Enhanced stress-resilience training for surgical trainees.

INTRODUCTION: Core surgical training programmes are associated with a high risk of burnout. This study aimed to assess the influence of a novel enhanced stress-resilience training (ESRT) course delivered at the start of core surgical training in a single UK statutory education body. METHOD: All newly appointed core surgical trainees (CSTs) were invited to participate in a 5-week ESRT course teaching mindfulness-based exercises to develop tools to deal with stress at work and burnout. The primary aim was to assess the feasibility of this course; secondary outcomes were to assess degree of burnout measured using Maslach Burnout Inventory (MBI) scoring. RESULTS: Of 43 boot camp attendees, 38 trainees completed questionnaires, with 24 choosing to participate in ESRT (63.2 per cent; male 13, female 11, median age 28 years). Qualitative data reflected challenges delivering ESRT because of arduous and inflexible clinical on-call rotas, time pressures related to academic curriculum demands and the concurrent COVID-19 pandemic (10 of 24 drop-out). Despite these challenges, 22 (91.7 per cent) considered the course valuable and there was unanimous support for programme development. Of the 14 trainees who completed the ESRT course, nine (64.3 per cent) continued to use the techniques in daily clinical work. Burnout was identified in 23 trainees (60.5 per cent) with no evident difference in baseline MBI scores between participants (median 4 (range 0-11) versus 5 (1-11), P = 0.770). High stress states were significantly less likely, and mindfulness significantly higher in the intervention group (P < 0.010); MBI scores were comparable before and after ESRT in the intervention cohort (P = 0.630, median 4 (range 0-11) versus 4 (1-10)). DISCUSSION: Despite arduous emergency COVID rotas ESRT was feasible and, combined with protected time for trainees to engage, deserves further research to determine medium-term efficacy.

Predictive value of Altmetric score on citation rates and bibliometric impact.

BACKGROUND: Bibliometric and Altmetric analyses provide different perspectives regarding research impact. This study aimed to determine whether Altmetric score was associated with citation rate independent of established bibliometrics. METHODS: Citations related to a previous cohort of 100 most cited articles in surgery were collected and a 3-year interval citation gain calculated. Citation count, citation rate index, Altmetric score, 5-year impact factor, and Oxford Centre for Evidence-Based Medicine levels were used to estimate citation rate prospect. RESULTS: The median interval citation gain was 161 (i.q.r. 83-281); 74 and 62 articles had an increase in citation rate index (median increase 2.8 (i.q.r. -0.1 to 7.7)) and Altmetric score (median increase 3 (0-4)) respectively. Receiver operating characteristic (ROC) curve analysis revealed that citation rate index (area under the curve (AUC) 0.86, 95 per cent c.i. 0.79 to 0.93; P < 0.001) and Altmetric score (AUC 0.65, 0.55 to 0.76; P = 0.008) were associated with higher interval citation gain. An Altmetric score critical threshold of 2 or more was associated with a better interval citation gain when dichotomized at the interval citation gain median (odds ratio (OR) 4.94, 95 per cent c.i. 1.99 to 12.26; P = 0.001) or upper quartile (OR 4.13, 1.60 to 10.66; P = 0.003). Multivariable analysis revealed only citation rate index to be independently associated with interval citation gain when dichotomized at the median (OR 18.22, 6.70 to 49.55; P < 0.001) or upper quartile (OR 19.30, 4.23 to 88.15; P < 0.001). CONCLUSION: Citation rate index and Altmetric score appear to be important predictors of interval citation gain, and better at predicting future citations than the historical and established impact factor and Oxford Centre for Evidence-Based Medicine quality descriptors.

Surgical training rotation design: effects of hospital type, rotation theme and duration.

