Angiosarcoma: a 10-year retrospective study from a high-volume UK regional referral centre.

PURPOSE: Angiosarcoma (AS) is a rare malignancy with considerable heterogeneity seen in its aetiology, anatomical location, and clinicopathological behaviour. Diagnosis is often delayed and prognosis poor. The purpose of this study was to perform a retrospective review of all cases of AS over 10 years at a high-volume regional UK referral centre. METHODS/PATIENTS: We reviewed all cases of AS discussed at the sarcoma multidisciplinary meetings of University Hospitals Birmingham NHS Foundation Trust from September 2013 to August 2023. Demographic and clinicopathologic features at diagnosis, approaches to treatment, and outcomes were compared between four AS subtypes. RESULTS: A total of 130 cases were identified. The median age at diagnosis was 71 years, with the majority being female (78%). The most common AS subtype was radiation-induced AS (RIAS) (n = 72; 55%), followed by primary cutaneous (n = 28; 22%), primary non-cutaneous (n = 25; 19%), and AS secondary to lymphoedema (n = 5; 4%). Metastases were present at diagnosis in 18% of patients. Treatment was with surgery in the majority of patients (71%). The median survival for the cohort was 30 months (95% CI 20-40), although this differed significantly by AS subtype (p < 0.001), ranging from 5 months in primary non-cutaneous AS to 76 months in RIAS. CONCLUSION: RIAS is the most common AS subtype, with surgery the only potentially curative treatment modality. Overall prognosis varies significantly by subtype. An international consensus on classification of AS subtypes is required to allow meaningful comparisons across studies and/or a prospective multi-centre registry.

Enhanced Recovery Pathways for Flap-Based Reconstruction: Systematic Review and Meta-Analysis.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) pathways are known to improve patient outcomes after surgery. In recent years, there have been growing interest in ERAS for reconstructive surgery. OBJECTIVES: To systematically review and summarise literature on the key components and outcomes of ERAS pathways for autologous flap-based reconstruction. DATA SOURCES: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Current Controlled Trials, World Health Organization International Clinical Trials Registry Platform and reference lists of relevant studies. INCLUSION CRITERIA: All primary studies of ERAS pathways for free and pedicled flap-based reconstructions reported in the English language. OUTCOME MEASURES: The primary outcome measure was length of stay. Secondary outcomes were complication rates including total flap loss, partial flap loss, unplanned reoperation within 30 days, readmission to hospital within 30 days, surgical site infections and medical complications. RESULTS: Sixteen studies were included. Eleven studies describe ERAS pathways for autologous breast reconstructions and five for autologous head and neck reconstructions. Length of stay was lower in ERAS groups compared to control groups (mean reduction, 1.57 days; 95% CI, - 2.15 to - 0.99). Total flap loss, partial flap loss, unplanned reoperations, readmissions, surgical site infections and medical complication rates were similar between both groups. Compliance rates were poorly reported. CONCLUSION: ERAS pathways for flap-based reconstruction reduce length of stay without increasing complication rates. ERAS pathways should be adapted to each institution according to their needs, resources and caseload. There is potential for the development of ERAS pathways for chest wall, perineum and lower limb reconstruction. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Ever-Present Costs of Cosmetic Surgery Tourism: A 5-Year Observational Study.

