Lead Clinician Research Articles

Regional anaesthesia training in the UK – a national survey

BackgroundAdequate training of anaesthetists in regional anaesthesia is important to ensure optimal patient access to regional anaesthesia. MethodsWe undertook a national survey of UK trainee anaesthetists and Royal College of Anaesthetists (RCoA) tutors to assess experiences of training in regional anaesthesia. We performed descriptive statistics for baseline characteristics, and logistic regression of training indices and tutor confidence that their hospital could provide regional anaesthesia training at all three stages of the RCoA 2021 curriculum. ResultsA total of 492 trainees (19.2%) and 114 tutors (45.2%) completed the survey. Trainees were less likely to have received training in chest/abdominal wall compared with upper/lower limb blocks {erector spinae vs femoral block (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.16–0.39), P<0.001}, or achieved >20 chest/abdominal wall blocks by Stage 3 of training (chest vs lower limb block [OR 0.09, 95% CI 0.05–0.15, P<0.001]. There was a strong association between training received, number of blocks performed (>20 vs 0–5 blocks), and self-reported ability to perform blocks independently, OR 20.9 (95% CI 9.38–53.2). 24/182 (13%) and 10/182 (5.5%) of trainees had performed ≥50 non-obstetric lumbar and thoracic epidurals, respectively, by Stage 3 training. There was a positive association between having a lead clinician for regional anaesthesia, particularly those with paid sessions, and reported confidence to provide regional anaesthesia training at all stages of the curriculum (Stage 3 OR 7.27 [95% CI 2.64–22.0]). ConclusionOur results confirm the importance of clinical experience and access to training in regional anaesthesia, and support the introduction of departmental regional anaesthesia leads to improve equity and quality in training opportunities.

A87Live Virtual Placements: An alternative to traditional ‘in person’ placements

The role of the paramedic is diversifying, and universities need to respond by developing curriculums that support paramedic graduates to meet future workforce needs. Placements are key to our students developing the necessary competencies to become qualified paramedics and the pressure is on universities to offer a wide range of placements to reflect professional diversification. In addition, Health and Care Professions Council’s new standards of proficiency acknowledge that paramedics of the future are likely to consult patients in the virtual world [1]. As universities strive to meet this demand, they are often faced with placement capacity issues. Rising student numbers, staff retention issues and competition for placements from other healthcare students can make it extremely challenging to secure placements, especially in desirable areas such as primary care. The author, with the support from colleagues, was successful in obtaining funding from Health Education England to pilot a series of live virtual placement experiences, the first of which was successfully delivered on 20th April. On this date, 30 learners from our paramedic degree apprenticeship programme, in a classroom on our Lancaster campus, virtually attended a live clinic in a primary care setting in the south of England. The clinic was rigged with various cameras and microphones, with real patients consenting to being filmed. The experience comprised of 5 patients, with the lead clinician providing a brief to the learners before each patient arrived for their consultation. Afterwards, the clinician would complete their clinical documentation before engaging in a two-way conversation with our learners and academic staff via Microsoft teams. Following the clinic, our apprentices had the opportunity to consolidate their learning via case study driven seminars which linked to the mornings experience. Overall, student feedback was supportive, with the majority stating they found the experience enjoyable and engaging. The video stream of the placement was recorded for reuse in the programme’s curriculum, and we hope that future live virtual placements will see other professions, such as physiotherapy and nursing, take part. Eventually, we want to develop the model for other disciplines and placement settings The academic team are looking forward to the second of three experiences, in May, with the view to contributing to the growing evidence base in this area, to reflect the value that we believe ‘Live Virtual Placement’ experiences have in the development of our future workforce. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

Editorial introductions.

