Learning Journeys: Exploring the wider benefits of participation in adult and community learning

EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Interventions to improve perinatal outcomes among migrant women in high-income countries: a systematic review protocol

INTRODUCTION: Women who are migrants and who are pregnant or postpartum are at high risk of poorer perinatal outcomes compared with host country populations due to experiencing numerous additional stressors including social exclusion and language barriers. High-income countries (HICs) host many migrants, including forced migrants who may face additional challenges in the peripartum period. Although HICs' maternity care systems are often well developed, they are not routinely tailored to the needs of migrant women. The primary objective will be to determine what interventions exist to improve perinatal outcomes for migrant women in HICs. The secondary objective will be to explore the effectiveness of these interventions by exploring the impact on perinatal outcomes. The main outcomes of interest will be rates of preterm birth, birth weight, and number of antenatal or postnatal appointments attended. METHODS AND ANALYSIS: This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Protocols guidelines. EMBASE, EMCARE, MEDLINE and PsycINFO, CENTRAL, Scopus, CINAHL Plus, and Web of Science, as well as grey literature sources will be searched from inception up to December 2022. We will include randomised controlled trials, quasi-experimental and interventional studies of interventions, which aim to improve perinatal outcomes in any HIC. There will be no language restrictions. We will exclude studies presenting only qualitative outcomes and those including mixed populations of migrant and non-migrant women. Screening and data extraction will be completed by two independent reviewers and risk of bias will be assessed using the Quality Assessment Tool for Quantitative Studies. If a collection of suitably comparable outcomes is retrieved, we will perform meta-analysis applying a random effects model. Presentation of results will comply with guidelines in the Cochrane Handbook of Systematic Reviews of Interventions and the PRISMA statement. ETHICS AND DISSEMINATION: Ethical approval is not required. Results will be submitted for peer-reviewed publication and presented at national and international conferences. The findings will inform the work of the Lancet Migration European Hub. PROSPERO REGISTRATION NUMBER: CRD42022380678

Aneurysm of antecubital vein: an unusual complication of peripheral intravenous cannulation

<p>Abstract</p> <p>Background</p> <p>Intravenous cannulation is a very common procedure. Venous aneurysm secondary to peripheral intravenous cannulation is extremely rare. Moreover, venous aneurysm can mimic other conditions and may confuse the issue.</p> <p>Case presentation</p> <p>We describe a case of a 45-year-old woman who was referred with the diagnosis of varicose vein of right arm. A history of intravenous cannulation at the same site was noted that raised suspicion. The swelling was compressible and turned out to be a venous aneurysm. The lesion was completely excised. Postoperative recovery was uneventful. Histology findings were in conformity with the preoperative diagnosis.</p> <p>Conclusion</p> <p>Caution should be exercised in diagnosing varicose vein at a site that bears a history of intravenous cannulation. The case also raises an important issue regarding consent. Should patients undergoing peripheral intravenous cannulation be warned of this rare complication?</p

Dermoscopy, with and without visual inspection, for the diagnosis of melanoma in adults

