Impact of adrenal surgeon volume on outcome: analysis of 4464 operations from the United Kingdom Registry of Endocrine and Thyroid Surgery (UKRETS).

BACKGROUND: There is a surgeon volume-outcome effect in adrenal surgery but the threshold for high-volume surgeon remains controversial. This study aimed to determine predictors of high-risk adrenal operations and to explore whether these should be restricted to high-volume surgeons. METHODS: Patients undergoing adrenal surgery and registered in the United Kingdom Registry of Endocrine and Thyroid Surgery between 2004 and 2021 were analysed. Outcomes included postoperative complications, duration of hospital stay, and mortality. Factors included in multivariable analysis were age, sex, diagnosis, surgical approach, laterality, and surgeon volume. Patients with missing data were excluded. RESULTS: A total of 4464 of 6174 patients (72.3%) were analysed. Postoperative complications occurred in 418 patients (9.4%) and 14 (0.3%) died. Median duration of hospital stay was 3 (i.q.r. 2-5) days. Co-variables significantly associated with an increase or decrease in postoperative complications (P < 0.050) were age (OR 1.02, 95% c.i. 1.01 to 1.03), adrenal cancer (OR 1.64, 1.14 to 2.36), minimally invasive approach (OR 0.317, 0.248 to 0.405), bilateral surgery (OR 1.66, 1.03 to 2.69), and surgeon volume (OR 0.98, 0.96 to 0.99). An increase or decrease in mortality was associated with patient age (OR 1.08, 1.03 to 1.13), minimally invasive approach (OR 0.08, 0.02 to 0.27), and bilateral surgery (OR 6.93, 1.40 to 34.34). The incidence of postoperative complications was significantly lower above a threshold of 12 operations per year (P = 0.034) and 20 per year (P < 0.001), but not six per year (P = 0.540). Median duration of hospital stay was 2 days for surgeons doing over 20 operations per year, compared with 3 days for those undertaking fewer than 20, fewer than 12 or fewer than 6 operations per year. CONCLUSION: Increasing surgical volume is associated with shorter hospital stay and fewer complications. This analysis supports the case for centralization of surgery for adrenal cancer and bilateral tumours to higher-volume surgeons performing a minimum of 12 operations per year.

The adrenal glands are found in the fatty tissue at the back of the abdomen above each kidney, and produce steroid and adrenaline hormones. Surgery on tumours of the adrenal gland is uncommon compared with surgery for other tumours such as those of the breast, bowel, kidney, and lung. Research has shown that the more adrenal operations a surgeon undertakes per year, the better the overall outcomes for patients undergoing that type of surgery. In this study, the outcomes from adrenal operations recorded over 18 years in the national adrenal surgical registry by members of the British Association of Endocrine and Thyroid Surgeons were analysed. The results confirmed previous findings showing that postoperative complications and length of hospital stay were reduced for patients operated by surgeons who did more adrenal operations per year. Operations done by keyhole surgery had better outcomes. Operations done either in older patients, or for the rare adrenal cancer tumours had worse outcomes, as did operations in which both adrenal glands were removed. The authors recommended that all surgeons performing adrenal surgery should monitor the outcomes of their operations, ideally in a national registry, and discuss these with patients before surgery; and undertake a minimum of 6 adrenal operations per year, but a minimum of 12 per year if doing surgery for adrenal cancer or surgery to remove both adrenal glands.

A retrospective database analysis of pediatric parathyroidectomies from the United Kingdom registry of endocrine and Thyroid Surgeons.

