Service implications of the revised 2022 National Institute for Health and Care Excellence (NICE) follow-up guidelines for stage IA-IIC melanoma.

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 €2.74 million (€1.87 million-€3.61 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.

The epidemiology, healthcare and societal burden of basal cell carcinoma in Wales 2000-2018: a retrospective nationwide analysis.

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.

The incidence of non-melanoma skin cancer in the UK and the Republic of Ireland: a systematic review.

BACKGROUND: Basal 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. OBJECTIVES: A 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 & METHODS: Sixteen UK and Republic of Ireland epidemiological studies on BCC/cSCC over a 48-year period were compiled, examining incidence, trends and emerging risk factors. RESULTS: Incidence 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%. CONCLUSION: This 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.

Rapid redesign and effect on clinical workload of a supra-regional burns and plastic surgery service during the COVID-19 pandemic.

INTRODUCTION: In March 2020, South Wales experienced the most significant COVID-19 outbreak in the UK outside of London. We share our experience of the rapid redesign and subsequent change in activity in one of the busiest supra-regional burns and plastic surgery services in the UK. METHODS: A time-matched retrospective service evaluation was completed for a 7-week "COVID-19" study period and the equivalent weeks in 2018 and 2019. The primary aim of this study was to evaluate plastic surgery theatre use and the impact of service redesign. Comparison between study periods was tested for statistical significance using two-tailed t-tests. RESULTS: Operation numbers reduced by 64% and total operating time by 70%. General anaesthetic cases reduced from 41% to 7% (p<0.0001), and surgery was mainly carried out in ringfenced daycase theatres. Emergency surgery decreased by 84% and elective surgery by 46%. Cancer surgery as a proportion of total elective operating increased from 51% to 96% (p<0.0001). The absolute number of cancer-related surgeries undertaken was maintained despite the pandemic. CONCLUSION: Rapid development of COVID-19 SOPs minimised inpatient admissions. There was a significant decrease in operating while maintaining emergency and cancer surgery. Our ringfenced local anaesthetic Plastic Surgery Treatment Centre was essential in delivering a service. COVID-19 acted as a catalyst for service innovations and the uptake of activities such as telemedicine, virtual MDTs, and online webinars. Our experiences support the need for a core burns and plastic service during a pandemic, and show that the service can be effectively redesigned at speed.

Innovation in a Time of Crisis: A Systematic Review of Three-Dimensional Printing in the COVID-19 Pandemic.

The coronavirus (COVID-19) global pandemic resulted in the breakdown of traditional supply chains responsible for providing essential equipment to hospitals and personal protective equipment (PPE) for health and social care workers. The three-dimensional (3D) printing community has responded to emerging need by recognizing shortages across health care systems and providing innovative solutions in real time, circumventing short-term global supply issues. A systematic review was undertaken to investigate the role of 3D printing in the COVID-19 pandemic in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the MEDLINE, EMBASE, and World Health Organization (WHO) COVID-19 databases. Newspaper and internet article sources were identified using the NEXIS media database. All studies and articles on the application of 3D printed solutions during the peak of the COVID-19 pandemic were included. The literature search identified 26 related articles, and 13 studies met inclusion criteria and were suitable for full-text review. One thousand two hundred and one unique digital media articles were identified; after removal of duplicates and screening of headlines for the inclusion and exclusion criteria, 460 articles were suitable for full-text review. The cross-collaboration between the 3D printing community and health care systems has aided in the provision of innovative solutions to combat the COVID-19 crisis. The applications for 3D printing ranged from oxygenation equipment to noninvasive and invasive ventilatory parts and innovative solutions for infection control and quarantine hubs. This review has identified that 3D printing technology has made the biggest contribution to the production of PPE in particular face shields, mirroring the areas of greatest shortage and need. Additive manufacturing has played a pivotal role in aligning disciplines in engineering, science, and medicine for the greater good. We have witnessed the rapid reconfiguration of traditional supply chains to circumvent global shortages, while making advancements in effort to limit the impact of this and future pandemics.

Biodegradeable temporising matrix use in a traumatic chest wound.

The Welsh Centre for Burns and Plastic Surgery is responsible for a population of 10 million people in Wales and England. We describe the use of biodegradable temporising matrix (BTM) in a large traumatic chest wound in a 23-year-old woman. BTM is a synthetic dermal substitute and has been utilised to achieve soft tissue coverage in complex wounds. This wound was sustained after the patient fell from a tractor into a large silage rake, resulting in injuries to her chest and limbs. Following meticulous debridement, her resulting full thickness skin defect measured 30 × 30 cm extending from the sternal notch to the upper abdomen, with bone, muscle and breast tissue exposure. The central chest area is complex to reconstruct due to the contours of the breasts and tendency to contracture following skin graft reconstruction. We demonstrate the first reported use of BTM for breast reconstruction, as far as we are aware.

