Retrospective analysis of radiological investigation of surgically excised head and neck lipomas.

PURPOSE: Differentiating benign lipomas from malignant causes is challenging and preoperative investigative guidelines are not well-defined. The purpose of this study was to retrospectively identify cases of head and neck lipomas that were surgically resected over a 5-year period and to identify the radiological modality chosen and features discussed in the final report. Multidisciplinary outcomes and pathology reports were examined with a view to identifying high risk features of a lipoma to aid in future risk stratification. METHODS: Retrospective chart review of pathology characteristics, radiological features (modality, size, calcifications, septations, globular/nodular foci), multidisciplinary discussion and history of presenting complaint was performed. RESULTS: Two liposarcomas and 138 lipomas were identified. Twenty-two percent of all lipomas received radiological investigation. Twenty-two percent of imaging referrals were possibly inappropriate. Furthermore, radiological features suggestive of malignancy were not present in the final radiology report, X2 = 28.8, p < 0.0001. CONCLUSION: As expected, the incidence of liposarcoma is low. There is limited awareness of radiology referral guidelines superimposed with a tendency to over-investigate lipomas. Furthermore, radiological features suggestive of malignancy were inconsistently reported on and not documented in multidisciplinary discussions. Therefore, we propose a multidisciplinary checklist for referring physicians and radiologists to aid in diagnostic work-up.

White phosphorous civilian hand burns - An aid to timely treatment of a rare entity.

First discovered in 1669, white phosphorus is well known for its use in military warfare (Davis, 2002). Its application has since been expanded to include industrial disinfectants, fertilisers and fireworks (Davis, 2002). Exposure to white phosphorus can lead to severe chemical burns with high morbidity and potentially fatal systemic effects. Fortunately, civilian casualties from this potent agent are remarkably rare with few reports in the literature to date (Frank et al., 2008; Aviv et al., 2017). We present the case of a 27-year-old fisherman who sustained a chemical burn to his right hand from a substance suspected to be white phosphorus. We propose an evidence-based algorithm to guide non-military physicians literature on the acute management of white phosphorus burns to optimise timely emergency management of this uncommonly encountered substance.

Indocyanine green fluorescence angiography: A critical intra-operative assessment tool to aid decision making in complex hand trauma.

Indocyanine green fluorescence angiography (ICG-FA) is a validated non-invasive imaging tool used to assess tissue perfusion and guide intra-operative decision making in many surgical disciplines. Clinical assessment of tissue perfusion following crush or degloving traumatic hand injuries presents a significant challenge. This case report supports the critical role of intra-operative ICG-FA as a decision aid in complex hand trauma. We propose ICG-FA will minimise unnecessary tissue debridement, negating complex soft tissue reconstructive surgery and ultimately expediting tissue healing and return to function for hand trauma patients. A 35-year-old right hand dominant manual labourer presented to the emergency department after sustaining a crush injury to his right hand. Examination under anaesthetic revealed a comminuted open fracture of middle finger P2 with compromised soft tissue coverage. A formal assessment of hand perfusion was performed using a triad of clinical assessment, critical judgement and ICG-FA. The ICG-FA revealed a small skin flap affecting the dorsoradial P2 skin which was not perfused. This prompted meticulous minimal debridement of this tissue and prevented unnecessary over-debridement that would have resulted in complex soft tissue reconstruction. Currently the gold standard assessment for tissue perfusion in hand injuries is clinical judgement and is limited by subjective interobserver error [1]. IGA-FA has been proven to offer a real time assessment of tissue perfusion. This case demonstrates the use of ICG-FA as an adjunct to clinical examination and judgement, to optimise the accuracy of soft tissue perfusion assessment in complex hand trauma.

Species specificity and intraspecific variation in the chemical profiles of Heliconius butterflies across a large geographic range.