INTRODUCTION: The United Kingdom Registry of Endocrine and Thyroid Surgery (UKRETS) holds the largest database of pediatric parathyroidectomy cases globally. There are currently no quoted acceptable cure or complication rates in the literature. METHODS: This retrospective database analysis evaluates the efficacy and safety of targeted parathyroidectomy (tPTx) and bilateral neck exploration (BNE) in first-time parathyroidectomy for pediatric primary hyperparathyroidism (PHPT) through analysis of the UKRETS database (1995-2022). Pre-, intra- and postoperative outcomes were assessed and analyzed. RESULTS: 168 cases underwent parathyroidectomy; 25 (15%) familial and 143 (85%) sporadic PHPT. 69% were female with a mean age of 10 years (Range 0-17). BNE was the most common operative approach (61%; n = 103/168). The most frequently used imaging modality was US (80%; n = 135/168). Mean number of glands excised in familial cases was three compared to one gland in sporadic cases (p < 0.05). Familial cases had a significantly higher rate of postoperative hypocalcemia (32% vs. 9%, p < 0.05) and all were BNE. Cure rate was 96.9% (n = 127/131), with differences in cure rates that did not reach statistical significance (sporadic 98.2% vs. familial 90.5%, p = 0.06). Preoperative localization (image-positive or negative) made no difference to cure rates in either familial (90% vs. 91%, p = 0.94) or sporadic (97.5% vs. 100%, p = 0.4) cases. CONCLUSIONS: This analysis demonstrates that first-time pediatric parathyroidectomy for PHPT is safe and effective. Familial cases have a higher rate of postoperative hypocalcemia; therefore, parents should be informed of this when consented. Targeted parathyroidectomy is safe and effective in both sporadic and familial cases, as long as there is positive preoperative imaging.

Prognostic significance of socioeconomic deprivation in patients undergoing emergency laparotomy: A retrospective cohort study.

OBJECTIVES: Deprivation is a complex, multifaceted concept and not synonymous with poverty. The aim of this study was to assess the prognostic influence of the multiple deprivation index on emergency laparotomy (EL) outcome. METHODS: STROCSS statement standards were followed to conduct a retrospective cohort study. Consecutive 1723 adult patients [median age (range): 66 (18-98), 762 M, and 961 F] undergoing EL over eight years (2014-22) at two hospitals [a tertiary teaching center and district general hospital (DGH)] were studied. Deprivation scores and ranks were derived from patients' postcodes using the Welsh Index of Multiple Deprivation and ranks categorized into quartiles. Primary outcome measure was a 30-day operative mortality (OM). RESULTS: OM risk was higher in the most deprived quartile (Q1) compared with the least deprived quartile (Q4) (13.2% vs. 7.9% and p = 0.008). Deprivation was an independent predictor of OM on both univariate (unadjusted OR: 1.75, 95% CI 1.17-2.61, and p = 0.006) and multivariable logistic regression analyses (OR: 1.03, 95% CI 1.01-1.06, and p = 0.023; adjusted for age ≥80 years, American Society of Anesthesiologists grade, need for bowel resection, and peritoneal contamination). Deprivation had poor discriminatory value in predicting OM (AUC: 0.56 and 95% CI 0.54-0.59). Subgroup analysis showed that although the risk of OM was lower in the tertiary center compared with the DGH (7.9% vs. 14.5% and p < 0.001), the predictive significance of deprivation was similar in both hospitals (AUC: 0.54 vs. 0.56 and p = 0.674). CONCLUSION: Deprivation is an independent but modest predictor of OM after EL. The potential prognostic value of incorporating deprivation into preoperative risk assessment algorithms deserves further evaluation.

Accreditation of endocrine surgery units.

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.

The prevalence of hyperglycaemia and its relationship with mortality, readmissions and length of stay in an older acute surgical population: a multicentre study.

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: <7.1, between 7.1 and 11.1 and ≥11.1 mmol/L. 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 <7.1, 7.1-11.1 and ≥11.1 mmol/L were 171 (58.4), 99 (33.8) and 23 (7.8), respectively. On univariate analysis, admission hyperglycaemia was not predictive of any of the outcomes investigated. Although the characteristics of those with no glucose level were not different from the included sample, 30-day mortality was significantly higher in those who had not had their admission glucose level checked (10.2% vs 2.7%), suggesting a potential type II error. 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.

Electrostatic precipitation is a novel way of maintaining visual field clarity during laparoscopic surgery: a prospective double-blind randomized controlled pilot study.

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.

A study of variation in therapeutic approach to low-risk differentiated thyroid cancer in the UK.

