Customisable Silicone Vessels and Tissue Phantoms for In Vitro Photoplethysmography Investigations into Cardiovascular Disease.

Age-related vessel deterioration leads to changes in the structure and function of the heart and blood vessels, notably stiffening of vessel walls, increasing the risk of developing cardiovascular disease (CVD), which accounts for 17.9 million global deaths annually. This study describes the fabrication of custom-made silicon vessels with varying mechanical properties (arterial stiffness). The primary objective of this study was to explore how changes in silicone formulations influenced vessel properties and their correlation with features extracted from signals obtained from photoplethysmography (PPG) reflectance sensors in an in vitro setting. Through alterations in the silicone formulations, it was found that it is possible to create elastomers exhibiting an elasticity range of 0.2 MPa to 1.22 MPa. It was observed that altering vessel elasticity significantly impacted PPG signal morphology, particularly reducing amplitude with increasing vessel stiffness (p < 0.001). A p-value of 5.176 × 10-15 and 1.831 × 10-14 was reported in the red and infrared signals, respectively. It has been concluded in this study that a femoral artery can be recreated using the silicone material, with the addition of a softener to achieve the required mechanical properties. This research lays the foundation for future studies to replicate healthy and unhealthy vascular systems. Additional pathologies can be introduced by carefully adjusting the elastomer materials or incorporating geometrical features consistent with various CVDs.

A High-Yielding Active Template Click Reaction (AT-CuAAC) for the Synthesis of Mechanically Interlocked Nanohoops.

Mechanically interlocked molecules (MIMs) represent an exciting yet underexplored area of research in the context of carbon nanoscience. Recently, work from our group and others has shown that small carbon nanotube fragments-[n]cycloparaphenylenes ([n]CPPs) and related nanohoop macrocycles-may be integrated into mechanically interlocked architectures by leveraging supramolecular interactions, covalent tethers, or metal-ion templates. Still, available synthetic methods are typically difficult and low yielding, and general methods that allow for the creation of a wide variety of these structures are limited. Here we report an efficient route to interlocked nanohoop structures via the active template Cu-catalyzed azide-alkyne cycloaddition (AT-CuAAC) reaction. With the appropriate choice of substituents, a macrocyclic precursor to 2,2'-bipyridyl embedded [9]CPP (bipy[9]CPP) participates in the AT-CuAAC reaction to provide [2]rotaxanes in near-quantitative yield, which can then be converted into the fully π-conjugated catenane structures. Through this approach, two nanohoop[2]catenanes are synthesized which consist of a bipy[9]CPP catenated with either Tz[10]CPP or Tz[12]CPP (where Tz denotes a 1,2,3-triazole moiety replacing one phenylene ring in the [n]CPP backbone).

Monocyte chemotactic protein (MCP)-1 (CCL2) and its receptor (CCR2) are elevated in chronic heart failure facilitating lung monocyte infiltration and differentiation which may contribute to lung fibrosis.

BACKGROUND: Dyspnea, the cardinal manifestation of chronic heart failure (CHF), may reflect both pulmonary oedema and pulmonary remodeling resulting in tissue stiffening. Emerging evidence suggests that predominance of distinct phenotypes of alveolar and recruited macrophages, designated M1 and M2, may regulate the course of inflammatory tissue repair and remodeling in the lung. METHODS: In a CHF rat model, we found fibrotic reinforcement of the extracellular matrix with an increase in monocyte chemotactic protein (MCP)-1/CCL2 in bronchoalveolar lavage (BAL), corresponding to a 3-fold increase in recruited macrophages. In this clinical cross sectional study, we aimed to examine potential mediators of leukocyte activation and lung infiltration in parallel BAL and blood from CHF patients compared to non-CHF controls. RESULTS: Mini-BAL and peripheral blood samples were obtained from hospitalized CHF, acute decompensated CHF and non-CHF patients. CHF patients and decompensated CHF patients demonstrated increases from non-CHF patients in BAL MCP-1, as well as the M2 macrophage cytokines interleukin-10 and transforming growth factor-ß. BAL and plasma MCP-1 were significantly correlated; however, MCP-1 was 20-fold higher in epithelial lining fluid in BAL, indicative of an alveolar chemotactic gradient. An increase in transglutaminase 2 positive M2 macrophages in parallel with a decrease in the MCP-1 receptor, CC chemokine receptor 2 (CCR2), was apparent in BAL cells of CHF patients compared to non-CHF. CONCLUSION: These data suggest a pathway of MCP-1 mediated M2 macrophage prevalence in the lungs of CHF patients which may contribute to pulmonary fibrotic remodeling and consequent increased severity of dyspnea.

