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OBJECTIVES: Laryngology disease burden is growing while theater capacity is falling. Over half a million patients are waiting for ENT care in England alone (1). The demand for laryngology services has continued to grow significantly, particularly post-COVID (2). Meanwhile, the number and efficiency of ENT theater lists are reduced (3). To tackle the growing backlog, NHS England has emphasized the need for innovative strategies by separating elective from emergency services and by increasing the resilience of elective delivery (4). The establishment of an office-based laryngology procedure clinic is a potential solution. METHODS: We offer a narrative review and audit of our experience in founding an in-office laryngology procedure service within a tertiary NHS center with the aim of streamlining this setup process for other interested ENT units. RESULTS: We outline an in-depth exploration of the personnel, equipment, and processes necessary to establish an in-office procedure clinic. Our experience showed that the procedure clinic functions well when implemented within the framework of existing ENT elective and emergency services. Although there is initial investment required in terms of money, effort, and time, our outcomes show that the clinical and economic benefits of the clinic outweigh the costs, also allowing for patients to access investigations and treatments reliably and efficiently. CONCLUSION: Setting up a laryngology in-office procedure clinic within the NHS confers patient, organizational, and economic benefits. It provides a novel and resilient approach in addressing the growing backlog of patients awaiting laryngology care and should be popularized in the current health care environment. LEVEL OF EVIDENCE: Level 4 Laryngoscope, 2024.
RESUMO
Detection of hepatocellular carcinoma (HCC) through screening can improve outcomes. However, HCC surveillance remains costly, cumbersome and suboptimal. We tested whether and how serum Alpha-Fetoprotein (AFP) should be used in HCC surveillance. Record linkage, dedicated pathways for management and AFP data-storage identified i) consecutive highly characterised cases of HCC diagnosed in 2009-14 and ii) a cohort of ongoing HCC-free patients undergoing regular HCC surveillance from 2009. These two well-defined Scottish patient cohorts enabled us to test the utility of AFP surveillance. Of 304 cases of HCC diagnosed over 6 years, 42% (129) were identified by a dedicated HCC surveillance programme. Of these 129, 47% (61) had a detectable lesion first identified by screening ultrasound (US) but 38% (49) were prompted by elevated AFP. Despite pre-HCC diagnosis AFP >20kU/L being associated with poor outcome, 'AFP-detected' tumours were offered potentially curative management as frequently as 'US-detected' HCCs; and had comparable survival. Linearity of serial log10-transformed AFPs in HCC cases and in the screening 'HCC-free' cohort (n = 1509) provided indicators of high-risk AFP behaviour in HCC cases. An algorithm was devised in static mode, then tested dynamically. A case/control series in hepatitis C related disease demonstrated highly significant detection (p<1.72*10-5) of patients at high risk of developing HCC. These data support the use of AFP in HCC surveillance. We show proof-of-principle that an automated and further refine-able algorithmic interpretation of AFP can identify patients at higher risk of HCC. This approach could provide a cost-effective, user-friendly and much needed addition to US surveillance.