BACKGROUND: Entrants into UK surgical specialty training undertake a 2-year programme of core surgical training, rotating through specialties for varying lengths of time, at different hospitals, to gain breadth of experience. This study aimed to assess whether these variables influenced core surgical trainee (CST) work productivity. METHODS: Intercollegiate Surgical Curriculum Programme portfolios of consecutive CSTs between 2016 and 2019 were examined. Primary outcome measures were workplace-based assessment (WBA) completion, operative experience and academic outputs (presentations to learned societies, publications and audits). RESULTS: A total of 344 rotations by 111 CSTs were included. Incremental increases in attainment were observed related to the duration of core surgical training rotation. The median number of consultant-validated WBAs completed during core surgical training were 48 (range 0-189), 54 (10-120) and 75 (6-94) during rotations consisting of 4-, 6- and 12-month posts respectively (P < 0·001). Corresponding median operative caseloads (as primary surgeon) were 84 (range 3-357), 110 (44-394) and 134 (56-366) (P < 0·001) and presentations to learned societies 0 (0-12), 0 (0-14) and 1 (0-5) (P = 0·012) respectively. Hospital type and specialty training theme were unrelated to workplace productivity. Multivariable analysis identified length of hospital rotation as the only factor independently associated with total WBA count (P = 0·001), completion of audit (P = 0·015) and delivery of presentation (P = 0·001) targets. CONCLUSION: Longer rotations with a single educational supervisor, in one training centre, are associated with better workplace productivity. Consideration should be given to this when reconfiguring training programmes within the arena of workforce planning.

ANTECEDENTES: Los residentes de especialidades quirúrgicas del Reino Unido realizan un período troncal de formación quirúrgica de 2 años, en el que rotan por diversas especialidades durante periodos de tiempo variables y en diversos hospitales, a fin de conseguir una experiencia amplia. Este estudio tuvo como objetivo evaluar si estas variables influyeron en la productividad de los residentes durante el período troncal (core surgical trainee, CST). MÉTODOS: Se examinaron los inventarios de los programas del Intercollegiate Surgical Curriculum Programme (ISCP) de CST consecutivos entre 2016 y 2019. Las variables principales fueron la puntuación final del Workplace-Based Assessment (WBA), y la actividad quirúrgica y académica (presentaciones a sociedades académicas, publicaciones y auditorías) realizadas. RESULTADOS: Se incluyeron 344 rotaciones de 111 CST. Se constataron mejores resultados en relación con la duración de la rotación de CST. La mediana (rango) de la puntuación de los supervisores en las WBA fue de 48 (0'189), 54 (10'120) y 75 (6'94) (P < 0,001) en las rotaciones a los 4, 6 y 12 meses, respectivamente. El número de intervenciones (como cirujano principal) fue de 84 (3'357), 110 (44'394) y 134 (56'366) (P < 0,001) y de presentaciones a sociedades científicas fue de 0 (0-12), 0 (0- 14) y 1 (0-5) (P = 0,012). No hubo relación entre el tipo de hospital o la especialidad y la productividad en el lugar de trabajo. El análisis multivariable identificó la duración de la rotación como único factor independientemente relacionado con la puntuación de la WBA (P = 0,001), la finalización de la auditoría (P = 0,015) y el número de presentaciones realizadas (P = 0,001). CONCLUSIÓN: Las rotaciones de periodos de tiempo largos con un solo supervisor y en un solo centro se asocian con una mejor productividad en el lugar de trabajo. Debería tenerse en cuenta este factor al reconfigurar los programas de capacitación desde el punto de vista laboral.

Proof of surgical publication prowess: prospective observational study of factors associated with surrogate markers of academic reach.

