Background The 2022 National Institute for Health and Care Excellence melanoma guideline update made significant changes to follow-up. The aim of this study was to assess the impact these changes will have on a national melanoma cohort over a 5-year follow-up interval.Methods Anonymized, individual-level, population-scale, linkable primary and secondary care National Health Service data for an 18-year interval (2000-2018) in Wales, UK were analysed. These data were used to predict the number of patients over a 10-year interval (2020-2030) that would be diagnosed with melanoma. Follow-up schedules for the 2015 and 2022 National Institute for Health and Care Excellence melanoma guidelines were then used to calculate the number of clinician-led appointments, the number of radiological investigations, and the total healthcare cost between 2025 and 2030, corresponding to a 5-year patient follow-up interval, for those with stage IA-IIC melanoma.Results Between 2025 and 2030 it is predicted that implementation of the 2022 guidelines would lead to 21 122 (range 19 194-23 083) fewer clinician-led appointments for patients with stage IA-IIC melanoma. However, there would be a significant increase in the number of radiological investigations (7812; range 7444-8189). These changes would lead to a euro2.74 million (euro1.87 million-euro3.61 million) reduction in the total cost of follow-up over the interval 2025-2030.Conclusion Melanoma follow-up guideline changes will result in a substantial reduction in the number of clinical follow-up appointments, but a significant additional burden to radiological services. The overall cost of follow-up at a national level will be reduced. Changes to the National Institute for Health and Care Excellence melanoma follow-up guidelines in 2022 will result in approximately 20 000 fewer clinician-led appointments over a 5-year interval in Wales. Despite the increase in radiology requirements, there will be a euro2.74 million reduction in healthcare cost.

Background The psychological burden of cutaneous malignant melanoma (CM) is all-encompassing, affecting treatment adherence, recurrence and mortality. However, the prevalence and risk factors of anxiety and depression in CM remain unclear. Objectives To establish a benchmark pooled prevalence of anxiety and depression in CM, to provide magnitudes of association for clinical, therapeutic and demographic correlates, and to elucidate temporal trends in anxiety and depression from the time of diagnosis. Methods This review followed the MOOSE guidelines. MEDLINE, Embase, PsychINFO, Web of Science and the Cochrane Library were queried from database inception to 24 August 2023. Study selection, data extraction and quality assessment were performed by two independent authors, utilizing both the Joanna Briggs Institute (JBI) and National Institutes of Health risk-of-bias tools for the latter. The GRADE approach was used to rate the certainty of evidence. Prevalence rates, 95% confidence intervals (CIs) and prediction intervals (PIs) were derived using a random-effects model and estimating between- and within-study variance. Results Nine longitudinal and 29 cross-sectional studies were included (7995 patients). Based on the JBI and NIH tools, respectively, quality assessment found 20 and 17 to be at low risk of bias, 12 and 15 to be at moderate risk and 6 and 5 to be at high risk of bias. The prevalence of anxiety [30.6% (95% CI 24.6-37.0; PI 18-47%)] and depression [18.4% (95% CI 13.4-23.9; PI 10-33%)] peaked during treatment, declining to pretreatment levels after 1 year [anxiety: 48% vs. 20% (P = 0.005); depression: 28% vs. 13% (P = 0.03)]. Female sex [odds ratio (OR) 1.8, 95% CI 1.4-2.3; P < 0.001], age < 60 years (OR 1.5, 95% CI 1.2-2.0; P = 0.002) and low educational level (OR 1.5, 95% CI 1.2-2.0; P < 0.001) were likely to result in a large increase in the odds of anxiety. Depression was 12.3% higher in those with stage IV vs. those with stage I CM (P = 0.05). Relative to immune checkpoint inhibition, the rates of depression were 22% (P = 0.002) and 34% (P < 0.001) higher among patients with advanced-stage CM receiving interferon-alpha and chemotherapy, respectively. A significant reduction in self-reported depression scores was demonstrated over time (P = 0.003). Conclusions Notably, anxiety and depression in CM affect women, those younger than 60 years of age and the less educated, with up to 80% higher odds of anxiety in these groups. Anxiety and depression surge during chemotherapy and interferon treatment, especially in advanced CM. Our findings facilitate risk stratification and underscore the need for multidisciplinary vigilance.

