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Objectives The aim of this study was to assess the current post-tonsillectomy haemorrhage and return to theatre rates in Scotland. Design National cross-sectional study. Participants and setting Tonsillectomy outcomes data were collated for all NHS patients undergoing tonsillectomy in Scotland between 1998-2002 and 2013-2017. Main outcome measures Using Information Services Division (ISD) Scotland retrospective data, 30-day re-admission and 30-day return to theatre rates allowed an assessment of post-tonsillectomy haemorrhage rates. Data were validated through comparison with an audit conducted in NHS Greater Glasgow & Clyde between 2015 and 2016. Results Tonsillectomy was performed in 27 819 patients between 1998 and 2002, and 23 184 patients between 2013 and 2017. 30-day re-admission rates increased considerably between the 1998-2002 and 2013-2017 cohorts, from 4.7% to 12.1% in paediatric patients, and 9.8%-19.9% in adult patients. Similarly, 30-day "return to theatre rates" increased between the two cohorts, from 1.2% to 1.7% in paediatric patients, and 3.6%-4.9% in adult patients. Re-admission and return to theatre rates were similar across Health Boards for both adult and paediatric tonsillectomies in each cohort. Conclusions Current 30-day re-admission and return to theatre rates are significantly higher than the majority of reported series to date. The rising rate of tonsillectomy haemorrhage between cohorts is likely to be multifactorial, possibly reflecting an underestimation of previous rates and the changing profile of the tonsillectomy patient. A detailed audit of current practice is needed to investigate these tonsillectomy outcomes, which are similar across all Health Boards in Scotland. Of most significance are the implications for accurate patient consent and non-elective ENT service provision.

1. The overall success rate for TEES tympanoplasty was 83%.\ud 2. A learning curve of approximately 60 cases was evident, with success in the final 33% of cases being 93.5%.\ud 3. The only significant factor affecting the tympanoplasty success rate was the year since starting TEES.\ud 4. Hearing outcomes are related to pre‐operative ABG, ossicle erosion, and COM risk factors, but not to the level of experience in TEES.\ud 5. TEES has comparable outcomes, efficacy and complications to microscopic or combined techniques.

Objectives Review of the literature to identify practical, high-fidelity, commercially available animal models for simulation training and surgical skills maintenance in laryngotracheal reconstruction (LTR). Methods A systematic review of PubMed and Embase databases was conducted independently by two authors, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Search terms included "laryngotracheal reconstruction," "laryngotracheoplasty," "pig and larynx," "sheep and larynx," and "rabbit and larynx." Articles were then assessed, identifying model cost and availability, model validation, feasibility as a training tool, and verisimilitude to pediatric LTR. Results In total, 79 articles were considered suitable for inclusion in the study, incorporating both in vitro and in vivo models. Models utilized included rabbit (n = 69), pig (n = 7), sheep (n = 1), and goat (n = 2). The rabbit model was similar in size to the neonate, but differences in laryngeal anatomy and cartilage texture made graft insertion difficult. The anatomy of the pig, sheep, and goat larynges more closely resembled the pediatric patient, allowing improved grafting, but corresponded more in size to that of an older child. Commercial availability of the pig and sheep was considered greatest, and was reflected in cost. None of the animal models identified in the literature have been validated as a simulation tool. Conclusions The rabbit, sheep and pig models seemed to demonstrate the greatest potential for use as advanced pediatric airway surgery simulation models, with the rabbit model being most utilized in the literature. However, as yet there have been no models formally validated as a simulation training tool. Laryngoscope, 129:235-243, 2019.

To assess and compare the feasibility of using ovine and porcine models as surgical simulation training tools for otolaryngology trainees performing parotid surgery and facial nerve dissection. Trainees performed parotid surgery (total parotidectomy, retrograde facial nerve dissection and facial nerve grafting) on an ovine and porcine model. Participants completed a 22-item, five-point Likert scale questionnaire on each model, assessing three validation domains; face validity (FV), global content validity (GCV) and task-specific content validity (TSCV). Data were prospectively collected and analysed using descriptive and non-parametric statistics. Twelve trainees completed two consecutive parotidectomies and facial nerve dissections on an ovine and porcine model. Twenty-four dissections were completed. Validation questionnaires were completed for each model by all trainees. The ovine model achieved median validation threshold scores (≥ 4/5) for all aspects of FV, GCV and TSCV. The porcine model did not achieve validation threshold scores for any aspect of the validation questionnaire. Comparison of the ovine and porcine model demonstrated that the ovine model was statistically superior to the porcine model across most validation criteria excluding realistic appearance of skin, identification and ligation of the trans-oral parotid duct and facial nerve grafting. Adequate experience with facial nerve dissection during parotid surgery is vital to ensuring good outcomes and avoiding complications. This study is the first to compare validity of two animal models for simulation training in parotid surgery and facial nerve dissection. We have validated the ovine model as a useful tool for simulation training and advocate its incorporation into otolaryngology training programmes.

