Call detail record aggregation methodology impacts infectious disease models informed by human mobility.

This paper demonstrates how two different methods used to calculate population-level mobility from Call Detail Records (CDR) produce varying predictions of the spread of epidemics informed by these data. Our findings are based on one CDR dataset describing inter-district movement in Ghana in 2021, produced using two different aggregation methodologies. One methodology, "all pairs," is designed to retain long distance network connections while the other, "sequential" methodology is designed to accurately reflect the volume of travel between locations. We show how the choice of methodology feeds through models of human mobility to the predictions of a metapopulation SEIR model of disease transmission. We also show that this impact varies depending on the location of pathogen introduction and the transmissibility of infections. For central locations or highly transmissible diseases, we do not observe significant differences between aggregation methodologies on the predicted spread of disease. For less transmissible diseases or those introduced into remote locations, we find that the choice of aggregation methodology influences the speed of spatial spread as well as the size of the peak number of infections in individual districts. Our findings can help researchers and users of epidemiological models to understand how methodological choices at the level of model inputs may influence the results of models of infectious disease transmission, as well as the circumstances in which these choices do not alter model predictions.

Detecting behavioural changes in human movement to inform the spatial scale of interventions against COVID-19.

On March 23 2020, the UK enacted an intensive, nationwide lockdown to mitigate transmission of COVID-19. As restrictions began to ease, more localized interventions were used to target resurgences in transmission. Understanding the spatial scale of networks of human interaction, and how these networks change over time, is critical to targeting interventions at the most at-risk areas without unnecessarily restricting areas at low risk of resurgence. We use detailed human mobility data aggregated from Facebook users to determine how the spatially-explicit network of movements changed before and during the lockdown period, in response to the easing of restrictions, and to the introduction of locally-targeted interventions. We also apply community detection techniques to the weighted, directed network of movements to identify geographically-explicit movement communities and measure the evolution of these community structures through time. We found that the mobility network became more sparse and the number of mobility communities decreased under the national lockdown, a change that disproportionately affected long distance connections central to the mobility network. We also found that the community structure of areas in which locally-targeted interventions were implemented following epidemic resurgence did not show reorganization of community structure but did show small decreases in indicators of travel outside of local areas. We propose that communities detected using Facebook or other mobility data be used to assess the impact of spatially-targeted restrictions and may inform policymakers about the spatial extent of human movement patterns in the UK. These data are available in near real-time, allowing quantification of changes in the distribution of the population across the UK, as well as changes in travel patterns to inform our understanding of the impact of geographically-targeted interventions.

Regional surnames and genetic structure in Great Britain.

Following the increasing availability of DNA-sequenced data, the genetic structure of populations can now be inferred and studied in unprecedented detail. Across social science, this innovation is shaping new bio-social research agendas, attracting substantial investment in the collection of genetic, biological and social data for large population samples. Yet genetic samples are special because the precise populations that they represent are uncertain and ill-defined. Unlike most social surveys, a genetic sample's representativeness of the population cannot be established by conventional procedures of statistical inference, and the implications for population-wide generalisations about bio-social phenomena are little understood. In this paper, we seek to address these problems by linking surname data to a censored and geographically uneven sample of DNA scans, collected for the People of the British Isles study. Based on a combination of global and local spatial correspondence measures, we identify eight regions in Great Britain that are most likely to represent the geography of genetic structure of Great Britain's long-settled population. We discuss the implications of this regionalisation for bio-social investigations. We conclude that, as the often highly selective collection of DNA and biomarkers becomes a more common practice, geography is crucial to understanding variation in genetic information within diverse populations.

Malignancy-related mortality following kidney transplantation is common.

There is a paucity of studies describing malignancy-related mortality after kidney transplantation. To help quantify this, we extracted data for all kidney-alone transplant procedures performed in England between April 2001 and March 2012. Data linkage analysis was performed between Hospital Episode Statistics and the Office for National Statistics to identify all deaths occurring in this cohort. Among 19,103 kidney transplant procedures analyzed (median follow-up 4.4 years), 2085 deaths occurred, of which 376 (18.0%) were due to malignancy (crude mortality rate 361 malignancy-related deaths per 100,000 person-years). Common sites of malignancy-related death were lymphoma (18.4%), followed by lung (17.6%) and renal (9.8%), with 14.1% unspecified. The risk of malignancy-related death increased with age: under 50 (0.8%), 50-59 (2.5%), 60-69 (4.8%), 70-79 (6.5%) and over 80 years (9.1%). Age- and gender-stratified malignancy-related mortality risk difference was higher in the transplant compared with the general population. Cox proportional hazard models identified increased age, pretransplant history of malignancy and deceased-donor kidney transplantation to be independently associated with risk for post-transplant death from malignancy. Thus, malignancy as a cause of post-kidney transplantation death is common and requires heightened surveillance.

