ObjectiveRevision parathyroidectomy is made necessary by recurrent or persistent parathyroid disease. This study aimed to identify challenges in revision surgery compared to primary parathyroid surgery.MethodsAll revision parathyroidectomies performed by one surgeon over a 17-year period were assessed for demographics, imaging, histology, biochemistry, cure rate, gland weight, gland location and gland ectopia, and compared to a series of 100 primary parathyroidectomies.ResultsTwenty-eight revision surgical procedures were identified. Sestamibi scanning for gland localisation was superior to ultrasound in both primary and revision surgery. Pre-operative calcium and gland weight were significantly higher in revision cases. There were no significant differences in post-operative calcium levels, pre- or post-operative parathyroid hormone levels, or gland location. 36 per cent of glands excised in revision surgery were ectopic, compared to 25 per cent in primary procedures. The cure rate was significantly lower in revision surgery.ConclusionRevision parathyroidectomy patients present with higher pre-operative calcium and larger adenomas; the cure rate is significantly lower in these patients.

PURPOSE Cardiorespiratory fitness (VO2max) garners little attention in kidney transplant recipients (KTRs). The primary objectives were to establish the prevalence, impact and predictors of reduced VO2max. The role of VO2max assessment in potential KTRs remains controversial. The secondary objective was to evaluate the prognostic value of pre-transplant cardiorespiratory exercise test. METHODS Primary objectives were tested by a cross-sectional cohort of KTRs ≥1 year post-transplantation (n=55; mean age=46±14 years; 58% male). Secondary objectives were tested by a longitudinal cohort of living-donor KTRs within 1 month pre-transplantation (n=26; mean age=41±16 years; 58% male). VO2max was estimated by submaximal exercise test. “Reduced” (≤0.81 predicted) and “severely reduced” (<0.62 predicted) VO2max were delineated. QoL was assessed with SF-36. Clinical outcome data were retrieved from medical records. Demographic, nutritional and clinical predictors of VO2max were assessed. RESULTS Mean KTRs' VO2max=26.7±9.0 ml/kg/min. “Reduced VO2max” was found in 58% of KTRs, with 22% being “severely reduced”. Post-transplant VO2max positively correlated with QoL (p<0.001), but did not predict 2-year hospitalisation rates and days to first hospitalisation. Predictors of reduced VO2max were female (p=0.004), increased fat mass (p=0.002), hypovolemia (p<0.001), and hypervolemia (p<0.001). In patients awaiting kidney transplantation, pre-transplant VO2max did not correlate with QoL up to 1 year post-transplantation, and did not predict 2-year hospitalisation rates and days to first hospitalisation post-transplantation. Similarly, pre-transplant VO2max did not predict early clinical outcomes within the 1st week post-transplantation including systolic and diastolic blood pressure, lowest standardised early warning score, creatinine reduction ratio, and length of hospital stay. No patient required dialysis, inotropes, and ICU admission within the 1st week post-transplantation. There was no incidence of delayed graft function. CONCLUSION Reduced cardiorespiratory fitness is common in KTRs, and is associated with reduced QoL. This study identified potential modifiable predictors, setting the scene for interventional studies. The limited predictive value of pre-transplant cardiorespiratory exercise testing on post-transplant QoL and early clinical outcomes needs further validation.