IntroductionChildren with visible facial differences are believed to be at increased risk of negative psychosocial behaviours which may manifest as affective disorders. The aim of this study was to determine whether a diagnosis of microtia, and the associated surgical intervention, is associated with psychosocial implications including impaired educational attainment and a diagnosis of an affective disorder.MethodsA retrospective case-control study was conducted using data linkage to identify patients in Wales with a diagnosis of microtia. Matched controls were sought on the basis of age, gender and socioeconomic deprivation status to yield a total sample size of 709. incidence was calculated using annual and geographic birth rates. Surgical operation codes were used to classify patients into those that had no surgery, autologous reconstruction or prosthetic reconstruction. Educational attainment at 11 years of age, plus a diagnosis of depression or anxiety were used as markers of adverse psychosocial outcomes and the relative risk was attained using logistic regression analyses.ResultsThere were no significant associations between a diagnosis of microtia and an increased risk of adverse educational attainment or a risk of an affective disorder diagnosis. Male gender and higher deprivation scores were significantly associated with poorer educational attainment, irrespective of a diagnosis of microtia. Surgical intervention of any nature was also not associated with any increased risk of adverse educational or psychosocial outcomes in microtia patients.DiscussionMicrotia patients in Wales do not appear to be at greater risk of developing affective disorders or impaired academic performance as a result of their diagnosis or associated surgical intervention. Whilst reassuring, the need for appropriate support mechanisms to maintain positive psychosocial wellbeing and academic achievement in this patient cohort is reinforced.

BackgroundBasal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) remain the most prevalent malignancies, contributing a higher workload to cancer registries than all cancers combined. The nature of skin cancers in addition to current coding methods employed by registries give a skewed representation of the workload.ObjectivesA comprehensive search examining the incidence of BCC and/or cSCC at a regional or national level in the UK and Ireland was devised. Standardisation methods were grouped to permit comparison, and a bias assessment tool was employed.Materials & MethodsSixteen UK and Republic of Ireland epidemiological studies on BCC/cSCC over a 48-year period were compiled, examining incidence, trends and emerging risk factors.ResultsIncidence of BCC within the UK is increasing annually by up to 4%, with rates in Wales increasing by up to 6.6% and 1.6% annually for BCC and cSCC, respectively. Inverse relationships are noted between BCC/cSCC and social deprivation. Although the elderly remain the most at risk, the 30-49 age group have illustrated growth rates of approximately 4%.ConclusionThis review outlines increasing incidence in the UK with higher rates noted in Wales, the Southeast, West and Central regions. Incidence rates are higher amongst the least socially deprived and an increasing incidence amongst younger age groups was found, however further trend analysis is required. A more comprehensive data collection method within registries is necessary to ensure accurate representation and fluid comparison. Service planning and public awareness campaigns must be implemented to prevent overwhelming future services.

BACKGROUND:Basal cell carcinoma (BCC) represents the most commonly occurring cancer worldwide within the white population. Reports predict 298 308 cases of BCC in the UK by 2025, at a cost of £265-366 million to the National Health Service (NHS). Despite the morbidity, societal and healthcare pressures brought about by BCC, routinely collected healthcare data and global registration remain limited.OBJECTIVES:To calculate the incidence of BCC in Wales between 2000 and 2018 and to establish the related healthcare utilization and estimated cost of care.METHODS:The Secure Anonymised Information Linkage (SAIL) databank is one of the largest and most robust health and social care data repositories in the UK. Cancer registry data were linked to routinely collected healthcare databases between 2000 and 2018. Pathological data from Swansea Bay University Health Board (SBUHB) were used for internal validation.RESULTS:A total of 61 404 histologically proven BCCs were identified within the SAIL Databank during the study period. The European age-standardized incidence for BCC in 2018 was 224.6 per 100 000 person-years. Based on validated regional data, a 45% greater incidence was noted within SBUHB pathology vs. matched regions within SAIL between 2016 and 2018. A negative association between deprivation and incidence was noted with a higher incidence in the least socially deprived and rural dwellers. Approximately 2% travelled 25-50 miles for dermatological services compared with 37% for plastic surgery. Estimated NHS costs of surgically managed lesions for 2002-2019 equated to £119.2-164.4 million.CONCLUSIONS:Robust epidemiological data that are internationally comparable and representative are scarce for nonmelanoma skin cancer. The rising global incidence coupled with struggling healthcare systems in the post-COVID-19 recovery period serve to intensify the societal and healthcare impact. This study is the first to demonstrate the incidence of BCC in Wales and is one of a small number in the UK using internally validated large cohort datasets. Furthermore, our findings demonstrate one of the highest published incidences within the UK and Europe.

