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Adrenal vein sampling (AVS) is the gold standard for diagnosing unilateral primary aldosteronism. Point-of-care rapid cortisol assays such as the gold nanoparticle based quick cortisol assay (QCA) are used to confirm accurate cannulation of the adrenal veins during the procedure and have improved AVS success rates. In this retrospective cohort study, we reviewed the results of consecutive AVS procedures (n = 37) performed with and without ACTH (synacthen) infusion between October 2020 and December 2022 at our institution. We compared (1) the accuracy of point-of-care QCA at semi-quantitatively assessing successful adrenal vein cannulation before and after ACTH infusion when compared with selectivity index based on laboratory cortisol measurements, (2) accuracy of QCA based on peripheral and adrenal vein cortisol levels and (3) the impact of time of day on the accuracy of QCA. We found the accuracy of QCA compared with formal laboratory cortisol measurements was 71% pre-ACTH and 100% post-ACTH (p-value < 0.001). Pre-ACTH, the accuracy of QCA was higher in the lowest (28-257 nmol/L) and highest (466-25130 nmol/L) adrenal vein cortisol tertiles compared to the mid-tertile. Post-ACTH, the accuracy of QCA remained high regardless of adrenal vein cortisol levels. Time of day did not affect the accuracy of the QCA. We conclude that during basal AVS subjective, visual estimates of adrenal vein cortisol levels using the QCA semi-quantitively should not be solely relied upon to guide catheter placement. These results will help guide clinicians in the appropriate clinical situations in which QCA should be used during AVS., Competing Interests: Competing interests: The authors declare no competing interests. Ethical approval: The project was approved by our institutional ethics committee as a quality assurance study (QA 22031) and patient consent was not required., (© 2025. Crown.)

Background: Adrenal vein sampling (AVS), integral to identifying surgically remediable unilateral primary aldosteronism (PA), is technically challenging and subject to fluctuations in cortisol and aldosterone secretion. Intra-procedural adrenocorticotropic hormone (ACTH), conventionally administered as a 250-μg bolus and/or 50 μg per hour infusion, increases cortisol and aldosterone secretion and can improve AVS success, but may cause discordant lateralisation compared to unstimulated AVS., Aims: To assess if AVS performed with ultra-low dose ACTH infusion causes discordant lateralisation., Methods: Here, we describe our preliminary experience using an ultra-low dose ACTH infusion AVS protocol. We retrospectively reviewed the results of consecutive AVS procedures (n = 37) performed with and without ultra-low dose ACTH (1-μg bolus followed by 1.25 μg per hour infusion)., Results: Bilateral AV cannulation was successful in 70% of procedures pre-ACTH and 89% post-ACTH (p < 0.01). Sixty-nine percent of studies lateralised pre-ACTH and 55% post-ACTH, improving to 79% when both groups were combined. Lateralisation was discordant in 11 cases, including eight in which lateralisation was present only on basal sampling, and three in which lateralisation occurred only with ACTH stimulation., Discussion: Overall, the decrease in lateralisation rates with ACTH was higher than previously reported for some protocols utilising conventional doses of ACTH. Our results suggest that AVS performed with ultra-low dose ACTH can cause discordant lateralisation similar to AVS performed with conventional doses of ACTH., Conclusion: Prospective studies directly comparing low and conventional dose ACTH AVS protocols and long-term patient outcomes are needed to help define the optimal ACTH dose for accurate PA subtyping., (© 2024 The Author(s). Endocrinology, Diabetes & Metabolism published by John Wiley & Sons Ltd.)