Background: Melanoma has one of the fastest rising incidence rates of any cancer. It accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Although history-taking and visual inspection of a suspicious lesion by a clinician are usually the first in a series of ‘tests’ to diagnose skin cancer, dermoscopy has become an important tool to assist diagnosis by specialist clinicians and is increasingly used in primary care settings. Dermoscopy is a magnification technique using visible light that allows more detailed examination of the skin compared to examination by the naked eye alone. Establishing the additive value of dermoscopy over and above visual inspection alone across a range of observers and settings is critical to understanding its contribution for the diagnosis of melanoma and to future understanding of the potential role of the growing number of other highresolution image analysis techniques. Objectives: To determine the diagnostic accuracy of dermoscopy for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults, and to compare its accuracy with that of visual inspection alone. Studies were separated according to whether the diagnosis was recorded face-to-face (in-person) or based on remote (image-based) assessment. Search methods: We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles. Selection criteria: Studies of any design that evaluated dermoscopy in adults with lesions suspicious for melanoma, compared with a reference standard of either histological confirmation or clinical follow-up. Data on the accuracy of visual inspection, to allow comparisons of tests, was included only if reported in the included studies of dermoscopy. Data collection and analysis: Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic threshold were missing. We estimated accuracy using hierarchical summary ROC methods. Analysis of studies allowing direct comparison between tests was undertaken. To facilitate interpretation of results, we computed values of sensitivity at the point on the SROC curve with 80% fixed specificity and values of specificity with 80% fixed sensitivity. We investigated the impact of in-person test interpretation; use of a purposely developed algorithm to assist diagnosis; observer expertise; and dermoscopy training. Main results: A total of 104 study publications reporting on 103 study cohorts with 42,788 lesions (including 5700 cases) were included, providing 354 datasets for dermoscopy. The risk of bias was mainly low for the index test and reference standard domains and mainly high or unclear for participant selection and participant flow. Concerns regarding the applicability of study findings were largely scored as ‘High’ concern in three of four domains assessed. Selective participant recruitment, lack of reproducibility of diagnostic thresholds and lack of detail on observer expertise were particularly problematic. The accuracy of dermoscopy for the detection of invasive melanoma or atypical intraepidermal melanocytic variants was reported in 86 datasets; 26 for evaluations conducted in-person (dermoscopy added to visual inspection) and 60 for image-based evaluations (diagnosis based on interpretation of dermoscopic images). Analyses of studies by prior testing revealed no obvious effect on accuracy; analyses were hampered by the lack of studies in primary care, lack of relevant information and the restricted inclusion of lesions selected for biopsy or excision. Accuracy was higher for in-person diagnosis compared to image-based evaluations (relative diagnostic odds ratio (RDOR) of 4.6; 95% CI 2.4, 9.0, P<0.001). Accuracy was compared for (a) in-person evaluations of dermoscopy (26 evaluations; 23,169 lesions and 1664 melanomas) versus visual inspection alone (13 evaluations; 6740 lesions and 459 melanomas) and for (b) image-based evaluations of dermoscopy (60 evaluations; 13,475 lesions and 2851 melanomas) versus image-based visual inspection (11 evaluations; 1740 lesions and 305 melanomas). For both comparisons, meta-analysis found dermoscopy to be more accurate than visual inspection alone, with RDORs of (a) 4.7 (95% CI: 3.0 to 7.5; P < 0.001) and (b) 5.6 (95% CI: 3.7 to 8.5; P < 0.001). These effects correspond to predicted differences in sensitivity of (a) 16% (95% CI: 8%, 23%) (92% for dermoscopy+visual inspection vs 76% for visual inspection) and (b) 35% (95% CI 24% to 46%) (81% for dermoscopy vs 47% for visual inspection) at a fixed specificity of 80%; and topredicted differences in specificity of (a) 20% (95% CI 7%, 33) (95% for dermoscopy plus visual inspection vs 75% for visual inspection) and (b) 40% (95% CI 27, 57) (82% for dermoscopy vs 42% for visual inspection) at a fixed sensitivity of 80%. Using the median prevalence of disease in each set of studies ((a) 12% for in-person and (b) 24% for image-based) for a hypothetical population of 1000 lesions, an increase in sensitivity of (a) 16% (in-person) and (b) 35% (image-based) from using dermoscopy at a fixed specificity of 80% equates to a reduction in the number of melanomas missed of (a) 19 and (b) 81 with (a) 176 and (b) 152 false positive results. An increase in specificity of (a) 20% (in-person) and (b) 40% (image-based) at a fixed sensitivity of 80% equates to a reduction in the number of unnecessary excisions from using dermoscopy of (a) 176 and (b) 304 with (a) 24 and (b) 48 melanomas missed. The use of a named or published algorithm to assist dermoscopy interpretation (as opposed to no reported algorithm or reported use of pattern analysis) had no significant impact on accuracy either for in-person (RDOR 1.4, 95% CI 0.34, 5.6; P=0.17) or image-based (RDOR 1.4, 95% CI 0.60, 3.3; P=0.22) evaluations. This result was supported by subgroup analysis according to algorithm used. Higher accuracy for observers reported as having high experience and for those classed as ‘expert consultants’ in comparison to those considered to have less experience in dermoscopy was observed, particularly for image-based evaluations. Evidence for the effect of dermoscopy training on test accuracy was very limited but suggested associated improvements in sensitivity. Authors' conclusions: Despite the observed limitations in the evidence base, dermoscopy is a valuable tool to support the visual inspection of a suspicious skin lesion for the detection of melanoma and atypical intraepidermal melanocytic variants, particularly in referred populations and in the hands of experienced users. Data to support its use in primary care is limited however it may assist in triaging suspicious lesions for urgent referral when employed by suitably trained clinicians. Formal algorithms may be of most use for dermoscopy training purposes and for less expert observers, however reliable data comparing approaches using dermoscopy in-person are lacking

Dermoscopy, with and without visual inspection, for the diagnosis of melanoma in adults