In many animals, mate choice is important for the maintenance of reproductive isolation between species. Traits important for mate choice and behavioral isolation are predicted to be under strong stabilizing selection within species; however, such traits can also exhibit variation at the population level driven by neutral and adaptive evolutionary processes. Here, we describe patterns of divergence among androconial and genital chemical profiles at inter- and intraspecific levels in mimetic Heliconius butterflies. Most variation in chemical bouquets was found between species, but there were also quantitative differences at the population level. We found a strong correlation between interspecific chemical and genetic divergence, but this correlation varied in intraspecific comparisons. We identified "indicator" compounds characteristic of particular species that included compounds already known to elicit a behavioral response, suggesting an approach for identification of candidate compounds for future behavioral studies in novel systems. Overall, the strong signal of species identity suggests a role for these compounds in species recognition, but with additional potentially neutral variation at the population level.

Using a portable hydrogen cyanide gas meter to uncover a dynamic phytochemical landscape.

PREMISE: Over 3000 species of plants and animals release toxic hydrogen cyanide (HCN) gas when their tissues are crushed. To investigate the role of cyanogenesis in Passiflora-herbivore interactions, we developed an inexpensive, rapid, sensitive method for measuring HCN emissions from crushed tissues. METHODS: The method includes crushed tissue confinement in a closed chamber, where cyanogenesis reactions occur, followed by evacuation of gas to a portable HCN meter. Parts per million readings are repeated at 5-min intervals until HCN is depleted. Three versions of the closed reaction chamber apparatus were tested: plastic cup, airtight combination mortar-pestle, and glass desiccator jar. RESULTS: We calibrated the method by comparing with a closed chamber measurement apparatus. The procedure's repeatability was demonstrated with a standard curve using known quantities of cyanogenic glycoside standard. Data collected with this method were also compared with the conventional colorimetric procedure. We processed over 2000 samples using this technique, revealing diverse elements of cyanogenic variation. CONCLUSIONS: These methods produced well-defined data with minimal error. Results illustrated a one to four order-of-magnitude variation at organizational levels ranging from individual leaves to the entire Passiflora community. We now have a promising tool for uncovering the HCN phytochemical landscape in unprecedented detail.

Interplay between Developmental Flexibility and Determinism in the Evolution of Mimetic Heliconius Wing Patterns.

To what extent can we predict how evolution occurs? Do genetic architectures and developmental processes canalize the evolution of similar outcomes in a predictable manner? Or do historical contingencies impose alternative pathways to answer the same challenge? Examples of Müllerian mimicry between distantly related butterfly species provide natural replicates of evolution, allowing us to test whether identical wing patterns followed parallel or novel trajectories. Here, we explore the role that the signaling ligand WntA plays in generating mimetic wing patterns in Heliconius butterflies, a group with extraordinary mimicry-related wing pattern diversity. The radiation is relatively young, and numerous cases of wing pattern mimicry have evolved within the last 2.5-4.5 Ma. WntA is an important target of natural selection and is one of four major effect loci that underlie much of the pattern variation in the group. We used CRISPR/Cas9 targeted mutagenesis to generate WntA-deficient wings in 12 species and a further 10 intraspecific variants, including three co-mimetic pairs. In all tested butterflies, WntA knockouts affect pattern broadly and cause a shift among every possible scale cell type. Interestingly, the co-mimics lacking WntA were very different, suggesting that the gene networks that pattern a wing have diverged considerably among different lineages. Thus, although natural selection channeled phenotypic convergence, divergent developmental contexts between the two major Heliconius lineages opened different developmental routes to evolve resemblance. Consequently, even under very deterministic evolutionary scenarios, our results underscore a surprising unpredictability in the developmental paths underlying convergence in a recent radiation.

Variation in Host Plant Usage and Diet Breadth Predict Sibling Preference and Performance in the Neotropical Tortoise Beetle Chelymorpha alternans (Coleoptera: Chrysomelidae: Cassidinae).