BACKGROUND: Cosmetic surgery tourism is an ever-growing industry. Despite its associated risks, an increasing number of patients are presenting to NHS services with resulting complications. This study aims to evaluate the current presentation patterns for complications in cosmetic surgery tourism, and the financial burden to the NHS reported by a single UK level one trauma centre in Birmingham, UK. METHODS: From 2015 to 2020, all patients presenting to the department of plastic surgery with complications of cosmetic surgery performed outside of the UK were included. Data were collected for patients' characteristics including demographics, performed procedures, complications and treatment. A cost analysis was performed for each patient using published "National Schedule of NHS Costs." RESULTS: A total of 26 patients presented to our hospital within the study period. All patients were female, with the mean age being 35.1 years (range 22-55years). A total of 32 cosmetic procedures were undertaken, with the majority performed in Turkey (n = 14). Abdominoplasty was the most common procedure, followed by gluteal enhancement surgery. The total financial cost to the NHS from all cosmetic surgery-related complications was £152,946, with an average cost per patient of £5,882.54 (range £362-£26,585). CONCLUSION: Patients seek out medical tourism for multiple reasons including cost savings, shorter waiting times and surgical expertise. The costs displayed should predominantly be viewed as a reflection of the detrimental effect these complications can have on patients' lives. Global governing bodies should focus efforts on educating patients and raising awareness on this ever-prevalent issue. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Orthoplastic Management of Open Midfoot Injuries: Is Functional Limb Salvage Possible?

High energy open midfoot injuries are uncommon but devastating injuries. A combination of complex fracture dislocations and soft tissue injury patterns render reconstruction challenging. The aim of this study was to assess the surgical and patient reported outcomes following orthoplastic management of open midfoot injuries in a Major Trauma Center. A retrospective review of all open midfoot fractures admitted to our unit between January 2015 and December 2016 was undertaken. Demographics, operative details, complications, additional surgeries, and patient reported outcomes in the form of EQ-5D and Enneking scores were collected. Fifteen patients were identified (13 male, mean age 39.2 years). One patient underwent amputation at initial debridement and 8 required additional debridement. Of these 8 patients, 3 had an amputation during their index admission. In the limb salvage group (11 patients), definitive soft tissue cover involved free flaps in 6 patients, split skin graft in 3 patients, and delayed primary closure in 2 patients. Definitive orthopedic treatment was internal fixation in 8 and external fixation in 3 patients. Two patients required a Masquelet procedure for bone loss. One patient had a toe amputation and 1 had a below knee amputation for deep infection. The median EQ-5D score was 66 (interquartile range 43), and the median Enneking score was 20.5 (interquartile range 9). Limb salvage following open midfoot fractures is technically possible in most cases, however this often involves multiple procedures and the outcomes are variable and difficult to predict. Patients should be carefully counseled, and amputation considered in all such cases.

Avoiding the night terrors: the effect of circadian rhythm on post-operative urine output and blood pressure in free flap patients.

Multiple studies demonstrate the importance of goal-directed fluid regimens in avoiding complications. These regimens do not take account of circadian fluctuations in urine output (UO), MAP (mean arterial pressure) and pulse rate (PR). This is the first study that aims to demonstrate the effect of circadian rhythm on these haemodynamic parameters in post-operative patients with free flaps, as well as analysing clinicians' response to these variations. Retrospective analysis of 116 patients with free flaps. Records were assessed for UO, MAP, IV fluid infusion rate, oral fluid intake. Parameters were measured from 8 am to 8 pm (diurnal) and from 8 pm to 8 am (nocturnal) in the first 48 h post operatively. Patients with diabetes or hypertension were excluded. Mean diurnal UO rate (1.7 ml/kg/hr) was higher than nocturnal UO rate (0.7 ml/kg/hr); and mean diurnal MAP (93) was higher than nocturnal MAP (73.8). Mean diurnal IV infusion rate was 1.25 ml/kg/hr (lower) and mean nocturnal infusion rate 1.81 ml/kg/hr (higher). These differences were all statistically significant by paired student t-test (p < 0.05). This study demonstrates that circadian rhythm has a statistically significant impact on UO, MAP and PR. UO, MAP and PR are expected to dip overnight. This dip is normal and does not necessarily need to be treated by increasing IV fluids to avoid over filling of free flap patients.

Comment on: "A structured pathway for accelerated postoperative recovery reduces hospital stay and cost of care following microvascular breast reconstruction without increased complications".