Background: Circumferential deep burns on the limb lead to a constrictive, tourniquet-like effect causing critical limb ischaemia. The treatment, escharotomy, is a time-critical pro-cedure that sometimes is required before the patient arrives at a burn centre. At present, no practical method of teaching this procedure is incorporated into formal educational courses.Methods: The feasibility of a comprehensive education package to teach upper limb es-charotomy was assessed in a group of plastic and general surgery trainees in Wales. Small group workshops focused on the clinical presentation of patients requiring escharotomy. Participants then executed this on a custom-made high-fidelity simulation upper limb model. The articulated limb has subcutaneous silicone fat which bulges upon decom-pression and a finger-tip which turns pink indicating satisfactory reperfusion. A before and after five-point Likert scale was used to evaluate changes in participants' self-assessed confidence in the surgical management of escharotomy. Statistical significance between scores was assessed using the Wilcoxon signed-rank test.Results: A total of 34 participants took part. Following completion of the course, general surgery trainees' confidence in executing the procedure increased from a median score of 1.00 "not confident at all" (IQR 1.00-2.00) to 4.00 "fairly confident" (IQR 4.00-5.00, p < 0.01). Plastic surgery trainees' confidence increased from a median score of was 3.00 "somewhat confident" (IQR 1.75-4.00) to 4.00 "fairly confident" (IQR 3.00-4.25, p < 0.01). Discussion: We developed a comprehensive simulator course that has been demonstrated to improve candidate's confidence in performing escharotomy. The next stage in the course development is to confirm the results in a larger cohort. By developing this simu-lator course we aim to improve emergency burn care education in the UK and globally. Crown Copyright (c) 2022 Published by Elsevier Ltd. All rights reserved.

Introduction At present, vaccines form the only mode of prophylaxis against COVID-19. The time needed to achieve mass global vaccination and the emergence of new variants warrants continued research into other COVID-19 prevention strategies. The severity of COVID-19 infection is thought to be associated with the initial viral load, and for infection to occur, viruses including SARS-CoV-2 must first penetrate the respiratory mucus and attach to the host cell surface receptors. Carrageenan, a sulphated polysaccharide extracted from red edible seaweed, has shown efficacy against a wide range of viruses in clinical trials through the prevention of viral entry into respiratory host cells. Carrageenan has also demonstrated in vitro activity against SARS-CoV-2. Methods and analysis A single-centre, randomised, double-blinded, placebo-controlled phase III trial was designed. Participants randomised in a 1:1 allocation to either the treatment arm, verum Coldamaris plus (1.2 mg iota-carrageenan (Carragelose®), 0.4 mg kappa-carrageenan, 0.5% sodium chloride and purified water), or placebo arm, Coldamaris sine (0.5% sodium chloride) spray applied daily to their nose and throat for 8 weeks, while completing a daily symptom tracker questionnaire for a total of 10 weeks. Primary outcome Acquisition of COVID-19 infection as confirmed by a positive PCR swab taken at symptom onset or seroconversion during the study. Secondary outcomes include symptom type, severity and duration, subsequent familial/household COVID-19 infection and infection with non-COVID-19 upper respiratory tract infections. A within-trial economic evaluation will be undertaken, with effects expressed as quality-adjusted life years. Discussion This is a single-centre, phase III, double-blind, randomised placebo-controlled clinical trial to assess whether carrageenan nasal and throat spray reduces the risk of development and severity of COVID-19. If proven effective, the self-administered prophylactic spray would have wider utility for key workers and the general population. Trial registration NCT04590365; ClinicalTrials.gov NCT04590365. Registered on 19 October 2020.