Photoplethysmography for the Assessment of Arterial Stiffness.

This review outlines the latest methods and innovations for assessing arterial stiffness, along with their respective advantages and disadvantages. Furthermore, we present compelling evidence indicating a recent growth in research focused on assessing arterial stiffness using photoplethysmography (PPG) and propose PPG as a potential tool for assessing vascular ageing in the future. Blood vessels deteriorate with age, losing elasticity and forming deposits. This raises the likelihood of developing cardiovascular disease (CVD), widely reported as the global leading cause of death. The ageing process induces structural modifications in the vascular system, such as increased arterial stiffness, which can cause various volumetric, mechanical, and haemodynamic alterations. Numerous techniques have been investigated to assess arterial stiffness, some of which are currently used in commercial medical devices and some, such as PPG, of which still remain in the research space.

A 12-year experience in endobronchial intervention using rigid bronchoscopy - account of a tertiary referral centre.

We describe our experience of rigid bronchoscopy and endobronchial intervention at a single tertiary centre over a 12-year period. All rigid bronchoscopy procedures between July 2008 and July 2020 (inclusive) were reviewed. All procedures were performed in cardiothoracic theatres by a designated team under general anaesthesia. 2135 rigid bronchoscopies were performed on 1301 patients aged between 18 and 93 years. Complications occurred in 24 (1.12%) procedures. There was one fatality (0.05%). Haemorrhage >100mls occurred in seven (0.33%) all of which were successfully managed endobronchially. Ten procedures (0.5%) were complicated by pneumothorax and an intercostal drain was required for eight. Five patients required intensive care admission post operatively, all of whom were subsequently discharged from hospital. One patient had stent migration. To the best of our knowledge, this is amongst the largest single centre collection of data available for endobronchial intervention using rigid bronchoscopy. We show that rigid bronchoscopy is a safe and effective procedure when performed in a high-volume specialist centre with designated lists involving a specialist multidisciplinary team.

A retrospective audit of cumulative ionising radiation levels in hospitalised pregnant patients.

BACKGROUND: Among hospitalised patients, diagnostic radiation is possibly used least on pregnant patients due to the fear of ionising radiation on the fetus; however, what levels are currently being prescribed. AIMS: To assess the cumulative levels of ionising radiation received by pregnant patients during a single admission to a tertiary hospital. MATERIALS AND METHODS: A retrospective audit of pregnant patients admitted to Flinders Medical Centre, South Australia, Australia, between 2013 and 2017 inclusive was performed. All procedures utilising ionising radiation were collected including conventional radiology, computed tomography, fluoroscopy and nuclear medicine. Individual and cumulative effective doses for mother and fetus were calculated using patient dose reports and published conversion factors. RESULTS: From 547 patients, the median cumulative effective dose was 0.02 mSv and only five patients received more than 10 mSv, with 19.07 mSv the highest dose received. The median fetal cumulative effective dose was 0.01 mSv but only three fetuses received more than 10 mSv, likely due to fetal exclusion in some procedural fields of view. Stays longer than ten days were associated with significantly higher cumulative effective dose, as did those with maternal cardiovascular related admission, for both maternal and fetal exposures. CONCLUSION: These results suggest that pregnant patients are exposed to low doses of ionising radiation, in both individual procedures and cumulative doses. The detrimental risks associated with these levels of ionising radiation are not overt and so clinicians should question which risk is higher, the ionising radiation from the radiological procedures received or the lack of diagnostic information if avoided?

Effects of Contact Pressure in Reflectance Photoplethysmography in an In Vitro Tissue-Vessel Phantom.