Current Opinion in Organ Transplantation was launched in 1996. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of organ transplantation is divided into 18 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Editors-in-Chief, Associate Editor and Section Editors for this issue. SECTION EDITORS Matthew HartwigMatthew HartwigDr. Hartwig is a thoracic surgeon with a clinical focus in robotic assisted minimally invasive thoracic surgery for the treatment of diseases of the chest. He serves as the Surgical Director of the Esophageal Center at Duke. He is also the Director of the Minimally Invasive Thoracic Surgery Fellowship at Duke, while providing advanced instruction in robotic surgery to surgeons around the world. He also leads a successful program of clinical, basic and translational research in thoracic surgery and lung transplantation. He currently directs the Duke Ex Vivo Organ Laboratory (DEVOL), is the Chief of Lung Transplant Research, and is a faculty member at the Duke Clinical Research Institute (DCRI). John L.R. ForsytheJohn L.R. ForsytheProfessor John Forsythe was first appointed as a Consultant Transplant Surgeon at the Royal Infirmary of Edinburgh, UK in 1995. Prior to this, he was a Consultant Surgeon with special interest in renal transplantation at the Royal Victoria Infirmary, Newcastle upon Tyne, UK. He is currently an Organ Utilisation Consultant for NHSBT, working with all departments of health for the UK. Professor Forsythe has held many professional committee appointments, among them Lead Clinician for Organ Donation and Transplantation in Scotland, Chairman of the Scottish Donation and Transplant Group and Chairman of the Safety of Blood, Tissues and Organs Advisory Committee to all four UK health ministers. He is a Past President of the British Transplantation Society and remains Honorary President of the British Society for Histocompatibility and Immunogenetics. Shunji NagaiShunji NagaiDr. Shunji Nagai is a general surgeon in Detroit, Michigan and is affiliated with Henry Ford Hospital. He received his medical degree from Nagoya University- School of Medicine and has been in practice for more than 20 years.

E002 Management of adults with systemic lupus erythematosus (SLE) in 2021: a multi-centre audit within Wales as part of an ongoing quality improvement exercise

Abstract Background/Aims Significant changes to working practices within rheumatology have occurred since the beginning of the COVID-19 pandemic: virtual consultations have now become commonplace. This audit was undertaken as part of ongoing quality improvement work to assess the standards of care provided to patients with SLE attending rheumatology departments across Wales. Care was audited against the standards outlined in the 2018 British Society of Rheumatology guideline for the management of adults with SLE. Results were compared with the previous multi-centre audits of SLE care in Wales and the UK. We were interested to see whether changes to working practices had significantly affected the care of patients with SLE across Wales. Methods Rheumatology services in Wales were invited via email to participate. Data collection occurred between June and August 2021. Data was collected via online questionnaire, held securely by the Dudley Group NHSFT. Unit questionnaires were submitted by a lead clinician in each centre. Five centres across Wales submitted data from 62 clinical encounters with patients with SLE. Results: Conclusion Results of this multi-centre audit do not demonstrate any widespread significant changes in care for patients with SLE in Wales between 2019 and 2021, despite 48% of consultations audited being undertaken virtually. Blood pressure and urinalysis were not consistently measured in 2021, likely secondary to the increased prevalence of virtual consultations. Group education has been undertaken as to the importance of facilitating observations in the virtual environment and centres have shared their experiences of how they tackle this challenge locally. Disclosure S.E. Wright: None. P. O'Beirn: None. C. Rhys-Dillon: None.

Abstract P3-05-39: Expert consensus on the definition of high risk of recurrence in HER2-negative early breast cancer: a modified Delphi panel