Objectives: To assess and compare the face (FV) and content validity (CV) of three ex vivo animal models for simulation training in pediatric laryngotracheal reconstruction (LTR). Methods: Feasibility of performing LTR was assessed on the head and neck of three different animals (lamb/suckling-pig/rabbit) and laryngeal dimensions and qualitative observations were recorded. A 19-item five-point Likert scale questionnaire was completed for each model to assess FV and CV. Data was prospectively collected and analyzed using descriptive and nonparametric statistics. Results: All three models were suitable for LTR simulation with laryngeal dimensions corresponding to 0-2 years (rabbit), 5-10 (pig) and >10 years (lamb model). Five trainees and five expert pediatric otolaryngologists performed LTR on each model. The overall median FV score was 5 for the lamb model (IQR 4-5), 3 for the rabbit (IQR 2-3), and 4 for the pig (IQR 4-4). The overall median CV score was 5 for the lamb (IQR 5-5), 2 for the rabbit (IQR 2-3), and 4 for the pig model (IQR 4-4). Comparison of the models demonstrated the lamb to be favored as the most realistic and practical model for simulation training in pediatric LTR, with both the lamb and the porcine model attaining validation thresholds. Conclusion: Our study is the first comparative validation assessment of animal models for use in pediatric LTR simulation and it supports the use of ex vivo lamb and porcine models for use in LTR surgical skills training. The lamb model was the favored simulation model while the rabbit was considered inferior for simulation training in pediatric LTR. Level of Evidence: 3b

OBJECTIVE Recent studies have suggested good hearing preservation following stereotactic radiosurgery (STRS) in patients with vestibular schwannomas (VS). This study aims to assess audiological outcomes in patients with growing VS treated either with STRS, or managed conservatively. STUDY DESIGN Retrospective cohort study. SETTING Tertiary referral center. PATIENTS Out of 540 patients with VS, 69 patients with growing VS fulfilled the inclusion criteria; 24 treated conservatively and 45 with STRS. VS were considered growing if demonstrating more than 15% tumor volume increase during 1 year of watchful waiting. INTERVENTION American Association of Otolaryngology-Head and Neck Surgery (AAOHNS) hearing threshold (dB averaged over 500-3000 Hz) deterioration and Gardner-Robertson class deterioration over time were used as the primary outcome measures. Rate of progression to loss of functional hearing (Gardner-Robertson class I-II) was also determined between cohorts. RESULTS Mean follow-up was similar between treatment cohorts (STRS = 69.6 mo, conservative management = 71.7 mo). There was no significant difference in AAOHNS deterioration (t = 1.05, df = 53, p = 0.301) or Gardner-Robertson deterioration (χ = 0.47, df = 1, p = 0.492) between cohorts. Furthermore, rate of progression to loss of functional hearing was similar between cohorts (Hazard ratio = 0.704, 95% CI 0.287-1.728, p = 0.44). In STRS patients, AAOHNS deterioration was greater in those with lower AAOHNS thresholds at diagnosis (t = -2.683, df = 28, p = 0.0121). Similarly, Gardner-Robertson deterioration was significantly more likely in STRS patients with functional hearing (Gardner-Robertson class I-II) (Adjusted odds ratio = 32.14, 95% CI 3.15-328, p = 0.0034). CONCLUSIONS STRS results in similar audiological outcomes compared with patients managed conservatively; Consequently, STRS given to patients with VS to preserve hearing is not justified. In contrast to recent studies, patients with preserved hearing at diagnosis have significantly greater audiological deterioration when undergoing STRS.

Vandetanib has been shown to improve progression-free survival in adults with advanced medullary thyroid cancer. This article describes a pediatric patient with metastatic medullary thyroid cancer secondary to sporadic multiple endocrine neoplasia 2B, treated with vandetanib. At presentation, he had an inoperable primary tumor, with carotid encasement, and pulmonary metastases. Vandetanib induced a significant response: calcitonin and carcinoembryonic antigen levels both fell considerably, primary tumor maximal diameter decreased by 68%, and pulmonary metastases became no longer detectable. This allowed surgical resection of the primary tumor. The patient remains well after over 6 years of vandetanib therapy, with no treatment toxicity.