BACKGROUND: The British Thyroid Association and American Thyroid Association guideline definitions for low-risk differentiated thyroid cancers are susceptible to differing interpretations, resulting in different clinical management in the UK. OBJECTIVE: To explore the national effect of these guidelines on the management of low-risk differentiated thyroid cancers. METHODS: Anonymised questionnaires were sent to multidisciplinary teams performing thyroidectomies in the UK. Risk factors that multidisciplinary teams considered important when managing low-risk differentiated thyroid cancers were established. RESULTS: Most surgeons (71 out of 75; 94.7 per cent) confirmed they were core multidisciplinary team members. More than 80 per cent of respondents performed at least 30 hemi- and/or total thyroidectomies per annum. A majority of multidisciplinary teams (50 out of 75; 66.7 per cent) followed British Thyroid Association guidelines. Risk factors considered important when managing low-risk differentiated thyroid cancers included: type of tumour histology findings (87.8 per cent), tumour size of greater than 4 cm (86.5 per cent), tumour stage T3b (85.1 per cent) and central neck node involvement (85.1 per cent). Extent of thyroid surgery (e.g. hemi- or total thyroidectomy) was highly variable for low-risk differentiated thyroid cancers. CONCLUSION: Management of low-risk differentiated thyroid cancers is highly variable, leading to a heterogeneous patient experience.

Robotic and Laparoscopic Adrenalectomy for Pheochromocytoma: An International Multicenter Study.

BACKGROUND AND OBJECTIVE: Robotic adrenalectomy (RA) has attracted interest as an alternative to laparoscopic adrenalectomy (LA) for patients with pheochromocytoma, although its beneficial effects are uncertain. Our aim was to compare RA and LA outcomes for these patients. METHODS: Data for patients who underwent RA or LA for pheochromocytoma in 46 international centers between 2012 and 2022 were reviewed. We analyzed baseline characteristics and postoperative complications at discharge, 90 d, and 1 yr. We conducted propensity score matching (PSM; 1:1 ratio) and multivariable analyses to evaluate outcomes and risk factors for the occurrence of complications and higher Comprehensive Complication Index (CCI). KEY FINDINGS AND LIMITATIONS: Of 1755 patients, 1613 (91.9%) underwent LA and 142 (8.1%) underwent RA. Estimated blood loss, conversion rate, complication rate, and CCI at discharge, 90 d, and 1 yr were similar between the groups. However, RA was associated with a longer operative time in comparison to LA (100 vs 123 min; p < 0.001), but not after PSM (p = 0.120). Multivariable analysis revealed that Charlson comorbidity index (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.07-1.29; p = 0.001), and tumor size per 1-cm increment (OR 1.13, 95% CI 1.07-1.21; p < 0.001) were independently associated with the incidence of complications, but there was no significant difference in complication rates between the LA and RA groups (OR 1.09, 95% CI 0.63-1.87; p = 0.767). After PSM, RA was associated with a lower rate of severe (grade ≥3a) complications in comparison to LA (p = 0.023). CONCLUSIONS AND CLINICAL IMPLICATIONS: RA is a safe alternative to LA and yields similar outcomes for patients with pheochromocytoma. RA may be associated with a lower likelihood of severe complications. Further studies are warranted to determine the role of robotic surgery in pheochromocytoma. PATIENT SUMMARY: Pheochromocytoma is a rare tumor in the adrenal gland and the gold-standard treatment is surgical removal. We assessed patient outcomes after robot-assisted surgery compared with laparoscopic surgery and found that outcomes are similar, but the rate of severe complications may be lower if a surgical robot is used.

The value of intraoperative PTH measurements in patients with mild primary hyperparathyroidism.

PURPOSE: 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. METHODS: 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 <2.85 mmol/L were grouped as severe and mild hypercalcaemia, respectively. Correlation coefficients were calculated to assess the relationship between biochemical markers of calcium homeostasis and ioPTH measurements with respect to parathyroid gland weight. RESULTS: There was a weak correlation of preoperative serum calcium (r = 0.248, r = 0.207), PTH (r = 0.392, r = 0.275), and baseline ioPTH (r = 0.516, r = 0.244) with parathyroid gland weight in severe (n = 113) and mild groups (n = 190), respectively. No correlation between the magnitude in ioPTH drop with parathyroid gland weight at 5 or 10 min post-excision for either group was observed. Success rates (post-operative normocalcaemia) were similar for each group (99.1 % severe, 98.9 % mild). CONCLUSION: This prospective study provides evidence that ioPTH assay is a valuable tool in predicting adequate tissue removal in patients with milder and more severe hypercalcaemia due to single gland primary HPT.