BACKGROUND: In the UK, general surgery higher surgical trainees (HSTs) must publish at least three peer-reviewed scientific articles (as first, second or corresponding author) to qualify for certification of completion of training (CCT). This study aimed to identify the factors associated with success in this arena. METHODS: Deanery rosters supplemented with data from the Intercollegiate Surgical Curriculum Programme, PubMed and ResearchGate were used to identify the profiles of consecutive HSTs. Primary outcomes were publication numbers at defined points in higher training (speciality training year (ST) 3-8); secondary outcomes were the Hirsch index and ResearchGate scores. RESULTS: Fifty-nine consecutive HSTs (24 women, 35 men) were studied. The median publication number was 3 (range 0-30). At least three published articles were obtained by 30 HSTs (51 per cent), with 19 (38 per cent) of 50 HSTs achieving this by ST4 (of whom 15 (79 per cent) had undertaken out of programme for research (OOPR) time) and 24 (80 per cent) by ST6. Thirteen HSTs (22 per cent) (ST3, 6; ST4, 4; ST5, 2; ST8, 1) had yet to publish at the time of writing. OOPR was associated with achieving three publications (24 of 35 (69 per cent) versus 6 of 24 (25 per cent) with no formal research time; P = 0·001), higher overall number of publications (median 6 versus 1 respectively; P < 0·001), higher ResearchGate score (median 23·37 versus 5·27; P < 0·001) and higher Hirsch index (median 3 versus 1; P < 0·001). In multivariable analysis, training grade (odds ratio (OR) 1·89, 95 per cent c.i. 0·01 to 3·52; P = 0·045) and OOPR (OR 6·55, 2·04 to 21·04; P = 0·002) were associated with achieving three publications. CONCLUSION: If CCT credentials are to include publication profiles, HST programmes should incorporate research training in workforce planning.

ANTECEDENTES: En el Reino Unido, para obtener el título de especialista (certification of completion of training, CCT), los residentes de cirugía general durante la etapa de formación específica (higher general surgical trainees, HST) deben publicar, al menos, tres artículos científicos en revistas con sistema de revisión por pares (peer review) (como primer o segundo autor o como autor para la correspondencia). Este estudio tuvo como objetivo identificar los factores asociados con el éxito en este aspecto. MÉTODOS: Se identificaron las reseñas de HST consecutivos, mediante datos propios de cada institución y del Intercollegiate Surgical Curriculum Programme, PubMed y ResearchGate. La variable principal fue el número de publicaciones en puntos definidos de la etapa de formación específica (ST3-8); las variables secundarias fueron los índices de Hirsch y las puntuaciones de ResearchGate. RESULTADOS: Se analizó la actividad científica de 59 HST consecutivos (24 mujeres, 35 varones). La mediana del número de publicaciones fue de 3 (rango 0-33). Treinta HST (50,8%) lograron >3 publicaciones; 19 (38,0%) lo lograron en ST4 (78,9% durante el período de investigación al margen del programa de formación quirúrgica (Out of Programme Research (OOPR)), y 24 (80,0% de la totalidad de la cohorte) en ST6. Trece HST (22,0%) no habían publicado ningún trabajo hasta el momento de la redacción de este artículo (6 ST3, 4 ST4, 2 ST5 y 1 ST8). El OOPR se asoció con la consecución de las 3 publicaciones (68,6% versus 25,0%, P = 0,001), con un mayor número de publicaciones (mediana 6 versus 1, P < 0,001), con puntuaciones ResearchGate más elevadas (23,37 versus 5,27, P < 0,001) e índices de Hirsch más altos (3 versus 1, P < 0,001). En el análisis multivariable, el año de residencia (razón de oportunidades, odds ratio, OR 1,890, i.c. del 95% 0,014-3,522, P = 0,045) y el OOPR (OR 6,545, i.c. del 95% 2,037-21,036, P = 0,020) se asociaron con la consecución de las tres publicaciones. CONCLUSIÓN: Si la CCT exige un número de publicaciones, los programas de los HST deberían incorporar formación en investigación dentro de la actividad laboral habitual.

Patient and physician perceptions of lung cancer care in a multidisciplinary clinic model.