Specialized interactions between insects and the plants that they consume are one of the most ubiquitous and consequential ecological associations on the plant. Decades of investigation suggest that a narrow diet favors an individual phytophagous insect's performance relative to a dietary generalist. However, this body of research has tended to approach questions of diet breadth and host usage from the perspective of temperate plant-insect associations. Relationships between diet breadth, host usage, and variation in tropical insect preference and performance remain largely uninvestigated. Here we characterize how variation in diet breadth and host usage affect oviposition preference, development, survival, and gain in mass of a Neotropical tortoise beetle Chelymorpha alternans Boheman 1854 (Coleoptera: Chrysomelidae), using a split-brood, sibling experimental design. Host performance was measured after splitting broods among four no-choice host diets. Groups consuming single hosts varied among themselves in developmental time and survival from larva to adult. Performance did not vary among groups consuming multiple and single hosts. Oviposition preference was measured in choice and no-choice tests. Females displayed preference for the original host in both experiments. Developmental time and survival of offspring sourced from the no-choice experiment was measured for two complete generations to explore correlations with female oviposition preference. Preference for the original host correlated with high survivorship and an intermediate developmental time. Survivorship and time to develop were also high on an alternative host that was less preferred. Departures from predictions of prevailing preference-performance hypotheses suggest that host usage presents C. alternans with fitness trade-offs.

Male sex pheromone components in Heliconius butterflies released by the androconia affect female choice.

Sex-specific pheromones are known to play an important role in butterfly courtship, and may influence both individual reproductive success and reproductive isolation between species. Extensive ecological, behavioural and genetic studies of Heliconius butterflies have made a substantial contribution to our understanding of speciation. Male pheromones, although long suspected to play an important role, have received relatively little attention in this genus. Here, we combine morphological, chemical and behavioural analyses of male pheromones in the Neotropical butterfly Heliconius melpomene. First, we identify putative androconia that are specialized brush-like scales that lie within the shiny grey region of the male hindwing. We then describe putative male sex pheromone compounds, which are largely confined to the androconial region of the hindwing of mature males, but are absent in immature males and females. Finally, behavioural choice experiments reveal that females of H. melpomene, H. erato and H. timareta strongly discriminate against conspecific males which have their androconial region experimentally blocked. As well as demonstrating the importance of chemical signalling for female mate choice in Heliconius butterflies, the results describe structures involved in release of the pheromone and a list of potential male sex pheromone compounds.

Aesthetic surgery training in a changing healthcare environment.

Aesthetic surgery is a rapidly evolving sub-speciality, both technologically and conceptually. It is therefore critical that plastic surgery training coincides with this rapid evolution. Recent fiscal limitations in public health provision and trainee working-time legislation may impact the delivery of high quality aesthetic surgery training. There is an urgent need to address the delivery of aesthetic training in current training paradigms in Ireland and we propose a number of strategies to obliterate the learning curve.

The Aesthetic Surgery Literature: Do Plastic Surgeons Remain at the Cutting Edge?

BACKGROUND: The aesthetic surgery arena has become a competitive marketplace. Recognition as an authority in aesthetic surgery remains a powerful marketing tool for plastic surgeons, but have significant inroads been made by other specialties? The aims of this study were to analyze publication trends relating to the top five most commonly performed aesthetic surgical procedures, and to assess the origins (i.e., source specialty, authorship, institutions, and countries) of published aesthetic surgical research. METHODS: Based on the seventeenth annual multispecialty data set provided by the American Society for Aesthetic Plastic Surgery, the top five most commonly performed aesthetic surgical procedures were selected. A temporal analysis of publication and citation rates, source institution and country, publishing journal, funding agency trends, and level of evidence was undertaken from 1970 to 2013. RESULTS: Using the search criteria, 7762 articles were identified. There was an 8.8-fold increase in publication volume when the first decade (n = 375) was compared with the last decade (n = 3326). Over the past four decades, 52.2 percent of publications (n = 4053 of 7762) originated from plastic surgery research institutions, with varying contributions from other specialties. Competition was greatest in relation to authorship of blepharoplasty- and rhinoplasty-related publications. CONCLUSIONS: Although plastic surgeons continue to maintain a center-stage presence in terms of authorship of aesthetic surgical literature, significant contributions are now made by other specialties. Plastic surgeons must continue to foster high-quality, peer-reviewed research and innovations to maintain their visibility as leaders in the aesthetic surgery literature and sustain a competitive advantage in aesthetic surgery practice.

