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Aims Hypocalcaemia is a common complication after parathyroidectomy for secondary hyperparathyroidism (SHPT) and is often the cause of a prolonged hospital stay post operatively. Although there is no current guidance on targets for total parathyroidectomy for SHPT, current guidance recommends a day-case rate of 90% for patients undergoing surgery for primary hyperparathyroidism. Our centre has developed a safe protocol which allows us to perform total parathyroidectomies as a day-case procedure in patients with SHPT. This protocol, developed in conjunction with the renal physicians, involves giving the patients alpha calcidol pre-operatively for 5 days, to minimise the incidence of hypocalcaemia, and close monitoring of the calcium levels post operatively, to permit safe discharge. Methods We carried out a single centre retrospective study on all patients who underwent a total parathyroidectomy for SHPT between February 2005 and May 2021. All the patients received the alpha calcidol regimen pre-operatively. Data on patient baseline characteristics, peri-operative calcium, potassium and PTH levels, length of hospital stay, operative procedure details, hospital readmission and 30-day morbidity were collected. Results 49 patients underwent a total parathyroidectomy during the study period. 67% of patients were discharged on day 0 or on day 1 post-operatively. Reasons for prolonged hospital stay in the remaining patients included refractory hyperkalaemia requiring dialysis, complications secondary to anaesthesia, as well as hypocalcaemia in a few cases. No patients required readmission during the 30-day post-operative period. Conclusion Day-case surgery for SHPT can be achieved safely with a pre-operative regimen of alpha calcidol and close monitoring of calcium levels post-operatively.

Aim Total parathyroidectomy in end-stage renal failure (ESRF), is an effective way to improve or stabilise calcium and parathormone levels and thus improve renal osteodystrophy. Previous BAEST guidelines were not in favour of true day-case neck surgery due to the risk of airway compromise from bleeding. Additionally, ESRF patients are at risk of profound hypocalcaemia after total parathyroidectomy. Patients undergoing total parathyroidectomy are prescribed Alfacalcidol 4mcg daily for 5 days prior to surgery. Following surgery under GA on a morning list, the potassium and calcium levels are checked in the afternoon. Calcium levels are then monitored daily for 3 days and subsequently when required. Oral Alfacalcidol is continued at the same dose until the nephrologists advise otherwise. Methods All ESRF patients undergoing total parathyroidectomy for secondary hyperparathyroidism were identified between 01/01/2005 and 31/12/2019 from a prospectively maintained electronic database. Demographics, biochemistry, length of stay (LoS) and outcomes were analysed. Results There were 43 (30 male) total parathyroidectomies. The median age was 53 (range 14 – 78), and median LoS 1 day (range 0 -13). 26 patients (60%) were discharged within 23 hours (26% were day-case). Prolonged stay was due to calcium replacement (n = 8) or dialysis (n = 4) requirements. Pre- and post-operative calcium values over 2.49mmol/L were significantly related to 23-hour stay (p = 0.010482 and p = 0.000263 respectively). No 30-day re-admissions were observed Conclusions Careful patient selection and adherence to a perioperative management protocol in total parathyroidectomy may enable early discharge within 23 hours. Preoperative calcium levels help predict this outcome.

Background:Sport sampling is recommended to promote fundamental movement skill acquisition and physical activity. In contrast, sport specialization is associated with musculoskeletal injury risk, burnout, and attrition from sport. There is limited evidence to support the influence of sport sampling on neuromuscular control, which is associated with injury risk, in youth athletes.Hypothesis:Athletes who participated in only 1 sport during the previous year would demonstrate higher Landing Error Scoring System (LESS) scores than their counterparts.Study Design:Cross-sectional study.Level of Evidence:Level 3.Methods:A total of 355 youth athletes (age range, 8-14 years) completed a test session with a jump-landing task, which was evaluated using the LESS. Participants were categorized as single sport (SS) or multisport (MS) based on their self-reported sport participation in the past year. Their duration of sport sampling (low, moderate, high) was determined based on their sport participation history. Participants were dichotomized into good (LESS Results:The MS group was 2.5 times (95% CI, 1.9-3.1) as likely to be categorized as having good control compared with the SS group (χ2(355)= 10.10, P < 0.01). Recreational participants in the “high” sport-sampling duration group were 5.8 times (95% CI, 3.1-8.5) and 5.4 times (95% CI, 4.0-6.8) as likely to be categorized as having good control compared with the moderate and low groups (χ2(216)= 11.20, P < 0.01).Conclusion:Sport sampling at a young age is associated with improved neuromuscular control, which may reduce injury risk in youth athletes.Clinical Relevance:Youth athletes should be encouraged to try participating in multiple sports to enhance their neuromuscular control and promote long-term physical activity.