Skin cancer is more common in transplant recipients, although the quoted incidence is variable. This study investigated the incidence of skin cancer in solid organ transplant recipients (OTRs) in a national cohort and the effect of pharmacotherapeutic agents Transplant patients were identified from Patient Episode Database for Wales (PEDW) using Office of Population Census and Surveys Classifications of Interventions and Procedures-4 (OPCS-4) codes. Controls were matched to cases according to age, sex and socioeconomic status. Skin cancer data were obtained from linkage with other national data sources. Incidence was calculated per 100,000 person-years at risk (PYAR). Negative binomial regression was used to calculate adjusted incidence rate ratios (IRRs) for each organ type. During 2000–2018, 2,852 Welsh patients underwent solid organ transplantation. A total of 13,527 controls were matched from the general population. The incidence of skin cancer within the OTR cohort was 1203.2 per 100,000 PYAR vs 133.9 in the matched control group. Age, male gender and azathioprine use were all associated with an increased risk of skin cancer. Contemporary immunomodulators such as tacrolimus and mycophenolate were associated with a reduction in skin cancer risk when compared to their predecessors, cyclosporin and azathioprine. The highest adjusted IRR was observed in heart transplant recipients (IRR: 10.82; 95% CI: 3.64–32.19) and the lowest in liver transplant recipients (IRR: 2.86; 95% CI: 1.15–7.13). This study highlights the need for long-term routine skin cancer surveillance for all OTRs and the importance of using contemporary immunomodulators, when possible, for risk reduction.

Abstract Introduction The severity of Covid-19 infection is associated with viral load. For infection to occur, viruses including SARS-CoV-2 must first penetrate the respiratory mucus to attach to the host cell surface receptors. Iota-carrageenan (I-C), a sulphated polysaccharide extracted from red edible seaweed, has shown efficacy against a range of viruses in clinical trials, through prevention of viral entry into respiratory host cells and in-vitro activity against SARS-CoV-2. Our aim, as an academic surgical department, was to design and implement a clinical trial to investigate whether I-C nasal and throat sprays are effective in reducing the rate and severity of Covid-19 infection. Method The study is a single centre, double-blinded randomised controlled trial. Recruitment of 480 participants aged ≥18 years without previous Covid-19 infection and who have not yet been vaccinated, commenced in December 2020. Participants are randomised to either the treatment (0.12% I-C in 0.5% saline spray) or placebo (0.5% saline spray) arm and will prophylactically apply the spray to their nose and throat while completing a daily symptom tracker for a total of 10 weeks. The primary outcome is the acquisition of Covid-19 infection. Secondary outcomes include symptom type, severity and duration, subsequent familial/household Covid-19 infection and infection with non-Covid-19 upper respiratory tract infections. Discussion Our hypothesis is that I-C sprays will reduce SARS-CoV-2 attachment to the naso- and oropharyngeal mucosal epithelial cells thus reducing the effective viral infective dose. If proven effective, the self-administered prophylactic spray would have wider utility for key workers and the general population. Trial registration number NCT04590365

