Breast Angiosarcoma Surveillance Study: UK national audit of management and outcomes of angiosarcoma of the breast and chest wall.

BACKGROUND: Breast angiosarcomas are rare tumours of vascular origin. Secondary angiosarcoma occurs following radiotherapy for breast cancer. Angiosarcomas have high recurrence and poor survival rates. This is concerning owing to the increasing use of adjuvant radiotherapy for the treatment of invasive breast cancer and ductal cancer in situ (DCIS), which could explain the rising incidence of angiosarcoma. Outcome data are limited and provide a poor evidence base for treatment. This paper presents a national, trainee-led, retrospective, multicentre study of a large angiosarcoma cohort. METHODS: Data for patients with a diagnosis of breast/chest wall angiosarcoma between 2000 and 2015 were collected retrospectively from 15 centres. RESULTS: The cohort included 183 patients with 34 primary and 149 secondary angiosarcomas. Median latency from breast cancer to secondary angiosarcoma was 6 years. Only 78.9 per cent of patients were discussed at a sarcoma multidisciplinary team meeting. Rates of recurrence were high with 14 of 28 (50 per cent ) recurrences in patients with primary and 80 of 124 (64.5 per cent ) in those with secondary angiosarcoma at 5 years. Many patients had multiple recurrences: total of 94 recurrences in 162 patients (58.0 per cent). Median survival was 5 (range 0-16) years for patients with primary and 5 (0-15) years for those with secondary angiosarcoma. Development of secondary angiosarcoma had a negative impact on predicted breast cancer survival, with a median 10-year PREDICT prognostic rate of 69.6 per cent, compared with 54.0 per cent in the observed cohort. CONCLUSION: A detrimental impact of secondary angiosarcoma on breast cancer survival has been demonstrated. Although not statistically significant, almost all excess deaths were attributable to angiosarcoma. The increased use of adjuvant radiotherapy to treat low-risk breast cancer and DCIS is a cause for concern and warrants further study.

Current perceptions of 'Brazilian butt lift' (BBL) surgery in the UK: A BAAPS-led survey of BAAPS members.

BACKGROUND: The BAAPS advice against Brazilian butt lift (BBL) surgery in the UK was set in October 2018. A Delphi study conducted by BAAPS highlighted the importance of defining current practice and perceptions amongst UK surgeons, as this is currently unknown. OBJECTIVES: To evaluate BAAPS members' current practice and perceptions around BBL surgery to ensure patient safety and propose better recommendations. METHODS: A BAAPS-commissioned survey was emailed to all BAAPS members through an on-line link. The survey collected quantitative and qualitative information in several domains. RESULTS: This survey received a 44% response rate. Of 102 respondents, 32 surgeons undertook BBL surgery before the BAAPS advice to halt it. There was a wide variation in actual fat volumes injected, and in perceptions of what constituted a small or large volume. Virtually all respondents (96.9%) performed only subcutaneous fat injections. There were differences in fat harvest techniques. The majority (66.7%) felt that BAAPS should maintain its recommendation against undertaking BBL surgery until further data became available. Nearly a quarter of 102 respondents (20.6%) had been treated for BBL complications, the majority as a result of surgical tourism. CONCLUSIONS: The survey provides member-reported perception and experience with regard to BBL surgery in the UK. The demand for BBL surgery and its provision should be reassessed in the UK. This information will be analysed with further national and international data to better define and shape the scope of the safety of BBL surgery in the UK. BAAPS will use such data towards the production of future guidance and support for surgeons and patients.

Carotid endarterectomy in the elderly: risk factors, intraoperative carotid hemodynamics and short-term complications: a UK tertiary center retrospective analysis.

