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Background People who suffer facial injury, whether from accidents or interpersonal violence, face a range of psychosocial issues as a result. Though standards of oral and maxillofacial surgery (OMFS) to restore function and appearance continue to improve, psychological problems may be overlooked in busy wards and clinics. Major trauma patients are known to be at risk of high levels of acute stress disorder (ASD), as well as depression and anxiety and, in the longer term, may develop post-traumatic stress disorder (PTSD); however, there has been limited exploration of the experience of OMFS trauma patients. Changes to appearance can be distressing and can impede the return to normal life; they can also exacerbate problems by reminding patients of traumatic events. This study aims to establish the prevalence of psychological distress (ASD, depression, anxiety, appearance concerns) in facial injury patients. Methods This prospective study recruited injury patients being treated at the Royal London Hospital by OMFS, and discussed at bi-weekly multidisciplinary meetings. Participants completed standardised self-completion questionnaires within two weeks of injury: these assessed symptoms of ASD (ASDS: Acute Stress Disorder Scale), psychological distress (HADS: Hospital Anxiety and Depression Scale) and appearance concerns (DAS24: Derriford Appearance Scale). Patients were excluded on the basis of cognitive impairment; self-harm leading to admission; and insufficient understanding of English. Results Data from 106 patients show that a high proportion of patients experienced clinically significant symptoms of distress. Twenty nine (29) percent of patients experienced symptoms indicative of ASD on the ASDS, which is associated with subsequent PTSD. Twenty nine (29) percent and 48 percent respectively experienced symptoms of depression and anxiety, using the HADS to assess clinically significant symptoms. Those experiencing clinically significant levels of distress on the ASDS or HADS had higher levels of appearance concern on the DAS24 (mean=40, SD=13.6), compared with those without significant distress (mean=26, SD=7.6). Refusal rates were low (>10%), however in this diverse East London population, English language requirements excluded many otherwise eligible patients (22%). Discussion There are high levels of psychological distress and unmet needs in this cohort. Rehabilitation involves a return to normal psychosocial functioning as well as physical function and appearance, and there is a need for a simple, practical means of assessing distress. These psychological conditions are treatable, however, and the ability to identify those at risk would enable healthcare practitioners to provide important interventions.

Objectives Many randomised trials in surgery suffer from recruitment rates that lag behind projected targets. We aim to identify perceived barriers to recruitment among these pioneering trials in the field of head and neck cancer surgery. Design Recruiting centres to all three trials (Selective Elective Neck Dissection (SEND), Positron Emission Tomography (PET)-Neck and Hyperbaric Oxygen in the Prevention of Osteoradionecrosis (HOPON)) were contacted by email by the chief investigators. Responders were asked to complete a web-based survey in order to identify the barriers to recruitment in their centre and grade each by severity. Setting Secondary care: 44 head and neck oncology regional referral centres. Participants Analysis was based on 85 responses evenly distributed between the three trials. Results The most commonly identified perceived barriers to recruitment (more than 50% of responders identified the item as a barrier in all the three trials) in the order of frequency were: patients consent refusal because of expressed treatment preference, patients consent refusal owing to aversion to randomisation, excess complexity/amount of information provided to patients and lack of time in clinic to accommodate research. The most severely rated of these problems was consent refusal because of the expressed treatment preference and lack of time in the clinic. Conclusions Our findings confirm others’ work in surgery that the most significant barrier to trial recruitment in head and neck cancer surgery is the patient9s preference for one arm of the trial. It may be that additional training for those taking consent may be helpful in this regard. It is also important to adequately resource busy surgical clinics to support clinical trial recruitment.

Next week 200 of Britain's oral and maxillofacial surgeons will visit secondary schools to warn pupils about the risks of facial injury from drinking and fighting and, with the help of patients, to show them the consequences of such injuries. What are those risks, and how may they be prevented? In few places is the effectiveness of legislation on seat belts and drinking and driving more obvious than in oral and maxillofacial trauma. From 1977 to 1987 the proportion of patients with maxillofacial fractures sustained in road accidents fell by 34%,1 and rates of facial bone fracture sustained in road accidents fell from 6.2 to 4.1 per 100 000 population. Violent crime, however, more than compensated for this decrease, and, although the incidence of serious injury such as complex pan-facial fractures decreased, the overall incidence of facial injury rose from 20 to 24 per 100 000 population.1 The proportion of injuries sustained in assaults increased from 40% in 1977 …

EDITOR,—Doctors are obliged to obtain signed consent from patients to take their clinical photographs. Guidelines to authors of scientific papers require patients' signed consent to the publication of clinical photographs when the patients are recognisable.1 2 It seems, however, that the press can take photographs …