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Objectives Clinical experts recommend against testing for lupus anticoagulant (LAC) during anticoagulation. Methods We quantitated the risk of a single-positive dilute Russell viper venom time (dRVVT) result or partial thromboplastin time–based phospholipid neutralization (PN) result on anticoagulation. Results Any anticoagulation led to a fourfold greater likelihood of single-positive results, primarily by rivaroxaban (odds ratio [OR] = 8.6) and warfarin (OR = 6.6), resulting in a positive dRVVT test with a normal PN test. Heparin and apixaban were twofold more likely to show single-positive results, but enoxaparin did not show significant single positivity. Conclusions Our results quantitatively support experts’ avoidance of LAC testing during anticoagulation.

In 2019 the Centers for Disease Control and Prevention (CDC) reported a series of 4 transfusion reactions that resulted from contamination of apheresis platelet products. Products involved in all 4 cases were contaminated with Acinetobacter calcoaceticus-baumannii complex (ACBC) and in 3 products Staphylococcus saprophyticus was found as well. CDC investigation found that bacterial isolates from the cases were genetically related and suggested a common source of contamination. The contamination of blood products with ACBC is rare and polymicrobial contamination of blood products even less common. ACBC and S. saprophyticus have been observed to adhere to one another and sediment out of suspension in vitro, a process referred to as coaggregation, and we hypothesized that there was an interaction between the strains from these cases that contributed to their co-contamination of blood products.To test the hypothesis of bacterial interaction, we performed coaggregation experiments and observed the growth characteristics of ACBC and S. saprophyticus strains recovered from contaminated blood products involved in a subset of the CDC cases.An increase in S. saprophyticus CFU concentration was observed after several days of co-culture with ACBC in LB and plasma; however, no other findings suggested coaggregation or augmentative growth interaction between the bacterial strains.Ultimately, an interaction between ACBC and S. saprophyticus that could help explain their co-occurrence and growth in contaminated platelet units was not found; however future studies of potential interactions may be warranted.

We sought to determine risk factors for iv iron infusion-related reactions (IRR), and identify strategies for iron repletion after IRR.We conducted a retrospective chart review of patients treated in the classical hematology clinic at Yale Cancer Center (n = 330 consecutive patients) from 2016 to 2021, who received iv ferumoxytol (60.3%), iron sucrose (14.8%), or iron dextran (10.9%).The iv iron IRR was noted in 58 (17.6%) patients, 62.1% of whom had previously tolerated iv iron. The severity of IRR was mild in 22, moderate in 23, and severe in 11 patients. Most (72.4%) patients who experienced IRR tolerated a subsequent iv iron infusion. On multivariable analysis, a history of non-medication allergies was associated with greater odds of IRR (odds ratio [OR] 2.12, 95% confidence interval (CI): 1.16-3.87, p = .01). No patients with type AB blood, and few with type A blood (n = 6), had IRR; compared to type A or AB together, patients with type B (OR 5.00, 95% CI: 1.56-16.06, p = .007) or type O (OR 3.71, 95% CI: 1.44-9.55, p = .007) blood had greater odds of IRR.This study highlights a possible association of blood type with iv iron IRR; prospective studies with larger patient numbers are warranted to explore this association.

Introduction Neutrophil-lymphocyte ratio (NLR) is an established strong predictor of mortality in colorectal, hepatocellular, gastric, pancreatic and lung cancers, however there is limited evidence regarding breast cancer. The relationship of the host immune system and tumour biology plays a known integral role in oncological outcomes. The NLR provides an approximate quantification of host inflammatory response in advancing or more aggressive tumours. Routine inclusion of the full blood count in preoperative workup thereby offers a possible cost-effective prognostic biomarker. This project explores the association between preoperative NLR and breast cancer overall survival. Methods This retrospective cohort study reviewed an institutional database of breast cancer patients undergoing primary curative surgery at University Hospital Limerick from January 1, 2010 to June 1, 2017. The primary endpoint studied was overall survival. Log-rank testing examined overall survival between groups of patients with NLR Results In the included cohort of 579 cases, the mortality rate was 18% (n=105). The cohort had a median preoperative NLR of 2.63 (SD 1.42). Patients with NLR ≥ 2.5 were significantly associated with poorer overall survival (HR 1.71, 95% CI 1.12 to 2.60, p=0.011). Median survival time is not available for this dataset at this time and will be reported upon longer follow up. Conclusion Preoperative NLR ≥2.5 was found to be an independent predictor of breast cancer overall survival. Analysis of this data is ongoing to adjust for confounders, as well as evaluate recurrence free survival.