Cutaneous laser surgery for secondary burn reconstruction: Cost benefit analysis.

Thermal disease presents a major burden to individual patient morbidity, healthcare cost as well as to over all economy. Burns also also represent a significant per-patient utlilisation of finite healthcare resources. Secondary complications in these patients, such as multiple drug resistant organisms, may have a devastating effect. Laser surgery has recently come of age as an optimal tool in the secondary reconstruction of burn injury, that is able to simultaneously address significant sheet scar tightness, hypertrophic, atrophic, and keloid complications, pruritus, microstomia, ectropion, skin graft honeycombing, and improve range of movement whilst reducing the risk of infection to <1%. Yet, cutaneous laser surgery is often underutilised due to the perceived concerns about the sustainability of a new service with relatively high startup cost. We present a dual methodology to explore this concern: an evidence-based background review of the last 5 years of current best evidence, and a 22-year cost-analysis comparison at an established, high volume UK Centre of reconstructive surgery. We report that fiscal viability for laser surgery services for secondary burn reconstruction is supported by: level 2 (one systematic review) level 4 evidence (2 studies) and level 5 evidence (expert reports). Evidence over 22 years from an established super-regional NHS laser centre shows that introduction of this service led to sustained and substantial cost saving, producing excellent surgical results at a fraction of the cost of traditional surgery. Analysis of the potential dollar-effect of these advantages to the general population supports state investment in expertise and capital equipment as a medium to long-term cost saving strategy, which may also aid re-integrating patients into the workforce making a meaningful contribution to the economy.

Could Vitamins Help in the Fight Against COVID-19?

There are limited proven therapeutic options for the prevention and treatment of COVID-19. The role of vitamin and mineral supplementation or "immunonutrition" has previously been explored in a number of clinical trials in intensive care settings, and there are several hypotheses to support their routine use. The aim of this narrative review was to investigate whether vitamin supplementation is beneficial in COVID-19. A systematic search strategy with a narrative literature summary was designed, using the Medline, EMBASE, Cochrane Trials Register, WHO International Clinical Trial Registry, and Nexis media databases. The immune-mediating, antioxidant and antimicrobial roles of vitamins A to E were explored and their potential role in the fight against COVID-19 was evaluated. The major topics extracted for narrative synthesis were physiological and immunological roles of each vitamin, their role in respiratory infections, acute respiratory distress syndrome (ARDS), and COVID-19. Vitamins A to E highlighted potentially beneficial roles in the fight against COVID-19 via antioxidant effects, immunomodulation, enhancing natural barriers, and local paracrine signaling. Level 1 and 2 evidence supports the use of thiamine, vitamin C, and vitamin D in COVID-like respiratory diseases, ARDS, and sepsis. Although there are currently no published clinical trials due to the novelty of SARS-CoV-2 infection, there is pathophysiologic rationale for exploring the use of vitamins in this global pandemic, supported by early anecdotal reports from international groups. The final outcomes of ongoing trials of vitamin supplementation are awaited with interest.

Influence of sulfobutylether-beta-cyclodextrin on the stability of S- and R- omeprazole.

Omeprazole (OME), a proton pump inhibitor used to treat acid reflux disease and gastric ulcers presents a formulation challenge due to its rapid decomposition at acidic and neutral pHs. Thus, the aim of this project was to investigate whether interaction with sulfobutylether-beta-cyclodextrin (Captisol-CD) could improve omeprazole stability and provide more efficient oral liquid formulations. A stability-indicating high performance liquid chromatography assay allowed for the quantitation of S- and R-forms of OME in the presence and absence of Captisol-CD. The developed method was validated to discriminate between OME and its degradation products and used to describe the kinetic model of OME at different pH values over a period of 36 days. Calculated degradation constants (k(obs)), were directly correlated with the H(+) concentrations of the solutions regardless of whether the omeprazole was complexed with the Captisol-CD or not. Moreover, the pH-rate profile curve indicated that in all cases, maximum stability was achieved at pH 11. Though it was anticipated that interaction of OME with Captisol-CD might increase the relative stability of OME at a lower pH, the cavity of the cyclodextrin was too small to allow the inclusion to occur. However the R-isomer of OME, both in the presence or absence of the cyclodextrin appeared to be slightly less stable than the corresponding S-form at the same pH conditions.