Abstract PURPOSE: There is currently no standardised definition for patients at high risk of recurrence of HER2-negative early breast cancer (eBC, stages 1–3) after surgery. Recognising that the assessment of high risk is often multifactorial, the aim of this modified Delphi panel was to establish expert UK consensus on this definition, separately considering HR-positive and triple-negative (TN) patients. METHODS: A total of 45 UK-based clinicians, including breast cancer oncologists and surgeons, were invited to participate. The number of respondents in each of three rounds was 29, 24 and 22 respectively. Statements were developed using the results from a targeted literature review and the guidance of a lead clinician, and comprised free-text, single-choice or numerical formats. The first round aimed to determine which factors are currently used in clinical practice to assess risk of recurrence in the populations of interest. In the subsequent rounds, the objective was to establish thresholds indicative of high risk in a 10-year timeframe for each of the factors retained in Round 1. Between each round, statements were refined, considering the distribution of responses and free-text notes provided by participants. Consensus for single-choice questions was set at a pre-defined threshold of ≥70% of respondents. RESULTS: Consensus was achieved on the need to assess age, tumour size, tumour grade, number of positive nodes, presence of inflammatory breast cancer and one or more risk prediction tools to define high risk of recurrence in all HER2-negative patients. In HR-positive patients, there was agreement on the use of one or more tumour profiling tests and biomarkers to define high risk of recurrence. However, there was no consensus on biomarker use in TN patients, and support for specific biomarkers (such as Ki-67) was conflicting for both sub-populations based on the analysis of free-text notes. Similarly, while there was consensus on the use of pCR status/residual disease to indicate high risk in TN patients, this factor failed to reach consensus for the HR-positive sub-population. Germline BRCA status and menopausal status were not considered to be key factors for risk of recurrence in either biological subtype. In the second and third rounds, thresholds indicative of high recurrence risk were agreed; it should be noted that the free-text responses provided by the participants frequently highlighted that many of the factors should be considered along a continuous scale when assessing the risk of individual patients. In HR-positive patients, these thresholds included: age &amp;lt; 35 years, tumour size &amp;gt;5 cm (each when considered independently from other risk factors); tumour grade 3 (independently or in combination with other factors); number of positive lymph nodes ≥4 when considered independently or ≥1 in combination with other factors. For patients with TN tumours, the following thresholds reached consensus, whether considered independently or in combination with other factors: tumour size &amp;gt;2 cm, tumour grade 3, number of positive lymph nodes ≥1. In several cases, however, no consensus could be reached on the appropriate threshold indicating high risk of recurrence. In the HR-positive sub-population, these included thresholds for age and tumour size, when considered in combination with other factors. In the TN sub-population, this included age, whether independently or in combination with other factors. CONCLUSIONS: The expert consensus reached in this panel highlights that an integrated model is important in assessing recurrence risk in eBC and that definitions of high risk differ according to biological subtype. The results may serve as a valuable reference point for clinicians to use in assessing risk of disease recurrence and in making treatment decisions after surgery in the HER2-negative eBC population. FUNDING: AstraZeneca UK Ltd. Writing support: Costello Medical. Citation Format: Ellen R. Copson, Jean E. Abraham, Jeremy P. Braybrooke, Stuart A. McIntosh, Caroline O. Michie, Carlo Palmieri, Rebecca Roylance, Saiqa Spensley. Expert consensus on the definition of high risk of recurrence in HER2-negative early breast cancer: a modified Delphi panel [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-05-39.

Editorial introductions.

Editorial introductions.

Editorial introductions.

Editorial introductions.

Increasing incidence of spondylodiscitis in England: An analysis of the national health service (NHS) hospital episode statistics from 2012 to 2021

BackgroundSpondylodiscitis is a potentially life-threatening infection of the intervertebral disk and adjacent vertebral bodies, with a mortality rate of 2–20%. Given the aging population, the increase in immunosuppression, and intravenous drug use in England, the incidence of spondylodiscitis is postulated to be increasing; however, the exact epidemiological trend in England remains unknown. ObjectiveThe Hospital Episode Statistics (HES) database contains details of all secondary care admissions across NHS hospitals in England. This study aimed to use HES data to characterise the annual activity and longitudinal change of spondylodiscitis in England. MethodsThe HES database was interrogated for all cases of spondylodiscitis between 2012 and 2019. Data for the length of stay, waiting time, age-stratified admissions, and ‘Finished Consultant Episodes’ (FCEs), which correspond to a patient's hospital care under a lead clinician, were analysed. ResultsIn total, 43135 FCEs for spondylodiscitis were identified between 2012 and 2022, of which 97.1% were adults. Overall admissions for spondylodiscitis have risen from 3 per 100,000 population in 2012/13 to 4.4 per 100,000 population in 2020/21. Similarly, FCEs have increased from 5.8 to 10.3 per 100,000 population, in 2012–2013 and 2020/21 respectively. The highest increase in admissions from 2012 to 2021 was recorded for those aged 70–74 (117% increase) and aged 75-59 (133% increase), among those of working age for those aged 60–64 years (91% increase). ConclusionPopulation-adjusted admissions for spondylodiscitis in England have risen by 44% between 2012 and 2021. Healthcare policymakers and providers must acknowledge the increasing burden of spondylodiscitis and make spondylodiscitis a research priority.

