WALANT Protocol: Stop before you block

The use of Wide Awake Local Anaesthetic No Tourniquet (WALANT) amongst Plastic and Orthopaedic Hand Surgeons has been accelerated by the impact of the COVID-19 pandemic and associated risks of general anaesthesia. Benefits of WALANT include a bloodless field, improved recovery, on-table testing, as well as cost and time savings. Whilst more clinical trials are underway to fully elucidate safety-profile and outcomes, there is a lack of consensus and clarity over contraindications to WALANT. A survey of trainees identified that only one-in-five were aware of the appropriate reversal agent in the event of inadequate perfusion. We feel that a WALANT checklist should be developed and implemented for use immediately prior to administration of local anaesthetic with adrenaline to an extremity, building on the successes of the World Health Organisation (WHO) and the Royal College of Anaesthetists checklists. Such a checklist should include contraindications to WALANT and make the operator aware of the availability, dose and location of Phentolamine as a reversal agent. Introducing this checklist will help to facilitate safer and more effective use of WALANT within Hand Surgery

Facial skin ageing: Key concepts and overview of processes

INTRODUCTION: The face is a cosmetically sensitive region where the process of ageing is most clearly manifested. With increased focus on anti-ageing and longevity, more anti-senescent treatments are being proposed despite limited evidence. This study outlines the pathways and mechanisms underpinning the biological process of ageing in the face. METHODS: Comprehensive searches of MEDLINE, EMBASE, Cochrane Library and CINAHL from inception to 2020. Inclusion criteria included all empirical human research studies specific to facial ageing features, written in the English language. RESULTS: A total of 65 papers met inclusion criteria for analysis. Pathways were subdivided into intrinsic and extrinsic senescence mechanisms. Intrinsic pathways included genetics, generation of reactive oxygen species and hormonal changes. Extrinsic pathways included photoageing and damage to skin layers. The combined intrinsic and extrinsic pathway alterations result in wrinkles, higher laxity, slackness and thinning of the skin. Skin functions such as barrier immune function, wound healing, thermoregulation and sensory function are also impaired. CONCLUSION: The ageing process is unique to the individual and depends on the interplay between an individual's genetics and external environmental factors. Through understanding the molecular and cellular mechanisms, an appreciation of the consequent structural and functional changes can be achieved. Based on this knowledge, further research can focus on how to slow or impede the ageing process and identify specific targets to develop and evolve new treatment strategies

Cosmetic business mechanics in London: A cross-sectional analysis and audit of ASA compliance

INTRODUCTION: The proliferation of providers and practitioners of cosmetic botulinum toxin and dermal filler has profound public health implications. The Advertising Standards Authority (ASA) regulates the use of advertising materials in the United Kingdom and prohibits the promotion of prescription-only medicines. AIMS: We aim to perform a cross-sectional analysis of the practitioners in London, UK to evaluate the distribution of clinics within Greater London, prices advertised for interventions, and compliance with the ASA code. We also aim to identify whether there are any differences in cost of botulinum toxin or dermal filler between the boroughs. METHODS: Between December 2021 and January 2022, we performed a systematic search using the internet search engine Google. Five searches were performed (1) [london] botox, (2) [london] botulinum toxin, (3) [london] anti wrinkle injection, (4) [london] filler, (5) [london] dermal filler. One hundred websites per search string were systematically reviewed and those which met the inclusion/exclusion criteria of each search string were included and analyzed. Each clinic's product/service range compliance with the ASA/CAP code was assessed. Any reference to Botulinum Toxin or anti-wrinkle injections was noted and analyzed. Further analysis would look to calculate price per milliliter (mL) of botulinum toxin and dermal filler per borough and to calculate whether there were any statistical differences between the 32 different London boroughs. RESULTS: A total of 500 websites were visited and evaluated. After removal of duplicates, a total of 233 independent clinics was identified. A total of 206 out of the 233 clinics sampled (88%) were in direct infringement of the enforcement notice through advertising a prescription medicine. The overall average cost per mL of dermal filler was £330.89 and there was a statistically significant variance across London boroughs (p < 0.05). The overall average cost per mL of Botulinum Toxin was £284.45 and the variance across London boroughs was close to significant (p = 0.058). CONCLUSION: This paper demonstrates poor compliance with the ASA/CAP guidelines and further provides an insight into the industry mechanics associated with aesthetic injectables in a major UK city, identifying regional variance in price and clinic density. The advertising of prescription-only medication may pose a potential risk to patients and will be an important consideration in proposed legislation to introduce licensing to the industry

