INTRODUCTION:Parathyroid localisation is now routine before first-time surgery for patients with primary hyperparathyroidism (PHPT). The aim of this study was to investigate the contribution of intraoperative parathyroid hormone (PTH) (ioPTH) in patients in whom localisation was either not undertaken or negative for a tumour. METHODS:This was a retrospective study of patients undergoing first-time parathyroidectomy for PHPT in a regional endocrine centre. Data were collected prospectively (Microsoft Excel) and the all-Wales electronic patient record portal was used to retrieve missing data. Statistical analysis appropriate for nonparametric data was undertaken, with statistical significance reached when p<0.05. RESULTS:Between 1 July 2002 and 31 December 2022, 1,490 patients underwent a first-time parathyroidectomy for PHPT. Of this cohort, 1,133 patients had at least one positive imaging modality; the study group consisted of 343 patients that had negative imaging, and 13 that had no preoperative localisation. Patients with MEN-1 (n=26), an incorrect diagnosis (n=4), or less than six months follow-up (n=6) were excluded. Of the remaining 321, 106 patients underwent surgery without ioPTH (Group A), 215 cases with ioPTH (Group B). In Group B there were more women (170 female/45 male; 79% vs 67 female/37 male; 63% p=0.002, chi-squared), lower calcium (median [range] 2.77 [2.63-3.24] mmol/l; vs 2.85 [2.60-4.52] p=0.001) and lower PTH (12.0pmol/l [3.4-39.5] vs 14.4 [3.9-97.0] p=0.001) and smaller weights of resected tissue (320mg [50-9,000] vs 454 [46-8,280] p=0.02) (Student's t-test). The rate of multiple gland disease was similar (Group A 29%; Group B 27%). The rate of normocalcaemia at 6 months was significantly higher when ioPTH was used (Group B 202/215; 94% vs Group A 90/106; 85%) (p=0.014, chi-square test). The sensitivity and specificity of ioPTH was 98.5% [confidence interval (CI) 96.2-99.6] and 91.2% [80.7-97.0] (positive predictive value 99.9%, CI 93.6-100.0). CONCLUSION:Despite milder hyperparathyroidism and smaller tumour weight, the outcome in patients in whom ioPTH was used was superior, with failure rates 2.5-fold higher in the cohort where ioPTH was not utilised. The results of this study demonstrate that ioPTH is a valuable adjunct for the surgeon in cases where localisation has failed or not been undertaken.

IntroductionThe acute medical clerking process is a critical stage of a patient's hospital journey, with evidence suggesting its positive impact on patient outcomes. [1,2] The development of clerking pro-formas, recommended by the Royal College of Physicians, produces an improved completeness of essential information. [3] However, clerking pro-formas have led to an increased documentation load for clerking physicians, subsequently impacting the time taken to assess, diagnose and initiate management plans. This, in turn, may delay patient assessment by acute medical physicians once accepted under the take.Though there are several factors that may impair physicians’ abilities to perform their roles, including frequent interruptions and seniority, observational studies indicate that documentation takes up the largest proportion of time, approximately 25–40%. [4,5] Our project aims to explore a strategy to reduce the documentation time taken for clerking physicians. The aim was to determine whether the addition of allied healthcare professionals (HCPs) increases the efficiency of admitting patients to hospital by decreasing the time taken to complete documentation as well as decreasing the number of patients waiting to be seen at the start of each subsequent handover.MethodThe project measured the start and end times for a junior doctor clerking a patient. This time included documenting a patient's medical history, medications, allergies, social history, investigation results as well as their current presentation. Data was recorded when (i) a patient was admitted to the medical team and clerked solely by the admitting physician, and (ii) when a patient was admitted to the medical team and clerking documentation was completed by an allied HCP.In cases where an allied HCP assisted in completing clerking documentation, the start time was recorded when the clerking physician received the appropriate information from the HCP prior to seeing the patient.DiscussionData was collected from 110 patients needing hospital admission. 55 were clerked by a doctor alone and 55 patients were admitted by a doctor whose documentation was supported by an allied HCP.The average time taken to admit patients was 51 minutes, compared to 22 minutes when HCPs assist with documentation. This shows a 57% reduction in the time taken to clerk with the assistance of allied HCPs. Furthermore, the number of patients awaiting clinical review and clerking at subsequent handovers were reduced by 2.5 times.This data highlights a substantial improvement in the efficiency of clerking physicians when supported by allied HCPs in completing clerical documentation.ConclusionOur project shows that the inclusion of allied HCPs significantly reduces the time taken for the clerking process while ensuring the appropriate completion of medical clerking pro-formas. We therefore recommend the continued involvement of allied HCPs in the medical take to assist with documentation as this approach has the potential to streamline processes and enhance overall efficiency. We hope that this quality improvement project provides strong foundations for further studies to assess the qualitative impact on Acute Medical Units, promoting continuous advancement in patient care and hospital workflow.