The DEFINITE Audit: a prospective audit of diabetic foot debridement in theatre – a protocol

Background: People with diabetes are commonly affected by foot ulceration (DFU) and subsequent or concurrent infection (DFI). Surgical debridement is often needed to contain infection. Despite international guidelines, there remains significant variation in surgical practice of diabetic foot wound debridement in the operating theatre. Methods: Diabetic Foot Ulcer Debridement in Theatre Audit (DEFINITE) is a global multicentre, prospective audit of consecutive patients undergoing a debridement or minor amputation in theatre for a diabetic foot complication. DEFINITE is led by the Vascular and Endovascular Research Network (VERN). The primary outcome is adherence to recommended practice as outlined in the International Working Group on the Diabetic Foot and Global Vascular Guidelines. Secondary outcomes are incidence of healing, re-admission, further amputation (minor and major) and mortality at 90 days. Anonymised data will be collected via REDCap. Eligibility and study registration at all hospital institutions performing in-theatre management of diabetic foot complications are eligible to participate after obtaining appropriate institutional level audit approvals. A lead clinician will be responsible for approvals and data management. Pathway to impact: This audit addresses shared patient-clinician priorities and is supported by the UK Vascular Society multidisciplinary Special Interest Group on the Diabetic Foot. The results will be presented at international scientific meetings and submitted for publication in peer-reviewed publications. The results will also be used to initiate improvement in patient care.

Benchmarking Paediatric Sickle Cell Care in Australia

Background: Sickle cell disease (SCD) is a severe, multisystem vasculopathy, associated with significant reduction in life expectancy, and high burden of care for patients/families and clinicians. Haematologists in Australia have observed an increase in numbers of children presenting for care with SCD in recent years that disproportionately affects migrant families with socio-economic challenge. Models of care for these patients in Australia are still evolving and there is a need for service benchmarking to define consensus best practice for service delivery. Key issues include access to affordable Hydroxyurea (HU) paediatric formulations, red cell exchange (RCE), antenatal/newborn screening policy and consideration of expanding indications for curative therapies (bone marrow transplantation). Aim: To survey aspects of health care service delivery for paediatric SCD at six specialist centres in Australia. Method: Lead clinicians at the six centres were surveyed to determine: basic demographics, availability of current treatment modalities, transfusion practices, service integration, care pathways and access to support services and transition services. Current challenges to optimal health care delivery were identified. Results: A total of 293 cases were identified. Variations in care included: inequity of funding for HU formulation, access to RCE as recommended transfusion method, screening protocols for stroke prevention, disease specific pain management pathways. Identified challenges to optimal care delivery were consistent across the centres, with common themes identified: difficulty accessing adequate support services (social work, mental health) and care co-ordinationinability to provide comprehensive care such as educational resources/neuropsychology testing (as is best practice in international centres)financial restrictions (variations in funding for paediatric formulations where HU is the only disease modifying therapy DMT available in Australia, liquid Hydroxyurea mixture is a special access product often requiring patient co-payment despite PBS coverage of capsules)limited networks of clinicians to provide multi-disciplinary care modelslack of designated transition pathways for young adults in some locations. Conclusion - This survey has identified key challenges in access to RCE, affordable HU formulations for children, as well as allied health support/care co-ordination for this disadvantaged population. We recommend the need for the development of consensus recommendations for standards of care for sickle cell services in Australia. These standards will provide a useful benchmark for advocacy and interactions with policymakers. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Risk factors for mortality in a hospitalised neonatal cohort in Botswana

ObjectivesA disproportionate number of neonatal deaths occur in low/middle-income countries, with sepsis a leading contributor of mortality. In this study, we investigate risk factors for mortality in a cohort of...

EP04.01-009 Performance Indicators of Lung Cancer MDT at a Regional Center: Disagreements Between Trust and NLCA Data

• The NLCA has developed a set of Quality Performance Indicators that Trusts providing high quality lung cancer care could be expected to deliver. These require high levels of data completeness to provide meaningful performance indicators such as surgical resection or radical intent treatment for patients to assist Lead Clinicians & Trusts to understand service disparities and maintain quality assurance.• Based on the NCLA 2020 report for patients seen in 2018, we conducted an audit to clarify reasons for not attaining compliance with expected key performance indicators following the merger of two large acute Trusts in 2017• For the affected KPI’s, the National Audit recommends that the following benchmarks should be achieved by each trust: 1.