Immunotherapy is rapidly becoming a standard of care for many cancers. However, colorectal cancer had been generally resistant to immunotherapy, despite features in common with sensitive tumors. Observations of substantial clinical activity for checkpoint blockade in colorectal cancers with defective mismatch repair (microsatellite instability–high tumors) have reignited interest in the search for immunotherapies that could be extended to the larger microsatellite stable (MSS) population. The Cancer Research Institute and Fight Colorectal Cancer convened a group of scientists, clinicians, advocates, and industry experts in colorectal cancer and immunotherapy to compile ongoing research efforts, identify gaps in translational and clinical research, and provide a blueprint to advance immunotherapy. We identified lack of a T-cell inflamed phenotype (due to inadequate T-cell infiltration, inadequate T-cell activation, or T-cell suppression) as a broad potential explanation for failure of checkpoint blockade in MSS. The specific cellular and molecular underpinnings for these various mechanisms are unclear. Whether biomarkers with prognostic value, such as the immunoscores and IFN signatures, would also predict benefit for immunotherapies in MSS colon cancer is unknown, but if so, these and other biomarkers for measuring the potential for an immune response in patients with colorectal cancer will need to be incorporated into clinical guidelines. We have proposed a framework for research to identify immunologic factors that may be modulated to improve immunotherapy for colorectal cancer patients, with the goal that the biomarkers and treatment strategies identified will become part of the routine management of colorectal cancer. Cancer Immunol Res; 5(11); 942–9. ©2017 AACR.

Supplemental Tables 1 and 2

S1. Therapeutic strategies and corresponding laboratory tests.

S2. Policy and Infrastructure driven solutions noted for support of immunology work.

Chemotherapy combined with immunotherapy has improved the treatment of certain solid tumors, but effective regimens remain elusive for pancreatic ductal adenocarcinoma (PDAC). We conducted a randomized phase 2 trial evaluating the efficacy of nivolumab (nivo; anti-PD-1) and/or sotigalimab (sotiga; CD40 agonistic antibody) with gemcitabine/nab-paclitaxel (chemotherapy) in patients with first-line metastatic PDAC (NCT03214250). In 105 patients analyzed for efficacy, the primary endpoint of 1-year overall survival (OS) was met for nivo/chemo (57.7%, P = 0.006 compared to historical 1-year OS of 35%, n = 34) but was not met for sotiga/chemo (48.1%, P = 0.062, n = 36) or sotiga/nivo/chemo (41.3%, P = 0.223, n = 35). Secondary endpoints were progression-free survival, objective response rate, disease control rate, duration of response and safety. Treatment-related adverse event rates were similar across arms. Multi-omic circulating and tumor biomarker analyses identified distinct immune signatures associated with survival for nivo/chemo and sotiga/chemo. Survival after nivo/chemo correlated with a less suppressive tumor microenvironment and higher numbers of activated, antigen-experienced circulating T cells at baseline. Survival after sotiga/chemo correlated with greater intratumoral CD4 T cell infiltration and circulating differentiated CD4 T cells and antigen-presenting cells. A patient subset benefitting from sotiga/nivo/chemo was not identified. Collectively, these analyses suggest potential treatment-specific correlates of efficacy and may enable biomarker-selected patient populations in subsequent PDAC chemoimmunotherapy trials.