With the continued development and rapid growth of wearable technologies, PPG has become increasingly common in everyday consumer devices such as smartphones and watches. There is, however, minimal knowledge on the effect of the contact pressure exerted by the sensor device on the PPG signal and how it might affect its morphology and the parameters being calculated. This study explores a controlled in vitro study to investigate the effect of continually applied contact pressure on PPG signals (signal-to-noise ratio (SNR) and 17 morphological PPG features) from an artificial tissue-vessel phantom across a range of simulated blood pressure values. This experiment confirmed that for reflectance PPG signal measurements for a given anatomical model, there exists an optimum sensor contact pressure (between 35.1 mmHg and 48.1 mmHg). Statistical analysis shows that temporal morphological features are less affected by contact pressure, lending credit to the hypothesis that for some physiological parameters, such as heart rate and respiration rate, the contact pressure of the sensor is of little significance, whereas the amplitude and geometric features can show significant change, and care must be taken when using morphological analysis for parameters such as SpO2 and assessing autonomic responses.

A challenging case of tracheal foreign body retrieval following COVID-19 swabbing.

The COVID-19 pandemic has resulted in a significant increase in the number of tracheostomised patients in hospitals requiring ventilatory support. These patients require highly specialist care, but overwhelmed hospital systems with stretched human resources potentially leave these patients cared for by undertrained healthcare professionals. We describe a rare complication where a routine COVID-19 swab done incorrectly via a tracheostomy tube, resulted in a snapped-off swab in the trachea. We outline the events and our method of removal using rigid bronchoscopy through the tracheostomy stoma as endo-tracheal bronchoscopy was impossible due to significant sub-glottic stenosis. This case highlights the paramount importance of the unique care needed to safely manage tracheostomies during this ongoing pandemic.

Large airway complications in COVID-19 pneumonia.

COVID-19 pneumonia can cause respiratory failure which requires specialist management. However the inflammatory nature of the condition and the interventions necessary to manage these patients such as endotracheal intubation and tracheostomy can lead to large airway pathology which may go unrecognised. We describe five of the 44 (11%) consecutive patients referred to our specialist ARDS team between April and June 2020 with confirmed COVID-19 pneumonia who developed diverse large airway pathology which comprised of: supraglottic oedema, tracheal tear, tracheal granulation tissue formation, bronchomalacia, and tracheal diverticulum. Large airway pathology may be underappreciated in severely ill patients with COVID-19 pneumonia and should be considered in patients with unexplained air leak, prolonged need for mechanical ventilatory support, and repeated failed extubation or decannulation. If suspected, such patients should be managed by a team with expertise in large airway intervention and early specialist advice should be sought.

Theoretical, Solid-State, and Solution Quantification of the Hydrogen Bond-Enhanced Halogen Bond.

Proximal noncovalent forces are commonplace in natural systems and understanding the consequences of their juxtaposition is critical. This paper experimentally quantifies for the first time a Hydrogen Bond-Enhanced Halogen Bond (HBeXB) without the complexities of protein structure or preorganization. An HBeXB is a halogen bond that has been strengthened when the halogen donor simultaneously accepts a hydrogen bond. Our theoretical studies suggest that electron-rich halogen bond donors are strengthened most by an adjacent hydrogen bond. Furthermore, stronger hydrogen bond donors enhance the halogen bond the most. X-ray crystal structures of halide complexes (X- =Br- , I- ) reveal that HBeXBs produce shorter halogen bonds than non-hydrogen bond analogues. 19 F NMR titrations with chloride highlight that the HBeXB analogue exhibits stronger binding. Together, these results form the foundation for future studies concerning hydrogen bonds and halogen bonds in close proximity.

Loss of 2 Akt (Protein Kinase B) Isoforms in Hematopoietic Cells Diminished Monocyte and Macrophage Survival and Reduces Atherosclerosis in Ldl Receptor-Null Mice.