Adherence to published guidelines for perioperative care of the elderly: a survey of Scottish anaesthetic departments

BackgroundIn 2010, a national enquiry into elderly patient outcomes after surgery identified that only 36% received ‘good’ care. Guidance was subsequently published by the Association of Anaesthetists of Great Britain and Ireland regarding perioperative care of the elderly and those with dementia; this study aims to assess current adherence to these guidelines in anaesthetic departments across Scotland.MethodsA web-based survey was sent to all Scottish departments. The questions assessed department patient demographic, access to specialist pre-assessment services, availability of multidisciplinary input, perioperative care of patients with cognitive impairment and departmental training on geriatric perioperative care.ResultsResponses were collected from November-December 2020 with a 92.6% response rate. A total of 64% of departments stated that > 50% of their workload involved patients over 75. One department had a lead clinician for geriatric anaesthesia, whilst 20% could access a geriatric specialist when coordinating perioperative care. Specialist geriatric pre-assessment services operate in 20% of centres. A total of 60% of respondents used a clinical frailty score when pre-assessing patients over 75, with 48% specifically screening for cognitive impairment. The vast majority of centres, 76%, did not routinely provide information regarding post-operative delirium and 24% ‘never or very rarely’ invite caregivers to accompany patients with dementia into the department. Education sessions regarding perioperative elderly care had occurred in 56% of departments.ConclusionsElderly patients represent a significant proportion of anaesthetic workload in Scotland. Despite this, adherence to recommended practice is low. The vast majority of centres lack access to specialist multidisciplinary input or specialist pre-assessment services which are essential to providing good care. Reported screening for frailty and cognitive impairment is variable, with opportunities for improvement in communication and education (patient and clinician) surrounding these conditions.

Hospitalisation for degenerative cervical myelopathy in England: insights from the National Health Service Hospital Episode Statistics 2012 to 2019

PurposeDegenerative cervical myelopathy (DCM) is the most common cause of adult spinal cord dysfunction worldwide. However, the current incidence of DCM is poorly understood. The Hospital Episode Statistics (HES) database contains details of all secondary care admissions across NHS hospitals in England. This study aimed to use HES data to characterise surgical activity for DCM in England.MethodsThe HES database was interrogated for all cases of DCM between 2012 and 2019. DCM cases were identified from 5 ICD-10 codes. Age-stratified values were collected for ‘Finished Consultant Episodes’ (FCEs), which correspond to a patient’s hospital admission under a lead clinician. Data was analysed to explore current annual activity and longitudinal change.Results34,903 FCEs with one or more of the five ICD-10 codes were identified, of which 18,733 (53.6%) were of working age (18–64 years). Mean incidence of DCM was 7.44 per 100,000 (SD ± 0.32). Overall incidence of DCM rose from 6.94 per 100,000 in 2012–2013 to 7.54 per 100,000 in 2018–2019. The highest incidence was seen in 2016–2017 (7.94 per 100,000). The median male number of FCEs per year (2919, IQR: 228) was consistently higher than the median female number of FCEs per year (2216, IQR: 326). The rates of both emergency admissions and planned admissions are rising.ConclusionsThe incidence of hospitalisation for DCM in England is rising. Health care policymakers and providers must recognise the increasing burden of DCM and act to address both early diagnoses and access to treatment in future service provision plans.

Facilitators and barriers for clinical implementation of a 30-minute point-of-care test for Neisseria gonorrhoeae and Chlamydia trachomatis into clinical care: A qualitative study within sexual health services in England.

Point-of-care tests (POCTs) to diagnose sexually transmitted infections (STIs) have potential to positively impact patient management and patient perceptions of clinical services. Yet there remains a disconnect between development of new technologies and their implementation into clinical care. With the advent of new STI POCTs arriving to the global market, guidance for their successful adoption and implementation into clinical services is urgently needed. We conducted qualitative in-depth interviews with professionals prior to and post-implementation of a Chlamydia trachomatis/Neisseria gonorrhoeae POCT into clinical services in England to define key stakeholder roles and explore the process of POCT integration. Participants self-identified themselves as key stakeholders in the STI POCT adoption and/or implementation processes. Data consisted of interview transcripts, which were analysed thematically using NVIVO 11. Six sexual health services were included in the study; three of which have implemented POCTs. We conducted 40 total interviews: 31 prior to POCT implementation and 9 follow-up post-implementation. Post-implementation data showed that implementation plans required little or no change during service evaluation. Lead clinicians and managers self-identified as key stakeholders for the decision to purchase, while nurses self-identified as "change champions" for implementation. Many identified senior clinical staff as those most likely to introduce and drive change. However, participants stressed the importance of engaging all clinical staff in implementation. While the accuracy of the POCT, its positive impact on patient management and the ease of its integration within existing pathways were considered essential, costs of purchasing and utilising the technology were identified as central to the decision to purchase. Our study shows that key decision-makers for adoption and implementation require STI POCTs to have laboratory-comparable accuracy and be affordable for purchase and ongoing use. Further, successful integration of POCTs into sexual health services relies on supportive interpersonal relationships between all levels of staff.