We read with great interest a recent article by O'Neill et al. on the implementation of an accelerated postoperative recovery protocol following DIEP flap breast reconstruction. Our department has formally introduced a DIEP Enhanced Recovery After Surgery (ERAS) Pathway in May 2019. Although in a much smaller sample size, our results were similar to this article and we would agree with the authors' conclusion that implementation of such protocol could effectively reduce the length of inpatient stay (LoS) and cost of care, without compromising patient care nor increasing complication rates. Prior to the introduction of ERAS Pathway, 28 of our patients who had DIEP between November 2018 and May 2019 had an mean LoS of 7.1 days (median 6 days, range 5-21 days); whereas 27 patients who experienced the ERAS Pathway between May and December 2019 had an mean LoS of 4.8 days (median 5 days, range 3-7 days). The cost of inpatient stay in a normal ward at our hospital is approximately £232 per patient per day. By reducing an extra 2.3 days of inpatient stay, our Trust could save at least an average of £32,016 per annum with the estimated 60 DIEP performed annually at our department. We would like to emphasise the benefits and effectiveness of this multimodal, patient-centre and evidence-based ERAS. This, perhaps, should be the standard of care for all patients who undergo microvascular breast reconstruction in the future.

Fake spawns and floating particles: a rebuttal of Karkarey et al. "Alternative reproductive tactics and inverse size-assortment in a high-density fish spawning aggregation".

Courtship and spawning behaviors of coral reef fishes are very complex, and sufficient sampling effort and proper methods are required to draw informed conclusions on their mating systems that are grounded in contemporary theories of mate choice and sexual selection. We reviewed the recent study by Karkarey et al. (BMC Ecol 17:10, 2017) on the spawning behavior of Squaretail coralgrouper (Plectropomus areolatus) from India and found no evidence to support their findings of alternative reproductive tactics, unique school-spawning involving a single male with multiple females, or inverse size-assortment. The study lacks scientific credibility due to a lack of rigor in the methodology used, misinterpretation of observed behaviors, misinterpretation of the literature, and insufficient data. Their approach led the authors to produce spurious results and profound, invalid conclusions that violate the most basic assumptions of mate choice and sexual selection theory as applied to mating systems in marine fishes.

Metaplastic Breast Cancer Masquerading as Liposarcoma of the Breast: A Case Report following Oncoplastic Treatment.

Mammary liposarcoma is among the rarest of breast tumours. Here we report the presentation, macroscopic, microscopic, and immunohistochemical features of an extremely rare case of metaplastic carcinoma with extensive pleomorphic liposarcomatous differentiation. A 47-year-old woman presented with bilateral grade III breast ptosis and a 3 × 4 cm mass in the lower outer quadrant of the left breast. Mammography and ultrasound confirmed a well-defined mass. A core biopsy performed was diagnosed as pleomorphic liposarcoma. Microscopically, this was a well-defined, lobulated tumour comprising solid sheets of large pleomorphic and spindle cells with bizarre forms, vacuolated cytoplasm, and ample mitoses. Atypical lipoblasts were easily identifiable. Due to the strong, though patchy, cytokeratin expression, the diagnosis of metaplastic carcinoma with pleomorphic liposarcomatous differentiation was made. Extensive sampling, careful search for a biphasic pattern, ductal carcinoma in situ, and/or epithelial differentiation, and a panel of broad-spectrum cytokeratins are essential to establish the diagnosis.

Protection of large predators in a marine reserve alters size-dependent prey mortality.

Where predator-prey interactions are size-dependent, reductions in predator size owing to fishing has the potential to disrupt the ecological role of top predators in marine ecosystems. In southern California kelp forests, we investigated the size-dependence of the interaction between herbivorous sea urchins and one of their predators, California sheephead (Semicossyphus pulcher). Empirical tests examined how differences in predator size structure between reserve and fished areas affected size-specific urchin mortality. Sites inside marine reserves had greater sheephead size and biomass, while empirical feeding trials indicated that larger sheephead were required to successfully consume urchins of increasing test diameter. Evaluations of the selectivity of sheephead for two urchin species indicated that shorter-spined purple urchins were attacked more frequently and successfully than longer-spined red urchins of the same size class, particularly at the largest test diameters. As a result of these size-specific interactions and the higher biomass of large sheephead inside reserves, urchin mortality rates were three times higher inside the reserve for both species. In addition, urchin mortality rates decreased with urchin size, and very few large urchins were successfully consumed in fished areas. The truncation of sheephead size structure that commonly occurs owing to fishing will probably result in reductions in urchin mortality, which may reduce the resilience of kelp beds to urchin barren formation. By contrast, the recovery of predator size structure in marine reserves may restore this resilience, but may be delayed until fish grow to sizes capable of consuming larger urchins.