Intraspecific phytochemical variation shapes community and population structure for specialist caterpillars.

Chemically mediated plant-herbivore interactions contribute to the diversity of terrestrial communities and the diversification of plants and insects. While our understanding of the processes affecting community structure and evolutionary diversification has grown, few studies have investigated how trait variation shapes genetic and species diversity simultaneously in a tropical ecosystem. We investigated secondary metabolite variation among subpopulations of a single plant species, Piper kelleyi (Piperaceae), using high-performance liquid chromatography (HPLC), to understand associations between plant phytochemistry and host-specialized caterpillars in the genus Eois (Geometridae: Larentiinae) and associated parasitoid wasps and flies. In addition, we used a genotyping-by-sequencing approach to examine the genetic structure of one abundant caterpillar species, Eois encina, in relation to host phytochemical variation. We found substantive concentration differences among three major secondary metabolites, and these differences in chemistry predicted caterpillar and parasitoid community structure among host plant populations. Furthermore, E. encina populations located at high elevations were genetically different from other populations. They fed on plants containing high concentrations of prenylated benzoic acid. Thus, phytochemistry potentially shapes caterpillar and wasp community composition and geographic variation in species interactions, both of which can contribute to diversification of plants and insects.

Metazoans of redoxcline sediments in Mediterranean deep-sea hypersaline anoxic basins.

BACKGROUND: The deep-sea hypersaline anoxic basins (DHABs) of the Mediterranean (water depth ~3500 m) are some of the most extreme oceanic habitats known. Brines of DHABs are nearly saturated with salt, leading many to suspect they are uninhabitable for eukaryotes. While diverse bacterial and protistan communities are reported from some DHAB haloclines and brines, loriciferans are the only metazoan reported to inhabit the anoxic DHAB brines. Our goal was to further investigate metazoan communities in DHAB haloclines and brines. RESULTS: We report observations from sediments of three DHAB (Urania, Discovery, L'Atalante) haloclines, comparing these to observations from sediments underlying normoxic waters of typical Mediterranean salinity. Due to technical difficulties, sampling of the brines was not possible. Morphotype analysis indicates nematodes are the most abundant taxon; crustaceans, loriciferans and bryozoans were also noted. Among nematodes, Daptonema was the most abundant genus; three morphotypes were noted with a degree of endemicity. The majority of rRNA sequences were from planktonic taxa, suggesting that at least some individual metazoans were preserved and inactive. Nematode abundance data, in some cases determined from direct counts of sediments incubated in situ with CellTracker(TM) Green, was patchy but generally indicates the highest abundances in either normoxic control samples or in upper halocline samples; nematodes were absent or very rare in lower halocline samples. Ultrastructural analysis indicates the nematodes in L'Atalante normoxic control sediments were fit, while specimens from L'Atalante upper halocline were healthy or had only recently died and those from the lower halocline had no identifiable organelles. Loriciferans, which were only rarely encountered, were found in both normoxic control samples as well as in Discovery and L'Atalante haloclines. It is not clear how a metazoan taxon could remain viable under this wide range of conditions. CONCLUSIONS: We document a community of living nematodes in normoxic, normal saline deep-sea Mediterranean sediments and in the upper halocline portions of the DHABs. Occurrences of nematodes in mid-halocline and lower halocline samples did not provide compelling evidence of a living community in those zones. The possibility of a viable metazoan community in brines of DHABs is not supported by our data at this time.

Scar Wars: Preferences in Breast Surgery.