Post-traumatic abdominal aortic pseudoaneurysms remain a rare yet severe complication of aortic injuries and may present many years later. Clinical presentations vary, from the traditional aneurysmal symptoms of abdominal and/or back pain with or without a pulsatile mass, to a fatal rupture. We present the case of a man aged 42 years, with a history of blunt abdominal trauma 14 years ago, presenting with symptoms of non-specific lower abdominal pain and a recent history of straining due to constipation. Clinical examination revealed umbilical bruising, in keeping with Cullen's sign, and extensive postsacral bruising. This case highlights some of the atypical manifestations of aneurysmal rupture and the importance of early recognition and management.

Background Traditionally, multilevel arterial disease has been treated with an inflow procedure only but simultaneous multilevel bypass graft procedures have been attempted. However, these procedures are potentially high risk. We report our single-center experience of performing multilevel bypass grafts over the last 15 years. Methods We retrospectively identified patients undergoing simultaneous aortoiliac and infrainguinal bypasses between January 1996 and January 2011 at a single district general hospital. Results There were 32 multilevel procedures performed. Indication for surgery was acute ischemia in 10 (31.3%), critical ischemia without tissue loss in 10 (31.3%), with tissue loss in 10 (31.3%), and claudication in 2 (6.3%). In 23 (71.9%) cases inflow was restored using a direct iliofemoral or aortofemoral reconstruction. In the remaining 9 (28.1%), an extra-anatomic bypass was constructed. Two (6.3%) patients died within 30 days of surgery. Twenty-nine (90.6%) patients survived to discharge. Twenty-eight patients (87.5%) were alive 1 year after surgery. Limb salvage was 96.9%, 85.7%, and 75.9% at 30 days, 1 year, and 5 years, respectively. Twelve (37.5%) patients required a total of 19 further ipsilateral vascular procedures. Conclusions Our results demonstrate that multilevel bypass procedures can be performed with good long-term outcomes and acceptable mortality, in what is typically a high-risk group with extensive comorbidities. In patients with severe critical limb ischaemia and tissue loss, who have a combination of aortoiliac and infrainguinal disease, there are significant benefits to a primary multilevel grafting procedure.

This study investigates the changes in radial micro-texture via Kearn’s f-factors during single cold pilger reduction of a titanium Ti-3-2.5 alloy as a result of strain path changes from tooling modifications. EBSD results confirm that the texture intensity as well as the radial f-factors can be increased by modifications of pilgering tooling. In addition a switch between the secondary prism planes which lie normal to the pilger direction in the starting tube to primary prism planes after pilgering has been observed.

The management of intravascular metallic foreign bodies (FB) can be difficult and challenging. We report a case of a migrating FB, initially within the femoral vein which subsequently migrated to the intrahepatic venacava. Following a change of posture, the metallic FB moved with gravity against the normal venous blood flow to the left renal vein. It was finally fixed in position in a peripheral branch of the renal vein using an intravascular stent. Employing gravity as a therapeutic intervention and the technique used in isolating the FB has not, to our knowledge, been reported before. A case is described, and the literature is reviewed.

Les AA. presentent une approche permettant d'utiliser les services Web pour interagir avec les vocabulaires controles. L'implementation des services se fait dans le cadre d'une architecture orientee service (AOS). L'AOS est une approche d'informatique repartie dans laquelle les services sont associes de facon lâche et reperables sur le reseau. Un ensemble de services experimentaux pour vocabulaires controles est fourni via la fenetre de tâche de recherche de Microsoft Office.