Human activities change marine ecosystems by altering predation risk.

In ocean ecosystems, many of the changes in predation risk - both increases and decreases - are human-induced. These changes are occurring at scales ranging from global to local and across variable temporal scales. Indirect, risk-based effects of human activity are known to be important in structuring some terrestrial ecosystems, but these impacts have largely been neglected in oceans. Here, we synthesize existing literature and data to explore multiple lines of evidence that collectively suggest diverse human activities are changing marine ecosystems, including carbon storage capacity, in myriad ways by altering predation risk. We provide novel, compelling evidence that at least one key human activity, overfishing, can lead to distinct, cascading risk effects in natural ecosystems whose magnitude exceeds that of presumed lethal effects and may account for previously unexplained findings. We further discuss the conservation implications of human-caused indirect risk effects. Finally, we provide a predictive framework for when human alterations of risk in oceans should lead to cascading effects and outline a prospectus for future research. Given the speed and extent with which human activities are altering marine risk landscapes, it is crucial that conservation and management policy considers the indirect effects of these activities in order to increase the likelihood of success and avoid unfortunate surprises.

Recovery trajectories of kelp forest animals are rapid yet spatially variable across a network of temperate marine protected areas.

Oceans currently face a variety of threats, requiring ecosystem-based approaches to management such as networks of marine protected areas (MPAs). We evaluated changes in fish biomass on temperate rocky reefs over the decade following implementation of a network of MPAs in the northern Channel Islands, California. We found that the biomass of targeted (i.e. fished) species has increased consistently inside all MPAs in the network, with an effect of geography on the strength of the response. More interesting, biomass of targeted fish species also increased outside MPAs, although only 27% as rapidly as in the protected areas, indicating that redistribution of fishing effort has not severely affected unprotected populations. Whether the increase outside of MPAs is due to changes in fishing pressure, fisheries management actions, adult spillover, favorable environmental conditions, or a combination of all four remains unknown. We evaluated methods of controlling for biogeographic or environmental variation across networks of protected areas and found similar performance of models incorporating empirical sea surface temperature versus a simple geographic blocking term based on assemblage structure. The patterns observed are promising indicators of the success of this network, but more work is needed to understand how ecological and physical contexts affect MPA performance.

Marine defaunation: animal loss in the global ocean.

Marine defaunation, or human-caused animal loss in the oceans, emerged forcefully only hundreds of years ago, whereas terrestrial defaunation has been occurring far longer. Though humans have caused few global marine extinctions, we have profoundly affected marine wildlife, altering the functioning and provisioning of services in every ocean. Current ocean trends, coupled with terrestrial defaunation lessons, suggest that marine defaunation rates will rapidly intensify as human use of the oceans industrializes. Though protected areas are a powerful tool to harness ocean productivity, especially when designed with future climate in mind, additional management strategies will be required. Overall, habitat degradation is likely to intensify as a major driver of marine wildlife loss. Proactive intervention can avert a marine defaunation disaster of the magnitude observed on land.

An assessment of chemical contaminants in sediments from the St. Thomas East End Reserves, St. Thomas, USVI.