Death within the first year after kidney transplantation--an observational cohort study.

The risk of death within the first year postkidney transplantation is not well described in the contemporary era. We extracted data on all kidney transplant procedures performed in England between April 2001 and March 2012. Data linkage analysis was performed between Hospital Episode Statistics and the Office for National Statistics to identify all deaths. Cox proportional hazard models were performed to identify factors associated with 1-year mortality. 566 deaths (3.0%) occurred within the first year post-transplant (from 19,103 kidney transplant procedures analysed). Infection, cardiovascular events and malignancy were classified in 21.6%, 18.3% and 7.4% of death certificates, respectively. Among recipients with prior myocardial infarct history who died within the first year, 38.8% of deaths were attributed to a cardiac-related event. Malignancy-related death was responsible for 61.5% of 1-year mortality for allograft recipients with pretransplant cancer history. 22.1% of deaths included kidney failure as a contributory factor on the death certificate (3.3% specifically stated allograft failure). Variables associated with 1-year mortality included deceased-donor kidney, increasing age, residence in socioeconomically deprived area and history of select medical comorbidities pre-operatively. We conclude 1-year mortality postkidney transplantation is low, but in select allograft recipients, the risk of death increases considerably.

Mortality after pediatric kidney transplantation in England--a population-based cohort study.

The aim of this study was to explore mortality after pediatric kidney transplantation in England over the last decade. We used data from HES to select all kidney transplant procedures performed in England between April 2001 and March 2012. Data linkage analysis was performed with the ONS to identify all deaths occurring among this study cohort. Data for 1189 pediatric recipients were compared to 17 914 adult recipients (number of deaths, 33 vs. 2052, respectively, p < 0.001), with median follow-up 4.4 yr (interquartile range 2.2-7.3 yr). There was no difference in mortality within the pediatric cohort; age 0-1 (n = 25, patient survival 100.0%), age 2-5 (n = 198, patient survival 96.0%), age 6-12 (n = 359, patient survival 97.5%), and age 13-18 (n = 607, patient survival 97.4%), respectively (p = 0.567). The most common causes of death were renal (n = 8, 24.2%), infection (n = 6, 18.2%), and malignancy (n = 5, 15.2%). All deaths from malignancy were secondary to PTLD. In a fully adjusted Cox regression model, only white ethnicity was significantly associated with risk of pediatric mortality post-kidney transplantation (hazard ratio 2.7, 95% confidence interval [1.0-7.3], p = 0.047). To conclude, this population-based cohort study confirms low mortality after pediatric kidney transplantation with short follow-up.

Analysis of cosmetic results of metopic synostosis: concordance and interobserver variability.

Trigonocephaly is caused by premature fusion of the metopic suture of the calvarium. The resultant facial and skull deformities place a newborn at a higher risk of cerebral impairment. Frontal orbital advancement and remodeling is the accepted surgical management. An analysis was undertaken to assess the cosmetic results for nonsyndromic metopic synostosis following frontal orbital advancement and remodeling and to determine whether the observer technique used had validity.The photographs of 20 consecutive patients with metopic synostosis were assessed preoperatively, postoperatively, and at 3 and 5 years of age. Each photograph was analyzed by 2 pairs of trained rotating observers. The findings were compared and reviewed by the fifth member, who acted as a "referee." Where there were disagreements between the findings, the referee came to a final decision. The presence and severity of trigonocephaly, temporal hollowing, hypotelorism, orbital asymmetry, epicanthic folds, and scarring were assessed. κ Analysis was used to determine the validity of observer concordance when using photographic material.There was a significant overall trend in craniofacial aesthetic improvement with time. However, 12% had some persistence of trigonocephaly. Temporal hollowing was usually persistent. κ Statistics varied among attributes and time period assessed. The greatest concordance was for improvement of epicanthic folds and trigonocephaly, with observers agreeing 84.1% and 82.6% of the time, respectively. There was least concordance for severity of hypotelorism and scarring.This study suggests that observer analysis of photographic records is a valid outcome measure for cosmesis, although it yields variable interobserver concordance according to the feature assessed. Surgery corrected most but not all the features of trigonocephaly. The prognostic indicators for good cosmetic outcome are presented.