BACKGROUND: The uptake of breast reconstruction is ever increasing with procedures ranging from implant-based reconstructions to complex free tissue transfer. Little emphasis is placed on scarring when counseling patients yet they remain a significant source of morbidity and litigation. The aim of this study was to examine the scarring preferences of men and women in breast oncoplastic and reconstructive surgery. METHODS: Five hundred men and women were asked to fill out a four-page questionnaire in two large Irish centres. They were asked about their opinions on scarring post breast surgery and were also asked to rank the common scarring patterns in wide local excisions, oncoplastic procedures, breast reconstructions as well as donor sites. RESULTS: Fifty-eight percent of those surveyed did not feel scars were important post breast cancer surgery. 61% said that their partners' opinion of scars were important. The most preferred wide local excision scar was the lower lateral quadrant scar whilst the scars from the deep inferior epigastric artery perforator (DIEP) flap were most favoured. The superior gluteal artery perforator flap had the most preferred donor site while surprisingly, the DIEP had the least favourite donor site. CONCLUSIONS: Scars are often overlooked when planning breast surgery yet the extent and position of the scar needs to be outlined to patients and it should play an important role in selecting a breast reconstruction option. This study highlights the need for further evaluation of patients' opinions regarding scar patterns.

Benthic protists and fungi of Mediterranean deep hypsersaline anoxic basin redoxcline sediments.

Some of the most extreme marine habitats known are the Mediterranean deep hypersaline anoxic basins (DHABs; water depth ∼3500 m). Brines of DHABs are nearly saturated with salt, leading many to suspect they are uninhabitable for eukaryotes. While diverse bacterial and protistan communities are reported from some DHAB water-column haloclines and brines, the existence and activity of benthic DHAB protists have rarely been explored. Here, we report findings regarding protists and fungi recovered from sediments of three DHAB (Discovery, Urania, L' Atalante) haloclines, and compare these to communities from sediments underlying normoxic waters of typical Mediterranean salinity. Halocline sediments, where the redoxcline impinges the seafloor, were studied from all three DHABs. Microscopic cell counts suggested that halocline sediments supported denser protist populations than those in adjacent control sediments. Pyrosequencing analysis based on ribosomal RNA detected eukaryotic ribotypes in the halocline sediments from each of the three DHABs, most of which were fungi. Sequences affiliated with Ustilaginomycotina Basidiomycota were the most abundant eukaryotic signatures detected. Benthic communities in these DHABs appeared to differ, as expected, due to differing brine chemistries. Microscopy indicated that only a low proportion of protists appeared to bear associated putative symbionts. In a considerable number of cases, when prokaryotes were associated with a protist, DAPI staining did not reveal presence of any nuclei, suggesting that at least some protists were carcasses inhabited by prokaryotic scavengers.

Opportunities to reduce plastic surgery claims through an analysis of complaints data.

BACKGROUND: Patient expectations and demands placed on the National Health Service have significantly increased over the last decade. The analysis of adverse outcomes and measures to improve practice remain fundamental to clinical governance. We decided to investigate the reasons for plastic surgery patients making complaints and claims of negligence in order to identify trends and potential areas of improvement. METHODS: In conjunction with the hospital Patient Advice and Liaison Services (PALS) and Legal Services departments, the complaints made against the Addenbrooke's Hospital Plastic Surgery Department over a 10 year period were analysed. Patients who proceeded to make formal claims of negligence were also identified and a retrospective case note review of these performed. RESULTS: 185 patients made complaints between April 2000 and April 2010. The most common reasons for complaints were poor communication and treatment delays. 20 claims of negligence were made; 14 of these were patients undergoing breast surgery. There were 3 successful cases which all mentioned adverse scarring, suggesting that this risk was either not discussed or the informed consent process was inadequately documented. The financial compensation awarded ranged from £6000 to £34,000. CONCLUSIONS: Poor communication is highlighted as the main reason for patients making formal complaints. Inadequate documentation of informed consent discussions may also contribute to successful negligence claims.