BACKGROUND:The COVID-19 pandemic has heavily impacted elective and emergency surgery around the world. We aimed to confirm the incidence of perioperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and associated mortality after surgery.METHODS:Analysis of routine electronic health record data from NHS hospitals in England. We extracted data from Hospital Episode Statistics in England describing adult patients undergoing surgery between January 1, 2020 and February 28, 2021. The exposure was SARS-CoV-2 infection defined by International Classification of Diseases (ICD)-10 codes. The primary outcome measure was 90 day in-hospital mortality. Data were analysed using multivariable logistic regression adjusted for age, sex, Charlson Comorbidity Index, Index of Multiple Deprivation, presence of cancer, surgical procedure type and admission acuity. Results are presented as n (%) and odds ratios (OR) with 95% confidence intervals (CI).RESULTS:We identified 2 666 978 patients undergoing surgery of whom 28 777 (1.1%) had SARS-CoV-2 infection. In total, 26 364 (1.0%) patients died in hospital. SARS-CoV-2 infection was associated with a much greater risk of death (SARS-CoV-2: 6153/28 777 [21.4%] vs no SARS-CoV-2: 20 211/2 638 201 [0.8%]; OR=5.7 [95% CI, 5.5-5.9]; P<0.001). Amongst patients undergoing elective surgery, 2412/1 857 586 (0.1%) had SARS-CoV-2, of whom 172/2412 (7.1%) died, compared with 1414/1 857 586 (0.1%) patients without SARS-CoV-2 (OR=25.8 [95% CI, 21.7-30.9]; P<0.001). Amongst patients undergoing emergency surgery, 22 918/582 292 (3.9%) patients had SARS-CoV-2, of whom 5752/22 918 (25.1%) died, compared with 18 060/559 374 (3.4%) patients without SARS-CoV-2 (OR=5.5 [95% CI, 5.3-5.7]; P<0.001).CONCLUSIONS:The low incidence of SARS-CoV-2 infection in NHS surgical pathways suggests current infection prevention and control policies are highly effective. However, the high mortality amongst patients with SARS-CoV-2 suggests these precautions cannot be safely relaxed.

Objective: The primary objective of this study was to quantify the risk of anaphylaxis to blue dyes used in SLNB for cancer. Secondary outcomes included the identification of factors that may influence this risk. Summary of Background Data: Blue dyes are widely used to help identify sentinel lymph nodes in oncological surgery. The rate of severe allergic reactions to blue dyes remains a controversial topic, with the true incidence and influencing factors uncertain. Methods: A systematic review and meta-analysis was performed to identify all studies which report on the incidence of severe adverse reactions and anaphylaxis to blue dyes (patent blue, isosulfan blue, methylene blue, and indigo carmine), when used for SLNB. Collected data included cancer and dye type, volume, and method of injection. Incidence was estimated using the arcsine method of statistical analysis. Results: One hundred nine studies documenting 94 episodes of anaphylaxis in a total of 61,951 SLNB procedures, resulting in a weighed anaphylaxis rate of 0.061%. SLNB for breast cancer carries an anaphylaxis risk of 0.083%, with the risk markedly lower in melanoma surgery (0.0043%). Low dye volume (<2 mL) and intradermal injection are both associated with lower rates of anaphylaxis (0.031% and 0.0068%). Isosulfan blue seems to be the most anaphylactogenic amongst blue dyes with a rate of 0.16%. There were no reported cases of death in this cohort. Conclusion: Anaphylaxis to blue dyes in SLNB is rare. Methylene blue, patent blue, lower dye volumes, and intradermal administration are all associated with a lower incidence of anaphylaxis.