There is an emerging role of artificial intelligence (AI) in endoscopy with studies on early systems showing promising results. However, various limitations inhibit widespread use. The aim of this study was to ascertain the sentiments of endoscopists and understand the benefits and barriers towards adoption of AI systems into healthcare. An anonymous online 18-question survey was disseminated to gastroenterology and surgical departments across UK. A total of 75 endoscopists completed the questionnaire. The majority felt that AI would increase adenoma detection rate (ADR) (72.8%) and aid lesion characterisation (78.6%). However, only a quarter of respondents were either moderately or very familiar with AI, and there was no consensus on necessity of AI in endoscopy. The key barriers identified were cost, accessibility and lack of guidelines. Endoscopists believe AI systems will have a positive impact on endoscopy; however, these systems must provide quality assurance through large clinical trials before adoption.

PURPOSE:This study aims to evaluate the outcomes of first-time parathyroidectomy for primary hyperparathyroidism using intraoperative PTH (IOPTH) assay in the light of the UK National Institute for Health and Care Excellence (NICE) guidelines for the management of primary hyperparathyroidism.METHOD:This is a retrospective cohort analysis of a prospectively maintained database of endocrine surgery in a tertiary centre. Preoperative radiological localisation (concordance and accuracy), intraoperative PTH parameters and adjusted serum calcium at minimum 6-month follow-up were analysed. The accuracy of IOPTH to predict post-operative normocalcaemia and the number needed to treat (NNT) within the cohort when IOPTH was utilised were determined. Differences between groups were evaluated with Chi-squared and Fisher's exact test.RESULTS:Between January 2004 and September 2018, 849 patients (75.4% women), median age 64 years (IQR 54-72), were analysed. The median preoperative adjusted serum calcium was 2.80mmol/l (IQR 2.78-2.90), and the median preoperative PTH was 14.20pmol/l (IQR 10.70-20.25). The overall first-time cure (normocalcaemia) rate was 96.4%. The sensitivity, specificity, positive predictive value and negative predictive values of IOPTH were 96.8%, 83.2%, 97.6% and 78.8%, respectively, with an accuracy of 95.1%. For patients with concordant scans (48.3%), a targeted approach without IOPTH would have achieved a cure rate of 94.1% compared with 98.0% using IOPTH (p<0.01) CONCLUSION: The use of IOPTH assay significantly improved the rate of normocalcaemia at 6 months. The low NNT to benefit from IOPTH, particularly those patients with a single positive scan, and the inevitable reduction in the potential costs incurred from failure and reoperation justify its utilisation.