Objective- Macrophages express 3 Akt (protein kinase B) isoforms, Akt1, Akt2, and Akt3, which display isoform-specific functions but may be redundant in terms of Akt survival signaling. We hypothesize that loss of 2 Akt isoforms in macrophages will suppress their ability to survive and modulate the development of atherosclerosis. Approach and Results- To test this hypothesis, we reconstituted male Ldlr-/- mice with double Akt2/Akt3 knockout hematopoietic cells expressing only the Akt1 isoform (Akt1only). There were no differences in body weight and plasma lipid levels between the groups after 8 weeks of the Western diet; however, Akt1only→ Ldlr-/- mice developed smaller (57.6% reduction) atherosclerotic lesions with more apoptotic macrophages than control mice transplanted with WT (wild type) cells. Next, male and female Ldlr-/- mice were reconstituted with double Akt1/Akt2 knockout hematopoietic cells expressing the Akt3 isoform (Akt3only). Female and male Akt3only→ Ldlr-/- recipients had significantly smaller (61% and 41%, respectively) lesions than the control WT→ Ldlr-/- mice. Loss of 2 Akt isoforms in hematopoietic cells resulted in markedly diminished levels of white blood cells, B cells, and monocytes and compromised viability of monocytes and peritoneal macrophages compared with WT cells. In response to lipopolysaccharides, macrophages with a single Akt isoform expressed low levels of inflammatory cytokines; however, Akt1only macrophages were distinct in expressing high levels of antiapoptotic Il10 compared with WT and Akt3only cells. Conclusions- Loss of 2 Akt isoforms in hematopoietic cells, preserving only a single Akt1 or Akt3 isoform, markedly compromises monocyte and macrophage viability and diminishes early atherosclerosis in Ldlr-/- mice.

Novel Polydimethylsiloxane (PDMS) Pulsatile Vascular Tissue Phantoms for the In-Vitro Investigation of Light Tissue Interaction in Photoplethysmography.

Currently there exists little knowledge or work in phantoms for the in-vitro evaluation of photoplethysmography (PPG), and its' relationship with vascular mechanics. Such phantoms are needed to provide robust, basic scientific knowledge, which will underpin the current efforts in developing new PPG technologies for measuring or estimating blood pressure, blood flow and arterial stiffness, to name but a few. This work describes the design, fabrication and evaluation of finger tissue-simulating pulsatile phantoms with integrated custom vessels. A novel technique has been developed to produce custom polydimethylsiloxane (PDMS) vessels by a continuous dip-coating process. This process can accommodate the production of different sized vessel diameters (1400-2500 µm) and wall thicknesses (56-80 µm). These vessels were embedded into a mould with a solution of PDMS and India ink surrounding them. A pulsatile pump experimental rig was set up to test the phantoms, where flow rate (1-12 L·min-1), heart rate (40-120 bpm), and total resistance (0-100% resistance clamps) could be controlled on demand. The resulting flow profiles approximates human blood flow, and the detected contact PPG signal (red and infrared) from the phantom closely resembles the morphology of in-vivo PPG waveforms with signal-to-noise ratios of 38.16 and 40.59 dB, for the red and infrared wavelengths, respectively. The progress made by this phantom development will help in obtaining new knowledge in the behaviour of PPG's under differing flow conditions, optical tissue properties and differing vessel stiffness.

Factors associated with treatment retention in pregnant women with opioid use disorders prescribed methadone or electing non-pharmacological treatment.

Opioid use during pregnancy is rising, with an estimated 14-22% of women obtaining an opioid prescription during pregnancy. Methadone maintenance therapy (MMT) has been the gold standard for treatment of opioid use disorders during pregnancy; however, its use is limited in clinical practice due to availability, stigma, and reluctance on the part of clinicians. The present study compared against medical advice (AMA) treatment dropout from seven days of residential care between pregnant women diagnosed with opioid dependence who elected either MMT (n = 119) or non-pharmacological treatment (NPT) (n = 91) within the same treatment program in Baltimore, Maryland from 1996 to 1998. Multiple logistic regression analysis was conducted to compare the rate of AMA drop out between the two modalities. Patients who elected NPT were 2.77 times as likely to leave residential treatment as patients who elected MMT (adjusted odds ratio [OR = 2.77, 95% confidence interval [CI]: 1.23-6.17]. AMA was associated with interviewer-assessed drug severity and patient's rating of the importance of psychiatric treatment. The present findings further support the clinical utility of MMT and suggest that policies that facilitate the implementation of MMT in clinical practice would be beneficial to the engagement and retention of pregnant women with opioid use disorders.

