There is still much controversy surrounding whether interval appendicectomy is appropriate for adults with an appendiceal mass or abscess. The main debate centres on the recurrence rate, the complication rate of interval appendicectomy, and the potential for underlying malignancy. This review aims to assess current practice and to determine whether it is possible to define "best practice" for the asymptomatic patient who has had an appendiceal mass or abscess treated conservatively. I sent a postal questionnaire to 90 consultant general surgeons requesting information about their practice of interval appendicectomy. I also conducted a literature search confined to studies involving only adult patients. The 77.8% of questionnaires returned revealed that 53% of the surgeons perform routine interval appendicectomy, mainly because of concerns about recurrence. The preference was for open appendicectomy at 6 weeks to 3 months. The literature search revealed a recurrence rate of 10%-25%, with a complication rate of 23%. It was evident that the chances of missing malignancy are low and thorough investigation is better than interval appendicectomy in detecting colonic cancer. The practice of performing interval appendicectomy varies, with just over half of the surgeons surveyed performing this procedure routinely. The literature provides little evidence that interval appendicectomy is routinely indicated and would support the view that it is unnecessary in 75%-90% of cases. However, there is scope for further consideration of the use of laparoscopic interval appendicectomy and a randomised trial is needed to fully evaluate this issue.

Ann R Coll Surg Engl 2008; 90: 377-380 377Non-attendance at hospital out-patient clinics has been a cause for concern for many years with no simple and costeffective solution to date. Non-attendance has potentially adverse clinical consequences for the non-attender, other patients who could have benefited from the appointment and financial consequences for the NHS. To overbook each clinic for the estimated number of 'did-not-attends' is not the ideal solution as it fails to solve the first concern and 'did-notattends' are subject to a degree of randomness. It has been calculated that 15% more appointments than necessary would need to be made to allow for this randomness, 1 which is not a good use of resources. Furthermore, on days where the overbooked patients do attend, this will cause an increase in waiting time in the clinic and will likely breach the Patients' Charter.The reported 'did-not-attend' rate for inner city outpatient clinics varies from 5.4% to 33%. 2,3The clinic speciality appears not to be a major factor in non-attendance. 4 Higher 'did-not-attend' rates are found in young males, higher Jarman index (the 'did-not-attend' rate is higher in deprived areas) and with an interval between referral and appointment date of more than 2 or 3 months. 2,5The reasons for not attending given by patients range from appointment notice to personal or family problems. Previous studies have reported that 5-20% did not receive the appointment notification, 1% received the appointment after the appointment date, 25% stated they had cancelled and 2% rang to cancel but could not get through. 6,7 Several authors have tried various methods to reduce the 'did-not-attend' rate. Telephone reminders have significant- Non-attendance in the out-patient department has financial costs for the NHS and clinical implications to the non-attender and those awaiting an appointment. The aim of this audit was to quantify the percentage of non-attenders at colorectal clinics in a UK teaching hospital, assess which factors affected attendance, establish why individuals fail to attend and to implement appropriate change.

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INTRODUCTION The post-implantation syndrome after endovascular aneurysm repair (EVAR) is increasingly recognised. However, when non-vascular trainees are responsible for the care of these patients out of hours, many are investigated if pyrexial. This study assesses the role of microbiological investigations in pyrexia after endovascular aneurysm repair. PATIENTS AND METHODS The notes of 75 EVAR patients were reviewed retrospectively. The incidence of postoperative pyrexia and infective complications were calculated and the result of any cultures obtained. RESULTS Overall, 58 (77.3%) patients were pyrexial with 48 h of stent insertion. Twenty-four had blood cultures and 12 had urine cultures taken within 48 h of surgery. All of these cultures were negative. However, of those with a pyrexia after 48 h, one of nine blood cultures and two of 11 urine cultures grew organisms. Five pyrexial patients and one apyrexial patient developed a wound infection (a non-significant difference, P = 1.00). CONCLUSIONS Pyrexia within 48 h of EVAR is common. Microbiological investigation in the first 48 h in these patients is unrewarding. After 48 h, cultures are more likely to show growth. Although each patient must be assessed clinically for signs of sepsis, blood and urine cultures within 48 h of EVAR are generally unnecessary.

Fibrodysplasia ossificans progressiva is a rare disorder characterized by the progressive development of heterotopic bone in the connective tissues of skeletal muscle, ligaments and tendons. Surgical trauma is one of the most potent stimuli for ossification and surgical treatment is generally considered to be contraindicated in this condition. We report a good functional result in a patient with severe hand disability secondary to an ulna-carpal bar in fibrodysplasia ossificans progressiva.

This study aims to explore the perceptions of foundation doctors (FDs) in the United Kingdom (UK) surrounding raising concerns in the workplace. An online survey was sent to all FDs in the UK between February and March 2018. Respondents were asked what they had observed or experienced that had been ethically challenging during their foundation training. The qualitative responses were coded into themes. Reasons why FDs wished to raise concerns in the workplace included disagreements about clinical decisions within the team, insufficient availability of resources, lack of senior colleague support and having to work beyond their competencies. Challenges faced by FDs when raising concerns included organisational resistance to change, difficulties in communicating ideas to those higher up in the hierarchy and the emotional stress of whistleblowing regarding senior colleagues.Perceived consequences of raising concerns included negative impact on FDs' reputation and career, and fear of bullying. To overcome these barriers, changes within organisations at all levels must take place in order to provide an environment where FDs are encouraged to raise concerns and thus make positive changes to their work environments for themselves, their colleagues and patients.

Venous compression due to external cystic lesions, although rare, is recognised. This case serves as a reminder that the rarer causes of limb swelling should not be forgotten, especially where potentially treatable.