Review of the literature to identify practical, high-fidelity, commercially available animal models for simulation training and surgical skills maintenance in laryngotracheal reconstruction (LTR).A systematic review of PubMed and Embase databases was conducted independently by two authors, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Search terms included "laryngotracheal reconstruction," "laryngotracheoplasty," "pig and larynx," "sheep and larynx," and "rabbit and larynx." Articles were then assessed, identifying model cost and availability, model validation, feasibility as a training tool, and verisimilitude to pediatric LTR.In total, 79 articles were considered suitable for inclusion in the study, incorporating both in vitro and in vivo models. Models utilized included rabbit (n = 69), pig (n = 7), sheep (n = 1), and goat (n = 2). The rabbit model was similar in size to the neonate, but differences in laryngeal anatomy and cartilage texture made graft insertion difficult. The anatomy of the pig, sheep, and goat larynges more closely resembled the pediatric patient, allowing improved grafting, but corresponded more in size to that of an older child. Commercial availability of the pig and sheep was considered greatest, and was reflected in cost. None of the animal models identified in the literature have been validated as a simulation tool.The rabbit, sheep and pig models seemed to demonstrate the greatest potential for use as advanced pediatric airway surgery simulation models, with the rabbit model being most utilized in the literature. However, as yet there have been no models formally validated as a simulation training tool. Laryngoscope, 129:235-243, 2019.

Summary Recent studies have shown that the number of women undergoing risk-reducing mastectomy has increased rapidly in the USA in the past 15 years. Although a small rise in the number of bilateral risk-reducing procedures has been noted in high-risk gene mutation carriers who have never had breast cancer, this number does not account for the overall increase in procedures undertaken. In patients who have been treated for a primary cancer and are judged to be at high risk of a contralateral breast cancer, contralateral risk-reducing mastectomy is often, but not universally, indicated. However, many patients undergoing contralateral risk-reducing mastectomy might not be categorised as high risk and therefore any potential benefit from this procedure is unproven. At a time when breast-conserving surgery has become more widely used, this sharp increase in contralateral risk-reducing mastectomy is surprising. We have reviewed the literature in an attempt to establish what is driving the increase in this procedure in moderate-to-low-risk populations and to assess its justification in terms of risk–benefit analysis.

We present a report of a patient with signs and symptoms of acute unilateral parotitis. The patient was subsequently found to have multiple metal wires embedded within the right sternocleidomastoid muscle, with no evidence of preceding trauma. Although the etiology was unclear, a childhood injury was suspected, highlighting the need for a high index of suspicion for foreign bodies in any child presenting with unexplained persistent aerodigestive tract symptoms.

Galectin-3 is a pro-inflammatory, pro-fibrotic molecule implicated in the pathogenesis of heart failure, and associated with poor prognostic outcome. When measured following ST-elevation myocardial infarction (STEMI), a high plasma galectin-3 predicts greater 30-day morbidity and mortality, and increased heart failure incidence at a median of 2 years. This study aims to elucidate the temporal aspects of galectin-3 expression immediately post-STEMI and how expression relates to severity of myocardial injury.Plasma galectin-3 levels were compared in 53 STEMI patients and 23 control patients with stable angina. Consecutive plasma galectin-3 levels, measured at a mean of 30 hours (sample A) and 54 hours (sample B) post pain, and analysis of galectin-3 vs time since onset of pain/time since reperfusion allowed assessment of temporal expression in STEMI patients. Myocardial injury markers included troponin and left ventricular ejection fraction (LVEF) at primary percutaneous coronary intervention (PCI).Circulating galectin-3 levels were significantly higher in STEMI patients than control patients when measured at a mean of 30 hours post pain (t = 2.72, df = 66, P = 0.008). However, levels had significantly decreased when measured 24 hours later (t = 2.13, df = 47, P = 0.039), with a negative linear relationship apparent between plasma galectin-3 levels and time since reperfusion on univariate analysis (OR = 0.871, 95% CI = 0.779-0.975, P = 0.021). A significantly lower circulating galectin-3 concentration was also found for sample A in those reperfused within 3 hours post-onset of pain (OR 0.045, 95% CI 0.003-0.669, P = 0.029).Plasma galectin-3 levels vary significantly following a STEMI over a short time period, in relation to timing of reperfusion.