PURPOSE The mechanisms of physical fatigue in kidney transplant recipients (KTRs) remained unexplored. The primary objectives were to determine the prevalence of physical fatigue in KTRs; assess its impact on quality of life (QoL); and identify the mechanisms of physical fatigue through examinations of cardiorespiratory function (VO2max), perceived exertion, as well as muscle mass, function and conditioning. The secondary objective was to investigate the predictors of raised perceived exertion, a determinant of physical fatigue in KTRs. METHODS This single-centre cross-sectional study enrolled 55 KTRs ≥1 year post-transplantation. Mean age=46±14 years; 58% male. Physical fatigue was measured by multi-dimensional fatigue inventory-20. QoL was assessed with SF-36. VO2max was estimated by sub-maximal exercise test. Rating of perceived exertion (RPE) was determined by age-adjusted Borg-ratings during exercise, with RPE index calculated. Lean body mass (LBM) was quantified with dual energy x-ray absorptiometry. Muscle function was assessed by jumping mechanography (single 2-legged jump [S2LJ] and chair rise test [CRT]). Muscle conditioning was determined by changes in myokine (serum IL-6) levels, taken at rest (Trest), immediately (Timmediate) and 1-hour (T1-hour) after exercise. Demographic, clinical, psychosocial and behavioural predictors of perceived exertion were assessed. RESULTS Physical fatigue was found in 22% of KTRs, and exerted a negative impact on QoL (p<0.001). Median RPE index=1.2 (0.8-2.0). Mean values of VO2max=26.7±9.0 ml/kg/min; LBM=50.7±11.5 kg; muscle function measured by S2LJ=4045±1136 W, and CRT=1118±268 W. No significant changes of serum IL-6 levels were detected between Trest, Timmediate, and T1-hour. Independent predictors of physical fatigue were reduced VO2max in male (p=0.04) and increased perceived exertion in female (p=0.003). Independent predictors of raised perception were mental fatigue (p=0.03), anxiety (p=0.01), new-onset diabetes after transplantation (p=0.04), absence of cyclosporine (p=0.03), and low alcohol intake (p=0.03). CONCLUSION Physical fatigue in KTRs is driven by reduced VO2max in male, and increased perception in female. Predictors of raised perception were identified, paving the way for future interventional studies. Further research is needed to identify causes of reduced VO2max in KTRs.

The primary systemic vasculitides are complex multisystem disorder where accurate assessment of disease activity and disease damage is difficult. In order to evaluate therapies in clinical trials good outcome measures are necessary. In ANCA associated vasculitis (AAV), clinical checklists such as the BVAS are used to measure disease activity and the VDI to measure disease and treatment related damage. These tools were developed by consensus expert opinion; have been used for over a decade in clinical trials and are now well-validated and accepted measures. The availability of good outcome measure was a key factor in enabling therapeutic trials in AAV. OMERACT has endorsed a 'core set' of domains for trials in AAV with validated measures in each domain. In contrast, there has been an absence of outcome measures in large vessel vasculitis and as a consequence almost no clinical trials in giant cell arteritis or Takayasu's arteritis to date. The landscape may be changing with improved imaging techniques and the recent development of the Indian Takayasu's Arteritis Activity Score (ITAS2010). OMERACT has a working group to try and develop and validate outcome measures for large vessel vasculitis, which provides an opportunity for interested researchers to be involved in this process.

L’association irinotécan-bévacizumab est efficace au cours des récidives de glioblastome mais la survenue d’une fatigue pendant ce traitement est un effet secondaire fréquemment signalé. Notre objectif était d’étudier l’évolution du niveau de fatigue dans une série de patients traités par cette association thérapeutique.Deux échelles d’autoévaluation permettant de quantifier les aspects physique et psychique de la fatigue, la Norris Visual Analog Scale (VAS Norris) et la Multidimensional Fatigue Inventory-20 (MFI), ont été réalisées avant la première cure et à chaque cure jusqu’à progression de la tumeur chez 39 patients souffrant d’un glioblastome en récidive traités par l’association irinotécan-bévacizumab.L’analyse de l’échelle VAS Norris n’a pas révélé de modification de la fatigue affective mais une augmentation de la fatigue/asthénie qui restait toutefois non-significative (p = 0,0694). Pour l’échelle MFI-20, l’analyse a révélé une augmentation significative de la fatigue générale (p = 0,0260) et de la fatigue physique (p = 0,0141) sans modification des autres dimensions.Cette étude met en évidence une augmentation progressive de la fatigue physique et non mentale au cours du traitement par irinotécan-bévacizumab des glioblastomes récidivants. Une implication directe du traitement est suspectée mais d’autres facteurs peuvent être incriminés : une évolution tumorale insidieuse échappant au suivi radiologique ou la survenue retardée de complications de la radiochimiothérapie initiale.The combination of irinotecan-bevacizumab is effective in patients with glioblastoma relapse but fatigue is a commonly reported side effect. The objective of this study was to evaluate the level and evolution of fatigue in a series of patients treated with therapeutic combination.We used two self-evaluation tools to quantify the physical and emotional aspects of this fatigue. The Norris Visual Analog Scale (VAS Norris) and the Multidimensional Fatigue Inventory-20 (MFI) tools were undertaken by 39 patients with glioblastoma relapse treated with irinotecan-bevacizumab, initially before the first cycle and thereafter with each cycle up until tumor progression.Analysis of the results of the VAS Norris scale did not demonstrate an increase in emotional fatigue but did show an increase in physical fatigue that did not reach statistical significance. With regards to the MFI 20 tool, analysis of the results demonstrated a significant increase in general (P = 0.0260) as well as physical (P = 0.0141) fatigue but there was no difference in the other indices.This study demonstrated a progressive increase in physical fatigue in patients with glioblastoma relapse treated with irinotecan-bevacizumab. We suspect that this is as a direct consequence of the treatment. There are however other confounding factors: insidious tumour progression not detected on follow-up imaging or delayed side effects of the initial radiotherapy-chemotherapy.