This retrospective analysis aims to demonstrate the safety of carotid endarterectomy (CE) in patients >75 years with particular attention paid to intraoperative hemodynamics. Four hundred and ninety-six consecutive patients with >70% symptomatic and asymptomatic stenosis who underwent CE were prospectively assessed and divided into those <75 years (n = 408; mean 64 years) and those >75 years (n = 88; mean 78 years). Associated risk factors, hemodynamic parameters, surgical techniques and 30-day perioperative complications were compared. Carotid artery stump pressures of <25 mmHg (13 versus 29%) and middle cerebral artery velocities of <20 cm/sec (46 versus 29%) were more common in those >75 years (P = 0.0001 and P <0.005, respectively). However, there was no difference in the frequency of intraluminal shunt (34% in both groups) or synthetic patch usage (primary patching: 12.5%, older group versus 11%, younger group; secondary patching: 34% in both groups), and no difference in the combined 30-day stroke and death rates (3.4%, >75 years versus 1.1%, <75 years; P = 0.425). CE in this cohort of patients >75 years was not associated with increased morbidity or mortality. Altered intraoperative hemodynamics were not associated with increased use of shunting or patching. This analysis supports CE as a safe procedure in the elderly.

Treating stones in transplanted kidneys.

The formation of calculi in renal allografts is an uncommon complication in renal transplant recipients, with a reported incidence of 0.2-1.7% according to retrospective studies. Although the majority of these stones appear to form de novo following renal transplantation (RTX), there is a growing body of evidence suggesting that more often than previously thought they may be transplanted with the donor graft itself. The etiology and pathophysiology of renal graft stones is multifactorial. A combination of metabolic and urodynamic factors predispose to stone formation and these are generally found more frequently in allograft rather than native kidneys. In addition tertiary hyperparathyroidism (following RTX) plays an important role. Renal allograft stones can pose significant challenges for the clinician. The diagnosis requires a high index of suspicion and must be prompt, as these patients' reliance on a solitary kidney for their renal function leaves them susceptible to significant morbidity. However, reports in the literature come largely from anecdotal experience and case reports, meaning that there is a limited consensus regarding how best to manage the condition. We suggest that interventional treatment should be guided primarily by stone size and individual patient presentation. Good outcomes have been reported with shockwave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL) and ureteroscopy, but optimal management of the risk factors leading to calculi formation (i.e., prevention) will remain the most cost-effective management.

Who should set the standards for surgical assessments?

In light of national policy and educational theory, this article addresses the question of who should set the standards for surgical assessments, highlighting the multidisciplinary nature of those currently (and potentially) involved.

Is there a role for music in reducing anxiety in plastic surgery minor operations?

INTRODUCTION: It is well documented that music plays a role in reducing anxiety levels. Its role in reducing intra-operative anxiety levels in surgical patients while awake is less well known. We report the effects of music on intra-operative patient anxiety in both the elective and trauma plastic surgical setting. METHODS: Two groups of patients undergoing local anaesthetic surgical procedures were identified: those where music was played in the operating theatre (Group 1) and those where it was not (Group 2). Ninety-six patients were included. Subjectively anxiety was evaluated by the patient with a visual analogue scale (VAS) and objectively by the respiratory rate (RR), both pre and post-operatively. The unpaired t-test was used to evaluate the statistical significance of differences between the groups. RESULTS: The mean pre-operative VAS score was similar in both groups (5.7 in Group 1 and 5.8 in Group 2). The mean pre-operative RR was 15 breaths per minute in both groups. Post-operatively, the VAS score and RR were both lower in Group 1 (VAS: 3.5 vs 4.9; p<0.01 and RR: 11 vs 13 breaths per minute; p<0.05). CONCLUSIONS: In the era of the patient centred approach to clinical care, it is crucial to minimise patient anxiety. Music appears to reduce intra-operative anxiety in awake patients in both the elective and trauma plastic surgical setting. Easy listening music and chart classics appear to be suitable genres according to patients. We believe there is a role for a large, multicentre, randomised control study to examine the benefits of music in all local anaesthetic procedures across different specialties.

Heterotopic ossification in Dupuytren's disease: clinical and histological significance.