Recent data suggest basophils can adopt an atypical appearance in myeloid disorders including myeloproliferative neoplasms (MPNs) and myeloproliferative/myelodysplastic disease. We hypothesized that automated analysers may not accurately quantitate basophils in myeloid neoplasms based on scatter properties. This study examined basophil counts and properties in myeloid disorders by automated cell analyser, manual differential, and flow cytometry.Patients with myeloid neoplasms and control patients with no myeloid disorder diagnosis at a tertiary care centre were identified. Basophil percentage was compared for automated analyser counts (Sysmex XN9000), manual differential, and flow cytometry. Basophil scatter properties in MPNs were examined using flow cytometry.Thirty-one patients with myeloid neoplasms were included: 58% were male, mean age was 70.2 (±20.7) years, 32% had a diagnosis of chronic myeloid leukaemia with the remaining patients divided among various other forms of myeloid disease (including: essential thrombocythemia, polycythemia vera, unclassifiable MPN, myelodysplastic syndromes). For these patients, mean basophil percentage by automated analyser was significantly lower than manual differential (2.7 ± 2.9 vs. 7.1 ± 4.6, respectively, p 0.001). No significant difference was found between automated versus manual differential for basophils in control subjects (p = 0.373). For myeloid neoplasm patients, mean basophil percentage was not significantly different between manual differential and flow cytometry (p = 0.116); mean basophil percentage by automated analyser was significantly lower than flow cytometry (2.7 ± 2.9 vs. 5.3 ± 3.7, respectively, p = 0.003).Automated analysers underestimate basophil counts in patients with myeloid neoplasms. Manual differential and flow cytometry are recommended for more accurate quantitation and characterization of aberrant basophils.

Due to the unprecedented situation caused by a global pandemic, the traditional way of teaching that is reliant on face-to-face interaction between teachers and students has been dismantled. This article looks into university teachers’ experiences of teaching under lockdown, with an intention to understand what the change meant in terms of social practice. The research follows a qualitative design, in which ten university teachers were interviewed using a semi-structured interview guide. Three themes interwoven with a common thread were identified through teachers’ reflections, including displacement, routine, and role. The common thread was identified as the interaction between teachers and students, and analysing the quality of this interaction led to understanding the social kernel of teaching as embedded in social practice, suggesting that physical dislocation demands teachers to recreate meaning in the new situation. This change has been seen as difficult, yet unpacking teachers’ perceptions provided valuable lessons for the future.

Background Lipid disorders are now considered causal for atherosclerotic cardiovascular disease (ASCVD) which remains one of the most important contributors to morbidity and mortality in the developed world. Identification and early treatment of lipid disarrays remains the cornerstone of good clinical practice to prevent, halt and even reverse ASCVD. Guidelines for lipid management are imperative to help promote good clinical practice. Given the detail involved in comprehensive guidelines and the multiple areas of knowledge required by clinical practitioners, abbreviated, easy to understand, practical versions of guidelines are required to ensure dissemination of the most important information. The recent ESC lipid guidelines 2019 and the ESC guidelines on CVD prevention in clinical practice 2021 (1,2), provide an excellent detailed summary of all the latest evidence supporting lipid interventions that reduce ASCVD. Method We therefore developed a single-page document with hyperlinks to help practitioners gain easy access to practical information on lipid management. It has been developed for future electronic use in clinical practice. Conclusion It is presented here in a tabular format together with printable versions of the associated hyperlinks that provide the additional information required in decision making. It is hoped to audit the impact of this approach to help guide future ways of disseminating the latest clinical guideline updates.

The printing conditions in Fused Deposition Modelling (FDM) affect the amount of induced residual stresses within the printed part and its dimensional accuracy. Among the thermoplastic feedstock for FDM, semi-crystalline polymers are more prone to part distortion due to crystallisation. Therefore, this study aims to numerically investigate the behaviour of semi-crystalline polymer under various FDM printing conditions (namely print speed and ambient temperature) and the resultant residual stress and warpage in the printed parts. For this, the coefficient of thermal expansion (CTE) and the thermo-mechanical properties of the polymer under study (polypropylene), and the crystallisation kinetics are coupled with the evolving temperature and time during printing. The values of residual stress and warpage are calculated and compared for the bottom and top layers of the samples. From the results, it was observed that increasing the nozzle speed from 30 mm/s to 60 mm/s resulted in the bottom and top layers exhibiting a 15% and 13% decrease in residual stress, respectively. Similarly, a drop in warpage (~30%) was observed for both layers. The reduction in residual stress and warpage with increased printing speed is attributed to the improved heat transfer between the deposited roads and the reduced cooling rate. Increasing the ambient temperature from 25 °C to 75 °C resulted in a 2% and 3% decrease in residual stress in the bottom and top layers, respectively. In terms of warpage, an insignificant increase (~1%) was observed in both top and bottom layers. This is explained by the counter effects of reduced thermal gradients (i.e., lower cooling rate) and increased crystallisation on the overall amount of residual stress and warpage. 3D scanning of experimentally printed samples was used for verification of the simulation results, and good agreement between these is reported.