Background: Melanoma has one of the fastest rising incidence rates of any cancer. It accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Although history-taking and visual inspection of a suspicious lesion by a clinician are usually the first in a series of ‘tests’ to diagnose skin cancer, dermoscopy has become an important tool to assist diagnosis by specialist clinicians and is increasingly used in primary care settings. Dermoscopy is a magnification technique using visible light that allows more detailed examination of the skin compared to examination by the naked eye alone. Establishing the additive value of dermoscopy over and above visual inspection alone across a range of observers and settings is critical to understanding its contribution for the diagnosis of melanoma and to future understanding of the potential role of the growing number of other highresolution image analysis techniques. Objectives: To determine the diagnostic accuracy of dermoscopy for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults, and to compare its accuracy with that of visual inspection alone. Studies were separated according to whether the diagnosis was recorded face-to-face (in-person) or based on remote (image-based) assessment. Search methods: We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles. Selection criteria: Studies of any design that evaluated dermoscopy in adults with lesions suspicious for melanoma, compared with a reference standard of either histological confirmation or clinical follow-up. Data on the accuracy of visual inspection, to allow comparisons of tests, was included only if reported in the included studies of dermoscopy. Data collection and analysis: Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic threshold were missing. We estimated accuracy using hierarchical summary ROC methods. Analysis of studies allowing direct comparison between tests was undertaken. To facilitate interpretation of results, we computed values of sensitivity at the point on the SROC curve with 80% fixed specificity and values of specificity with 80% fixed sensitivity. We investigated the impact of in-person test interpretation; use of a purposely developed algorithm to assist diagnosis; observer expertise; and dermoscopy training. Main results: A total of 104 study publications reporting on 103 study cohorts with 42,788 lesions (including 5700 cases) were included, providing 354 datasets for dermoscopy. The risk of bias was mainly low for the index test and reference standard domains and mainly high or unclear for participant selection and participant flow. Concerns regarding the applicability of study findings were largely scored as ‘High’ concern in three of four domains assessed. Selective participant recruitment, lack of reproducibility of diagnostic thresholds and lack of detail on observer expertise were particularly problematic. The accuracy of dermoscopy for the detection of invasive melanoma or atypical intraepidermal melanocytic variants was reported in 86 datasets; 26 for evaluations conducted in-person (dermoscopy added to visual inspection) and 60 for image-based evaluations (diagnosis based on interpretation of dermoscopic images). Analyses of studies by prior testing revealed no obvious effect on accuracy; analyses were hampered by the lack of studies in primary care, lack of relevant information and the restricted inclusion of lesions selected for biopsy or excision. Accuracy was higher for in-person diagnosis compared to image-based evaluations (relative diagnostic odds ratio (RDOR) of 4.6; 95% CI 2.4, 9.0, P<0.001). Accuracy was compared for (a) in-person evaluations of dermoscopy (26 evaluations; 23,169 lesions and 1664 melanomas) versus visual inspection alone (13 evaluations; 6740 lesions and 459 melanomas) and for (b) image-based evaluations of dermoscopy (60 evaluations; 13,475 lesions and 2851 melanomas) versus image-based visual inspection (11 evaluations; 1740 lesions and 305 melanomas). For both comparisons, meta-analysis found dermoscopy to be more accurate than visual inspection alone, with RDORs of (a) 4.7 (95% CI: 3.0 to 7.5; P < 0.001) and (b) 5.6 (95% CI: 3.7 to 8.5; P < 0.001). These effects correspond to predicted differences in sensitivity of (a) 16% (95% CI: 8%, 23%) (92% for dermoscopy+visual inspection vs 76% for visual inspection) and (b) 35% (95% CI 24% to 46%) (81% for dermoscopy vs 47% for visual inspection) at a fixed specificity of 80%; and topredicted differences in specificity of (a) 20% (95% CI 7%, 33) (95% for dermoscopy plus visual inspection vs 75% for visual inspection) and (b) 40% (95% CI 27, 57) (82% for dermoscopy vs 42% for visual inspection) at a fixed sensitivity of 80%. Using the median prevalence of disease in each set of studies ((a) 12% for in-person and (b) 24% for image-based) for a hypothetical population of 1000 lesions, an increase in sensitivity of (a) 16% (in-person) and (b) 35% (image-based) from using dermoscopy at a fixed specificity of 80% equates to a reduction in the number of melanomas missed of (a) 19 and (b) 81 with (a) 176 and (b) 152 false positive results. An increase in specificity of (a) 20% (in-person) and (b) 40% (image-based) at a fixed sensitivity of 80% equates to a reduction in the number of unnecessary excisions from using dermoscopy of (a) 176 and (b) 304 with (a) 24 and (b) 48 melanomas missed. The use of a named or published algorithm to assist dermoscopy interpretation (as opposed to no reported algorithm or reported use of pattern analysis) had no significant impact on accuracy either for in-person (RDOR 1.4, 95% CI 0.34, 5.6; P=0.17) or image-based (RDOR 1.4, 95% CI 0.60, 3.3; P=0.22) evaluations. This result was supported by subgroup analysis according to algorithm used. Higher accuracy for observers reported as having high experience and for those classed as ‘expert consultants’ in comparison to those considered to have less experience in dermoscopy was observed, particularly for image-based evaluations. Evidence for the effect of dermoscopy training on test accuracy was very limited but suggested associated improvements in sensitivity. Authors' conclusions: Despite the observed limitations in the evidence base, dermoscopy is a valuable tool to support the visual inspection of a suspicious skin lesion for the detection of melanoma and atypical intraepidermal melanocytic variants, particularly in referred populations and in the hands of experienced users. Data to support its use in primary care is limited however it may assist in triaging suspicious lesions for urgent referral when employed by suitably trained clinicians. Formal algorithms may be of most use for dermoscopy training purposes and for less expert observers, however reliable data comparing approaches using dermoscopy in-person are lacking