We report the case of an 82-year-old man who underwent fasciectomy for a severe Dupuytren's contracture, during which an ossified lesion was encountered within the contracture and surrounding the neurovascular bundle. The abnormal tissue was removed with difficulty and heterotopic ossification was confirmed histologically. We believe this is the first report of heterotopic ossification in Dupuytren's disease.

Restenosis after carotid endarterectomy.

Multiple randomised trials over the last decade for both symptomatic and asymptomatic carotid stenosis have proven the efficacy of carotid endarterectomy (CE) in reducing the risk of stroke. The long-term patency of the carotid artery after CE is an important factor in the success of the operation. The incidence of recurrent carotid stenosis (excluding residual lesions) ranges from 1 to 37% with only 0-8% of patients having restenosis-related symptoms (1). Generally, recurrent carotid stenosis is attributed to myointimal hyperplasia during the early postoperative period (within 3 years) or recurrent atherosclerosis thereafter. The management of recurrent carotid stenosis after CE remains a dilemma. It is generally accepted that operation for significant recurrent carotid stenosis is indicated for symptomatic patients, and several authors also recommend CE for >80% asymptomatic recurrent stenosis. Treatment of recurrent carotid stenosis involves repeat endarterectomy with patch angioplasty, although more recently endovascular techniques have been used.

Macroprolactin: what is it and what is its importance?

Monomeric prolactin (PRL) of molecular weight 23 kDa constitutes up to 95% of adult serum PRL. Macroprolactin is a large antigen-antibody complex of molecular weight greater than 100 kDa and constitutes less than 1% of circulating PRL. Thus, in most cases, hyperprolactinaemia is usually a result of high levels of monomeric PRL, which may be due to excess production as with a prolactinoma or due to disinhibition by compression of the pituitary stalk. Nevertheless, it must be noted that macroprolactinaemia may be a cause of hyperprolactinaemia in some individuals, which may have no association with any pathology. The presence of macroprolactin should always be suspected when a patient's clinical history and/or radiological data are incompatible with his/her PRL value. Thus, it may be useful to screen all patients with high sera PRL levels in order to prevent unnecessary investigations into the cause for hyperprolactinaemia. This has recently been facilitated with the advent of simple laboratory tests such as the polyethyleneglycol precipitation method, although gel filtration chromatography remains the gold standard. It is hoped that macroprolactinaemia is included in the differential diagnosis of hyperprolactinaemia.

Effect of acute oral calcium load on serum PTH and bone resorption in young healthy subjects: an overnight study.

OBJECTIVE: To investigate the effects of a 400 mg acute oral calcium dose on PTH and bone resorption markers in a young, healthy population. DESIGN: Fasting serum parathyroid hormone (PTH), C-telopeptides (CTX), total calcium (Ca), albumin and urinary calcium/creatinine ratio (uCa/Cr) were measured on two separate days: one before and the other 10 h after oral administration of 400 mg calcium. Serum 25-hydroxy vitamin D (25-OHD) status was assessed at baseline. Dietary calcium intake was assessed using a food frequency questionnaire (FFQ). SUBJECTS: A total of 32 healthy, young adults (17 female, 15 male; mean+/-s.e.m. age: 21+/-1 y) took part in this study. Their mean (s.e.m.) calcium intake was 1125 (+/-56) mg/day. INTERVENTION: Effervescent Sandocal 400 tablets dissolved in water. RESULTS: After the calcium challenge, mean Ca and uCa/Cr ratio increased significantly, and both PTH and CTX concentrations were significantly lower. Multiple regression analysis showed no relationship between the response to the 400 mg load and previous dietary calcium intake (as assessed by FFQ) or serum 25-OHD. CONCLUSION: We have shown that in a young, healthy population, 400 mg oral calcium can inhibit bone resorption (as measured by serum CTX) and PTH, and this appears to be independent of previous dietary calcium intake and vitamin D status.