An Investigation of the Impact and Resilience of British High Streets Following the COVID-19 Lockdown Restrictions.

British high streets have faced significant economic and cultural challenges as a consequence of the COVID-19 pandemic. This is predominantly due to government enforced restrictions which required all 'non-essential' retail to close, resulting in a significant change in the way consumers interacted with high streets. While all premises related to the retail or hospitality sector were forced to close, leading to rising vacancy rates, some high streets were more resilient to the economic shock than others. In this paper we detect some of the unforeseen consequences of the pandemic on British high streets and create a measure of resilience. The impact of the lockdown restrictions have resulted in some high streets, notably Spring Street in Paddington, London, experiencing disproportionate decline. Others including Northolt Road in Harrow, London were able maintain their occupancy. This study provides a typology of high street resilience incorporating the impact of the COVID-19 lockdown restrictions and links the impact of government policy to the economic performance of high streets. The outcomes from this research address both local and national policy contexts as the resilience typology has the potential to assist in funding allocation for recovery and regeneration projects.

Spatial and social disparities in the decline of activities during the COVID-19 lockdown in Greater London.

We use data on human mobility obtained from mobile applications to explore the activity patterns in the neighbourhoods of Greater London as they emerged from the first wave of COVID-19 lockdown restrictions during summer 2020 and analyse how the lockdown guidelines have exposed the socio-spatial fragmentation between urban communities. The location data are spatially aggregated to 1 km2 grids and cross-checked against publicly available mobility metrics (e.g. Google COVID-19 Community Report, Apple Mobility Trends Report). They are then linked to geodemographic classifications to compare the average decline of activities in the areas with different sociodemographic characteristics. We found that the activities in the deprived areas dominated by minority groups declined less compared to the Greater London average, leaving those communities more exposed to the virus. Meanwhile, the activity levels declined more in affluent areas dominated by white-collar jobs. Furthermore, due to the closure of non-essential stores, activities declined more in premium shopping destinations and less in suburban high streets.

Tasks and Visualizations Used for Data Profiling: A Survey and Interview Study.

The use of good-quality data to inform decision making is entirely dependent on robust processes to ensure it is fit for purpose. Such processes vary between organisations, and between those tasked with designing and following them. In this paper we report on a survey of 53 data analysts from many industry sectors, 24 of whom also participated in in-depth interviews, about computational and visual methods for characterizing data and investigating data quality. The paper makes contributions in two key areas. The first is to data science fundamentals, because our lists of data profiling tasks and visualization techniques are more comprehensive than those published elsewhere. The second concerns the application question "what does good profiling look like to those who routinely perform it?," which we answer by highlighting the diversity of profiling tasks, unusual practice and exemplars of visualization, and recommendations about formalizing processes and creating rulebooks.

Evaluation of the FAST-M maternal sepsis intervention in Pakistan: A qualitative exploratory study.

INTRODUCTION: The World Health Organization and partners developed and evaluated a maternity-specific sepsis care bundle called 'FAST-M' for low-resource settings. However, this bundle has not yet been studied in Asia. Our study sought to evaluate the perceptions of healthcare providers about the implementation of the FAST-M intervention in Pakistan. MATERIALS AND METHODS: The study was conducted at a public sector hospital in Hyderabad. We conducted three focus group discussions with healthcare providers including doctors, nurses, and healthcare administrators (n = 22) who implemented the FAST-M intervention. The Consolidated Framework for Implementation Research was used as a guiding framework for data collection and analysis. The data were analyzed using a thematic analysis approach and deductive methods. RESULTS: Five overarching themes emerged: (I) FAST-M intervention and its significance including HCPs believing in the advantages of using the intervention to improve clinical practices; (II) Influence of outer and inner settings including non-availability of resources in the facility for sepsis care; (III) HCPs perceptions about sustainability, which were positive (IV) Integration into the clinical setting including HCPs views on the existing gaps, for example, shortage of HCPs and communication gaps, and their recommendations to improve these; and (V) Outcomes of the intervention including improved clinical processes and outcomes using the FAST-M intervention. Significant improvement in patient monitoring and FAST-M bundle completion within an hour of diagnosis of sepsis was reported by the HCPs. CONCLUSIONS: The healthcare providers' views were positive about the intervention, its outcomes, and long-term sustainability. The qualitative data provided findings on the acceptability of the overall implementation processes to support subsequent scaling up of the intervention.