Alloimmunization to K11 is an extremely rare event. However, given the potential clinical significance of K11 alloantibodies, allocating antigen-negative red blood cell (RBC) units is a clinical necessity. In brief, we report a 39-year-old woman with multiple comorbidities including a right lower-extremity, below-the-knee amputation, who developed aggressive osteomyelitis associated with continuous bloody oozing, leading to anemia. To address these issues, the patient required extremity amputation. Surgery required addressing the concomitant critical anemia (hemoglobin5 g/dL). However, with anti-K11 (in addition to anti-Jk

Therapeutic apheresis refers to a diversity of procedures in which specific hematologic components (e.g., plasma, erythrocytes, leukocytes, etc.) with pathological associations are removed from circulation (with possible replacement) in order to treat a variety of disease processes. As pharmacologic agents also circulate with these components, their removal is sometimes incidental, or in the scenario of drug toxicity, a therapeutic goal. The corpus of published manuscripts on this subject has grown immensely over the past few decades; however, the breadth of diseases, methods, and drugs that co-exist in this space make it challenging to generate generalizable evidence regarding drug removal via apheresis. This review discusses factors worth considering when interpreting literature-reported data on drug removal by apheresis with examples from several notable studies and highlights topics in need of evidential improvement and growth as our palette of therapeutic agents continues to expand.

Despite advances in opioid-sparing analgesia, opioid prescribing in breast surgery remains suboptimal. Besides delayed rehabilitation, excess post-operative opioids may contribute significantly to opioid dependence. This systematic review of guidelines evaluates current opioid-prescribing recommendations after breast surgery to identify trends in prescribing. Additionally, it compares recommendations on different non-opioid and non-pharmacological adjuncts.Electronic databases were searched systematically using terms "breast surgery", "analgesia", "opioid" and "guidelines". The grey literature was used to supplement the search. All articles that provided guidance on opioid prescribing in breast surgery were included. Quality of the guidelines were assessed using the AGREE II tool. Recommendations pertaining to opioid prescribing, analgesic adjuncts and non-pharmacological interventions were summarised and reported with descriptive statistics.Eight guidelines pertaining to mastectomies, breast conserving surgery and breast reconstructions were included in this review. Although an opioid-sparing approach was unanimous, there were conflicting recommendations on opioid doses. Opioid requirements were stratified by procedure in 3 guidelines, and by patient risk factors in 2 guidelines. There was significant variability in the recommended multimodal adjuncts. Notably, non-pharmacological interventions such as patient education were infrequently included in guidelines.There is a lack of high-quality guidance on opioid prescribing after breast surgery. The optimum approach for personalised opioid prescribing remains unknown. Significant variability between guidelines provide little actionable interventions for prescribers. This could be driven by the paucity in evidence supporting a single efficacious analgesic regimen for patients undergoing breast surgery. Future guidelines should also regularly incorporate non-pharmacological adjuncts to reduce opioid prescribing.

We perform a systematic review of the literature on emotions in engineering education. The review is of the type meta-synthesis as described by Siddayway et al (2019) and aims to (1) provide an overview and critical appraisal of the existing literature on emotions in engineering education, and (2) outline directions for future research in this emerging field.

These Guidelines are intended to help improve the conservation and management of geoheritage and geodiversity in protected and conserved areas and recognition of the interrelationships and interactions with biological features and processes. They are not a textbook on geoconservation management practice, but rather set out the essential background, context and principles. The use of best practice examples from around the world will hopefully give users renewed confidence in looking after geoheritage and in connecting geoconservation with biodiversity conservation.