Background: Lung cancer (lc) is a complex disease requiring coordination of multiple health care professionals. A recently implemented lc multidisciplinary clinic (mdc) at Kingston Health Sciences Centre, an academic tertiary care hospital, improved timeliness of oncology assessment and treatment. This study describes patient, caregiver, and physician experiences in the mdc. Methods: We qualitatively studied patient, caregiver, and physician experiences in a traditional siloed care model and in the mdc model. We used purposive sampling to conduct semi-structured interviews with patients and caregivers who received care in one of the models and with physicians who worked in both models. Thematic design by open coding in the ATLAS.ti software application (ATLAS.ti Scientific Software Development, Berlin, Germany) was used to analyze the data. Results: Participation by 6 of 72 identified patients from the traditional model and 6 of 40 identified patients from the mdc model was obtained. Of 9 physicians who provided care in both models, 8 were interviewed (2 respirologists, 2 medical oncologists, 4 radiation oncologists). Four themes emerged: communication and collaboration, efficiency, quality of care, and effect on patient outcomes. Patients in both models had positive impressions of their care. Patients in the mdc frequently reported convenience and a positive effect of family presence at appointments. Physicians reported that the mdc improved communication and collegiality, clinic efficiency, patient outcomes and satisfaction, and consistency of information provided to patients. Physicians identified lack of clinic space as an area for mdc improvement. Conclusions: This qualitative study found that a lc mdc facilitated patient communication and physician collaboration, improved quality of care, and had a perceived positive effect on patient outcomes.

Variations in competencies needed to complete surgical training.

Background: This study aimed to analyse the degree of relative variation in specialty-specific competencies required for certification of completion of training (CCT) by the UK Joint Committee on Surgical Training. Methods: Regulatory body guidance relating to operative and non-operative surgical skill competencies required for CCT were analysed and compared. Results: Wide interspecialty variation was demonstrated in the required minimum number of logbook cases (median 1201 (range 60-2100)), indexed operations (13 (5-55)), procedure-based assessments (18 (7-60)), publications (2 (0-4)), communications to learned associations (0 (0-6)) and audits (4 (1-6)). Mandatory courses across multiple specialties included: Training the Trainers (10 of 10 specialties), Advanced Trauma Life Support (6 of 10), Good Clinical Practice (9 of 10) and Research Methodologies (8 of 10), although no common accord was evident. Discussion: Certification guidelines for completion of surgical training were inconsistent, with metrics related to minimum operative caseload and academic reach having wide variation.

Antecedentes: Este estudio se propuso analizar el grado de variación relativa en las competencias específicas de la especialidad que se requieren para obtener el certificado de haber completado la formación (Certification of Completion of Training, CCT) por el Joint Committee for Surgical Training (JCST) del Reino Unido. Métodos: Se analizaron y compararon las guías del organismo regulador relacionadas con las competencias en habilidades quirúrgicas, tanto operatorias como no operatorias, requeridas para el CCT. Resultados: Se demostró una amplia variación entre especialidades en el número mínimo requerido del cuaderno de casos (mediana 1.201; rango 60­2.100), operaciones índices (13; 5­55), evaluaciones basadas en procedimientos (18; 7­60), publicaciones (2; 0­4), comunicaciones para determinar asociaciones (0; 0­6) y auditorias (4; 1­6). Los cursos obligatorios entre las distintas especialidades incluían: formación de los formadores (10 de 10 especialidades), apoyo vital avanzado en traumas (6/10), buena práctica clínica (9/10) y metodologías clínicas (8/10), aunque era evidente que no existía un acuerdo común. Conclusión: Las directrices sobre la certificación para completar la formación quirúrgica eran inconsistentes, con una amplia variación en los números relativos a los mínimos casos operados y objetivos académicos alcanzados.

Impact of the change from the seventh to eighth edition of the AJCC TNM classification of malignant tumours and comparison with the MACIS prognostic scoring system in non-medullary thyroid cancer.

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 < 0·001). Overall disease-specific 5-year mortality rates by stage for TNM7 versus TNM8 were: stage I, 0 of 85 versus 3 of 100 (P = 0·251); stage II, 0 of 16 versus 6 of 16 (P = 0·018); stage III, 3 of 23 versus 2 of 7 (P = 0·565); stage IV, 20 of 32 versus 11 of 11 (P = 0·020). Conclusion: Compared with TNM7, TNM8 downstaged more patients to stage I and accurately reflected worse prognosis for stage IV disease. TNM8 is an inferior predictor of mortality compared with MACIS.