'A problematic plum pit in the piping': a case of traumatic oesophageal perforation.

A 75-year-old man presented to accident and emergency having swallowed a plum pit. He initially experienced sharp neck pain, which was mild at presentation. He was otherwise haemodynamically stable and was able to subsequently eat a sandwich without consequence. He was referred to the ear, nose and throat senior house office (SHO), who reviewed the soft tissue radiograph, which appeared normal. The patient displayed no concerning clinical signs and was well; however, his pain persisted. Examination revealed a localised area of surgical emphysema on the left side of the neck. Retrospective review of the soft tissue radiograph showed a small region of subcutaneous free air. An urgent CT scan confirmed a pneumomediastinum indicative of an oesophageal perforation. The patient was admitted for observation, and was managed conservatively without surgical intervention. He was weaned onto sterile fluid and progressed to a solid diet. He was discharged from hospital with no long-term sequelae.

Improving efficiency and saving money in an otolaryngology urgent referral clinic.

A closed loop audit of the ear nose and throat (ENT) urgent referral clinic at a London hospital was conducted assessing the number of patients reviewed, referral source, appropriateness of referral, presenting complaint and assigned follow-up appointments. Data was sourced from clinic letters and the patient appointment system over a 3-mo period. The initial cycle analysed 490 patients and the subsequent cycle 396. The initial audit yielded clinically relevant and cost effective recommendations which were implemented, and the audit cycle was subsequently repeated. The re-audit demonstrated decreased clinic numbers from an average 9.8 to 7.2 patients per clinic, in keeping with ENT United Kingdom guidelines. A 21% decrease in patient follow-up and 13% decrease in inappropriate referrals was achieved. Direct bookings into outpatient clinics decreased by 8%, due to correct referral pathway utilisation. Comparisons of all data sets were found to show statistical significance P < 0.05. We reported a total financial saving of £32490 in a period of 3 mo (£590 per clinic). We demonstrated that simple guidelines, supervision and consultant-led education which are non-labour intensive can have a significant impact on service provision and cost.

A hairy situation.

A 2-day-old neonate was transferred to a specialist paediatric otolaryngology centre with stridor at rest, feeding difficulties and an apparent mass in the oropharynx. The newborn displayed evidence of respiratory distress, however, she remained self-ventilating. MRI highlighted a fat-containing lesion in the postnasal space with no intracranial extension. A CT scan under general anaesthesia showed no underlying bony abnormality, and hence an examination of the nasopharynx, oropharynx and microlaryngoscopy and bronchoscopy were performed. The macroscopically hairy lesion arising from the superior aspect of the soft palate was resected. Histology displayed a benign growth measuring 28×17×12 mm in keeping with a hairy polyp. This is one of very few cases, to the best of our knowledge, in which a hairy polyp (bigerminal choristomas) has resulted in stridor in the first few days of life. Nasal masses in neonates, although a rare phenomenon, remain clinically important as they are obligate nasal breathers.

The intracellular uptake of CD95 modified paclitaxel-loaded poly(lactic-co-glycolic acid) microparticles.

The CD95/CD95L receptor-ligand system is mainly recognised in the induction of apoptosis. However, it has also been shown that CD95L is over-expressed in many cancer types where it modulates immune-evasion and together with its receptor CD95 promotes tumour growth. Here, we show that CD95 surface modification of relatively large microparticles >0.5 µm in diameter, including those made from biodegradable polylactic-co-glycolic acid (PLGA), enhances intracellular uptake by a range of CD95L expressing cells in a process akin to phagocytosis. Using this approach we describe the intracellular uptake of microparticles and agent delivery in neurons, medulloblastoma, breast and ovarian cancer cells in vitro. CD95 modified paclitaxel-loaded PLGA microparticles are shown to be significantly more effective compared to conventional paclitaxel therapy (Taxol) at the same dose in subcutaneous medulloblastoma (∗∗∗P < 0.0001) and orthotopic ovarian cancer xenograft models where a >65-fold reduction in tumour bioluminescence was measured after treatment (∗P = 0.012). This drug delivery platform represents a new way of manipulating the normally advantageous tumour CD95L over-expression towards a therapeutic strategy. CD95 functionalised drug carriers could contribute to the improved function of cytotoxics in cancer, potentially increasing drug targeting and efficacy whilst reducing toxicity.