The role of sustainability education within dermatological surgery in the United Kingdom

Sustainability recognises the limited planetary resources and is characterised by being able to sufficiently meet the needs of the current population without compromising future generations. The most recent iteration of the General Medical Council (United Kingdom) ‘Outcome for Graduates’ document required newly qualified doctors to have knowledge of sustainable healthcare (General Medical Council, 2018). Medical education is a key pillar in empowering the medical workforce to recognise the sustainability of the health services they provide and build competencies to reconfigure services and care pathways that will be resilient to the effects of climate change. This correspondence discusses the role of sustainability education within dermatological surgery in the United Kingdom

Clinical integration of fast Raman spectroscopy for Mohs micrographic surgery of basal cell carcinoma

We present the first clinical integration of a prototype device based on integrated auto-fluorescence imaging and Raman spectroscopy (Fast Raman device) for intra-operative assessment of surgical margins during Mohs micrographic surgery of basal cell carcinoma (BCC). Fresh skin specimens from 112 patients were used to optimise the tissue pre-processing and the Fast Raman algorithms to enable an analysis of complete Mohs layers within 30 minutes. The optimisation allowed >95% of the resection surface area to be investigated (including the deep and epidermal margins). The Fast Raman device was then used to analyse skin layers excised from the most relevant anatomical sites (nose, temple, eyelid, cheek, forehead, eyebrow and lip) and to detect the three main types of BCC (nodular, superficial and infiltrative). These results suggest that the Fast Raman technique is a promising tool to provide an objective diagnosis “tumour clear yes/no” during Mohs surgery of BCC. This clinical integration study is a key step towards a larger scale diagnosis test accuracy study to reliably determine the sensitivity and specificity in a clinical setting

Integrating Human Health into Environmental Impact Assessment: An Unrealized Opportunity for Environmental Health and Justice

The National Environmental Policy Act and related state laws require many public agencies to analyze and disclose potentially significant environmental effects of agency actions, including effects on human health. In this paper we review the purpose and procedures of environmental impact assessment (EIA), existing regulatory requirements for health effects analysis, and potential barriers to and opportunities for improving integration of human health concerns within the EIA process. We use statutes, regulations, guidelines, court opinions, and empirical research on EIA along with recent case examples of integrated health impact assessment (HIA)/EIA at both the state and federal level. We extract lessons and recommendations for integrated HIA/EIA practice from both existing practices as well as case studies. The case studies demonstrate the adequacy, scope, and power of existing statutory requirements for health analysis within EIA. The following support the success of integrated HIA/EIA: a proponent recognizing EIA as an available regulatory strategy for public health; the openness of the agency conducting the EIA; involvement of public health institutions; and complementary objectives among community stakeholders and health practitioners. We recommend greater collaboration among institutions responsible for EIA, public health institutions, and affected stakeholders along with guidance, resources, and training for integrated HIA/EIA practice

Case Reports1. A Late Presentation of Loeys-Dietz Syndrome: Beware of TGFβ Receptor Mutations in Benign Joint Hypermobility

Background: Thoracic aortic aneurysms (TAA) and dissections are not uncommon causes of sudden death in young adults. Loeys-Dietz syndrome (LDS) is a rare, recently described, autosomal dominant, connective tissue disease characterized by aggressive arterial aneurysms, resulting from mutations in the transforming growth factor beta (TGFβ) receptor genes TGFBR1 and TGFBR2. Mean age at death is 26.1 years, most often due to aortic dissection. We report an unusually late presentation of LDS, diagnosed following elective surgery in a female with a long history of joint hypermobility. Methods: A 51-year-old Caucasian lady complained of chest pain and headache following a dural leak from spinal anaesthesia for an elective ankle arthroscopy. CT scan and echocardiography demonstrated a dilated aortic root and significant aortic regurgitation. MRA demonstrated aortic tortuosity, an infrarenal aortic aneurysm and aneurysms in the left renal and right internal mammary arteries. She underwent aortic root repair and aortic valve replacement. She had a background of long-standing joint pains secondary to hypermobility, easy bruising, unusual fracture susceptibility and mild bronchiectasis. She had one healthy child age 32, after which she suffered a uterine prolapse. Examination revealed mild Marfanoid features. Uvula, skin and ophthalmological examination was normal. Results: Fibrillin-1 testing for Marfan syndrome (MFS) was negative. Detection of a c.1270G > C (p.Gly424Arg) TGFBR2 mutation confirmed the diagnosis of LDS. Losartan was started for vascular protection. Conclusions: LDS is a severe inherited vasculopathy that usually presents in childhood. It is characterized by aortic root dilatation and ascending aneurysms. There is a higher risk of aortic dissection compared with MFS. Clinical features overlap with MFS and Ehlers Danlos syndrome Type IV, but differentiating dysmorphogenic features include ocular hypertelorism, bifid uvula and cleft palate. Echocardiography and MRA or CT scanning from head to pelvis is recommended to establish the extent of vascular involvement. Management involves early surgical intervention, including early valve-sparing aortic root replacement, genetic counselling and close monitoring in pregnancy. Despite being caused by loss of function mutations in either TGFβ receptor, paradoxical activation of TGFβ signalling is seen, suggesting that TGFβ antagonism may confer disease modifying effects similar to those observed in MFS. TGFβ antagonism can be achieved with angiotensin antagonists, such as Losartan, which is able to delay aortic aneurysm development in preclinical models and in patients with MFS. Our case emphasizes the importance of timely recognition of vasculopathy syndromes in patients with hypermobility and the need for early surgical intervention. It also highlights their heterogeneity and the potential for late presentation. Disclosures: The authors have declared no conflicts of interes