A 10-year Review of Surgical Management of Dermatofibrosarcoma Protuberans

Background: Dermatofibrosarcoma protuberans (DFSP) is a rare skin cancer. Standard treatment in the United Kingdom (UK) is either surgical wide local excision (WLE) or Mohs micrographic surgery (MMS). It is unclear which approach has the lower recurrence rate.Objectives: We undertook a retrospective comparative review of DFSP surgical management in the UK National Health Service (NHS) in order to define:1) current surgical practice for primary and recurrent DFSP2) local recurrence rates for primary DFSP3) survival outcomes for DFSP.Methods: Retrospective clinical case-note review of patients with histologically-confirmed DFSP (January 2004–2014) who have undergone surgical treatment.Results: Surgical management of 483 primary and 64 recurrent DFSP in 11 plastic surgery and 15 dermatology departments was analysed. Almost 75% of primary DFSP (n=362) were treated with WLE and 20.1% (n=97) with MMS. For recurrent DFSP, 68.7% (n=44) and 23.4% (n=15) underwent WLE and MMS, respectively. Recurrent primary DFSP occurred in 6 patients after WLE and none after MMS. Median follow-up was 4.8 years [IQR 3.5, 5.8] with 8 reported deaths during the follow-up analysis period; one confirmed to be DFSP-related.Conclusions: WLE was the commonest surgical modality used to treat DFSP across the UK. The local recurrence rate was very low, occurring only after WLE. Although a prospective RCT may provide more definitive outcomes, in the absence of a clearly superior surgical modality, treatment decisions should be based on patient preference, clinical expertise and cost

Are we stripping the care out of care plans?

In 2013, NHS England specified that: "‘... every person with a long-term condition or disability has a personalised care plan supporting them to develop the knowledge, skills and confidence to manage their own health’.1" Around 40% of the UK population experience a long-term condition while 65% of people aged 65–84 years have two or more.2 This is an all-time high, with figures set to rise. This places significant personal, social, and economic burden on individuals, their families, and the community. The use of care plans to manage multiple long-term conditions — by assessing individual behaviour, setting joint goals, supporting self-management, and ensuring proactive follow-up — is based on Wagner’s Chronic Care Model.3 The model takes into account the need to provide support and structure to patients, and the fact that all long-term conditions have common challenges. Care planning has received extraordinary interest in the NHS. Policymakers endorse care planning as a way of containing high costs, encouraging a more person-centred approach, improving quality of life, and reducing mortality rates and emergency admissions to hospitals. But are care plans effective in this regard and what challenges do GP practices face in implementation

Challenges in quantifying changes in the global water cycle

Human influences have likely already impacted the large-scale water cycle but natural variability and observational uncertainty are substantial. It is essential to maintain and improve observational capabilities to better characterize changes. Understanding observed changes to the global water cycle is key to predicting future climate changes and their impacts. While many datasets document crucial variables such as precipitation, ocean salinity, runoff, and humidity, most are uncertain for determining long-term changes. In situ networks provide long time-series over land but are sparse in many regions, particularly the tropics. Satellite and reanalysis datasets provide global coverage, but their long-term stability is lacking. However, comparisons of changes among related variables can give insights into the robustness of observed changes. For example, ocean salinity, interpreted with an understanding of ocean processes, can help cross-validate precipitation. Observational evidence for human influences on the water cycle is emerging, but uncertainties resulting from internal variability and observational errors are too large to determine whether the observed and simulated changes are consistent. Improvements to the in situ and satellite observing networks that monitor the changing water cycle are required, yet continued data coverage is threatened by funding reductions. Uncertainty both in the role of anthropogenic aerosols, and due to large climate variability presently limits confidence in attribution of observed changes

Direct microscopic examination of imprints in patients undergoing cardiac valve replacement

BACKGROUND: Bacteriological analysis of cardiac valves might be indicated in patients with suspected endocarditis. METHODS: We report here a prospective study on fifty-three consecutive patients whose native valves were sent to the bacteriological and pathological laboratories, to investigate the performance of direct microscopic examination of imprints and valve culture. RESULTS: On the basis of a histopathological gold standard to classify the inflammatory valve process, the sensitivity, the specificity, the positive and the negative predictive values of direct microscopic examination of imprints and valve culture were 21%, 100%, 100%, 60%, and 21%, 72%, 38%, 52% respectively. This weak threshold of the direct microscopic examination of imprints could be due to antimicrobial therapy prescribed before cardiac surgery and the fact that the patients came from a tertiary hospital receiving patients with a prolonged history of endocarditis. CONCLUSION: Clinical context and histopathology are indispensable when analyzing the imprints and valve culture

Decadal changes of the Western Arabian sea ecosystem

Historical data from oceanographic expeditions and remotely sensed data on outgoing longwave radiation, temperature, wind speed and ocean color in the western Arabian Sea (1950–2010) were used to investigate decadal trends in the physical and biochemical properties of the upper 300 m. 72 % of the 29,043 vertical profiles retrieved originated from USA and UK expeditions. Increasing outgoing longwave radiation, surface air temperatures and sea surface temperature were identified on decadal timescales. These were well correlated with decreasing wind speeds associated with a reduced Siberian High atmospheric anomaly. Shoaling of the oxycline and nitracline was observed as well as acidification of the upper 300 m. These physical and chemical changes were accompanied by declining chlorophyll-a concentrations, vertical macrofaunal habitat compression, declining sardine landings and an increase of fish kill incidents along the Omani coast

Rex Shunt Preoperative Imaging: Diagnostic Capability of Imaging Modalities

The purpose of this study was to evaluate the diagnostic capability of imaging modalities used for preoperative mesenteric-left portal bypass (“Rex shunt”) planning. Twenty patients with extrahepatic portal vein thrombosis underwent 57 preoperative planning abdominal imaging studies. Two readers retrospectively reviewed these studies for an ability to confidently determine left portal vein (PV) patency, superior mesenteric vein (SMV) patency, and intrahepatic left and right PV contiguity. In this study, computed tomographic arterial portography allowed for confident characterization of left PV patency, SMV patency and left and right PV continuity in 100% of the examinations. Single phase contrast-enhanced CT, multi-phase contrast-enhanced CT, multiphase contrast-enhanced MRI, and transarterial portography answered all key diagnostic questions in 33%, 30%, 0% and 8% of the examinations, respectively. In conclusion, of the variety of imaging modalities that have been employed for Rex shunt preoperative planning, computed tomographic arterial portography most reliably allows for assessment of left PV patency, SMV patency, and left and right PV contiguity in a single study

Have greenhouse gases intensified the contrast between wet and dry regions?

While changes in land precipitation during the last 50 years have been attributed in part to human influences, results vary by season, are affected by data uncertainty and do not account for changes over ocean. One of the more physically robust responses of the water cycle to warming is the expected amplification of existing patterns of precipitation minus evaporation. Here, precipitation changes in wet and dry regions are analyzed from satellite data for 1988–2010, covering land and ocean. We derive fingerprints for the expected change from climate model simulations that separately track changes in wet and dry regions. The simulations used are driven with anthropogenic and natural forcings combined, and greenhouse gas forcing or natural forcing only. Results of detection and attribution analysis show that the fingerprint of combined external forcing is detectable in observations and that this intensification of the water cycle is partly attributable to greenhouse gas forcing