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.

Prevalence and odds of anxiety and depression in cutaneous malignant melanoma: a proportional meta-analysis and regression.

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-α 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.

Melanoma is a serious type of skin cancer that is becoming more prevalent, particularly in people with lighter skin. The UK-based ReconRegen research group conducted a study to understand the psychological impact of melanoma on people, focusing on anxiety and depression. To do this, a systematic review approach was used to analyse data from existing studies and gather a comprehensive perspective. The study discovered that 30% of people with melanoma are affected by anxiety and 18% by depression, significantly higher than the general population. Key risk factors for anxiety included being female, being younger than 60 years of age and having lower educational attainment. Women are 1.8 times more likely to experience anxiety than men, those under 60 years of age are 1.5 times more likely to experience it and individuals with lower educational levels are also 1.5 times more likely to experience anxiety. Findings showed that anxiety and depression levels peaked during treatment phases, especially in people undergoing chemotherapy and immunotherapy. This highlights the need for targeted mental health support during these treatment periods. The findings advocate for mental health considerations in melanoma care, suggesting regular mental health assessments, particularly for high-risk groups and during intense treatment phases. Highlighting the importance of a holistic treatment approach, the study suggests that future research should include long-term studies to understand the chronic impacts of anxiety and depression. Improved clarity and detail in research reporting are essential for developing effective mental health support for people with melanoma, enhancing overall patient care by addressing both physical and emotional health needs.

The association of anxiety disorders and depression with facial scarring: population-based, data linkage, matched cohort analysis of 358 158 patients.

BACKGROUND: Estimates suggest that 1 in 100 people in the UK live with facial scarring. Despite this incidence, psychological support is limited. AIMS: The aim of this study was to strengthen the case for improving such support by determining the incidence and risk factors for anxiety and depression disorders in patients with facial scarring. METHOD: A matched cohort study was performed. Patients were identified via secondary care data sources, using clinical codes for conditions resulting in facial scarring. A diagnosis of anxiety or depression was determined by linkage with the patient's primary care general practice data. Incidence was calculated per 1000 person-years at risk (PYAR). Logistic regression was used to determine risk factors. RESULTS: Between 2009 and 2018, 179 079 patients met the study criteria and were identified as having a facial scar, and matched to 179 079 controls. The incidence of anxiety in the facial scarring group was 10.05 per 1000 PYAR compared with 7.48 per 1000 PYAR for controls. The incidence of depression in the facial scarring group was 16.28 per 1000 PYAR compared with 9.56 per 1000 PYAR for controls. Age at the time of scarring, previous history of anxiety or depression, female gender, socioeconomic status and classification of scarring increased the risk of both anxiety disorders and depression. CONCLUSIONS: There is a high burden of anxiety disorders and depression in this patient group. Risk of these mental health disorders is very much determined by factors apparent at the time of injury, supporting the need for psychological support.

The psychosocial impact of microtia and ear reconstruction: A national data-linkage study.

Introduction: Children 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. Methods: A 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. Results: There 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. Discussion: Microtia 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.

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.

Surgical simulation training for escharotomy: A novel course, improving candidate's confidence in a time critical procedure.

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 procedure 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 escharotomy 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 decompression 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 simulator course we aim to improve emergency burn care education in the UK and globally.

The association between immunosuppression and skin cancer in solid organ transplant recipients: a control-matched cohort study of 2,852 patients.

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.

Surgical activity in England and Wales during the COVID-19 pandemic: a nationwide observational cohort study.

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.

Microtia: A Data Linkage Study of Epidemiology and Implications for Service Delivery.

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.

Making the Most of Big Data in Plastic Surgery: Improving Outcomes, Protecting Patients, Informing Service Providers.

ABSTRACT: In medicine, "big data" refers to the interdisciplinary analysis of high-volume, diverse clinical and lifestyle information on large patient populations. Recent advancements in data storage and electronic record keeping have enabled the expansion of research in this field. In the United Kingdom, Big data has been highlighted as one of the government's "8 Great Technologies," and the Medical Research Council has invested more than £100 million since 2012 in developing the Health Data Research UK infrastructure. The recent Royal College of Surgeons Commission of the Future of Surgery concluded that analysis of big data is one of the 4 most likely avenues to bring some of the most innovative changes to surgical practice in the 21st century.In this article, we provide an overview of the nascent field of big data analytics in plastic and highlight how it has the potential to improve outcomes, increase safety, and aid service planning.We outline the current resources available, the emerging role of big data within the subspecialties of burns, microsurgery, skin and breast cancer, and how these data can be used. We critically review the limitations and considerations raised with big data, offer suggestions regarding database optimization, and suggest future directions for research in this exciting field.

The Patient-Reported Outcome Measures In Skin Cancer Reconstruction (PROMISCR) study: Anglicisation and initial validation of the FACE-Q Skin Cancer Module in a UK cohort.

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.

Long-term seizure recurrence after eclampsia: A systematic review and meta-analysis.