Abstract Background Although there is surgeon volume-outcome effect in adrenal surgery the threshold for ‘high volume’ surgeon remains controversial. This retrospective cohort study of the UKRETS database explores this issue further. Methods Adrenal data on adults aged 18–90 years from 2004 to 2021 was analysed. Outcomes included postoperative complications, post-operative, length of stay (LOS) and mortality. Factors included in multivariable analysis were patient age, gender, diagnosis, surgical approach, anatomy, and surgeon volume. Cases with missing data on any variable and LOS > 60 days were excluded. Results Of 6174 operations, 4464 (72.3%) cases were analysed. Postoperative complications occurred in 418/4064 (9.4%) and mortality in 14/4064 (0.3%). Median LOS was 3 (IQR 2-5) days. Co-variables significantly (p<0.05) associated with adverse outcomes were: postoperative complications - age [OR 1.02 (95% CI 1.01-1.03)], adrenal cancer [OR 1.64 (95% CI 1.14-2.36)], bilateral surgery [OR 1.66 (95% CI 1.03-2.69)] and surgeon volume [OR 0.98 (95% CI 0.96-0.99)]; mortality - age [OR 1.08 (95% CI 1.03-1.13)], laparoscopic approach [OR 0.08 (95% CI 0.02-0.27)] and bilateral surgery [OR 6.93 (95% CI 1.40-34.34)] and LOS (standardised beta co-efficient) - male sex (-0.03), age (0.09), phaeochromocytoma (0.07), adrenal cancer (0.08), bilateral surgery (0.11), laparoscopic approach (-0.40) and surgeon volume (-0.06). Conclusion Surgery for adrenal cancer and bilateral tumours could be restricted to high volume surgeons, but the threshold still needs to be defined.

AIMS:Chronic degenerative mitral regurgitation leads to volume overload causing left ventricular (LV) enlargement and eventually LV impairment. Current guidelines determining thresholds for intervention are based on LV diameters and ejection fraction (LVEF). There are sparse data examining the value of LV volumes and newer markers of LV performance on outcomes of surgery in mitral valve prolapse. The aim of this study is to identify the best marker of LV impairment after mitral valve surgery.METHODS AND RESULTS:Prospective, observational study of patients with mitral valve prolapse undergoing mitral valve surgery. Pre-operative LV diameters, volumes, LVEF, global longitudinal strain (GLS), and myocardial work measured. Post-operative LV impairment defined as LVEF < 50% at 1 year post-surgery. Eighty-seven patients included. Thirteen percent developed post-operative LV impairment. Patients with post-operative LV dysfunction showed significantly larger indexed LV end-systolic diameters, indexed LV end-systolic volumes (LVESVi), lower LVEF, and more abnormal GLS than patients without post-operative LV dysfunction. In multivariate analysis, LVESVi [odds ratio 1.11 (95% CI 1.01-1.23), P = 0.039] and GLS [odds ratio 1.46 (95% CI 1.00-2.14), P = 0.054] were the only independent predictors of post-operative LV dysfunction. The optimal cut-off of 36.3 mL/m2 for LVESVi had a sensitivity of 82% and specificity of 78% for detection of post-operative LV impairment.CONCLUSION:Post-operative LV impairment is common. Indexed LV volumes (36.3 mL/m2) provided the best marker of post-operative LV impairment.

The current guidelines recommend intervention in severe degenerative mitral regurgitation (MR) in symptomatic patients or asymptomatic patients with left ventricular dilatation or dysfunction. The insidious onset of symptoms may mean that patients do not report their symptoms. The role of systematic exercise testing for symptoms in MR is not clearly defined. A total of 97 patients with moderate to severe asymptomatic MR underwent exercise echocardiography combined with cardiopulmonary exercise testing. The predictors of exercise-induced dyspnea, symptom-free survival, and mitral valve intervention were identified. A total of 18 patients (19%) developed limiting dyspnea on exercise. Spontaneous symptom-free survival at 24 months was significantly higher in those without exercise-induced symptoms than those with exercise-induced symptoms, p <0.0001. The only independent predictors of spontaneous symptoms at 2 years were effective regurgitant orifice area (odds ratio 27.45, 95% confidence interval [CI] 1.43 to 528.40, p = 0.03) and exercise-induced symptoms (odds ratio 11.56, 95% CI 1.71 to 78.09, p = 0.01). The only independent predictor of surgery was indexed left ventricular systolic volumes (odds ratio 1.17, 95% CI 1.04 to 1.30, p = 0.006). Where only the patients who underwent surgery due to symptoms were included, the only independent predictor was exercise-induced symptoms (odds ratio 13.94, 95% CI 1.39 to 140.27, p = 0.025). In conclusion, in patients with primary asymptomatic degenerative MR, 1/5 develop revealed symptoms during exercise. This predicts a subsequent development of spontaneous symptoms and mitral valve intervention due to symptoms.