The St. Thomas East End Reserves or STEER is located on the southeastern end of the island of St. Thomas, USVI. The STEER contains extensive mangroves and seagrass beds, along with coral reefs, lagoons, and cays. Within the watershed, however, are a large active landfill, numerous marinas, resorts, various commercial activities, an EPA Superfund Site, and residential areas, all of which have the potential to contribute pollutants to the STEER. As part of a project to develop an integrated assessment for the STEER, 185 chemical contaminants were analyzed in sediments from 24 sites. Higher levels of chemical contaminants were found in Mangrove Lagoon and Benner Bay in the western portion of the study area. The concentrations of polychlorinated biphenyls (PCBs), dichlorodiphenyltrichloroethane (DDT), zinc, copper, lead, and mercury were above a NOAA Effects Range-Low (ERL) sediment quality guideline at one or more sites, indicating impacts may be present in more sensitive species or life stages. Copper at one site in Benner Bay was above a NOAA Effects Range-Median (ERM) guideline indicating effects on benthic organisms were likely. The antifoulant boat hull ingredient tributyltin (TBT) was found at the third highest concentration in the history of NOAA's National Status and Trends (NS&T) Program, which monitors the nation's coastal and estuarine waters for chemical contaminants and bioeffects. The results from this project will provide resource managers with key information needed to make effective decisions affecting coral reef ecosystem health and gauge the efficacy of restoration activities.

Predicting evolutionary responses to climate change in the sea.

An increasing number of short-term experimental studies show significant effects of projected ocean warming and ocean acidification on the performance on marine organisms. Yet, it remains unclear if we can reliably predict the impact of climate change on marine populations and ecosystems, because we lack sufficient understanding of the capacity for marine organisms to adapt to rapid climate change. In this review, we emphasise why an evolutionary perspective is crucial to understanding climate change impacts in the sea and examine the approaches that may be useful for addressing this challenge. We first consider what the geological record and present-day analogues of future climate conditions can tell us about the potential for adaptation to climate change. We also examine evidence that phenotypic plasticity may assist marine species to persist in a rapidly changing climate. We then outline the various experimental approaches that can be used to estimate evolutionary potential, focusing on molecular tools, quantitative genetics, and experimental evolution, and we describe the benefits of combining different approaches to gain a deeper understanding of evolutionary potential. Our goal is to provide a platform for future research addressing the evolutionary potential for marine organisms to cope with climate change.

Phylogenetic perspectives on the evolution of functional hermaphroditism in teleost fishes.

Hermaphroditism is taxonomically widespread among teleost fishes and takes on many forms including simultaneous, protogynous, and protandrous hermaphroditism, bidirectional sex change, and androdioecy. The proximate mechanisms that influence the timing, incidence, and forms of hermaphroditism in fishes are supported by numerous theoretical and empirical studies on their mating systems and sexual patterns, but few have examined aspects of sex-allocation theory or the evolution of hermaphroditism for this group within a strict phylogenetic context. Fortunately, species-level phylogenetic reconstructions of the evolutionary history of many lineages of fishes have emerged, providing opportunities for understanding fine-scale evolutionary pathways and transformations of sex allocation. Examinations of several families of fishes with adequate data on phylogeny, patterns of sex allocation, mating systems, and with some form of hermaphroditism reveal that the evolution and expression of protogyny and other forms of sex allocation show little evidence of phylogenetic inertia within specific lineages but rather are associated with particular mating systems in accordance with prevalent theories about sex allocation. Transformations from protogyny to gonochorism in groupers (Epinephelidae), seabasses (Serranidae), and wrasses and parrotfishes (Labridae) are associated with equivalent transformations in the structure of mating groups from spawning of pairs to group spawning and related increases in sperm competition. Similarly, patterns of protandry, androdioecy, simultaneous hermaphroditism, and bidirectional sex change in other lineages (Aulopiformes, Gobiidae, and Pomacentridae) match well with particular mating systems in accordance with sex-allocation theory. Unlike other animals and plants, we did not find evidence that transitions between hermaphroditism and gonochorism required functional intermediates. Two instances in which our general conclusions might not hold include the expression of protandry in the Sparidae and the distribution of simultaneous hermaphroditism. In the Sparidae, the association of hypothesized mating systems and patterns of sex allocation were not always consistent with the size-advantage model (SAM), in that certain protandric sparids show evidence of intense sperm competition that should favor the expression of gonochorism. In the other case, simultaneous hermaphroditism does not occur in some groups of monogamous fishes, which are similar in ecology to the hermaphroditic serranines, suggesting that this form of sex allocation may be more limited by phylogenetic inertia. Overall, this work strongly supports sexual lability within teleost fishes and confirms evolutionary theories of sex allocation in this group of vertebrates.