Early recognition and management of maternal sepsis in Pakistan: a feasibility study of the implementation of FAST-M intervention.

OBJECTIVE: Maternal sepsis is the third leading cause of maternal mortality globally. WHO and collaborators developed a care bundle called FAST-M (Fluids, Antibiotics, Source identification and treatment, Transfer and Monitoring) for early identification and management of maternal sepsis in low-resource settings. This study aimed to determine feasibility of FAST-M intervention in a low-resource setting in Pakistan. The FAST-M intervention consists of maternal sepsis screening tools, treatment bundle and implementation programme. DESIGN AND SETTING: A feasibility study with before and after design was conducted in women with suspected maternal sepsis admitted at the Liaquat University of Medical and Health Sciences hospital Hyderabad. The study outcomes were compared between baseline and intervention phases. In the baseline phase (2 months), the existing sepsis care practices were recorded, followed by a training programme for healthcare providers on the application of FAST-M tools. These tools were implemented in the intervention phase (4 months) to assess any change in clinical practices compared with the baseline phase. RESULTS: During the FAST-M implementation, 439 women were included in the study. 242/439 were suspected maternal infection cases, and 138/242 were women with suspected maternal sepsis. The FAST-M bundle was implemented in women with suspected maternal sepsis. Following the FAST-M intervention, significant changes were observed. Improvements were seen in the monitoring of oxygen saturation measurements (25.5% vs 100%; difference: 74%; 95% CI: 68.4% to 80.5%; p<0.01), fetal heart rate assessment (58% vs 100%; difference: 42.0%; 95% CI: 33.7% to 50.3%; p≤0.01) and measurement of urine output (76.5% vs 100%; difference: 23.5%; 95% CI: 17.6% to 29.4%; p<0.01). Women with suspected maternal sepsis received all components of the treatment bundle within 1 hour of sepsis recognition (0% vs 70.5%; difference: 70.5%; 95% CI: 60.4% to 80.6%; p<0.01). CONCLUSION: Implementation of the FAST-M intervention was considered feasible and enhanced early identification and management of maternal sepsis at the study site. TRIAL REGISTRATION NUMBER: ISRCTN17105658.

The family name as socio-cultural feature and genetic metaphor: from concepts to methods.

A recent workshop entitled "The Family Name as Socio-Cultural Feature and Genetic Metaphor: From Concepts to Methods" was held in Paris in December 2010, sponsored by the French National Centre for Scientific Research (CNRS) and by the journal Human Biology. This workshop was intended to foster a debate on questions related to the family names and to compare different multidisciplinary approaches involving geneticists, historians, geographers, sociologists and social anthropologists. This collective paper presents a collection of selected communications.

Population disruption: estimating changes in population distribution of the UK during the COVID-19 pandemic.

Mobility data have demonstrated major changes in human movement patterns in response to COVID-19 and associated interventions in many countries. This can involve sub-national redistribution, short-term relocations as well as international migration. In this paper, we combine detailed location data from Facebook measuring the location of approximately 6 million daily active Facebook users in 5km2 tiles in the UK with census-derived population estimates to measure population mobility and redistribution. We provide time-varying population estimates and assess spatial population changes with respect to population density and four key reference dates in 2020 (First lockdown, End of term, Beginning of term, Christmas). We also show how population estimates derived from the distribution of Facebook users vary compared to mid-2020 small area population estimates by the UK national statistics agencies. We estimate that between March 2020 and March 2021, the total population of the UK declined and we identify important spatial variations in this population change, showing that low-density areas have experienced lower population decreases than urban areas. We estimate that, for the top 10% highest population tiles, the population has decreased by 6.6%. Further, we provide evidence that geographic redistributions of population within the UK coincide with dates of non-pharmaceutical interventions including lockdowns and movement restrictions, as well as seasonal patterns of migration around holiday dates. The methods used in this study reveal significant changes in population distribution at high spatial and temporal resolutions that have not previously been quantified by available demographic surveys in the UK. We found early indicators of potential longer-term changes in the population distribution of the UK although it is not clear if these changes may persist after the COVID-19 pandemic.