Abstract Introduction The potential of AI systems to support pre-hospital clinical decision-making is significant. However, whilst such algorithms are increasingly available, far less attention has been paid to understanding the impact of such systems on clinical performance. This study had two aims; first, to compare the performance of expert clinicians against an AI system in a real-world clinical setting and second, to assess the impact of augmenting expert clinical prediction with an AI system. Method We performed a prospective study at two UK Air Ambulances services over a six-month period. Expert pre-hospital clinicians’ judgement of the risk of Trauma Induced Coagulopathy (TIC) in injured patients was assessed and compared to the performance of an AI system. Two TIC risk predictions were generated for every patient: an AI prediction and a human prediction. Results Overall, 51 expert clinicians were enrolled in the study providing 184 patient interactions for analysis. Aim 1 The AI system performed better than clinicians; higher discrimination [AUROC 0.87 (0.79, 0.95) versus 0.83 (0.74, 0.92)] better calibration [0.37 (-0.14, 0.89) versus -1.19 (-1.73, -0.65)] and more accurate [Brier Skill Score 0.34 (0.19, 0.48) versus 0.00 (-0.41, 0.30)]. Aim 2 Risk prediction was better in all performance metrics when clinicians were assisted with the AI system [AUROC 0.88 (0.80, 0.95) versus 0.83 (0.74, 0.92)] Conclusions AI systems can improve human risk prediction in the pre-hospital setting. In settings of low resources where a lack of senior clinical expertise may affect outcomes, the benefit of implementing predictive AI is substantial.

Aims: Colorectal cancer is the fourth most prevalent cancer in the UK. Fortunately, with modern surveillance programmes, more patients are being diagnosed at an earlier stage. Although surgical excision remains the gold standard, many patients have co-morbidities that preclude them from having radical surgery. Additionally, a number of patients do not wish to live with a permanent colostomy. Radiotherapy has an established role in the non-surgical treatment of patients with rectal cancer. Increasing the radiation dose to the tumour increases the chance of local control. Using contact X-ray brachytherapy (CXB) it is possible to escalate the dose to the tumour and minimise the dose received by surrounding normal tissues. The aim of this study was to evaluate the outcomes of patients from our centre who have undergone CXB with or without external beam radiotherapy.Materials and methods: A prospectively maintained and locally managed colorectal database was used to collect clinical details and outcomes for colorectal cancer patients. All patients who were treated with CXB at our institution from the commencement of the service in April 2014 to the end of December 2019 were analysed. There was a minimum of 18 months of follow-up.Results: One hundred and ninety-three patients received at least one fraction of CXB. The median age at first treatment was 72 years (range 33-103 years). Seventy-three per cent of patients were male. Of the operable or high surgical risk patients, 105 were treated radically with radiotherapy, 28 were treated radically with radiotherapy after local resection and 22 patients were medically unfit for surgery. Most patients received external beam radiotherapy 45 Gy/25 fractions (87/146) or 25 Gy in five fractions (35/146). Forty-seven patients received CXB as sole treatment (51% had previous radiotherapy). Of those with a response assessment, with a median follow-up of 35 months, 78% of all patients achieved a clinical complete response (cCR) or a near cCR, 6% had a partial response and 16% had persistent disease. Of 154 radically treated patients with a response assessment, 84% achieved cCR or near cCR, 19% (24/129) of these subsequently relapsed.Conclusion: This series shows that CXB is a well-tolerated and effective treatment in a diverse cohort of patients with rectal cancer. Comparable favourable oncological outcomes were seen, in keeping with previously published work.(c) 2022 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

BACKGROUND Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues' experiences and published evidence. METHODS In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them. RESULTS BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training. CONCLUSION The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era.Members of the BJS Commission Team are co-authors of this study and are listed under the heading Collaborators.

