Radiotherapy after mastectomy for screen-detected ductal carcinoma in situ

Background. A role for radiotherapy after mastectomy for ductal carcinoma in situ (DCIS) is unclear. Using a prospective audit of DCIS detected through the NHS Breast Screening Programme we sought to determine a rationale for the use of postmastectomy radiotherapy for DCIS. Methods. Over a nine year period, from 9,972 patients with screen-detected DCIS and complete surgical, pathology, radiotherapy and follow up data, 2,944 women underwent mastectomy for DCIS of whom 33 (1.12%) received radiotherapy. Results. Use of post mastectomy radiotherapy was significantly associated with a close (<1mm) pathology margin, particularly (χ2(1) 95.81; p<0.00001), DCIS size (χ2 (3) 16.96; p<0.001) and the presence of microinvasion (χ2(1) 3.92; p<0.05). At median follow up 61 months, no woman who received radiotherapy had an ipsilateral further event, and only 1/33 women (3.0%) had a contralateral event. Of the women known not to have had radiotherapy post mastectomy, 45/2,894 (1.6%) had an ipsilateral further event and 83 (2.9%) had a contralateral event. Conclusion: For DCIS treated by mastectomy, a close (<1mm) margin, large tumour size and microinvasion, may merit radiotherapy to reduce ipsilateral recurrence

A cross-country review of strategies of the German development cooperation to strengthen human resources

ABSTRACT: BACKGROUND: Recent years have seen growing awareness of the importance of human resources for health in health systems and with it an intensifying of the international and national policies in place to steer a response. This paper looks at how governments and donors in five countries - Cameroon, Indonesia, Malawi, Rwanda and Tanzania - have translated such policies into action. More detailed information with regard to initiatives of German development cooperation brings additional depth to the range and entry doors of human resources for health initiatives from the perspective of donor cooperation. METHODS: This qualitative study systematically presents different approaches and stages to human resources for health development in a cross-country comparison. An important reference to capture implementation at country level was grey literature such as policy documents and programme reports. In-depth interviews along a predefined grid with national and international stakeholders in the five countries provided information on issues related to human resources for health policy processes and implementation. RESULTS: All five countries have institutional entities in place and have drawn up national policies to address human resources for health. Only some of the countries have translated policies into strategies with defined targets and national programmes with budgets and operational plans. Traditional approaches of supporting training for individual health professionals continue to dominate. In some cases partners have played an advocacy and technical role to promote human resources for health development at the highest political levels, but usually they still focus on the provision of ad hoc training within their programmes, which may not be in line with national human resources for health development efforts or may even be counterproductive to them. Countries that face an emergency, such as Malawi, have intensified their efforts within a relatively short time and by using donor funding support also through new initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. CONCLUSIONS: The country case studies illustrate the range of initiatives that have surged in recent years and some main trends in terms of donor initiatives. Though attention and priority attributed to human resources for health is increasing, there is still a focus on single initiatives and programmes. This can be explained in part by the complexity of the issue, and in part by its need to be addressed through a long-term approach including public sector and salary reforms that go beyond the health secto