The conserved Rap1 protein is part of the shelterin complex that plays critical roles in chromosome end protection and telomere length regulation. Previous studies have addressed how fission yeast Rap1 contributes to telomere length maintenance, but the mechanism by which the protein inhibits end fusions has remained elusive. Here, we use a mutagenesis screen in combination with high-throughput sequencing to identify several amino acid positions in Rap1 that have key roles in end protection. Interestingly, mutations at these sites render cells susceptible to genome instability in a conditional manner, whereby longer telomeres are prone to undergoing end fusions, while telomeres within the normal length range are sufficiently protected. The protection of long telomeres is in part dependent on their nuclear envelope attachment mediated by the Rap1-Bqt4 interaction. Our data demonstrate that long telomeres represent a challenge for the maintenance of genome integrity, thereby providing an explanation for species-specific upper limits on telomere length.

Additive manufacturing has received significant interest in the fabrication of functional channels for heat transfer; however, the inherent rough surface finish of the additively manufactured channels can influence thermal performance. This study investigates the impact of roughness on the thermo-fluid characteristics of laminar forced convection in rough minichannels. A numerical model was developed to create 3D Gaussian roughness with specified root-mean-square height. The finite volume method was used to solve the conjugate heat transfer of developed laminar flow in square minichannels. For Reynolds numbers ranging from 200 to 1600, the simulation results indicated enhanced heat transfer and increased flow resistance as Reynolds number increases, compared to a smooth minichannel, where effects on heat transfer and flow friction were negligible. For channels with relative roughness (root-mean-square height to channel hydraulic diameter) of 0.0068, 0.0113, and 0.0167, increasing the Reynolds number led to increased friction factor by 1.56, 1.71, and 2.91%, while the Nusselt number was enhanced up to 0.03%, 32.74%, and 46.05%, respectively. Heat transfer reduced in roughness valleys due to the presence of local low-velocity fluid in these regions; however, recirculation regions can occur in deep valleys of high roughness, increasing heat transfer and flow friction. Heat transfer was enhanced over roughness peaks due to flow impingement on the windward face of roughness as well as intensified energy transfer to the channel wall from roughness. Moreover, surfaces with higher roughness have a greater number of high peaks providing a thermal-flow path of a larger area and a thermal conductivity greater than that of the fluid.

Background High quality health care is information reliant. Access to high quality information in a timely manner is imperative in provision of quality patient care. A national standard for discharge summaries has been developed by the Health Information and Quality Authority (HIQA). A standard for surgical discharge letters is needed to avoid patient readmission, unnecessary presentation to primary care and to ensure continuity of care in the community. The aim is to assess the quality of surgical discharge summaries using the HIQA national Standard. To implement quality improvement strategies recommended by current research. To reassess the quality and close the audit loop. Methods For cycle one of audit, one month of discharge summaries in 2020 were generated across four consultant surgeons at the University Hospital Limerick. 33% of those were sampled evenly across consultants. 60 patient discharge summaries were audited. Training was implemented virtually. For cycle two of audit the same methodology was used, 43 discharge summaries were audited. Results Overall performance was 49%, improved to 69% following training. The worst performing category was future management, 20%, improved to 45%. The best performing categories were auto-populated, patient details 97% and primary care details, 100%. Patient medications were compliant in 25%, improving to 59%. Admission and discharge details were complete in 36% improving to 59%. Clinical narrative was present in 37% improving to 64%. Consultants had not signed off on any letters. Conclusions Surgical discharge summaries audited remain non-compliant with the national standard however, as research shows, NCHD training has improved performance across categories.

Aim Acute appendicitis (AA) is among the most common emergency surgical presentations to Irish hospitals. In 2020, the World Society of Emergency Surgery (WSES) updated its Jerusalem guidelines for the investigation, diagnosis, and management of AA. We aimed to evaluate our institutional compliance with these guidelines in the COVID era and outline potential areas for improvement. Methods We performed a retrospective chart review of all patients admitted to our institution with the diagnosis of AA in July 2021 and compared them against the standards outlined in the WSES Jerusalem guidelines. Results 39 patients were identified. Average age was 25.4 years. 2.6% (n=1) had clinical scores documented. 33.3% (n=13) had computerised tomography scans performed, 33.3% (n=13) underwent ultrasound scans and 33.3% (n=13) had no diagnostic imaging. 100% proceeded with surgical management. Average time to theatre was 16.9 hours. 23.1% (n=9) were open appendectomies, 74.4% (n=29) were laparoscopic appendectomies and 2.6% (n=1) was a laparoscopic converted to open appendectomy. 100% had histopathological analyses. 69.2% (n=27) were true AAs, 15.4% (n=6) were negative appendectomies and 15.4% (n=6) were non-inflamed appendices with other pathology including lymphoid hyperplasia, fecolith or enterobius. Average length of stay (AvLOS) was 3.6 days. Conclusions As regards timely surgical intervention and routine histopathology, we are compliant with the guidelines. However increased utilisation of validated clinical scoring systems could potentially reduce negative appendectomy rates and AvLOS. We believe an educational intervention is required to improve our compliance with these standards.