Evaluation of the feasibility of the FAST-M maternal sepsis intervention in Pakistan: a protocol.

BACKGROUND: Maternal sepsis is a life-threatening condition, defined by organ dysfunction caused by infection during pregnancy, childbirth, and the postpartum period. It is estimated to account for between one-tenth and half (4.7% to 13.7%) of all maternal deaths globally. An international stakeholder group, including the World Health Organization, developed a maternal sepsis management bundle called "FAST-M" for resource-limited settings through a synthesis of evidence and international consensus. The FAST-M treatment bundle consists of five components: Fluids, Antibiotics, Source identification and control, assessment of the need to Transport or Transfer to a higher level of care and ongoing Monitoring (of the mother and neonate). This study aims to adapt the FAST-M intervention and evaluate its feasibility in Pakistan. METHODS: The proposed study is a mixed method, with a before and after design. The study will be conducted in two phases at the Liaquat University of Medical and Health Sciences, Hyderabad. In the first phase (formative assessment), we will adapt the bundle care tools for the local context and assess in what circumstances different components of the intervention are likely to be effective, by conducting interviews and a focus group discussion. Qualitative data will be analyzed considering a framework method approach using NVivo version 10 (QSR International, Pty Ltd.) software. The qualitative results will guide the adaptation of FAST-M intervention in local context. In the second phase, we will evaluate the feasibility of the FAST-M intervention. Quantitative analyses will be done to assess numerous outcomes: process, organizational, clinical, structural, and adverse events with quantitative comparisons made before and after implementation of the bundle. Qualitative analysis will be done to evaluate the outcomes of intervention by conducting FGDs with HCPs involved during the implementation process. This will provide an understanding and validation of quantitative findings. DISCUSSION: The utilization of care bundles can facilitate recognition and timely management of maternal sepsis. There is a need to adapt, integrate, and optimize a bundled care approach in low-resource settings in Pakistan to minimize the burden of maternal morbidities and mortalities due to sepsis.

Adapting the FAST-M maternal sepsis intervention for implementation in Pakistan: a qualitative exploratory study.

OBJECTIVE: A maternal sepsis management bundle for resource-limited settings was developed through a synthesis of evidence and international consensus. This bundle, called 'FAST-M' consists of: Fluids, Antibiotics, Source control, assessment of the need to Transport/Transfer to a higher level of care and ongoing Monitoring (of the mother and neonate). The study aimed to adapt the FAST-M intervention including the bundle care tools for early identification and management of maternal sepsis in a low-resource setting of Pakistan and identify potential facilitators and barriers to its implementation. SETTING: The study was conducted at the Liaquat University of Medical and Health Sciences, which is a tertiary referral public sector hospital in Hyderabad. DESIGN AND PARTICIPANTS: A qualitative exploratory study comprising key informant interviews and a focus group discussion was conducted with healthcare providers (HCPs) working in the study setting between November 2020 and January 2021, to ascertain the potential facilitators and barriers to the implementation of the FAST-M intervention. Interview guides were developed using the five domains of the Consolidated Framework for Implementation Research: intervention characteristics, outer setting, inner setting, characteristics of the individuals and process of implementation. RESULTS: Four overarching themes were identified, the hindering factors for implementation of the FAST-M intervention were: (1) Challenges in existing system such as a shortage of resources and lack of quality assurance; and (2) Clinical practice variation that includes lack of sepsis guidelines and documentation; the facilitating factors identified were: (3) HCPs' perceptions about the FAST-M intervention and their positive views about its execution and (4) Development of HCPs readiness for FAST-M implementation that aided in identifying solutions to potential hindering factors at their clinical setting. CONCLUSION: The study has identified potential gaps and probable solutions to the implementation of the FAST-M intervention, with modifications for adaptation in the local context TRIAL REGISTRATION NUMBER: ISRCTN17105658.

Delineating Europe's cultural regions: population structure and surname clustering.