DESIGN-DRIVEN INNOVATION: AVANT GARDE 50M SUPERYACHT UNDER 500GT

The reduced regulatory framework for superyachts under 500GT offers a significant opportunity for a greater percentage of interior volume to be assigned to guest activities, due to a reduction in both crew area requirements and fire insulation and the absence of certain requirements such as an emergency generator. There has been growth in the value of the superyacht charter market in recent years, with the 30m-50m segment representing 58% of the market in 2013. In 2012 33% of the World's superyachts were delivered to Europe with Loa averaging 42.5m. Therefore, there is market opportunity for a privately owned yacht built with consideration to generate the maximum possible income when chartered. Clients expect to have their emotional needs fulfilled to elicit feelings of luxury and pleasure. The design challenge here is to address the cultural specificities of luxury for a range of potential charter clients. Adaptability of space is critical to facilitate a range of user activities through optimising the reduced space is the sub 500GT segment. This paper presents a design proposal which engages in Design-Driven Innovation, resulting in an avant garde vessel, which effectively engages in a range of roles through the use of transformable interior space, which has a reconfigurable layout combined with a highly adaptable exterior space. This is in contrast to current designs, which tend to have a linear approach to the usability of a vessel through elements that can add valuable extra client space, such as platforms that unfurl. Due to the sub 500GT interior volume being stretched over 50 m, the resulting superstructure is sleek and well proportioned. The styling is fluid and biomimetic, resulting in an elegant dynamic form, which is in contrast to the more architectural forms of contemporary vessels. Due to the vast amounts of exterior space it is aimed at the high net worth owner who prefers to cruise the warmer climates such as the Mediterranean, resulting in a yacht more suited to outdoor leisure usage. The sundeck canopy is a biomimetic design feature, which is partly constructed from ETFE. This facilitates Passive Design implementation through the heating effect of air trapped in the leaf like structure, which promotes the stack effect air flow from the interior, reducing the HVAC load. The design proposal addresses the sustainable luxury agenda through the implementation of Passive Design, and the use of a transformable interior layout to achieve a high degree of space utilisation, thus providing a range of user activities emulating the experience of a larger vessel

DESIGN-DRIVEN INNOVATION: AVANT GARDE 50M SUPERYACHT UNDER 500GT

The reduced regulatory framework for superyachts under 500GT offers a significant opportunity for a greater percentage of interior volume to be assigned to guest activities, due to a reduction in both crew area requirements and fire insulation and the absence of certain requirements such as an emergency generator. There has been growth in the value of the superyacht charter market in recent years, with the 30m-50m segment representing 58% of the market in 2013. In 2012 33% of the World's superyachts were delivered to Europe with Loa averaging 42.5m. Therefore, there is market opportunity for a privately owned yacht built with consideration to generate the maximum possible income when chartered. Clients expect to have their emotional needs fulfilled to elicit feelings of luxury and pleasure. The design challenge here is to address the cultural specificities of luxury for a range of potential charter clients. Adaptability of space is critical to facilitate a range of user activities through optimising the reduced space is the sub 500GT segment. This paper presents a design proposal which engages in Design-Driven Innovation, resulting in an avant garde vessel, which effectively engages in a range of roles through the use of transformable interior space, which has a reconfigurable layout combined with a highly adaptable exterior space. This is in contrast to current designs, which tend to have a linear approach to the usability of a vessel through elements that can add valuable extra client space, such as platforms that unfurl. Due to the sub 500GT interior volume being stretched over 50 m, the resulting superstructure is sleek and well proportioned. The styling is fluid and biomimetic, resulting in an elegant dynamic form, which is in contrast to the more architectural forms of contemporary vessels. Due to the vast amounts of exterior space it is aimed at the high net worth owner who prefers to cruise the warmer climates such as the Mediterranean, resulting in a yacht more suited to outdoor leisure usage. The sundeck canopy is a biomimetic design feature, which is partly constructed from ETFE. This facilitates Passive Design implementation through the heating effect of air trapped in the leaf like structure, which promotes the stack effect air flow from the interior, reducing the HVAC load. The design proposal addresses the sustainable luxury agenda through the implementation of Passive Design, and the use of a transformable interior layout to achieve a high degree of space utilisation, thus providing a range of user activities emulating the experience of a larger vessel

Assessment of deterministic and stochastic multi-model ocean predictions and uncertainties on acoustic propagation in shallow waters

It is well known that high environmental variability may significantly impact acoustic operations in shallow waters. In the framework of the BP07 sea trial South-East of Elba, Italy, several operational models were used to assess the uncertainty of ocean and acoustic predictions. They were further used to optimize MVP and CTD sampling strategies in the area and incorporated in super-ensemble predictions which aim at combining optimally individual forecasts. These different products were then compared and suggest that multi-model super-ensemble strategies provide more reliable predictions and further reduce the uncertainty on the environment. A sensitivity study of environmental predictions on low frequency (300 to 1800 Hz) acoustic signals was conducted. The analysis is performed within the perspective of geoacoustic inversion and conclusions are drawn about the limitations of oceanographic variability and uncertainty upon geoacoustic inversion methodologies