Aims This audit aims to determine if standards of best practice according to NICE guideline pancreatitis (September 2018) are being met. Methods Using the Hospital In-Patient Enquiry (HIPE) system, 129 admissions with AP during 2020 were retrospectively identified. Audit targets included adequate fluid resuscitation and nutritional support, frequency of radiological investigations, emergency cholecystectomy, lifestyle advice and appropriate follow up. Results Aetiologies identified were biliary (33.3%), alcohol (33.3%), idiopathic (7.8%), hypertriglyceridemia (3.8%), autoimmune (1.6%), medication (0.8%), anatomical variant (0.8%) and the remainder (18.6%) were unidentified since not fully investigated (NFI). 47.3% (n=61) had ultrasound while 61.2% (n=79) had computed tomography of abdomen and pelvis (CTAP) during hospital-stay. Out of 33.3% (n=43) with biliary aetiology, 25.6% (n=11) had successful ERCP and 41.9% (n=18) were referred for outpatient clinic or already awaiting outpatient laparoscopic cholecystectomy. No emergency cholecystectomies were performed. Out of 28 readmissions, biliary pathology accounted for 35.7% (n=10), alcohol 25% (n=7) and NFI 17.9% (n=5). 37.2% (16) of alcoholic pancreatitis admissions had documented cessation advice either as in-patient or on discharge. There was no documentation for HbA1C in 6 months or DEXA scan in 2 years’ time, or a yearly fecal elastase for chronic pancreatitis patients. Conclusion Audit of current practice identified areas for improvement, including bettering access to emergency theatre, increased focus on encouraging lifestyle modification and monitoring pancreatic endocrine and exocrine function. We aim to create an institutional standard operating procedure for investigating and managing pancreatitis, and re-audit next year to discern if management has moved closer to the established standard.

Aim Significant heterogeneity exists in the recommendations for the diagnosis and management of acute lower gastrointestinal bleeding (LGIB). This study aims to demonstrate the contemporary management strategies adopted by a busy tertiary hospital. Methods We conducted a single-centre retrospective review of adults presenting to our institution with LGIB between January and March 2021. Demographic data, observations, laboratory results, endoscopy and radiology reports, operation notes and discharge summaries were collected for each patient via a retrospectively maintained registry. Results 23 patients were included. Mean age was 66.6 years with a mean initial haemoglobin of 10.9 g/dL (Range 4.1–15.5g/dL). 17% of patients were in circulatory shock on presentation. 70% of patients presented with haematochezia. 47.8% of patients were on either an anticoagulant or anti-platelet agent at presentation. The transfusion index in this cohort was 30%. 26.1% of patients had a re-bleed during their admission. The diagnostic yield of cross-sectional imaging amongst 11 patients was 27.3% with no correlation with haemodynamic status or active bleeding. 47.8% of patients underwent endoscopy and 27% of patients who underwent an endoscopic procedure required endoscopic haemostasis. Flexible sigmoidoscopy was the commonest endoscopic modality (55%), followed by gastroscopy (27%) and colonoscopy (18%). No patients required surgical or radiological intervention. No cause of bleeding was identified in 26% of patients. Conclusion This study confirms the variation in diagnosis and management of LGIB. Despite access to onsite interventional radiology, endoscopy remained the predominant diagnostic and therapeutic modality. Routine cross-sectional imaging may not be justified given its suboptimal diagnostic yield.