A 68-year-old female presented with chest pain and breathlessness. She had breast carcinoma treated 17 years ago, with further surgical excision for recurrence 7 years ago. Computerised tomography (CT) demonstrated bi-lateral pulmonary embolism, with extensive lymphadenopathy and lung metastases. She was treated with therapeutic heparin. Echocardiography revealed a right ventricular mass attached to the tricuspid valve chordae (Fig. 1; Videos 1 and 2), which could be thrombus, marantic or infective vegetation. Blood cultures were negative. Lymph node biopsy showed malignant cells, likely of breast origin. Despite therapeutic anti-coagulation, echocardiogram 3 weeks after initial presentation demonstrated enlargement of the original mass and an additional mass (Fig. 1; Videos 3 and 4), implying that these were most probably marantic. We retrospectively reviewed the CT performed at first presentation, which also demonstrated the original right ventricular mass (Fig. 1). She died from recurrent embolic cerebrovascular events, confirmed on MRI, within a month from initial presentation. In advanced stages of malignancy, marantic endocarditis or non-bacterial thrombotic endocarditis can develop in hypercoagulable states. It has a rapidly progressive course, with embolisation of vegetations to other organs. The sterile vegetations consist of fibrin and platelets (1, 2). Patients should be anti-coagulated. In terminal cases, surgery rarely alters the final outcome (2, 3). Figure 1 (A and B) Right ventricular mass (arrowed) attached to the tricuspid valve chordae apparatus on echocardiography, in apical four-chamber view, and modified parasternal right ventricular inflow view respectively; (C and D) repeat echocardiogram demonstrating ... Video 1 The initial right ventricular mass attached to the tricuspid valve chordae apparatus on echocardiography, in modified parasternal right ventricular inflow view. Download Video 1 via http://dx.doi.org/10.1530/ERP-14-0066-v1 Download Video 1 Video 2 The initial right ventricular mass attached to the tricuspid valve chordae apparatus on echocardiography, in apical four-chamber view. Download Video 2 via http://dx.doi.org/10.1530/ERP-14-0066-v2 Download Video 2 Video 3 Repeat echocardiogram demonstrating enlargement of the original mass and an additional mass, in modified parasternal right ventricular inflow view. Download Video 3 via http://dx.doi.org/10.1530/ERP-14-0066-v3 Download Video 3 Video 4 Repeat echocardiogram demonstrating enlargement of the original mass and an additional mass, in apical four-chamber view. Download Video 4 via http://dx.doi.org/10.1530/ERP-14-0066-v4 Download Video 4

True infrainguinal vein graft aneurysms are reported infrequently in the literature. We sought to identify the true incidence of these graft aneurysms after popliteal aneurysm repair and identify factors which may increase the risk of such aneurysms developing. Using a prospectively compiled database, we identified patients who underwent a popliteal aneurysm repair between January 1996 and January 2011 at a single district general hospital. Patients were routinely followed up in a graft surveillance programme. Out of 45 patients requiring repair of a popliteal aneurysm over a 15-year period, four (8.8%) patients developed aneurysmal graft disease. Of the patients who developed graft aneurysms, all had aneurysmal disease at other sites compared with 18 (45.0%) patients who did not develop graft aneurysms. Patients with graft aneurysms had a mean of 1.60 aneurysms elsewhere compared to 0.58 in patients with non-aneurysmal grafts ( P = 0.005). True vein graft aneurysms occur in a significant number of patients following popliteal aneurysm repair. Our data would suggest this to be more likely in patients who have aneurysms elsewhere and therefore a predisposition to aneurysmal disease. It may be appropriate for patients with aneurysms at other sites to undergo more prolonged post-operative graft surveillance.

A 50-year-old man was found to have an incidental peri-adrenal cystic lesion on CT imaging which was removed laparoscopically. Histological examination showed a cystic structure composed of respiratory and cuboidal-type epithelium with underlying smooth muscle, cartilage and seromucinous glands. The differential diagnosis for such a lesion includes bronchogenic cyst or teratoma differentiated. This case report offers an overview of both the conditions and the difficulties encountered in the histological distinction.