Introduction: Previous studies of microtia epidemiology globally have demonstrated significant geographical and ethnic variation, cited broadly as affecting 3–5 in 10,000 live births. The aim of this study was to determine the incidence of microtia in a largely homogeneous ethnic population in the United Kingdom (Wales) and to identify factors, such as distance and socioeconomic status, which may influence the access to surgical intervention.Materials and Methods: A retrospective cohort study was conducted using data linkage to identify patients born between 2000 and 2018 with a diagnosis of microtia. Microtia incidence was calculated using annual and geographic birth rates. Surgical operation codes were used to classify patients into those that had no surgery, autologous reconstruction or prosthetic reconstruction. Sociodemographic attributes were compared using descriptive statistics to determine differences in access to each type of surgical intervention.Results: A total of 101 patients were identified, 64.4% were male and the median age was 12 (8–16). The mean annual incidence was 2.13 microtia cases per 10,000 births over the 19-year study period. Both temporal and geographic variation was noted. The majority of patients undergoing surgery opted for autologous reconstruction (72.9%) at a median age of 9 (7–10) compared to 7 (5–8) for prosthetic reconstruction. Autologous reconstruction had a higher median number of surgeries (2, 1–3) than prosthetic (1.5, 1–2) and a higher median socioeconomic status of 3 (2–4) compared to 2 (1–4) for the prosthetic cohort. There were no statistically significant differences in the distance traveled for surgery.Discussion: This study highlights a role for data linkage in epidemiological analyses and provides a revised incidence of microtia in Wales. Although the majority of patients opted for autologous reconstruction, demographic disparities in socioeconomic status warrant further investigation, emphasizing the importance of striving for equity in accessibility to surgical intervention.

BACKGROUND:A significant proportion of healthcare resource has been diverted to the care of those with COVID-19. This study reports the volume of surgical activity and the number of cancelled surgical procedures during the COVID-19 pandemic.METHODS:We used hospital episode statistics for all adult patients undergoing surgery between January 1, 2020 and December 31, 2020 in England and Wales. We identified surgical procedures using a previously published list of procedure codes. Procedures were stratified by urgency of surgery as defined by NHS England. We calculated the deficit of surgical activity by comparing the expected number of procedures from 2016 to 2019 with the actual number of procedures in 2020. Using a linear regression model, we calculated the expected cumulative number of cancelled procedures by December 31, 2021.RESULTS:The total number of surgical procedures carried out in England and Wales in 2020 was 3 102 674 compared with the predicted number of 4 671 338 (95% confidence interval [CI]: 4 218 740-5 123 932). This represents a 33.6% reduction in the national volume of surgical activity. There were 763 730 emergency surgical procedures (13.4% reduction) compared with 2 338 944 elective surgical procedures (38.6% reduction). The cumulative number of cancelled or postponed procedures was 1 568 664 (95% CI: 1 116 066-2 021 258). We estimate that this will increase to 2 358 420 (95% CI: 1 667 587-3 100 808) up to December 31, 2021.CONCLUSIONS:The volume of surgical activity in England and Wales was reduced by 33.6% in 2020, resulting in more than 1.5 million cancelled operations. This deficit will continue to grow in 2021.

Facial skin cancer is common, and its treatment affects patient's health-related quality of life (HRQoL), as demonstrated by patient-reported outcome measures (PROMs). In this study, we anglicise and validate the novel FACE-Q Skin Cancer Module for the UK population.Anglicisation of the FACE-Q Skin Cancer Module followed international guidance for cross-cultural adaptation. Cognitive interviews were performed, producing a reconciled and harmonised version for validation. Patients undergoing facial skin cancer excision were prospectively recruited and asked to complete the anglicised FACE-Q Skin Cancer Module, along with the Skin Cancer Index (SCI) and European Quality of Life-Five Dimensions (ED-5D) questionnaire, pre-operatively and 6–8 weeks post-operatively. Data were analysed using classical test theory. Ethical approval was obtained (REC: 16/WM/0445).One hundred and ten patients were recruited between August 2017 and July 2018. Internal consistency was high (Cronbach's alpha 0.867–0.967). All subscales had a single-factor solution using principal component analysis. Construct validity, as measured between the FACE-Q subscales and SCI subscales, was good, with >75% of a priori predictions confirmed. Pearson's r for item–total correlation was >0.80 for several items, and significant ceiling effects are shown in 7 of the 10 subscales, suggesting some item redundancy.The UK version of this well-designed PROM demonstrates good face and construct validity. There is however a degree of redundancy within the scales, and further work using Rasch analysis on a larger sample will help address this.