Background Trends in healthcare have caused a shift in training towards more competency based programmes. The COVID-19 pandemic has reduced time available for direct exposure and clinical learning, necessitating incorporation of simulation in training. The objectives of this study were to develop, pilot and evaluate a four week simulation based surgical teaching programme. Methods Interns pursuing a career in surgery joined a near-peer surgical training programme delivered by NCHDs. A survey established a baseline competency. Four skills workshops were delivered. Outcomes were measured using data from pre and post course surveys as well as a surgical skills competition. Results Of the 12 trainees, 71% had scrubbed in theatre before. 50% were already confident to scrub independently, increased to 75% post training. 28% were confident gowning/gloving, increased to 75% post training. 28% were confident to place a simple suture in theatre, this did not increase despite training. 42% were confident performing an instrument tie, increased to 75% post training. 14% were confident hand tying knots, this increased to 62%. 14% of participants were comfortable performing excisional biopsy in theatre, increased to 62% post training. Preparation and administration of local anaestetic could be performed confidently by 14% before training, this increased to 87%. On completion, a surgical skills competition showed that 100% were able to satisfactorily perform basic skills. Conclusions Near-peer delivery of surgical training has enhanced the basic surgical skills of interns. Similar programmes in other sites would ensure that interns have the skills required to safely care for surgical patients.

Aims Only 1% of all diagnosed breast cancers are in male patients. Overwhelmingly, current literature addresses breast cancer in female patients. This study aims to analyse the investigation and management of male breast cancers in a busy Symptomatic Breast Unit. Methods We conducted a single-centre review of male breast cancers diagnosed in our institution between January 2016 and December 2020. Initial presenting symptoms, imaging findings, histology and follow-up data were collected via a prospectively maintained database. Results The most common presenting symptom was a palpable breast lump (69%). Other symptoms included nipple bleeding/discharge (15%) and skin ulceration (8%). 62% of cases were located centrally behind, or involved, the nipple. The most common pathology was invasive ductal carcinoma (77%). One patient was diagnosed with invasive papillary carcinoma, while two patients were diagnosed with different cancers (spindle cell sarcoma and metastasis of medullary carcinoma of the thyroid). 77% of patients were managed operatively, with all undergoing a simple mastectomy. A sentinel lymph node biopsy or axillary clearance was performed in 62% and 8% of cases respectively. Several patients underwent adjuvant radiotherapy (62%) and chemotherapy (54%). 77% of patients were ER/PR positive, with 15% HER2+ positive. 100% of these patients received appropriate endocrine therapy. Conclusions Although female breast cancer commonly presents in the upper outer quadrant of the breast this study found that more male breast cancers occur centrally and involved the nipple. As breast cancer in male patients is rare, larger cohorts are required to confirm the findings of this study.

Bombay phenotype, an exceptionally rare blood type in individuals outside of Southeast Asia, occurs in approximately 1 in 1,000,000 individuals in Europe. This blood phenotype is characterized by the absence of the H antigen on red blood cells (RBCs) and in secretions. As the H antigen is the structure on which the ABO system is built, individuals lacking this antigen are unable to produce A or B antigens and appear as type O on routine ABO phenotyping. H deficiency does not cause ill effect; however, these individuals produce an anti-H alloantibody capable of causing severe acute hemolytic transfusion reactions when exposed to RBCs that express the H antigen. In this case study, we highlight the incidental discovery of a patient with Bombay phenotype in a North American hospital system, expected test results, the immunologic and genetic basis underlying the Bombay and para-Bombay phenotypes, and methods to ensure availability of compatible blood.

Horizontal angular resolution was measured in two bottlenose dolphins using a two-alternative forced-choice, biosonar target discrimination paradigm. The task required a stationary dolphin positioned in a hoop to discriminate two physical targets at a range of 4 m. The angle separating the targets was manipulated to estimate an angular discrimination threshold of 1.5°. In a second experiment, a similar two-target biosonar discrimination task was conducted with one free-swimming dolphin, to test whether its emission beam was a critical factor in discriminating the targets. The spatial separation between two targets was manipulated to measure a discrimination threshold of 6.7 cm. There was a relationship between differences in acoustic signals received at each target and the dolphin's performance. The results of the angular resolution experiment were in good agreement with measures of the minimum audible angle of both dolphins and humans and remarkably similar to measures of angular difference discrimination in echolocating dolphins, bats, and humans. The results suggest that horizontal auditory spatial acuity may be a common feature of the mammalian auditory system rather than a specialized feature exclusive to echolocating auditory predators.