Comparing the Immediate Effects of a Total Motion Release Warm-up and a Dynamic Warm-up Protocol on the Dominant Shoulder in Baseball Athletes.

Gamma, SC, Baker, R, May, J, Seegmiller, JG, Nasypany, A, and Iorio, SM. Comparing the immediate effects of a total motion release warm-up and a dynamic warm-up protocol on the dominant shoulder in baseball athletes. J Strength Cond Res 34(5): 1362-1368, 2020-A decrease in total range of motion (ROM) of the dominant shoulder may predispose baseball athletes to increased shoulder injury risk; the most effective technique for improving ROM is unknown. The purpose of this study was to compare the immediate effects of Total Motion Release (TMR) to a generic dynamic warm-up program in baseball athletes. Baseball athletes (n = 20) were randomly assigned to an intervention group: TMR group (TMRG; n = 10) or traditional warm-up group (TWG; n = 10). Shoulder ROM measurements were recorded for internal rotation (IR) and external rotation (ER), the intervention was applied, and postmeasurements were recorded. Each group then received the other intervention and postmeasurements were again recorded. The time main effect (p ≤ 0.001) and the time × group interaction effect were significant (p ≤ 0.001) for IR and ER. Post hoc analysis revealed that TMR produced significant increases in mean IR (p ≤ 0.005, d = 1.52) and ER (p ≤ 0.018, d = 1.22) of the dominant shoulder initially. When groups crossed-over, the TMRG experienced a decrease in mean IR and ER after the dynamic warm-up, whereas the TWG experienced a significant increase in mean IR (p ≤ 0.001, d = 3.08) and ER (p ≤ 0.001, d = 2.56) after TMR intervention. Total Motion Release increased IR and ER of the dominant shoulder more than a dynamic warm-up. Dynamic warm-up after TMR also resulted in decreased IR and ER; however, TMR after dynamic warm-up significantly improved IR and ER. Based on these results, TMR is more effective than a generic dynamic warm-up for improving dominant shoulder ROM in baseball players.

Validity and Intrarater Reliability Using a Smartphone Clinometer Application to Measure Active Cervical Range of Motion Including Rotation Measurements in Supine.

CONTEXT: Technological advances have given smartphones the capabilities of sensitive clinical measurement equipment at lesser cost and higher availability. The Clinometer is a smartphone application that can be used to measure the joint range of motion in a clinical setting, but psychometric properties of the tool's use measuring cervical range of motion (CROM) are not established. OBJECTIVES: The purpose of this study was to examine the validity and intrarater reliability of the Clinometer application for the measurement of CROM (ie, flexion, extension, rotation, lateral flexion) and to determine the minimal detectable change and SEM. DESIGN: A blinded, repeated-measures correlational design was employed. SETTING: The study was conducted collaboratively between 2 athletic training clinics. PARTICIPANTS: A convenience sample of healthy adults ages 18-30 years were recruited. Participants with any history in the last 3 months of cervical or thoracic pathology, pain, or any musculoskeletal injury were excluded. MAIN OUTCOME MEASURES: Three repetitions of each motion were measured by a primary researcher with a goniometer. The same researcher then conducted 3 blinded measurements with the Clinometer application following the same procedure. A second researcher, blinded to the goniometer measurements, recorded the results. Thirty minutes later, testing was repeated with the application. The Pearson correlation was calculated to determine validity of the application compared with goniometry. RESULTS: The measurements between devices had moderate to excellent concurrent validity, with the coefficients ranging between 0.544 and 0.888, P < .01. Test-retest reliability of the CROM measurement using the application was moderate to excellent, with intraclass correlation coefficients ranging between .774 and .928. Across all movements, the SEM ranged from 1.17° to 2.01°, and the minimal detectable change ranged from 1.18° to 2.02°. CONCLUSION: The Clinometer application is a valid and reliable instrument for measuring active CROM. LEVEL OF EVIDENCE: clinical measurement, level 1b.