Abstract Background National Institute for Health and Care Excellence guidelines (NICE CG95) recommends computed tomography coronary angiography [CTCA] as the first line investigation for all patients with suspected typical or atypical angina irrespective of pre-test probability due to its excellent performance and cost effectiveness. However previous cost effectiveness analyses have not factored in the burden of lung nodules [LN] or extracardiac incidentalomas, which are commonly identified on CTCA. Purpose As we increasingly detect LN on CTCA scans, it is prudent that a uniform pathway is followed for surveillance of LN. The British Thoracic Society (BTS) has enabled evidence-based development of an algorithm for the management of LN which defines a cut off LN size of ≥5mm requiring further follow up. We aimed to assess the compliance of LN follow up in our patients according to radiology recommendation on CTCA reports and also to assess how well these recommendations adhere to BTS guidelines. Method 117 patients who underwent CTCA as the initial diagnostic investigation were retrospectively identified from the rapid access chest pain clinic database. Data was collected during a 1 year period between January - December 2017. Data was analysed to determine whether appropriate surveillance pathway was followed for repeat imaging. According to BTS guidelines, nodules ≥5mm should have a systematic work up for surveillance and hence we have stratified our data based on the nodule size. In case of multiple nodules, the largest nodule size was considered. Results Out of 117 patients, 77% patients were female with average age 57.8±9.0 years. 40% patients were found to have incidental LN with an average size of 4.63±1.92mm; 44% had a history of cigarette smoking. Among patient with nodules, 22 (19%) had CT thorax to assess interval change and interestingly 16 (73%) had persisting LN; whereas in 4 (18%), the LN resolved and only 2 (9%) showed increase in LN size. Repeat CT chest was advised for these 2 patients; 1 was advised to undergo biopsy which eventually ruled out malignancy. 6 patients (5%) from group 1 were recommended for repeat CT despite having LN size <5mm. In the remaining 25 patients (21%) with LN, 15 (60%) did not have further surveillance imaging even though this was recommended by the reporting radiologist. Of these only 3 (12%) had LN ≥5mm which qualified for surveillance CT. Conclusion CTCA frequently detects incidentalomas especially LN which cannot be overlooked and require further imaging irrespective of the primary presentation. Our findings also suggest a discrepancy on surveillance CT recommendation against the current BTS guidelines, with potential significant impact on the overall cost effectiveness of CTCA. A systematic approach to LN surveillance could be best achieved with a multidisciplinary team approach (e.g. referral pathway to nodule MDT) and adherence to a standard guideline. Lung nodule surveillance following CTCA Funding Acknowledgement Type of funding source: None

Surgeon‐level operative mortality is widely seen as a measure of quality after gastric and oesophageal resection. This study aimed to evaluate this alongside a compound‐level outcome analysis.

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.

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.