A 78-year-old man presented with chest pain, left bundle branch block and raised troponin levels. Echocardiography demonstrated a 63 mm vein graft aneurysm with mural thrombus (Fig. 1A, B and C; Videos 1, 2, 3 and 4), and a dilated, severely dysfunctional and dyssynchronous left ventricle, with inferior akinesia. Eighteen years ago, he had undergone coronary artery bypass grafting following three myocardial infarctions. He had four grafts, including a vein graft to the left anterior descending artery (LADA). Percutaneous occlusion of this aneurysmal LADA graft had been considered when it measured 45 mm 3 years before, but on angiography, the graft contributed significantly to LADA flow and was not therefore occluded (Fig. 1D). The native LADA and two other vein grafts were occluded. Repeat computerised tomography scan revealed that the aneurysmal graft was patent, but had enlarged, compressing the pulmonary artery (Fig. 1E, F and G). The patient died from left ventricular failure. Vein graft aneurysms occur due to trauma during harvesting, weak points along the vein or atherosclerotic degeneration (1, 2). On echocardiography, it appears as a well-circumscribed, echo-lucent mass, surrounded by a crescentic, echo-dense region. Using i.v. echo-contrast agents, pulsatile diastolic flow within such aneurysms has been described before (3). Untreated aneurysms can cause myocardial infarctions, rupture and death (2). Figure 1 (A and B) Vein graft aneurysm with mural thrombus (labelled *) on echocardiography, in modified parasternal long- and short-axis views (LV, left ventricle); (C) vein graft aneurysm demonstrating flow within the aneurysm, on colour Doppler echocardiography, ... Video 1 Vein graft aneurysm with mural thrombus on echocardiography, in modified parasternal long-axis view. Download Video 1 via http://dx.doi.org/10.1530/ERP-14-0054-v1. Download Video 1 Video 2 Vein graft aneurysm with mural thrombus on echocardiography, in modified parasternal short-axis view at the level of the left ventricle. Download Video 2 via http://dx.doi.org/10.1530/ERP-14-0054-v2. Download Video 2 Video 3 Vein graft aneurysm with mural thrombus on echocardiography, in modified parasternal short-axis view at the level of the aortic valve. Download Video 3 via http://dx.doi.org/10.1530/ERP-14-0054-v3. Download Video 3 Video 4 Vein graft aneurysm with colour Doppler demonstrating flow within the aneurysm on echocardiography, in modified long-axis view. This also demonstrates the pulmonary artery with flow within, compressed between the aneurysm and the aortic root. Download Video 4 via http://dx.doi.org/10.1530/ERP-14-0054-v4. Download Video 4

This presentation describes the importance of communication network infrastructure to support the achievement of European Union policy goals, economic growth and employment. The future Internet will run on a high-speed broadband optical fibre infrastructure. Research is required to match the requirements of users, applications and services to the capabilities of the infrastructure.

Renal cell carcinoma is reported to have potent angiogenic activity with a high microvascular density in both primary and metastatic sites compared with other adenocarcinomas. Angiogenesis can lead to the formation of abnormal arteriovenous shunts that can, in patients with peripheral vascular disease, result in worsening of the degree of ischaemia by producing a vascular steal-like phenomena. Nevertheless, steal phenomena secondary to malignancies are extremely rare. We report a case of distal critical limb ischaemia in a patient with peripheral vascular disease exacerbated by massive arteriovenous shunting due to tibial metastases from renal cell carcinoma.

Protein-membrane interactions are a vital mechanism of propagating signals both across the membrane and between cells. One method of signal propagation is the formation of lipid microdomains that allow the preferential clustering of specific lipid types and proteins. To address this type of signal propagation, we investigated how lipid microdomains form in response to annexin binding to model membranes. Annexins bind to negatively charged (e.g., phosphatidylserine [PS]) membranes in a calcium-dependent manner and lead to the formation of PS-enriched microdomains in supported planar bilayers. Two distinct mechanisms of signal propagation via protein-lipid binding are addressed. First, we hypothesize that proteins can transmit binding information via the ordering of the lipid acyl chains upon binding. Alternatively, we predict that when a protein binds a specific lipid preferentially, protein-protein interactions are enhanced on a membrane surface. The role of lipid acyl chain ordering and protein-protein interactions as distinct mechanisms of signal propagation through lipid binding will be illustrated.

Exocytosis of neurotransmitters is triggered by the initial influx of Ca2+. Synaptotagmin I is known to bind Ca2+ and the phospholipid membrane to modulate this process. The mechanism, however, for this information transduction is not well known. We seek to understand how this information is conveyed through the protein. A single point mutation, Y180F, has been made to correlate with a mutant that has been seen in vivo to display diminished physiological function. This mutant will be utilized as a probe as we seek to ascertain the mechanism of the signal transduction. The Y180F mutation is located in the binding pocket of the first C2 domain of synaptotagmin. It was hypothesized that this mutation abolishes the hydrogen bonding potential between this position and His237 and that the lack of hydrogen bonding will lead to a drastic decrease in stability in the binding pocket. This mutation is predicted to manifest itself as a reduction in the domain's calcium ion affinity. To test these predictions, Ca2+ and phospholipid binding assays for wild type C2A and Y180F will be carried out and monitored via steady state fluorescence as well as protein denaturation assays. Partition functions will be derived to quantify the results so a thermodynamic comparison can be carried out.