Editorial introductions.

Editorial introductions.

Editorial introductions.

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Patients can accurately self-report their elbow range of motion following surgery for trauma

IntroductionThere is an increased demand of telemedicine in the recent century, especially with the outbreak of Covid-19. The aim of this study was to investigate patients' reliability in self-assessing own elbow range of motion following surgery for trauma. MethodsAll patients of age ≥16 years who underwent surgery for elbow trauma at the local trauma unit between March 2015 to Aug 2018 were reviewed retrospectively. Identified cohort was invited to self-assess their elbow range of motion (ROM) using questionnaire with image instruction. They were then followed up with a clinical review for objective measurements by the lead clinician. Independent T-test was used to compare the measurements between patients and clinician. The power of the study was calculated using G∗Power software. ResultsThirty-five patients were enrolled in the study with mean age of 41 years. 11 of 35 patients had an associated elbow fracture dislocation associated. Mean patient reported total ROM was 105.7° ± 32.8°, with mean extension of 24.6° ± 18.9° to mean flexion of 130.3° ± 18.2°. Mean objective ROM measured by lead clinician was 112.6° ± 18.3°, with mean extension 22.4° ± 10.9° to mean flexion 135.0° ± 10.8°. No statistical significance was found between self-reported and clinician-based extension (p = 0.36), flexion (p = 0.076), and overall range of motion (p = 0.12). ConclusionPatients can self-assess their elbow range of motion following surgery for trauma accurately. In the midst of increasing demands for telemedicine, we suggest the application of patients' self-reporting outcome in clinical settings.

Prohibit, Protect, or Adapt? The Changing Role of Volunteers in Palliative and Hospice Care Services During the COVID-19 Pandemic. A Multinational Survey (Covpall).

Volunteers are common within palliative care services, and provide support that enhances care quality. The support they provided, and any role changes, during the coronavirus disease 2019 (COVID-19) pandemic are unknown. The aim of this study is to understand volunteer deployment and activities within palliative care services, and to identify what may affect any changes in volunteer service provision, during the COVID-19 pandemic. Multi-national online survey disseminated via key stakeholders to specialist palliative care services, completed by lead clinicians. Data collected on volunteer roles, deployment, and changes in volunteer engagement. Analysis included descriptive statistics, a multivariable logistic regression, and analysis of free-text comments using a content analysis approach. 458 respondents: 277 UK, 85 rest of Europe, and 95 rest of the world. 68.5% indicated volunteer use pre-COVID-19 across a number of roles (from 458): direct patient facing support (58.7%), indirect support (52.0%), back office (48.5%) and fundraising (45.6%). 11% had volunteers with COVID-19. Of those responding to a question on change in volunteer deployment (328 of 458) most (256/328, 78%) indicated less or much less use of volunteers. Less use of volunteers was associated with being an in-patient hospice, (odds ratio [OR]=0.15, 95% CI=0.07-0.3, P<.001). This reduction in volunteers was felt to protect potentially vulnerable volunteers, with policy changes preventing volunteer support. However, adapting was also seen where new roles were created, or existing roles pivoted to provide virtual support. Volunteers were mostly prevented from supporting many forms of palliative care which may have quality and safety implications given their previously central roles. Volunteer re-deployment plans are needed that take a more considered approach, using volunteers more flexibly to enhance care while ensuring safe working practices. Consideration needs to be given to widening the volunteer base away from those who may be considered to be most vulnerable to COVID-19.

What is the role of the surgeon in the management of head and neck mucosal melanoma in the immunotherapy era?

The advent of immunotherapy has impacted both the management and, to a lesser extent, the outcomes for patients with head and neck mucosal melanoma. As a consequence, one might expect that the role of the surgeon would be limited to the diagnostic work-up and that systemic therapies would be the mainstay of treatment. Here, we present the surgical aspects of the recently published United Kingdom Head and Neck Mucosal Melanoma Guideline to highlight the continued role of surgeons in the management of this disease. We highlight key areas where surgeons remain the lead clinician and reinforce the multidisciplinary requirement for exemplary patient care. Despite the advent of immunotherapy, surgeons continue to have a key role to play in this disease. When indicated, it is essential that appropriate surgery is offered by a suitably experienced team.