Abstract Background Cardiac involvement is the main driver of outcome in systemic amyloidosis, but the relationship between amyloid deposits and outcomes is not well understood. The simple explanation of physical, mechanical replacement of the interstitium by amyloid seems insufficient. Preliminary studies support the hypothesis that myocardial ischaemia could contribute to cell damage. Purpose (1) To assess myocardial ischaemia in cardiac amyloidosis. (2) To compare patients with cardiac amyloidosis to patients assessed on invasive coronary angiography (ICA) to have normal coronary physiology (NCP), microvascular dysfunction (MVD) and triple vessel coronary disease (3VD). (3) To assess correlation of perfusion mapping to markers of disease severity and prognosis. Methods 86 patients and 20 healthy volunteers (HV) underwent CMR at 1.5T (Siemens) with standard cine, PSIR-LGE, T1, T2, Extracellular Volume (ECV) mapping and adenosine stress with myocardial blood flow (MBF) mapping. Thirty-eight patients also underwent ICA with 3 vessel assessment of Index of Microcirculatory Resistance and Fractional Flow Reserve: 7 had cardiac amyloidosis, 8 had NCP, 15 had MVD and 8 had 3VD. Results Cardiac amyloidosis patients had severe reduction in stress MBF and myocardial perfusion reserve (MPR) (1.22ml/g/min±0.70 and 1.62±0.63) compared to HV (3.21ml/g/min±0.64, p<0.001 and 4.17±0.78, p<0.001), NCP (2.66±0.56, p<0.001 and 2.51±0.43, p=0.036) and MVD (2.10±0.31, p<0.001 and 2.29±0.87, p=0.014) with the degree of reduction being similar only to patients with 3VD (1.44±0.54, p=1.000 and 1.64±0.68, p=1.000) (Figure 1). Rest MBF was also lower in amyloidosis than HV. Cardiac amyloidosis stress MBF and MPR inversely correlated with amyloid burden (ECV, r=−0.715, p<0.001, transmurality of LGE, p<0.01), systolic dysfunction (EF, r=0.405, p<0.01), and blood biomarkers (NT-proBNP (r=−0.678, p<0.001) and Troponin T (r=−0.628, p<0.001)). There was a correlation between stress MBF and native T1 (r=−0.588, p<0.001) but not T2 (p=0.591). Stress MBF and MPR were early disease markers, being elevated in patients with early cardiac amyloid infiltration (raised ECV, no LGE, P<0.01 vs HV). Conclusion Myocardial ischaemia is common in cardiac amyloidosis – with stress MBF and MPR similar to that of patients with 3VD. The reduction correlates with the degree of amyloid infiltration and markers of adverse prognosis, highlighting the potential role of myocardial ischaemia as a key mechanism in the pathophysiology of cardiac amyloidosis.

Purpose: A positive circumferential resection margin (CRM) is regarded as a poor prognostic indicator in oesophageal cancer (OC) but its prediction can be challenging. MRI is used to predict a threatened CRM in rectal cancer but is not commonly performed in OC unlike PET/CT, which is now routinely used. Therefore, this study assessed the additional predictive value of PET-defined tumour variables compared with EUS and CT T-stage. The prognostic significance of CRM status was also assessed. Materials and Methods: This retrospective study included 117 consecutive patients [median age 64.0 (range 24-78), 102 males, 110 adenocarcinomas, 6 squamous cell carcinoma (SCC), 1 neuro-endocrine] treated between 1st March 2012 and 31st July 2015. A binary logistic regression model tested 5 staging variables; EUS T-stage (<= T2 vs >= T3), CT T-stage (<= T2 vs >= T3), PET metabolic tumour length (MTL), PET metabolic tumour width (MTW) and the maximum standardised uptake value (SUVmax). Results: The CRM was positive in 43.6%. Sixty-seven (57.3%) patients received neo-adjuvant chemotherapy (NACT), 31 patients (26.5%) underwent surgery alone and 19 patients (16.2%) had neo-adjuvant chemoradiotherapy (NACRT). Median overall survival (OS) was 36.0 months (95% confidence interval (CI) 24.1-47.9) and the 2-year OS was 55.4%. A binary logistic regression model showed EUS >= T3 tumours were independently and significantly more likely to have a positive CRM than EUS <= T2 tumours (HR 5.188, 95% CI 1.265-21.273, p = 0.022). CT T-stage, PET MTL, PET MTW and SUVmax were not significantly associated with CRM status (p = 0.783, 0.852, 0.605 and 0.413, respectively). There was a significant difference in OS between CRM positive and negative groups (X-2 4.920, df 1, p = 0.027). Conclusion: Advanced EUS T-stage is associated with a positive CRM, but PET-defined tumour variables are unlikely to provide additional predictive information. This study demonstrates the continued benefit of EUS as part of a multi-modality OC staging pathway.