Introduction: Many similarities exist between the care of necrotising fasciitis (NF) and burn injury patients. Each group represents a small but complex cohort requiring multiple theatre trips, specialist reconstruction, meticulous wound care and multidisciplinary management. Over a six-year period, we sought to examine the clinical outcomes of NF patients managed within a burns centre against those managed by a plastic surgery service. Methods: A retrospective case-note review was performed for all identifiable patients referred to our institution’s designated burns centre or plastic surgery service between 2008–2014. Patient characteristics, length of stay, wound-related and clinical outcomes were extracted and descriptively presented with statistical analysis performed for survival and length of stay. Results: Twenty-nine patients were included in the study (burns centre [B]: 17 patients; plastic surgery service [P]: 12 patients). Median total length of stay (B: 37 vs. P: 50 days, P=0.38), local length of stay (27 vs. 19 days, P=0.29) and survival till discharge (94.4% vs. 100%, P=0.73) demonstrated no statistically significant difference. Conclusion: Caring for NF patients within a burns centre facilitated easier access to specialist reconstructive expertise and multidisciplinary care but did not lead to statistically significant differences in length of stay or survival. The management of NF within a burns centre facilitated provision of high-quality care to a highly challenging patient group.

Skin cancer is the most common cancer type in Western populations and melanoma is the most dangerous form of the disease. In recent years, a link between ‘social determinants’ and melanoma has emerged. Social determinants encompass both socioeconomic factors (including income, education, poverty level, area of residence, occupation and social status) and lifestyle factors (including exposure to UV light, marital status, hobbies, smoking, obesity). This study carried out by a team of investigators based in Swansea and London in the UK was designed to re-examine the relationship between people's smoking habits, as well as socioeconomic status, and the occurrence and progression of melanoma. In order to achieve this, the team used a population database that held details of patients diagnosed and treated in Wales. The investigators were able to analyse data from more than 9,000 patients diagnosed with melanoma over the five years included in this study, and in addition they reviewed information on 26,000 people without melanoma. They found that smoking was associated with a decreased occurrence of melanoma and that it had no effect on death rates caused by melanoma itself, although death rates due to other causes were higher amongst smokers than non-smokers. There was also a higher rate of melanoma in people of higher socioeconomic status, but these individuals also had a higher chance of survival from melanoma than those of lower socioeconomic status. The explanation for these findings needs to be clarified, as the differences may be due to a direct effect of smoking on the development and progress of melanoma, or may be related to other factors such as sun exposure rates amongst smokers and non-smokers. This is a summary of the study: The association of smoking and socioeconomic status on cutaneous melanoma: a population-based, data-linkage, case-control study.

BackgroundProminent ears are the most common congenital abnormality of the head and neck, occurring in 5% of the Caucasian population. Facial disfigurement can cause psychosocial distress, low self-esteem and varying levels of social isolation most notable in school-age children. Although prominent ear correction is the most frequently performed aesthetic operation in children and adolescents, to our knowledge, the relationship between prominent ears and psychological, social and educational issues has not been systematically assessed.Purpose of studyTo investigate the psychological, social and educational impact of prominent ears and to examine how prominent ear correction affects health-related quality of life (HRQoL).MethodsA systematic review was conducted using a protocol registered with PROSPERO and in line with the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses statement. A comprehensive search of the literature was conducted using MEDLINE, EMBASE, PyscINFO, HMIC Health Management Information Consortium, Ovid Journals Database, NHS Wales Full-Text Journals and The Cochrane Database. The inclusion criteria stated that any study investigating the association between psychological, social or educational issues, or HRQoL and prominent ears or otoplasty should be incorporated. All studies were reviewed by two authors, with data extracted for the studies finally included.FindingsFourteen articles were finally included, with a total of 786 patients. Thirteen out of 14 papers analysed the post-operative effect of surgical correction of prominent ears. The most common motivating factor for surgery was bullying, with young males of school age being the worst affected. Prominent ear patients report higher levels of bullying and social problems, and lower levels of physical activity than patients with more severe facial disfigurements. Every study that assessed the psychosocial impact of surgery on prominent ears found a significant benefit to HRQoL.Conclusion and relevanceProminent ears pose severe psychological and social issues that should not be underestimated. Surgical correction has consistently been shown to significantly improve HRQoL.