Surnames (family names) show distinctive geographical patterning and in many disciplines remain an underutilized source of information about population origins, migration and identity. This paper investigates the geographical structure of surnames, using a unique individual level database assembled from registers and telephone directories from 16 European countries. We develop a novel combination of methods for exhaustively analyzing this multinational data set, based upon the Lasker Distance, consensus clustering and multidimensional scaling. Our analysis is both data rich and computationally intensive, entailing as it does the aggregation, clustering and mapping of 8 million surnames collected from 152 million individuals. The resulting regionalization has applications in developing our understanding of the social and cultural complexion of Europe, and offers potential insights into the long and short-term dynamics of migration and residential mobility. The research also contributes a range of methodological insights for future studies concerning spatial clustering of surnames and population data more widely. In short, this paper further demonstrates the value of surnames in multinational population studies and also the increasing sophistication of techniques available to analyze them.

Escalation triggers and expected responses in obstetric early warning systems used in UK consultant-led maternity units.

BACKGROUND: The use of obstetric early warning systems (OEWS) are recommended as an adjunct to reduce maternal morbidity and mortality. The aim of this review was to document the variation in OEWS trigger thresholds and the quality of information included within accompanying escalation protocols. METHODS: A review of OEWS charts and escalation policies across consultant-led maternity units in the UK (n = 147) was conducted. OEWS charts were analysed for variation in the values of physiological parameters triggering different levels of clinical escalation. Relevant data within the escalation protocols were also searched for: urgency of clinical response; seniority of responder; frequency of on-going clinical monitoring; and clinical setting recommended for on-going care. RESULTS: The values of physiological parameters triggering specific clinical responses varied significantly between OEWS. Only 99 OEWS charts (67.3%) had an escalation protocol as part of the chart. For 29 charts (19.7%), the only escalation information included was generic, for example to "contact a doctor if triggers". Only 76 (51.7%) charts detailed the required seniority of responder, 37 (25.2%) the frequency for on-going clinical monitoring, eight (5.4%) the urgency of clinical response and two (1.4%) the recommended clinical setting for on-going care. CONCLUSION: The observed variations in the trigger thresholds used in OEWS charts and the quality of information included within the accompanying escalation protocols is likely to lead to suboptimal detection and response to clinical deterioration during pregnancy and the post-partum period. The development of a national OEWS and escalation protocol would help to standardise care across obstetric units.

Vitamin A deficiency due to chronic malabsorption: an ophthalmic manifestation of a systemic condition.

A 47-year-old woman presented with a 4-week history of progressive loss of vision, first manifesting as night blindness. Additionally, the patient reported frequent severe episodes of diarrhoea over the past month. Her medical history included end-stage renal failure for which she was currently on haemodialysis after a failed renal transplant, chronic pancreatitis and autonomic diabetes mellitus. Ophthalmological examination revealed severe bilateral corneal xerosis, bilateral Bitot's spots and inferior ulceration of the right cornea. A diagnosis of xerophthalmia due to vitamin A deficiency was made, most likely due to the presence of small intestinal bacterial overgrowth and the patient's chronic malabsorptive state. Standard management using oral vitamin A tablets was ineffective, resulting in the patient requiring intravenous supplementation. The extent of visual deterioration on presentation and the difficulties encountered managing the patient resulted in the patient's vision failing to improve.

Do the SRS-22 self-image and mental health domain scores reflect the degree of asymmetry of the back in adolescent idiopathic scoliosis?

BACKGROUND: Patient-reported outcomes are becoming increasingly recognised in the management of patients with adolescent idiopathic scoliosis (AIS). Integrated Shape Imaging System 2 (ISIS2) surface topography is a validated tool to assess AIS. Previous studies have failed to demonstrate strong correlations between AIS and patient-reported outcomes highlighting the need for additional objective surface parameters to define the deformities associated with AIS. The aim of this study was to examine whether the Scoliosis Research Society-22 (SRS-22) outcome questionnaire reflects the degree of measurable external asymmetry of the back in AIS and thus is a measure of patient outcome for external appearance. METHODS: A total of 102 pre-operative AIS patients were identified retrospectively. Objective parameters were measured using ISIS2 surface topography. The associations between these parameters and the self-image and mental health domains of the SRS-22 questionnaire were investigated using correlation coefficients. RESULTS: All correlations between the parameters of asymmetry and SRS-22 self-image score were of weak strength. Similarly, all correlations between the parameters of asymmetry and SRS-22 mental health score were of weak strength. CONCLUSION: The SRS-22 mental health and self-image domains correlate poorly with external measures of deformity. This demonstrates that the assessment of mental health and self-image by the SRS-22 has little to do with external torso shape. Whilst the SRS-22 assesses the patient as a whole, it provides little information about objective measures of deformity over which a surgeon has control.