What Do Plastic Surgery Patients Think of Financial Conflicts of Interest and the Sunshine Act?

BACKGROUND: The purpose of this study was to evaluate patients' views of conflicts of interest (COI) and their comprehension of recent legislation known as the Physician Payments Sunshine Act. This report constitutes the first evaluation of plastic surgery patients' views on COI and the government-mandated Sunshine Act. METHODS: This cross-sectional study invited patients at an academic, general plastic surgery outpatient clinic to complete an anonymous survey. The survey contained 25 questions that assessed respondents' perceptions of physician COI and awareness of the Sunshine Act. Analyses were performed to examine whether perspectives on COI and the Sunshine Act varied by level of education or age. RESULTS: A total of 361 individuals completed the survey (90% response rate). More than half of respondents with an opinion believed that COI would affect their physician's clinical decision-making (n = 152, 52.9%). Although almost three fourths (n = 196, 71.2%) believed that COI should be regulated and COI information reported to a government agency, the majority were not aware of the Sunshine Act before this survey (n = 277, 81.2%) and had never accessed the database (n = 327, 95.9%). More than half of patients (n = 161, 59.2%) stated that they would access a publicly available database with physicians' COI information. A larger proportion of older and educated patients believed that regulation of physicians' COI was important (P < 0.001). CONCLUSIONS: Awareness of and access to plastic surgeon COI information is low among plastic surgery patients. Older and more educated patients believed that transparency regarding COI is important with regard to their clinical care.

The Effects of Hip Mobilizations on Patient Outcomes: A Critically Appraised Topic.

Clinical Scenario: Hip osteoarthritis currently affects up to 28% of the population, and the number of affected Americans is expected to rise as the American population increases and ages. Limited hip range of motion (ROM) has been identified as a predisposing factor to hip osteoarthritis and limited patient function. Clinicians often apply therapy techniques, such as stretching and strengthening exercises, to improve hip ROM. Although traditional therapy has been recommended to improve hip ROM, the efficiency of the treatments within the literature is questionable due to lack of high-quality studies. More recently, clinicians have begun to utilize joint mobilization and the Mulligan Concept mobilization with movement techniques to increase ROM at the hip; however, there is a paucity of research on the lasting effects of mobilizations. Given the difficulties in improving ROM immediately (within a single treatment) and with long-lasting results (over the course of months), it is imperative to examine the evidence for the effectiveness of traditional therapy techniques and more novel manual therapy techniques. Focused Clinical Question: Is there evidence to suggest manual mobilizations techniques at the hip are effective at treating hip ROM limitations? Summary of Clinical Findings: 5 Randomized Controlled Studies, improved patient function and ROM with the Mulligan concept, high velocity low amplitude improved. Clinical Bottom Line: We found moderate evidence to suggest favorable outcomes following the use of hip mobilizations aimed at improving hip ROM and patient function. Strength of Recommendation: Strength of the studies identified are 1B.

Ascorbic acid attenuates endothelial permeability triggered by cell-free hemoglobin.

BACKGROUND: Increased endothelial permeability is central to shock and organ dysfunction in sepsis but therapeutics targeted to known mediators of increased endothelial permeability have been unsuccessful in patient studies. We previously reported that cell-free hemoglobin (CFH) is elevated in the majority of patients with sepsis and is associated with organ dysfunction, poor clinical outcomes and elevated markers of oxidant injury. Others have shown that Vitamin C (ascorbate) may have endothelial protective effects in sepsis. In this study, we tested the hypothesis that high levels of CFH, as seen in the circulation of patients with sepsis, disrupt endothelial barrier integrity. METHODS: Human umbilical vein endothelial cells (HUVEC) were grown to confluence and treated with CFH with or without ascorbate. Monolayer permeability was measured by Electric Cell-substrate Impedance Sensing (ECIS) or transfer of 14C-inulin. Viability was measured by trypan blue exclusion. Intracellular ascorbate was measured by HPLC. RESULTS: CFH increased permeability in a dose- and time-dependent manner with 1 mg/ml of CFH increasing inulin transfer by 50% without affecting cell viability. CFH (1 mg/ml) also caused a dramatic reduction in intracellular ascorbate in the same time frame (1.4 mM without CFH, 0.23 mM 18 h after 1 mg/ml CFH, p < 0.05). Pre-treatment of HUVECs with ascorbate attenuated CFH induced permeability. CONCLUSIONS: CFH increases endothelial permeability in part through depletion of intracellular ascorbate. Supplementation of ascorbate can attenuate increases in permeability mediated by CFH suggesting a possible therapeutic approach in sepsis.