SHARP risk score: A predictor of poor outcomes in adults admitted for emergency general surgery: A prospective cohort study.

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Risk factors for postoperative complications after adrenalectomy for phaeochromocytoma: multicentre cohort study.

BACKGROUND: To determine the incidence and risk factors for postoperative complications and prolonged hospital stay after adrenalectomy for phaeochromocytoma. METHODS: Demographics, perioperative outcomes and complications were evaluated for consecutive patients who underwent adrenalectomy for phaeochromocytoma from 2012 to 2020 in nine high-volume UK centres. Odds ratios were calculated using multivariable models. The primary outcome was postoperative complications according to the Clavien---Dindo classification and secondary outcome was duration of hospital stay. RESULTS: Data were available for 406 patients (female n = 221, 54.4 per cent). Two patients (0.5 per cent) had perioperative death, whilst 148 complications were recorded in 109 (26.8 per cent) patients. On adjusted analysis, the age-adjusted Charlson Co-morbidity Index ≥3 (OR 8.09, 95 per cent c.i. 2.31 to 29.63, P = 0.001), laparoscopic converted to open (OR 10.34, 95 per cent c.i. 3.24 to 36.23, P <0.001), and open surgery (OR 11.69, 95 per cent c.i. 4.52 to 32.55, P <0.001) were independently associated with postoperative complications. Overall, 97 of 430 (22.5 per cent) had a duration of stay ≥5 days and this was associated with an age-adjusted Charlson Co-morbidity Index ≥3 (OR 4.31, 95 per cent c.i. 1.08 to 18.26, P = 0.042), tumour size (OR 1.15, 95 per cent c.i. 1.05 to 1.28, P = 0.006), laparoscopic converted to open (OR 32.11, 95 per cent c.i. 9.2 to 137.77, P <0.001), and open surgery (OR 28.01, 95 per cent c.i. 10.52 to 83.97, P <0.001). CONCLUSION: Adrenalectomy for phaeochromocytoma is associated with a very low mortality rate, whilst postoperative complications are common. Several risk factors, including co-morbidities and operative approach, are independently associated with postoperative complications and/or prolonged hospitalization, and should be considered when counselling patients.

Risk factors for postoperative hypotension after adrenalectomy for phaeochromocytoma: derivation of the PACS risk score.

BACKGROUND: Due to the risk of postoperative hypotension (PH), invasive monitoring is recommended for patients who undergo adrenalectomy for phaeochromocytoma. Due to high costs and limited availability of intensive care, our aim was to identify patients at low risk of PH who may not require invasive monitoring. METHODS: Data for patients who underwent adrenalectomy for phaeochromocytoma between 2012 and 2020 were retrospectively collected by nine UK centres, including patient demographics, intraoperative and postoperative haemodynamic parameters. Independent risk factors for PH were analysed and used to develop a clinical risk score. RESULTS: PH developed in 118 of 430 (27.4%) patients. On univariable analysis, female sex (p = 0.007), tumour size (p < 0.001), preoperative catecholamine level (p < 0.001), open surgery (p < 0.001) and epidural analgesia (p = 0.006) were identified as risk factors for PH. On multivariable analysis, female sex (OR 1.85, CI95%, 1.09-3.13, p = 0.02), preoperative catecholamine level (OR: 3.11, CI95%, 1.74-5.55, p < 0.001), open surgery (OR: 3.31, CI95%, 1.57-6.97, p = 0.002) and preoperative mean arterial blood pressure (OR: 0.59, CI95%, 0.48-1.02, p = 0.08) were independently associated with PH, and were incorporated into a clinical risk score (AUROC 0.69, C-statistic 0.69). The risk of PH was 25% and 68% in low and high risk patients, respectively. CONCLUSION: The derived risk score allows stratification of patients at risk of postoperative hypotension after adrenalectomy for phaeochromocytoma. Postoperatively, low risk patients may be managed on a surgical ward, whilst high risk patients should undergo invasive monitoring.

