. Diagnosis of single or multigland disease was confirmed on pathology. Results From June 2007 to October 2011, 324 patients (251 female, median age 66, 10.89) underwent surgery for pHPT guided with ioPTH. Single-gland pathology was observed in 291 (89.8%) patients and multi-gland disease seen in 33 (10.2%). In single-gland disease patients, significantly higher preoperative calcium (p = 0.030) and PTH levels (p = 0.033) were seen with sensitivities of 65.6% for ultrasound and 66.0% for sestamibi scanning. A CaPTHUS score ≥3 was seen in 51.2% of all patients with a positive predictive value (PPV) for single-gland disease of 99.4%. Conclusion A CaPTHUS score ≥3 was accurate at predicting single-gland disease in >50% of patients with pHPT, providing a similar PPV and reducing the need for ioPTH implementation in this population. However, recent conflicting literature suggests the CaPTHUS score may not be universally applicable, local audit is recommended before implementation. How to cite this article James TW, Stechman MJ, Scott- Coombes DM. The CaPTHUS Scoring Model revisited: Applicability from a UK Cohort with Primary Hyperparathyroidism. World J Endoc Surg 2017;9(1):7-12.

Frailty assessed using Clinical Frailty Scale (CFS) is a good predictor of adverse clinical events including mortality in older people. CFS is also an essential criterion for determining ceilings of care in people with COVID-19. Our aims were to assess the prevalence of frailty in older patients hospitalised with COVID-19, their sex and age distribution, and the completion rate of the CFS tool in evaluating frailty. Methods: Data were collected from thirteen sites. CFS was assessed routinely at the time of admission to hospital and ranged from 1 (very fit) to 9 (terminally ill). The completion rate of the CFS was assessed. The presence of major comorbidities such as diabetes and cardiovascular disease was noted. Results: A total of 1277 older patients with COVID-19, aged ≥ 65 (79.9 ± 8.1) years were included in the study, with 98.5% having fully completed CFS. The total prevalence of frailty (CFS ≥ 5) was 66.9%, being higher in women than men (75.2% vs. 59.4%, p < 0.001). Frailty was found in 161 (44%) patients aged 65–74 years, 352 (69%) in 75–84 years, and 341 (85%) in ≥85 years groups, and increased across the age groups (

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

A 42-year-old man arrived at the emergency department in severe respiratory distress, requiring immediate intubation and ventilation. An emergency computed tomography (CT) neck scan identified a substantial haematoma within a multinodular goitre, necessitating an emergency total thyroidectomy. It was later discovered that the patient had been the victim of an assault involving blunt trauma to the anterior neck. Five days postoperatively the patient was extubated and was well enough to self-discharge the following day. Pathology revealed the lesion to be a ruptured follicular adenoma within his multinodular goitre. Signs of this rare but life-threatening condition may be subtle on initial presentation, particularly if the patient is obtunded. Patients with suspected blunt neck trauma should be observed for signs of respiratory distress. If this develops, the patient should be intubated to facilitate CT scan, and if thyroid haematoma is confirmed, emergency thyroidectomy is the definitive treatment.

Introducing the UK’s first thyroid FNA training course.

SummaryThis review identifies and examines the clinical application of risk prediction tools, including the American Society of Anaesthesiology (ASA) Classification System and POSSUM-based scores, in the older general surgical patient. Predicting outcomes in this patient group remains difficult; it is challenging to design a risk prediction tool that will apply to both emergency and elective surgery and that remains valid across the wide age range that this patient group encompasses. Risk prediction tools can have benefit but should be used in conjunction with the clinical assessment of those experienced in the care of this challenging patient group.

Evidence from clinical and experimental data suggests that thyrotropin receptor (TSHR) signaling is involved in energy expenditure through its impact on white adipose tissue (WAT) and brown adipose tissue (BAT). TSHR expression increases during mesenchymal stem cell (MSC) differentiation into fat. We hypothesize that TSHR activation [TSHR*, elevated thyroid-stimulating hormone, thyroid-stimulating antibodies (TSAB), or activating mutation] influences MSC differentiation, which contributes to body composition changes seen in hypothyroidism or Graves’ disease (GD). The role of TSHR activation on adipogenesis was first investigated using ex vivo samples. Neck fat (all euthyroid at surgery) was obtained from GD (n = 11, TSAB positive), toxic multinodular goiter (TMNG, TSAB negative) (n = 6), and control patients with benign euthyroid disease (n = 11, TSAB negative). The effect of TSHR activation was then analyzed using human primary abdominal subcutaneous preadipocytes (n = 16). Cells were cultured in complete medium (CM) or adipogenic medium [ADM, containing thiazolidinedione (TZD), PPARγ agonist, which is able to induce BAT formation] with or without TSHR activation (gain-of-function mutant) for 3 weeks. Adipogenesis was evaluated using oil red O (ORO), counting adipogenic foci, qPCR measurement of terminal differentiation marker (LPL). BAT [PGC-1α, uncoupling protein 1 (UCP1), and ZIC1], pre-BAT (PRDM16), BRITE− (CITED1), or WAT (LEPTIN) markers were analyzed by semiquantitative PCR or qPCR. In ex vivo analysis, there were no differences in the expression of UCP1, PGC-1α, and ZIC1. BRITE marker CITED1 levels were highest in GD followed by TMNG and control (p for trend = 0.009). This was associated with higher WAT marker LEPTIN level in GD than the other two groups (p

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

Background The purpose of the study is to examine the prevalence of hyperglycaemia in an older acute surgical population and its effect on clinically relevant outcomes in this setting. Methods Using Older Persons Surgical Outcomes Collaboration (OPSOC) multicentre audit data 2014, we examined the prevalence of admission hyperglycaemia, and its effect on 30-day and 90-day mortality, readmission within 30 days and length of acute hospital stay using logistic regression models in consecutive patients, ≥65 years, admitted to five acute surgical units in the UK hospitals in England, Scotland and Wales. Patients were categorised in three groups based on their admission random blood glucose: Results A total of 411 patients (77.25±8.14 years) admitted during May and June 2014 were studied. Only 293 patients (71.3%) had glucose levels recorded on admission. The number (%) of patients with a blood glucose Conclusion Despite current guidelines, nearly a third of older people with surgical diagnoses did not have their glucose checked on admission highlighting the challenges in prognostication and evaluation research to improve care of older frail surgical patients.

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

Aim The use of laparoscopy, with or without appendicectomy, is becoming more common in the management of acute right iliac fossa (RIF) pain, but little is known of the ‘unintended’ consequences of this change. This study aimed to evaluate the impact of increased use of laparoscopy on the number and type of patients treated surgically and on the rate of negative appendicectomy. Method A prospective audit was carried out of admissions to a teaching hospital over two, 3-month periods during 2007 and 2008. The management, investigations and outcome of patients presenting with RIF pain were studied. Results Admissions were stable over the two time-periods. There was a significant increase in the number of laparoscopic operations performed, from 22.5% (14/62) in 2007 to 85.7% (72/84) in 2008 (P

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.