Study Objective: The optimal methods of preoperative assessment and prehabilitation specific to patients with obesity undergoing non-bariatric surgery have not been described. We investigated two questions: 1) which methods of preoperative assessment in patients with obesity are associated with improved patient management, and 2) which methods of prehabilitation in patients with obesity are associated with improved patient outcomes?, Design: Systematic review., Setting: Preoperative assessment and optimisation, and postoperative outcomes., Patients: Patients with obesity scheduled for surgery of any type., Interventions: We searched six electronic databases for clinical studies addressing either preoperative assessment or preoperative optimisation., Measurements: The primary outcome measure for the assessment review was any impact on preoperative disease diagnosis or progression, or postoperative complications. The primary outcome measure for the prehabilitation review was any postoperative change in disease or health status, or any medical or surgical complications., Main Results: Twenty one papers were included in the assessment review (total of 5090 participants) and twenty five for prehabilitation (30,170 participants). Approximately two thirds of papers reported on bariatric surgery populations. In the assessment review, studies reported on either the preoperative detection of comorbidities or the prediction of postoperative complications. The only assessment tool with any suggestion of benefit was polysomnography. A range of methods of prehabilitation were found for question 2. Forty eight percent of papers reported improvement in some or all study outcomes. The most successful intervention was exercise, with 4 of 5 exercise-based trials showing improvement in either some or all postoperative outcomes., Conclusions: There is a limited body of work addressing preoperative assessment and prehabilitation specific to surgical patients with obesity, especially when undergoing non-bariatric surgery. Preoperative polysomnography was shown to improve both the diagnosis of obstructive sleep apnoea and the prediction of postoperative complications. Half of the prehabilitation studies showed evidence of benefit. From this review, we were unable to make strong recommendations as to best practice in patients with obesity presenting for non-bariatric surgery., (Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.)

Background: Adrenal vein sampling (AVS) is integral to identifying surgically remediable unilateral primary aldosteronism (PA). However, right adrenal vein (AV) cannulation can be challenging, limiting its success. Intra-procedural cortisol assays can improve the reliability of AVS. The aim of this study was to validate the use of semi-quantitative cortisol estimates obtained utilizing a quick cortisol assay (QCA) during AVS procedures at our institution., Methods: Retrospective review of results of AVS procedures before and after the introduction of the QCA. Twenty-three AVS procedures were performed with the provisional success determined by intra-procedural QCA. Successful AV cannulation was defined by an AV to peripheral vein cortisol ratio ≥ 4.0 (the selectivity index) from laboratory measurements. The control cohort consisted of 23 consecutive procedures prior to introduction of the QCA., Results: QCA correctly predicted all AV cannulation attempts. Successful bilateral AV cannulation increased from 52% to 91% of procedures when performed with the QCA (P = 0.01) and adequate cannulation of the right AV increased from 61% to 91% (P = 0.03). There was no increase in procedural time, number of AV cannulation or sampling attempts., Conclusions: Point-of-care, semi-quantitative cortisol estimates can be performed accurately during AVS with QCA, facilitating improvements in AVS success rates without increasing procedural time., (© 2021 Royal Australasian College of Surgeons.)

Background: Repeat transarterial chemoembolisation (rTACE) is often required for hepatocellular carcinoma (HCC) to achieve disease control, however, current practice guidelines regarding treatment allocation vary significantly. This study aims to identify key factors associated with patient survival following rTACE to facilitate treatment allocation and prognostic discussion., Method: Patients with HCC undergoing rTACE at six Australian tertiary centers from 2009 to 2014 were included. Variables encompassing clinical, tumour, treatment type and response factors were analysed against the primary outcome of overall survival. Univariate analysis and multivariate Cox regression modelling were used to identify factors pre- and post-TACE therapy significantly associated with survival., Results: Total of 292 consecutive patients underwent rTACE with mainly Child Pugh A cirrhosis (61%) and BCLC stage A (57%) disease. Median overall survival (OS) was 30 months (IQR 15.2-50.2) from initial TACE. On multivariate analysis greater tumour number (p = 0.02), higher serum bilirubin (p = 0.007) post initial TACE, and hepatic decompensation (p = 0.001) post second TACE were associated with reduced survival. Patients with serum AFP ≥ 200 ng/ml following initial TACE had lower survival (p = 0.001), compared to patients with serum AFP level that remained < 200 ng/ml post-initial TACE, with an overall survival of 19.4 months versus 34.7 months (p = 0.0001) respectively., Conclusion: Serum AFP level following initial treatment in patients undergoing repeat TACE for HCC is a simple and useful clinical prognostic marker. Moreover, it has the potential to facilitate appropriate patient selection for rTACE particularly when used in conjunction with baseline tumour burden and severity of hepatic dysfunction post-initial TACE.