Background With among the lowest urologist per population ratios in Europe, the demand for urology specialist review in Ireland far exceeds supply. Lower urinary tract symptoms (LUTS) account for a significant number of referrals. The traditional paradigm of every patient being reviewed in a consultant-led clinic is unsustainable. New models of care with nurse-led clinics represent an opportunity to optimise limited resources. Methods Existing long-waiting male LUTS referrals were triaged to a specialist nurse-led LUTS clinic. After urology CNS assessment, charts were reviewed by a consultant urologist and a plan formulated. Relevant data were prospectively collected and analysed. Results Fifty-eight new male patients with LUTS were seen over a 6-month period with an average waiting time of 15.8 months. Patients were assessed with uroflowmetry, IPSS and DRE. Mean age was 64, IPSS 14.5, Qmax 18.3 ml/s and PVR 89 ml. Thirty patients (52%) were discharged directly with lifestyle modification and medical therapy. Twenty-eight patients (48%) required one or more further investigations and subsequent review; 11 had flexible cystoscopy, 4 had urodynamics, 5 had prostate MRI, and 2 patients were listed for surgery (TURP and circumcision). The remaining 10 patients were for review post trial of lifestyle modifications and/or medical treatment. After review/investigations, 4 more patients were discharged. A total of 32 patients (55%) were discharged or listed for surgery after initial assessment. This total increased to 62% after a second review/investigations. Conclusion Introduction of a CNS-led LUTS clinic has significantly reduced the number of patients requiring follow-up in general urology clinics, representing a quality improvement in service provision. Supplementary Information The online version contains supplementary material available at 10.1007/s11845-020-02428-8.

Background Obstructive sleep apnea (OSA) is an increasingly common disorder associated with increased cardiovascular disease, mortality, reduced productivity, and an increased risk of road traffic accidents. A significant proportion of patients with OSA in the UK are undiagnosed. This study aims to identify risk factors for OSA in an obese cohort. Method A population-based study was conducted of obese patients (BMI ≥ 30 kg/m2) from the Clinical Practice Research Datalink (CPRD). A logistic regression model was used to calculate odds ratios (ORs) for developing OSA according to other clinicopathological characteristics. Multivariate analysis was conducted of individual factors that affect the propensity to develop OSA. Statistical significance was defined as p < 0.050. Results From 276,600 obese patients identified during a data extraction of the CPRD in July 2017, the prevalence of OSA was 5.4%. The following risk factors were found to be independently associated with increased likelihood of OSA: male sex (OR = 3.273; p < 0.001), BMI class II (OR = 1.640; p < 0.001), BMI class III (OR = 3.768; p < 0.001), smoking (OR = 1.179; p < 0.001), COPD (OR = 1.722; p < 0.001), GERD (OR = 1.557; p < 0.001), hypothyroidism (OR = 1.311; p < 0.001), acromegaly (OR = 3.543; p < 0.001), and benzodiazepine use (OR = 1.492; p < 0.001). Bariatric surgery was associated with reduced risk of OSA amongst this obese population (OR = 0.260; p < 0.001). Conclusions In obese patients, there are numerous comorbidities that are associated with increased likelihood of OSA. These factors can help prompt clinicians to identify undiagnosed OSA. Bariatric surgery appears to be protective against developing OSA.

Biliary disease and cholecystitis remain one of the most significant surgical challenges. Over 1,000,000 cholecystectomies are performed in the US every year [1, 2], and over 50,000 in the UK [3]. While minimally invasive laparoscopic cholecystectomy (LC) has afforded great advantages over open cholecystectomy, reducing variability and improving outcomes remains a challenge [4, 5]. It is only recently that operative classifications and grading of cholecystitis have been published [6]. LC related peri-operative complications, while infrequent may

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BACKGROUND Clinical equipoise exists regarding optimal sequencing in the definitive management of choledocholithiasis. Our current study compares sequential biliary ductal clearance and cholecystectomy at an interval to simultaneous laparoendoscopic management on index admission in a pragmatic retrospective manner. METHODS Records were reviewed for all patients admitted between January 2015 and December 2018 to a Swedish and an Irish university hospital. Both hospitals differ in their practice patterns for definitive management of choledocholithiasis. At the Swedish hospital, patients with choledocholithiasis underwent laparoscopic cholecystectomy with intraoperative rendezvous endoscopic retrograde cholangiopancreatography (ERCP) at index admission (one stage). In contrast, interval day-case laparoscopic cholecystectomy followed index admission ERCP (two stages) at the Irish hospital. Clinical characteristics, postprocedural complications, and inpatient duration were compared between cohorts. RESULTS Three hundred fifty-seven patients underwent treatment for choledocholithiasis during the study period, of whom 222 (62.2%) underwent a one-stage procedure in Sweden, while 135 (37.8%) underwent treatment in two stages in Ireland. Patients in both cohorts were closely matched in terms of age, sex, and preoperative serum total bilirubin. Patients in the one-stage group exhibited a greater inflammatory reaction on index admission (peak C-reactive protein, 136 ± 137 vs. 95 ± 102 mg/L; p = 0.024), had higher incidence of comorbidities (age-adjusted Charlson Comorbidity Index, ≥3; 37.8% vs. 20.0%; p = 0.003), and overall were less fit for surgery (American Society of Anesthesiologists, ≥3; 11.7% vs. 3.7%; p < 0.001). Despite this, a significantly shorter mean time to definitive treatment, that is, cholecystectomy (3.1 ± 2.5 vs. 40.3 ± 127 days, p = 0.017), without excess morbidity, was seen in the one-stage compared with the two-stage cohort. Patients in the one-stage cohort experienced shorter mean postprocedure length of stay (3.0 ± 4.7 vs. 5.0 ± 4.6 days, p < 0.001) and total length of hospital stay (6.5 ± 4.6 vs. 9.0 ± 7.3 days, p = 0.002). The only significant difference in postoperative complications between the cohorts was urinary retention, with a higher incidence in the one-stage cohort (19% vs. 1%, p = 0.004). CONCLUSION Where appropriate expertise and logistics exist within developing models of acute care surgery worldwide, consideration should be given to index-admission laparoscopic cholecystectomy with intraoperative ERCP for the treatment of choledocholithiasis. Our data suggest that this strategy significantly shortens the time to definitive treatment and decreases total hospital stay without any excess in adverse outcomes. LEVEL OF EVIDENCE Therapeutic/Care Management Level IV.