Outcomes of surgery for benign and malignant adrenal disease from the British Association of Endocrine and Thyroid Surgeons' national registry.

BACKGROUND: This 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. METHODS: Data 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. RESULTS: Some 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 < 0·001). A minimally invasive approach was employed in 90·2 per cent of operations for benign disease and 48·2 per cent for cancer (P < 0·001). The conversion rate was 3·5-fold higher in malignant disease (17·3 versus 4·7 per cent; P < 0·001). The length of hospital stay was 3 (i.q.r. 2-5) days for benign disease and 5 (3-8) days for malignant disease (P < 0·050). In multivariable analysis, risk factors for morbidity were malignant disease (odds ratio (OR) 1·69, 1·22 to 2·36; P = 0·002), tumour size larger than 60 mm (OR 1·43, 1·04 to 1·98; P = 0·028) and conversion to open surgery (OR 3·48, 2·16 to 5·61; P < 0·001). The in-hospital mortality rate was below 0·5 per cent overall, but significantly higher in the setting of malignant disease (1·2 versus 0·2 per cent; P < 0·001). Malignant disease (OR 4·88, 1·17 to 20·34; P = 0·029) and tumour size (OR 7·47, 1·52 to 39·61; P = 0·014) were independently associated with mortality in multivariable analysis. CONCLUSION: Adrenalectomy is a safe procedure but the higher incidence of open surgery for malignant disease appears to influence postoperative outcomes.

ANTECEDENTES: Este estudio investigó las indicaciones, procedimientos y resultados de la cirugía de la glándula suprarrenal a partir de la base de datos de la UKRETS desde 2005-2017 y comparó los resultados entre enfermedad benigna y maligna. MÉTODOS: Se examinó un registro nacional con datos notificados por cirujanos que incluye 3.994 suprarrenalectomías; 57% mujeres, mediana de edad 53 (8-88 años). Se evaluaron el diagnóstico preoperatorio, la técnica quirúrgica, la duración de la estancia hospitalaria, la morbilidad y la mortalidad hospitalaria. RESULTADOS: En el 82% de los casos la cirugía se realizó por enfermedad benigna. El tamaño del tumor fue significativamente mayor en la enfermedad maligna: 60 mm (34-100 mm) versus 40 mm (24-55 mm), P < 0,001. Se utilizó un abordaje mínimamente invasivo en el 90% de los casos de enfermedad benigna y en el 48% de las operaciones por cáncer (P < 0,001). La tasa de conversión fue 3,5 veces más alta en la enfermedad maligna (17% versus 4,9%, P < 0,001). La duración de la estancia fue 3 días (rango intercuartílico, interquartile range, IQR 2-5) para la enfermedad benigna y 5 (IQR 3-8) días para la enfermedad maligna (P < 0,05). En el análisis multivariable, los factores de riesgo para la morbilidad fueron: enfermedad maligna (razón de oportunidades, odds ratio, OR 1,64, 1,217-2,359; P = 0,002), tamaño del tumor (OR 1,433, 1.040-1,967; P = 0,028) y conversión a cirugía abierta (OR 3,483, 2,160-5,612; P < 0,0001). La mortalidad hospitalaria global fue baja (< 0,5%) pero significativamente mayor en el escenario de la enfermedad maligna (1,2% versus 0,2%, P < 0,001). La enfermedad maligna (OR 4,881, 1,171-20,343; P = 0,029) y el tamaño del tumor (OR 7,474, 1,515-39,610; P = 0,014) se asociaron de forma independiente con la mortalidad en el análisis multivariable. CONCLUSIÓN: La suprarrenalectomía es un procedimiento seguro, pero la mayor incidencia de cirugía abierta para la enfermedad maligna parece tener un impacto sobre los resultados postoperatorios.

Prognostic Significance of Acute Kidney Injury Following Emergency Laparotomy: A Prospective Observational Cohort Study.