Operating room fires: part II. optimizing safety.

BACKGROUND: The second part of the authors' study on operating room fires analyzes the construct of the nasal cannula used during facial surgery for patients under conscious sedation with supplemental oxygen. This prospective study compares two common styles of nasal cannulas with a nasopharyngeal system described in their first report. METHODS: Twenty patients underwent upper and/or lower lid blepharoplasty under conscious sedation with one of three methods of supplemental oxygen delivery: a Mac-Safe nasal cannula (Unomedical, Inc., McAllen, Texas), a Salter nasal cannula (Salter Laboratories, Arvin, Calif.), and a nasopharyngeal system with cut ends of a cannula placed into a rubber nasopharyngeal tube. Oxygen concentrations were measured at 24 locations around the face for each method at a low (3 liters/minute) and high flow rates (6 liters/minute) using a random access mass spectrometer unit. RESULTS: At both low and high oxygen flow rates, the median oxygen concentration at and above the nose was statistically lower (p < 0.001) using the nasopharyngeal system than with either the Mac-Safe or Salter nasal cannula. In addition, the oxygen concentrations measured using the two nasal cannulas were more variable than with the nasopharyngeal method, particularly at locations around and above the nose. CONCLUSIONS: This study demonstrates that mass spectrometry oxygen readings around the face are similar to room air when the cut ends of the oxygen cannulas are passed down the nasaopharyngeal tube, whereas readings are significantly higher with the nasal cannulas. The nasopharyngeal system that the authors describe represents a significantly safer means of oxygen delivery during conscious sedation.

Patient draping and endotracheal tube positioning during facelift surgery.

A comprehensive approach to facial rejuvenation often requires facelift surgery combined with ancillary facial procedures. This may require prolonged operating time under general anesthesia or conscious sedation. When general anesthesia is used, secure endotracheal tube fixation and ready access to the face is essential. We describe an anesthetic technique that assures secure tube placement, rapid intubation, and ready access to the entire face. A fiber-reinforced tube is placed orotracheally, wired to the mandibular dentition, and brought over the head in the fashion similar to a nasotracheal tube. The reinforced nature of the tube prevents kinking and allows rapid repositioning inferiorly to allow access to the upper face. In over 400 rhytidectomies, this technique has allowed rapid intubation and surgical preparation. There have been no airway-related problems or other related complications. This is a safe, effective, and rapid means of securing orotracheal intubation during facial esthetic surgery allowing ready access to the face.

A survey of cosmetic surgery training in plastic surgery programs in the United States.

BACKGROUND: Aesthetic surgery is evolving rapidly, both technologically and conceptually. It is critical for the specialty that aesthetic surgery training keep pace with this rapid evolution. To shed more light on this issue, a survey was sent to all program directors and senior plastic surgery residents to record their impressions of the quality of cosmetic surgery resident training. The authors report the results of this national cosmetic surgery training survey canvassing all 89 plastic surgery programs. METHODS: A three-page survey delineating resident preparedness in aesthetic surgery was sent to senior plastic surgery residents and program directors in April of 2006 and collected through October of 2006. RESULTS: Of 814 surveys, 292 responses were obtained from 64 percent of program directors and 33 percent of senior residents. Breast augmentation, breast reduction, and abdominoplasty were most frequently performed with the highest resident comfort levels. Rhinoplasty remained a particular area of trainee concern, but confidence levels were also low in face lifts, endoscopic procedures, and body contouring techniques. Experience with skin resurfacing, fillers, and botulinum toxin type A was another area of concern. Although 51 percent of residents felt prepared to integrate cosmetic surgery into their practices on graduation, 36 percent felt that further cosmetic training was desirable. CONCLUSIONS: The information collected revealed significant differences in opinions between program directors and senior residents. Senior residents felt deficient in facial cosmetic, minimally invasive, and recently developed body contouring techniques. On the basis of these results and the authors' experience in resident education, changes in cosmetic surgery training are suggested.