BACKGROUND: Seizure recurrence after a fit has implications for both individuals and healthcare providers guiding neurologic prognosis, treatment, and driving and work restrictions. A systematic review of long-term seizure recurrence after eclampsia will help to quantify recurrence risk in this setting. OBJECTIVE: To evaluate the long-term recurrence of seizures after eclampsia. SEARCH STRATEGY: After PROSPERO registration, Medline (Ovid), Embase, and Cochrane Library were searched by using the terms (eclampsia OR eclamp* OR eclamptic seizure* OR eclamptic fit*) AND (recur* OR recurrent fit* OR recurrent seizure*) for studies published up until December 2019. SELECTION CRITERIA: Studies describing long-term seizure recurrence after a diagnosis of eclampsia were included. DATA COLLECTION AND ANALYSIS: Data were extracted from studies independently by two authors. Pooled prevalence was calculated and weighted based on sample size with a 95% confidence interval (CI). MAIN RESULTS: Initially, 1754 unique studies were identified and 4 were included in the final analysis. The studies involved 1896 women, of whom 7 (0.37%) were affected by a further seizure. The weighted pooled prevalence of seizure recurrence was 0.18% (95% CI, 0.03-1.02). CONCLUSION: The absolute rate of long-term seizure recurrence after eclampsia is extremely low and within safe limits for driving.

The psychological, social and educational impact of prominent ears: A systematic review.

BACKGROUND: Prominent 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 STUDY: To investigate the psychological, social and educational impact of prominent ears and to examine how prominent ear correction affects health-related quality of life (HRQoL). METHODS: A 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. FINDINGS: Fourteen 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 RELEVANCE: Prominent ears pose severe psychological and social issues that should not be underestimated. Surgical correction has consistently been shown to significantly improve HRQoL.

Management of necrotising fasciitis within a burns centre: do outcomes differ?

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.

Patient-Reported Outcome Measures for Soft-Tissue Facial Reconstruction: A Systematic Review and Evaluation of the Quality of Their Measurement Properties.

BACKGROUND: A patient's health-related quality of life can be significantly impacted by facial scarring and disfigurement. Facial soft-tissue reconstruction should aim to improve this, with outcomes measured from the patient's perspective using patient-reported outcome measures. This systematic review identifies patient-reported outcome measures for soft-tissue facial reconstruction and appraises their methodologic and psychometric properties using up-to-date methods. METHODS: A systematic search of the MEDLINE, Embase, PsychINFO, and Cochrane databases was performed. Identified patient-reported outcome measures were assessed using the updated Consensus-Based Standards for the Selection of Health Measurement Instruments checklist. Psychometric properties were also assessed and a modified Grading of Recommendation Assessment, Development and Evaluation analysis was performed to aid in recommendations for future questionnaire use. RESULTS: Thirty-four studies covering nine patient-reported outcome measures were included. Methodologic quality and psychometric evidence were variable. FACE-Q, Skin Cancer Index, Patient Outcome of Surgery-Head/Neck, and the Derriford Appearance Scale 59/24 all demonstrated high enough evidence to be recommended as having potential for inclusion in future studies. CONCLUSIONS: This is the first systematic review to identify and critically appraise patient-reported outcome measures for soft-tissue facial reconstruction using internationally accepted criteria. Four questionnaires were deemed to have adequate levels of methodologic and psychometric evidence, although further studies should be conducted before they are used routinely in patients undergoing facial reconstruction. Through the use of psychometrically well-validated questionnaires, it is hoped that patients' concerns can be truly appreciated, the level of care improved, and the quality of reconstructive options offered advanced.

The association of affective disorders and facial scarring: Systematic review and meta-analysis.

BACKGROUND: Facial scarring can have a dramatic effect on a patient's psychological health and wellbeing and present unique management challenges. This patient population remains poorly characterised in the contemporary literature. AIMS: To evaluate the prevalence of, and risk factors associated with affective disorders in adult patients with facial scars. METHODS: A systematic review was conducted using a protocol registered with PROSPERO and in line with the PRISMA statement. A comprehensive search of the literature was conducted using PubMed, MEDLINE, EMBASE, PSYCHInfo and The Cochrane Library. RESULTS: Twenty one studies were included, with a total of 2,394 participants. Using a random effects model, the weighted pooled prevalence of anxiety was 26.1% (95% CI 17.9%-36.3%) and the weighted pooled prevalence of depression was 21.4% (95% CI 15.4%-29.0%). Studies identified female gender, past psychiatric history and violent causation as factors associated with anxiety and depression. LIMITATIONS: Included studies were limited to those published in peer reviewed journals. Longitudinal trends in both anxiety and depression were limited by a short duration of follow up. CONCLUSIONS: There is a high and persistent burden of affective disorders in patients with facial scars. Additional research is required to further characterise this population and develop effective management strategies.

Sister Mary Joseph nodule: a diagnostic challenge.

We present the case of a 72-year-old woman who presented with, to our knowledge, the largest reported Sister Mary Joseph lesion in the literature. Often associated with a poor prognosis, the patient went on to have a wide local excision of the lesion and has made a full recovery 2 years after the nodule initially developed. Histological examination confirmed the presence of underlying endometrial cancer and the patient subsequently underwent a total hysterectomy and bilateral salpingo-oopherectomy.