AIMS: 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. METHODS: 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. RESULTS: 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 < 0.010). Median length of hospital stay in AKI survivors was 15 days compared with 11 days in the absence of AKI (p < 0.001). On multivariable analysis, only AKI at 48 h post-EL was significantly and independently associated with mortality [HR 10.895, 95% CI 3.152-37.659, p < 0.001]. CONCLUSION: Peri-operative AKI after EL was common and associated with a more than sixfold significant greater mortality. Pre-operative risk profile assessment and prompt protocol-driven intervention should minimise AKI and reduce EL mortality.

Inflammatory cell ratios predict major septic complications following rectal cancer surgery.

INTRODUCTION: The inflammatory response is known to have an important role in tumourigenesis and the response to treatment. Previous studies have demonstrated that inflammatory cell ratios such as the neutrophil-to-lymphocyte ratio (NLR) can predict survival and recurrence following surgery for various cancers. The objective of this study was to demonstrate if pre-operative NLR has a role in predicting post-operative septic complications in patients undergoing rectal cancer surgery. METHODOLOGY: Consecutive patients undergoing scheduled resection for rectal cancer in a tertiary centre from July 2007 to Dec 2015 were included. Data was gathered from a prospectively held database of rectal cancer. Normally distributed data were compared with paired t tests (mean ± standard error in the mean (SEM)), and proportions were compared with Fisher's exact test. A p value of < 0.05 was considered statistically significant. RESULTS: Three hundred fourteen patients were identified in this study. Sixty nine (22.0%) patients had a major septic complication following surgery for rectal cancer, which was associated with a poor survival outcome (p < 0.01) Both pre and post-operative NLR and PLR (platelet lymphocyte ratio) were associated with post-operative septic complications (both p < 0.01). A pre-operative NLR threshold level of 4 was chosen from ROC analysis, and this provided a relatively specific test to predict post-operative septic complications in these patients (specificity = 83.7%, negative predictive value (NPV) = 74.8%). DISCUSSION: In this study, the pre-operative NLR and PLR were both predictive of major post-operative septic complications. A pre-operative NLR of less than 4 was strongly negative predictor of post-operative complications in rectal cancer surgery. It can be regarded as a predictive and prognostic factor for these patients.

Intraoperative Parathyroid Hormone Assay Remains Predictive of Cure in Renal Impairment in Patients with Single Parathyroid Adenomas.

BACKGROUND: 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). METHODS: A retrospective review of consecutive patients undergoes parathyroidectomy for pHPT. Patients with multi-gland disease, without ioPTH, failure-to-cure and those <18 years were excluded. Baseline demographics, pre-operative PTH, ioPTH and 6-month follow-up data were available. Patients were categorised into normal or chronic kidney disease (CKD stage 2-5) based on pre-operative eGFR. Nonparametric data were compared using Mann-Whitney U test/Kruskal-Wallis test. The primary outcome measure was to assess whether CKD-affected ioPTH decline in parathyroidectomy for pHPT. RESULTS: A total of 476 patients were included [75.4% women; median age 63.8 years (18-92)]. CKD was present in 362 (76%) (CKD2:289; CKD3:66; CKD4/5:7). Increasing CKD stage was associated with advancing age [normal 53 years (41-61); CKD2 65 (57-73); CKD3 73.5 (66-78); CKD4/5 74(63-81); p < 0.001] and higher pre-operative PTH [16.6 pmol/L (11.1-22.9); 13.1 (10.4-17.7); 22.6 (13.8-33.7); 33.8(12.4-41.7); p < 0.001]. Baseline and post-excision ioPTH were significantly higher in those with CKD4/5 (p < 0.05). The Miami criterion was met in all patients, but median fall in ioPTH at 10-min varied between groups [normal:0.78 (0.71-0.82); CKD2:0.76 (0.69-0.83); CKD3:0.75 (0.69-0.82); CKD4/5:0.69 (0.61-0.70); p = 0.048)]. It was significantly lower in those with CKD4/5 compared with the remainder of patients [0.69 (0.61-0.70) vs. 0.76 (0.70-0.82); p = 0.008]. CONCLUSIONS: Although the reduction in ioPTH after successful parathyroidectomy is lower in severe CKD, the Miami criterion remains predictive of cure. Differences in absolute levels of PTH and tumour weight suggest that renal HPT may be a confounding factor.