Background In breast cancer patients undergoing sentinel lymph node biopsy (SLNB) analysis using one-step nucleic acid amplification (OSNA), clarity is required as to the risk factors for non-sentinel lymph node (NSLN) involvement upon axillary lymph node dissection (ALND). This study aims to identify these factors, including categorising by extent of sentinel node positivity: solitary positive node (solitary), multiple nodes with some positive (multiple incomplete positive), or multiple nodes all of which are positive (multiple all positive). Methods We conducted a cohort study using prospectively collected data on 856 SLNBs analysed using OSNA, from patients with cT1-3 clinically node-negative invasive breast cancer. ALND was performed for 289 positive SLNBs. Results NSLN metastases were identified in 73 (25.3%) ALNDs. Significant factors for NSLN involvement on multivariate analysis were: SLNB macrometastases (cytokeratin-19 mRNA count >5000 copies/μl) (adj.OR = 3.01; 95% CI, 1.61–5.66; p = 0.0006), multiple all positive vs. multiple incomplete positive SLNB (adj.OR = 2.92; 95% CI, 1.38–6.19; p = 0.0050), and undergoing mastectomy (adj.OR = 1.89; 95% CI, 1.00–3.55; p = 0.0486). Amongst multiple incomplete positive SLNBs, an 8.8% NSLN risk was identified when only micrometastases were present. Conclusion Extent of sentinel lymph node positivity measured using OSNA predicts NSLN metastasis risk, aiding decisions surrounding axillary treatment.

INTRODUCTION Union Pacific Corporation is one of North America's leading transportation, computer technology and logistics companies, with operations in all 50 United States, Canada and Mexico. With headquarters in Omaha, Nebraska, Union Pacific Corporation currently has over 52,000 employees, covers more than 36,000 miles of track in 23 states and has an annual payroll in excess of $3 billion. There are 1700 people in information technology alone with a budget of about $250 M. The company's web site at http://www.uprr.com provides a comprehensive corporate pi'ofile of the company. Science Applications International Corporation is the nation's largest employee-owned research and engineering company, providing information technology and systems integration products and services to government and commercial customers. SAIC scientists and engineers work to solve complex technical problems in telecommunications, national security, health care, transportation, energy, the environment, and financial services. With annual revenues of $4.7 billion, SAIC and its subsidiaries have more than 38,000 employees at offices in more than 150 cities worldwide. Intermodal units are critical for the sustained success of a railroad company and hence it is important to ensure that these units are in good working condition. As customers' demand more speedy and efficient transportation of goods, rail intermodal service--the movement of trailers or containers by rail and at least one other mode of transportation--is ideally suited to meet this demand. That is one of the reasons intermodal is the fastest growing segment of the railroad industry (my.uprr.com/pub/notes). Intermodal traffic has grown from 3 million trailers and containers in 1980 to 8.7 million in 1997 and accounts for more than 17 percent of rail revenues, second only to coal at 22 percent (www.aar.org). Intermodal transportation yields many powerful benefits (www.aar.org): * Fuel efficiency. Rail intermodal service on average uses less than half as much fuel as highway transport to move the same shipment the same distance. * Convenience and partnerships. Intermodal combines the door-to-door convenience of trucks with the long-haul economy of rail service. As a result, railroads, trucking companies and intermodal marketing companies are forming productive partnerships to combine the best of both modes. * Improved air quality. Moving a ton of freight by rail instead of truck results in less than one-third the emissions into the air. * Reduced traffic congestion. A single intermodal train can remove as many as 280 trucks from the highways. * Innovative technology. Intermodal technology, such as double-stack trains (one container on top of another) permit one train with two crew members to remove up to 280 trucks from the highway, reduce pollution and save energy. Railroad regulations require the inspection of all intermodal equipment (vans, containers, chassis) during yard entry and exit to ensure that damages to a unit are positively identified and charged to the responsible party ("Building the Systems ...," 1999). This is a very critical step if the railroad is to recover damage claims assessed by equipment owners and also to win disputes regarding the timing and extent of damage. In January of 1995, during a strategic planning exercise at the company, it became clear that there was room for improvement in the way the company managed and maintained its intermodal units. Reengineering current intermodal operational process and practices would help the company be more responsive to customer needs while increasing its operational efficiencies and profits. Due to increased global competitiveness, customers expected their transportation companies to be agile and responsive. After considerable discussion among top and middle management, the company established the following primary goals for the reengineering effort of intermodal operations: * Increase data accuracy * Reduce transaction processing time * Increase the rate of collections from damage claims * Increase accuracy of the damage inspection * Decrease number of yard personnel As the reengineering team began to look closely at the intermodal operations, it became evident that two processes were big bottlenecks in achieving desired efficiencies. …