Does fish larval dispersal differ between high and low latitudes?

Several factors lead to expectations that the scale of larval dispersal and population connectivity of marine animals differs with latitude. We examine this expectation for demersal shorefishes, including relevant mechanisms, assumptions and evidence. We explore latitudinal differences in (i) biological (e.g. species composition, spawning mode, pelagic larval duration, PLD), (ii) physical (e.g. water movement, habitat fragmentation), and (iii) biophysical factors (primarily temperature, which could strongly affect development, swimming ability or feeding). Latitudinal differences exist in taxonomic composition, habitat fragmentation, temperature and larval swimming, and each difference could influence larval dispersal. Nevertheless, clear evidence for latitudinal differences in larval dispersal at the level of broad faunas is lacking. For example, PLD is strongly influenced by taxon, habitat and geographical region, but no independent latitudinal trend is present in published PLD values. Any trends in larval dispersal may be obscured by a lack of appropriate information, or use of 'off the shelf' information that is biased with regard to the species assemblages in areas of concern. Biases may also be introduced from latitudinal differences in taxa or spawning modes as well as limited latitudinal sampling. We suggest research to make progress on the question of latitudinal trends in larval dispersal.

Cooling properties of everyday liquids.

OBJECTIVE: To examine the cooling properties of a variety of 'everyday' hot liquids within the context of scald injuries in the United Kingdom. METHODS: The temperature of common hot liquids, including water, tea, coffee and various other liquids (i.e. takeaway coffees, "Indian tea", chicken curries, hot milk and oil) were recorded over a time period, using digital cooking thermometers. RESULTS: Minimal difference was detected between the cooling rates of hot water, coffee and tea. Indian tea cooled at a slower rate. The speed at which milk cooled was less than other liquids and the higher the fat content the slower it cooled. Takeaway beverages had a lower starting temperature and retained heat for substantially longer periods. The assessment of cooking oil revealed intense heat production and prolonged cooling. CONCLUSION: The authors propose that if a patient is exposed to a 'common' scalding agent that has been cooling for 10 min or less then the temperature of that fluid is likely to be greater than 60°C and therefore capable of causing a burn within seconds of exposure. Furthermore, most liquids tested take between 15 and 30 min to reach a "safe temperature" below 53°C.

Do behavioral foraging responses of prey to predators function similarly in restored and pristine foodwebs?

Efforts to restore top predators in human-altered systems raise the question of whether rebounds in predator populations are sufficient to restore pristine foodweb dynamics. Ocean ecosystems provide an ideal system to test this question. Removal of fishing in marine reserves often reverses declines in predator densities and size. However, whether this leads to restoration of key functional characteristics of foodwebs, especially prey foraging behavior, is unclear. The question of whether restored and pristine foodwebs function similarly is nonetheless critically important for management and restoration efforts. We explored this question in light of one important determinant of ecosystem function and structure--herbivorous prey foraging behavior. We compared these responses for two functionally distinct herbivorous prey fishes (the damselfish Plectroglyphidodon dickii and the parrotfish Chlorurus sordidus) within pairs of coral reefs in pristine and restored ecosystems in two regions of these species' biogeographic ranges, allowing us to quantify the magnitude and temporal scale of this key ecosystem variable's recovery. We demonstrate that restoration of top predator abundances also restored prey foraging excursion behaviors to a condition closely resembling those of a pristine ecosystem. Increased understanding of behavioral aspects of ecosystem change will greatly improve our ability to predict the cascading consequences of conservation tools aimed at ecological restoration, such as marine reserves.