Management of choledocholithiasis after previous gastrectomy.

Common bile duct stones in patients with a previous gastrectomy can be a technical challenge because of the altered anatomy. This paper presents the successful management of two such patients using non-traditional techniques as conventional endoscopic retrograde cholangiopancreatography was not possible.

Changes in awareness of cancer risk factors among adult New Zealanders (CAANZ): 2001 to 2015.

Behaviour change, specifically that which decreases cancer risk, is an essential element of cancer control. Little information is available about how awareness of risk factors may be changing over time. This study describes the awareness of cancer risk behaviours among adult New Zealanders in two cross-sectional studies conducted in 2001 and 2014/5.Telephone interviews were conducted in 2001 (n = 436) and 2014/5 (n = 1064). Participants were asked to recall things they can do to reduce their risk of cancer. They were then presented with a list of potential risk behaviours and asked if these could increase or decrease cancer risk.Most New Zealand adults could identify at least one action they could take to reduce their risk of cancer. However, when asked to provide specific examples, less than a third (in the 2014/5 sample) recalled key cancer risk reduction behaviours such as adequate sun protection, physical activity, healthy weight, limiting alcohol and a diet high in fruit. There had been some promising changes since the 2001 survey, however, with significant increases in awareness that adequate sun protection, avoiding sunbeds/solaria, healthy weight, limiting red meat and alcohol, and diets high in fruit and vegetables decrease the risk of developing cancer.

Modular emergency general surgery training: A pilot study of a novel programme.

Introduction Pan-speciality consensus guidance advocates mandatory emergency general surgery (EGS) training modules for specialist registrars (StRs). This pilot study evaluated the impact of EGS modules aimed at StRs over 1 year. Methods Eleven StRs were allocated a focused 4-week EGS module, in addition to the standard 1:12 on-call duty rota, in a tertiary surgical centre. Primary outcome measures included the number of indicative emergency operations and validated Procedure Based Assessments (PBAs) performed, both during the EGS module and over the training year. Results StRs performed a median of 11 (range 5-15) laparotomies during the EGS module versus 31 (range 9-49) over the whole training year. StRs attended 43.7% of available laparotomies during the module (range 24.1-63.7%). EGS modules provided more than one-third of the total emergency laparotomy experience, and a quarter of the emergency colectomy, appendicectomy and Hartmann's procedure experience. There were no differences in EGS module-related outcomes between junior and senior StRs. Significantly more PBAs related to laparotomy and segmental colectomy were completed during EGS modules than the on-call duty rota, at 32% versus 14% (p<0.001) and 48% versus 22% (p=0.019), respectively. Performance levels were maintained following module completion. Conclusions These findings provide an important baseline when considering future modular EGS training.

A flux extraction device to measure the magnetic moment of large samples; application to bulk superconductors.

We report the design and construction of a flux extraction device to measure the DC magnetic moment of large samples (i.e., several cm(3)) at cryogenic temperature. The signal is constructed by integrating the electromotive force generated by two coils wound in series-opposition that move around the sample. We show that an octupole expansion of the magnetic vector potential can be used conveniently to treat near-field effects for this geometrical configuration. The resulting expansion is tested for the case of a large, permanently magnetized, type-II superconducting sample. The dimensions of the sensing coils are determined in such a way that the measurement is influenced by the dipole magnetic moment of the sample and not by moments of higher order, within user-determined upper bounds. The device, which is able to measure magnetic moments in excess of 1 A m(2) (1000 emu), is validated by (i) a direct calibration experiment using a small coil driven by a known current and (ii) by comparison with the results of numerical calculations obtained previously using a flux measurement technique. The sensitivity of the device is demonstrated by the measurement of flux-creep relaxation of the magnetization in a large bulk superconductor sample at liquid nitrogen temperature (77 K).