The role of C-reactive protein as a prognostic marker in COVID-19.

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.

Routine use of immunosuppressants is associated with mortality in hospitalised patients with COVID-19.

BACKGROUND: Whilst there is literature on the impact of SARS viruses in the severely immunosuppressed, less is known about the link between routine immunosuppressant use and outcome in COVID-19. Consequently, guidelines on their use vary depending on specific patient populations. METHODS: The study population was drawn from the COPE Study (COVID-19 in Older People), a multicentre observational cohort study, across the UK and Italy. Data were collected between 27 February and 28 April 2020 by trained data-collectors and included all unselected consecutive admissions with COVID-19. Load (name/number of medications) and dosage of immunosuppressant were collected along with other covariate data. Primary outcome was time-to-mortality from the date of admission (or) date of diagnosis, if diagnosis was five or more days after admission. Secondary outcomes were Day-14 mortality and time-to-discharge. Data were analysed with mixed-effects, Cox proportional hazards and logistic regression models using non-users of immunosuppressants as the reference group. RESULTS: In total 1184 patients were eligible for inclusion. The median (IQR) age was 74 (62-83), 676 (57%) were male, and 299 (25.3%) died in hospital (total person follow-up 15,540 days). Most patients exhibited at least one comorbidity, and 113 (~10%) were on immunosuppressants. Any immunosuppressant use was associated with increased mortality: aHR 1.87, 95% CI: 1.30, 2.69 (time to mortality) and aOR 1.71, 95% CI: 1.01-2.88 (14-day mortality). There also appeared to be a dose-response relationship. CONCLUSION: Despite possible indication bias, until further evidence emerges we recommend adhering to public health measures, a low threshold to seek medical advice and close monitoring of symptoms in those who take immunosuppressants routinely regardless of their indication. However, it should be noted that the inability to control for the underlying condition requiring immunosuppressants is a major limitation, and hence caution should be exercised in interpretation of the results. PLAIN LANGUAGE SUMMARY: Regular Use of Immune Suppressing Drugs is Associated with Increased Risk of Death in Hospitalised Patients with COVID-19 Background: We do not have much information on how the COVID-19 virus affects patients who use immunosuppressants, drugs which inhibit or reduce the activity of the immune system. There are various conflicting views on whether immune-suppressing drugs are beneficial or detrimental in patients with the disease. Methods: This study collected data from 10 hospitals in the UK and one in Italy between February and April 2020 in order to identify any association between the regular use of immunosuppressant medicines and survival in patients who were admitted to hospital with COVID-19. Results: 1184 patients were included in the study, and 10% of them were using immunosuppressants. Any immunosuppressant use was associated with increased risk of death, and the risk appeared to increase if the dose of the medicine was higher. Conclusion: We therefore recommend that patients who take immunosuppressant medicines routinely should carefully adhere to social distancing measures, and seek medical attention early during the COVID-19 pandemic.

Impact of Surgery on Older Patients Hospitalized With an Acute Abdomen: Findings From the Older Persons Surgical Outcome Collaborative.

Background: The impact of surgery compared to non-surgical management of older general surgical patients is not 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 were: 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 hospitalization in older surgical patients is substantial. Whether early comprehensive geriatric assessment and post-op rehabilitation would improve this outcome require further evaluation.

Study protocol for the COPE study: COVID-19 in Older PEople: the influence of frailty and multimorbidity on survival. A multicentre, European observational study.

INTRODUCTION: This 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 ANALYSIS: Over 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 DISSEMINATION: This 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.

Prior Routine Use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Important Outcomes in Hospitalised Patients with COVID-19.

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 0.52-1.53, p = 0.67) or length of stay (aHR 0.89, 95% CI 0.59-1.35, 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.

The Clinical Frailty Scale: Estimating the Prevalence of Frailty in Older Patients Hospitalised with COVID-19. The COPE Study.

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 (<0.0001, test for trend). Conclusion: Frailty was prevalent in our cohort of older people admitted to hospital with COVID-19. This indicates that older people who are also frail, who go on to contract COVID-19 may have disease severity significant enough to warrant hospitalization. These data may help inform health care planners and targeted interventions and appropriate management for the frail older person.