As COVID-19 spreads quickly from Asia via Europe to the rest of the world, hospitals are evolving into hot zones for treatment and transmission of this disease. With the increasing acceptance that operating theatres are high risk areas for transmission of respiratory infections for both patients and surgeons,1Raphael T.Why surgeons don't want to operate right now. Bloomberg. Available at URL:https://www.bloomberg.com/opinion/articles/2020-03-24/the-coronavirus-crisis-is-putting-surgeons-at-risk-too(accessed April 3 2020,).Google Scholar and with our health care systems being generally well-designed to only deal with occasional high-risk cases, there is an obvious need to evolve our practice. Although social media campaigns via the British Association of Plastic, Reconstructive and Aesthetic Surgeons (#StaySafeStayHome) and British Society for Surgery of the Hand (#PlaySafeStaySafe) are attempting to raise awareness and reduce preventable injuries, we are still seeing a steady stream of patients present to our plastic surgery trauma service. We have had to act immediately so our systems can support essential surgical care while protecting patients and staff and conserving valuable resources. As a department we have developed a set of standard operating procedures which cover the full scope of plastic surgery from the facilitation of emergent life and limb saving surgeries, rationalised oncological management to the management of minor soft tissue and bony injuries. We have been cognisant of the need to reduce footfall to the hospital and the stratification into "dirty" and "clean" areas with attempted segregation of non-, suspected and confirmed COVID cases within inpatient clinical areas. This has resulted in displacement of assessment and procedure rooms within the unit. The ward itself has been earmarked as an extended intensive care unit due to its layout and facilities. Standards of practise have changed, with an emphasis on "see and treat" as operating theatre availability has been reduced due to the reduced availability of nurses and theatre staff and their conversion into intensive care areas for ventilated patients. There is also an emerging assumption that all patients are COVID-19 positive until proven otherwise.2Pearce C.GPs should assume 'most' patients have Covid-19 and use PPE, says NHS England. Pulse. Available at URL:http://www.pulsetoday.co.uk/clinical/clinical-specialties/respiratory-/gps-should-assume-most-patients-have-covid-19-and-use-ppe-says-nhs-england/20040541.article(accessed April 3 2020,).Google Scholar The combination of unfamiliar environments, lack of accessible equipment, requirement to reduce time spent with patients and adherence to social distancing has resulted in the need to provide a more mobile and flexible service. In order to support our mobile service, we have found that, as in other disaster situations where specialised bags have been deployed,3Ando W. et al.Handling and packaging of medical bags at acute disaster sites under high-temperature conditions.BMC Res Notes. 2020; 13: 158Crossref PubMed Scopus (1) Google Scholar using a simple bag containing essential equipment and consumables has revolutionised our ability to work at the point of referral and avoid unnecessary trips to theatre. Despite their simplicity, bags have been fundamental for the development of human civilization, with the word originating from the Norse word baggi and comparable to the Welsh baich (load, bundle)!!!4Wikipedia. Bag. Available at URL: https://en.wikipedia.org/wiki/Bag (accessed April 3 2020,).Google Scholar Our portable "pandemic pack" is now being carried by the first on-call in our department. This pack contains a 10 L Ultra Dry Adventurer™, polymer dry bag measuring 36 cm (W) × 70 cm (L) as shown in Figure 1. The contents are shown in Figure 2. We have found this adequate for managing most common plastic surgery trauma and emergency scenarios. The bag is easily cleaned with 1000 ppm available chlorine (in accordance with Public Health England guidance) after each patient exposure. We have found it useful to make up two packs in advance so that one is available at handover whilst the other is replenished by the outgoing team.Figure 2Contents of the Pandemic Pack.View Large Image Figure ViewerDownload Hi-res image Download (PPT) We are sure that this concept has been used elsewhere, but if it is not common practice in your unit, we would advocate implementing such a toolkit to facilitate management of trauma patients and reduce the amount time frontline staff need to be in a potential "dirty" environment during the COVID-19 pandemic. None. None.