Background Impaired quality of life (QOL) is of universal relevance and not just confined to the unhealthy. Although existing data demonstrates poor QOL amongst patients with AAV, it is essential to contextualise these reports with both general and other diseased populations in order to fully ascertain the scale of the problem. Thus far, studies have only made retrospective comparisons with unmatched populations using different methodologies. Furthermore, study sample sizes have been sufficient to quantify only the largest of differences. Objectives This large study aimed to quantify QOL in AAV patients compared to matched general and disease control populations. Methods A multi-centre case-control study using two groups of a) population and b) disease controls. AAV cases were recruited from rheumatology and renal departments across the UK. For each participating case, general population controls were identified from a commercial on-line sampling frame (>80% population coverage). They were matched according to age, sex and postcode. In addition, disease controls were invited, matched according to age, sex and department. Cases recruited from rheumatology departments were matched to patients with inflammatory arthritis while those recruited from renal departments were matched to patients with non-inflammatory chronic kidney disease, reflecting a typical clinic attendee from the respective specialty. All cases and controls completed a questionnaire which combined recognised measures of QOL. Specific instruments assessed physical and mental health status (SF36), sleep disturbance (Estimation of sleep problems questionnaire) and fatigue (Chalder Fatigue Scale).The scores of these were dichotomised into high and low categories by the mean of the population controls. In addition, anxiety and depression was defined using the Hospital Anxiety and Depression Scale (HADS) and data collected on employment status. Cases were compared to controls using conditional logistic regression and results expressed as odds ratios (OR). Results 410 cases were identified from 11 centres, with 470 population and 318 disease controls. Cases reported significantly poorer QOL than population controls across all domains. Compared to controls, cases were substantially more likely to report low physical and mental health respectively (OR 7.0,95%CI 4.4-11.1 and OR 2.5,95%CI 1.7-3.6). In addition they were much more likely to be unemployed due to their health (OR 6.9,95%CI 3.0-15.8), report high fatigue (OR 4.1,95%CI 2.7-6.3), feel depressed (OR 4.3,95%CI 2.4-7.5), endure sleep disturbance (OR 2.1, 95%CI 1.5-2.9) and suffer anxiety (OR 1.6,95%CI 1.1-2.3). Across all domains, cases reported no significant differences in QOL compared to disease controls. Conclusions Compared with the general population, AAV patients experienced significantly impaired QOL. QOL levels were as poor as those reported by typical rheumatology and renal clinic attendees whose considerable needs are already well established. Disclosure of Interest None Declared

We have analyzed our use of captopril-diethylene-triaminepentaacetic acid (DTPA) scanning in patients presenting to the Royal Free Hospital predominantly with renal impairment. The sensitivity was found to be as good in patients with bilateral disease or disease of a single kidney as in patients with unilateral disease. On a number of occasions, though, the scan suggested unilateral disease when bilateral disease existed. There were, however, a large number of patients for whom captopril-DTPA scanning was not performed because of severe renal impairment or the possibility of renal artery stenosis in a single functioning kidney.