Borderline Ovarian Tumors: Fifteen Years' Experience at a Scottish Tertiary Cancer Center.

OBJECTIVES: Since the recognition of borderline ovarian tumors (BOTs) in the 1970s, the management of this subset of epithelial ovarian tumors has presented a challenge to clinicians. The majority present at an early stage, but their diagnosis is often only made following surgery, hence the heterogeneity of surgical management. Borderline ovarian tumors are morphologically diverse, and their behavior is subsequently also heterogeneous. We aimed to assess recurrence rates and the rate of malignant transformation in patients diagnosed with BOT. Secondary objectives included a review of current management and assessment of tumor markers, stage, cyst dimensions, and the presence of micropapillary features as prognostic indicators of recurrence. METHODS: This retrospective cohort study included all patients treated with BOT between 2000 and 2015 in the southeast region of Scotland. Clinical, surgicopathological, and follow-up data were collated. Data were analyzed with reference to recurrence and malignant transformation. RESULTS: Two hundred seventy-five patients underwent treatment for BOT in the study period. Surgical management was highly variable. A diagnosis of recurrent/persistent BOT or ovarian malignancy following initial treatment of BOT was rare, with only 12 (4%) of 275 cases. There were 7 cases (3%) of ovarian malignancy. Advanced International Federation of Gynecology and Obstetrics stage was the most prominent prognostic factor. Elevated preoperative serum CA-125 and the presence of micropapillary features correlated with advanced stage at presentation. With a lack of clear guidance, follow-up was highly variable with a median of 43 months (0-136 months). CONCLUSIONS: To our knowledge, this study is the largest BOT cohort in the United Kingdom. Recurrent disease is rare in optimally staged, completely resected, early-stage BOT, without high-risk features. Caution is needed in women electing not to undergo completion staging after diagnosis and in those opting for a fertility-preserving approach. Thorough informed consent and clear plans for surveillance and follow-up are needed with consideration of delayed completion surgery as appropriate.

Day case paediatric tonsillectomy: a quality improvement project.

Tonsillectomy is one of the commonest ENT paediatric procedures. Recovery is best achieved at home, and cost-effectiveness of the day case pathway is significant in tonsillectomy. This project scrutinised the local practice regarding the effectiveness of day case pathway in paediatric tonsillectomy in a large regional teaching hospital. The project aimed to improve the rates of day case tonsillectomy discharges, to increase compliance of postoperative care with guidelines, and to assess long-term sustainability of the new practice. The project looked prospectively at the pre-existing paediatric tonsillectomy day case practice (cycle 1) prior to implementing a multifaceted intervention. The intervention consisted of an evidence-based change to local day case tonsillectomy guidelines, improved lists' planning/management, and clinicians' education. Thereafter, the outcomes were measured in the short term (cycle 2-prospective data collection) and in the long term (cycle 3-retrospective data collection). The gathered data revealed an improvement in post-tonsillectomy day case discharge rates (both short and long term), without an increase in postoperative complications. Moreover, our intervention had effectively reduced sleep study requests and resulted in a significant increase in list profitability.Conclusion: The departmental practice in paediatric day case tonsillectomy was improved via evidence-based relaxation of day case criteria, improved list management, and clinicians' education. The interventions resulted also in a positive significant financial impact with no increase in postoperative complications. What is Known: • Tonsillectomy is a common paediatric ENT procedure, with significant applicability and cost-effectiveness of the day case pathway. • There is a lack of a clear general consensus on criteria for patients' suitability for day case tonsillectomy. What is New: • This quality improvement project carried out a methodical relaxation of day case criteria of day case tonsillectomy. • The new criteria along with enhanced list management and clinician education had safely improved the local post-tonsillectomy day case care.