Profiling UK injectable aesthetic practitioners: a national cohort analysis

Introduction: The United Kingdom (UK) injectables market has been growing rapidly with a lack of robust regulation and to date, no information regarding the profile of practitioners has been published. Aim: We aim to provide a descriptive and qualitative analysis of the advertised practitioners in the United Kingdom. Methods: We performed a systematic search using the internet search engine Google to perform a qualitative descriptive analysis of aesthetic practitioners in the UK. For each contiguous country in the UK: England, Scotland, and Wales, five searches were performed. The list of practitioners was then cross-referenced with professional regulatory bodies, with extraction of registration number, date of registration and presence or absence from the Specialist Register or General Practitioner register. Results: 3,000 websites were visited and evaluated. 1,224 independent clinics with 4,405 practitioners were identified. 738 were identified as those in business support functions and the remaining 3,667 practitioners were undertaking injectable practice. The profile of professions were doctors 32%, nurses 13%, dentists 24% and dental nurses 8%. Of the 1,163 doctors identified 481 were on the specialist register (41%) and 219 were on the GP register (19%). 27 specialties were represented in this cohort analysis. Plastic Surgery formed the majority of those who were on the specialist register at 37%, followed by Dermatology at 18%. Conclusion: This paper is the first to describe the range of practitioners, their professional backgrounds and experience who perform non-surgical aesthetic interventions. The range of backgrounds may have an impact on the potential risks to patients and will be an important consideration in proposed legislation to introduce licensing to the industry

Quantitative and qualitative analysis of individual experiences post botulinum toxin injection ‐ United Kingdom Survey

Introduction In the United Kingdom (UK), complications that arise following the administration of Botulinum Toxin are reported to the Medicines and Health Regulatory Agency (MHRA) via the Yellow Card Reporting Scheme. Over the past decade, there has been a significant increase in the number of non-surgical aesthetic procedures. Concerns have been raised that the MHRA is not fully capturing complications in terms of volume and impact on patients. Aim This novel study explores the lived experiences of individuals who have experienced an adverse event following administration of Botulinum Toxin for aesthetic purposes. Using a combination of qualitative and quantitative methodologies, this analysis evaluates data relating to long-lasting physical, psychological, emotional, and financial sequelae of complications arising from cosmetic Botulinum Toxin injections in the UK. Methods A mixed method, qualitative and quantitative approach was adopted to gain comprehensive insights into patients' experiences. A focus group which comprised patient representatives, psychologists, and researchers reached a consensus on a 17-question survey which was disseminated via social media channels. Deductive thematic analysis was used to analyse coded themes. Furthermore, for secondary analysis, sentiment analysis was used computationally as an innovative approach to identify and categorise free text responses associated with sentiments using natural language processing (NLP). Results In the study, 655 responses were received, with 287 (44%) of respondents completing all questions. The mean age of respondents was 42.6 years old. 94.1% of respondents identified as female. In the sample, 79% of respondents reported an adverse event following their procedure, with the most common event being reported as ‘anxiety’. Findings revealed that 69% of respondents reported long-lasting adverse effects. From the responses, 68.4% reported not having recovered physically, 63.5% of respondents stated that they had not recovered emotionally from complications, and 61.7% said that they have not recovered psychologically. In addition, 84% of respondents stated that they do not know who regulates the aesthetics industry. Furthermore, 92% of participants reported that their clinic or practitioner did not inform them about the Yellow Card Reporting Scheme. The sentiment analysis using the AFINN Lexicon yielded adjusted scores ranging from −3 to +2, with a mean value of −1.58. Conclusion This is the largest survey in the UK completed by patients who experienced an adverse outcome following the aesthetic administration of Botulinum Toxin. Our study highlights the extent of the challenges faced by patients who experience an adverse event from physical, emotional, psychological, and financial perspectives. The lack of awareness of MHRA reporting structures and the lack of regulation within the UK's cosmetic injectables sector represent a significant public health challenge

Complications of Cosmetic Botulinum Toxin A Injections to the Upper Face: A Systematic Review and Meta-Analysis

