Immersion in water in spas has been practised for centuries and has many proponents. Despite fierce debate about its efficacy there has been little scientific evaluation of the effect of immersion in mineral waters. Eight normal subjects were immersed in Bath spa water for two hours and the renal, haematological, and cardiovascular responses were compared with those in the control periods before and after immersion. Significant, twofold diuresis and natriuresis, 5% haemodilution, and a 50% increase in cardiac index were observed in subjects immersed, sitting, in Bath spa water at 35°C. These changes may constitute part of the scientific rationale for spa treatment in many states of disease.

161Breast reconstruction and oncoplastic techniques have been widely adopted in the surgical management of patients with breast cancer. The National Mastectomy and Breast Reconstruction Audit (NMBRA) 1 is the largest prospective audit of breast reconstruction ever carried out. It was designed and implemented by the Clinical Effectiveness Unit at The Royal College of Surgeons of England with input from the Association of Breast Surgery (ABS), the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), and the Royal College of Nursing. The NMBRA examined a broad range of clinical and patient reported outcomes in more than 18,000 women. Factors examined included patient information and access to reconstructive services as well as the level of pain, complications, quality of life and wellbeing after surgery.The patient reported outcomes in the NMBRA highlight the positive effects of breast reconstruction on quality of life and the very high levels of satisfaction with the clinical care provided. The audit did, however, find complication rates, levels of postoperative pain and readmission rates that were much higher than expected. There were also variations in preoperative provision of information, access to services and some clinical outcomes.The original ABS guidelines 2 predated the NMBRA. One of the key recommendations of the audit was that new guid-ance should be written that describes 'best practice' and sets current standards of care. Following this, a multidisciplinary writing group of specialists with expertise in the management of patients undergoing oncoplastic procedures was set up by the ABS and BAPRAS to develop comprehensive new guidelines: Oncoplastic Breast Reconstruction: Guidelines for Best Practice. 3 A patient representative was involved throughout as a core member of the group. Feedback from a wide range of stakeholders has been incorporated into the document, which enjoys the support of Professor Sir Mike Richards, the National Cancer Director. The guidelines are available on the ABS and BAPRAS websites.The NMBRA identified more than 80 unique metrics, reflecting previously undisclosed standards of care. These provided a benchmark for the selection and development of 25 new quality criteria, which form the backbone of the new guidelines (Table 1). The quality criteria were selected to be outcome based, measurable and clinically relevant. They set standards that can be used for future audits, within individual units or nationally.Since oncoplastic breast surgery is a developing area of clinical practice with a limited evidence base, the guidance reflects a combination of peer opinion and the best available evidence informed by peer reviewed publications. External advice was commissioned on pain management from

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Purpose The B-MaP-C study investigated changes to breast cancer care that were necessitated by the COVID-19 pandemic. Here we present a follow-up analysis of those patients commenced on bridging endocrine therapy (BrET), whilst they were awaiting surgery due to reprioritisation of resources. Methods This multicentre, multinational cohort study recruited 6045 patients from the UK, Spain and Portugal during the peak pandemic period (Feb–July 2020). Patients on BrET were followed up to investigate the duration of, and response to, BrET. This included changes in tumour size to reflect downstaging potential, and changes in cellular proliferation (Ki67), as a marker of prognosis. Results 1094 patients were prescribed BrET, over a median period of 53 days (IQR 32–81 days). The majority of patients (95.6%) had strong ER expression (Allred score 7–8/8). Very few patients required expedited surgery, due to lack of response (1.2%) or due to lack of tolerance/compliance (0.8%). There were small reductions in median tumour size after 3 months’ treatment duration; median of 4 mm [IQR − 20, 4]. In a small subset of patients (n = 47), a drop in cellular proliferation (Ki67) occurred in 26 patients (55%), from high (Ki67 ≥ 10%) to low (< 10%), with at least one month’s duration of BrET. Discussion This study describes real-world usage of pre-operative endocrine therapy as necessitated by the pandemic. BrET was found to be tolerable and safe. The data support short-term (≤ 3 months) usage of pre-operative endocrine therapy. Longer-term use should be investigated in future trials.

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