BACKGROUND: Botulinum toxin A (BoNT-A) injections are a popular non-surgical procedure for facial rejuvenation. Its increase in popularity and utilization is met with limited regulations, potentially posing a significant risk to patient safety and public health. OBJECTIVES: The authors sought to assess the safety profile of cosmetic glabellar and forehead BoNT-A injections and evaluate BoNT-A type on complication rate. METHODS: A systematic search of MEDLINE and EMBASE was performed for studies reporting complications after cosmetic BoNT-A in the glabellar or in the forehead region in the glabellar or in the forehead region. A random effects meta-analysis was carried out to assess complication rate. Where there were sufficient randomized-controlled trials, a network meta-analysis was performed. RESULTS: Of 556 identified articles, 24 were included in the final quantitative analysis, with 4268 BoNT-A injection sessions and 1234 placebos. Frequently observed treatment-related complications in the BoNT-A intervention group included headache, local skin reactions, and facial neuromuscular symptoms. The overall BoNT-A complication rate was 16%. The odds ratio of developing complications from abobotulinum toxin injections compared with placebo was 1.62 (1.15, 2.27; P > 0.05) and that from onabotulinum toxin injections compared with placebo was 1.34 (0.52, 3.48; P > 0.05). In 30% of the studies, the injectors were doctors, whereas the training status of the practitioner was not reported in the remaining 70%. CONCLUSIONS: Cosmetic BoNT-A injections in the glabellar and forehead region appear to be safe, and most complications are mild and transient. Nevertheless, the literature demonstrates heterogeneous reporting of complications and a lack of consistency of the definition of treatment-related complications. LEVEL OF EVIDENCE: 2

Adjuvant Pluronic F68 is Compatible With a Plant Root-Colonizing Probiotic, \u3ci\u3ePseudomonas chlororaphis\u3c/i\u3e O6

Plant probiotic bacteria are being increasingly used to maximize both the productivity and quality of field crops. Pseudomonas chlororaphis O6 (PcO6) is a plant root colonizer with probiotic activities. This bacterium produces an array of metabolites, including a group of phenazines that are functional in plant protection. The paper reports responses of PcO6 to a nonionic triblock copolymer surfactant, Pluronic F68. This Pluronic exhibits membrane healing activity and improves cryopreservation recovery in eukaryotic cells. The product is FDA-approved and is applied as an adjuvant in formulations used in agriculture, medicine, and biotechnology. Growth of PcO6 on lysogeny broth at 25 °C was unhindered by 0.1 and 1.0 g/L F68, reduced at 10 g/L, and with significant inhibition at 100 g/L F68; micelle formation could account for inhibited growth at higher doses. Phenazine production was not changed by F68, whereas the surfactant activity of F68 induced the spread of bacterial colonization on 0.5% agar. Exposure of cells to fluorescein-labeled F68 resulted in intense fluorescence, stable to washing, showing a direct association of the Pluronic with the bacterium. However, neither protection nor harm was found for PcO6 cells suspended in either 0.1% or 1% F68 after three freeze (–20 °C)/thaw cycles. These findings suggest that F68 could be compatible for use in agricultural formulations with little effect on probiotics such as PcO6

Evaluating the Public Health Impact of the United Kingdom Aesthetic Botulinum Toxin and Dermal Filler Market

Background: The rapid growth of the United Kingdom (UK) aesthetic injectables sector, limited legislation, and lack of empirical research poses a significant public health challenge. Objectives: To quantify the risk to patients, as captured through Government databases, meta-analysis, as well as to create a database profiling aesthetic practitioners and their compliance with existing legislation. Finally, to evaluate the lived experience of patients who have experienced a complication and propose methods to improve patient safety. Methods: The UK’s Medicines and Health Regulatory Agency (MHRA) database of reported complications was evaluated then compared with a meta-analysis of the expected complication rate. A database of practitioners was created, cross referencing this with professional databases to identify the professional profile and background experience. Practitioner compliance with legislation was assessed, followed by a national survey of 656 patients with complications. Finally, Delphi consensus methodology was implemented to survey 122 industry practitioners and experts to propose a series of recommendation to improve patient safety. Results: We identified 188 complications over a 30-year period from MHRA records. The meta-analysis yielded an expected complication rate of 16% for Botulinum Toxin administration to the upper face. Registered doctors accounted for 32% of UK practitioners, with the remainder from a variety of professional and non-professional backgrounds, with 88% of practitioners breaking Advertising Standards Authority Rules. Our patient survey identified the physical, emotional, psychological and financial burden of complications. The Delphi study generated 38 recommendations, informing a unifying framework – the 5Ps to help contextualise future public health analyses Conclusion: This PhD provides a unique and in-depth insight into the aesthetic injectables sector, providing an important foundation for regulation to improve patient safety and safeguard public health. Current lack of regulation poses systemic risk to patients, and work is needed to reform the sector to provide robust safeguards