Mohs Micrographic Surgery for Dermatofibrosarcoma Protuberans of the Vulva

Introduction. Dermatofibrosarcoma Protuberans (DFSP) is a rare cutaneous tumour of low/intermediate malignant potential, which occasionally arises on the vulva. Historically, the treatment has been wide local excision (WLE). Mohs micrographic surgery (MMS) is now recommended to ensure precise margin control. MMS to treat DFSP of the trunk and extremities is well documented. However, no report to date has described its use in vulval DFSP. Case History. A 39 year old woman presented with a longstanding nodule in the left labium majus. Histology after surgical removal showed an incompletely excised DFSP. MMS was undertaken with primary closure of the defect. Three years following treatment there is no evidence of recurrence. Discussion. The local recurrence rate of DFSP after WLE ranges from 0–75%. Finger-like projections from DFSP into surrounding tissue often results in incomplete excision. Representative vertical sections used in WLE assess less than 1% of the total tumour margin. MMS uses systematic horizontal sectioning. 100% of the tumour margin is microscopically examined. MMS is now advocated to ensure precise margin control

Developing methods for the overarching synthesis of quantitative and qualitative evidence: the interweave synthesis approach

This is the author accepted manuscript. The final version is available on open access from Wiley via the DOI in this recordThe incorporation of evidence derived from multiple research designs into one single synthesis can enhance the utility of systematic reviews making them more worthwhile, useful and insightful. Methodological guidance for mixed-methods synthesis continues to emerge and evolve but broadly involves a sequential, parallel or convergent approach according to the degree of independence between individual syntheses before they are combined.We present two case studies in which we used novel and innovative methods to draw together the findings from individual but related quantitative and qualitative syntheses to aid interpretation of the overall evidence base. Our approach moved beyond making a choice between parallel, sequentialor convergent methods to interweave the findings of individual reviews and offers three key innovations to mixed-methods synthesis methods: i)The use of intersubjective questions to understand the findings of the individual reviews through different lenses, ii)Immersion of key reviewers in the entirety of the evidence base, and iii)Commencing the process during the final stages of the synthesis of individual reviews, at a point where reviewers are developing an understanding of initial findings. Underlying our approachis the process of exploration and identification of links between and across review findings; an approach that is fundamental to all evidence syntheses but usually occurs at the level of the study. Adapting existing methods for exploring and identifying patterns and links between and across studies to interweave the findings between and across reviews may prove valuable.NIHR Health Technology Assessment Programm

Women’s Experiences of Vulvodynia: An Interpretative Phenomenological Analysis of the Journey Toward Diagnosis

Vulvodynia is the experience of idiopathic pain characterized by burning, soreness, or throbbing in the external female genitalia or vulva and is estimated to be experienced by 4–16% of the female population, yet only half of women seek help regarding their symptoms. Of the women who do seek help, only around 2% obtain a diagnosis. Therefore, the aim of the current study was to explore the experiences of women with vulvodynia on their journey toward diagnosis, by using semi-structured interviews and an interpretative phenomenological analysis (IPA) methodology. Eight women were interviewed, and their experiences were analyzed and interpreted into three master themes, each with constituent sub-themes: (1) The Journey Is a Battle, (2) “What Is Vulvodynia?”: Ambivalence Toward Diagnosis, and (3) Patriarchy, Women, and Sex. Overall, women perceived a healthcare system which was dismissive and shaming, with an inadequate knowledge of vulvodynia. This in turn impacted on women’s psychological well-being. Psychological understanding, one-to-one therapy, and consultation and training for healthcare professionals may help to improve the psychological well-being of women with vulvodynia

No evidence synthesis about me without me: Involving young people in the conduct and dissemination of a complex evidence synthesis

This is the final version. Available from Wiley via the DOI in this record. Data sharing is not applicable to this article as no new data were created or analysed in this study.OBJECTIVES: To describe and reflect on the methods and influence of involvement of young people with lived experience within a complex evidence synthesis. STUDY DESIGN AND SETTING: Linked syntheses of quantitative and qualitative systematic reviews of evidence about interventions to improve the mental health of children and young people (CYP) with long-term physical conditions (LTCs). METHODS: Involvement was led by an experienced patient and public involvement in research lead. Young people with long-term physical conditions and mental health issues were invited to join a study-specific Children and Young People's Advisory Group (CYPAG). The CYPAG met face to face on four occasions during the project with individuals continuing to contribute to dissemination following report submission. RESULTS: Eight young people joined the CYPAG. Their views and experiences informed (a) a systematic review evaluating the effectiveness of interventions intended to improve the mental health of CYP with LTCs, (b) a systematic review exploring the experiences of interventions intended to improve the mental well-being of CYP with LTCs and (c) an overarching synthesis. The CYPAG greatly contributed to the team's understanding and appreciation of the wider context of the research. The young people found the experience of involvement empowering and felt they would use the knowledge they had gained about the research process in the future. CONCLUSION: Creating an environment that enabled meaningful engagement between the research team and the CYPAG had a beneficial influence on the young people themselves, as well as on the review process and the interpretation, presentation and dissemination of findings.Health Technology Assessment ProgrammeNational Institute for Health Research (NIHR)NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC

School‐based interventions for attention-deficit/hyperactivity disorder: a systematic review with multiple synthesis methods

This is the author accepted manuscript. The final version is available from Wiley via the DOI in this record.Non-pharmacological interventions for attention-deficit/hyperactivity disorder are useful treatments, but it is unclear how effective school-based interventions are for a range of outcomes and which features of interventions are most effective. This paper systematically reviews randomized controlled trial evidence of the effectiveness of interventions for children with ADHD in school settings. Three methods of synthesis were used to explore the effectiveness of interventions, whether certain types of interventions are more effective than others and which components of interventions lead to effective academic outcomes. Twenty-eight studies (n=1,807) were included in the review. Eight types of interventions were evaluated and a range of different ADHD symptoms, difficulties and school outcomes were assessed across studies. Meta-analysis demonstrated beneficial effects for interventions that combine multiple features (median effect size g=0.37, interquartile range 0.32, range 0.09 to 1.13) and suggest some promise for daily report card interventions (median g=0.0.62, IQR=0.25, range 0.13 to 1.62). Meta-regression analyses did not give a consistent message regarding which types of interventions were more effective than others. Finally, qualitative comparative analysis demonstrated that self-regulation and one-to-one intervention delivery were important components of interventions that were effective for academic outcomes. These two components were not sufficient though; when they appeared with personalisation for individual recipients and delivery in the classroom, or when interventions did not aim to improve child relationships, interventions were effective. This review provides updated information about the effectiveness of non-pharmacological interventions specific to school settings and gives tentative messages about important features of these interventions for academic outcomes

Evaluating enhanced recovery after surgery: time to cover new ground and discover the missing patient voice

Multicomponent peri-operative interventions offer to accelerate patient recovery and improve cost-effectiveness. The recent National Institute of Health Research-commissioned evidence synthesis review by Nunns et al. considers the effectiveness and cost-effectiveness of all types of multicomponent interventions for older adults undergoing elective inpatient surgery. Enhanced recovery programmes (ERPs) were the most commonly evaluated intervention. An association between ERPs and decreased length of stay was observed, whilst complication rates and time to recovery were static or sometimes reduced. Important areas which lack research in the context of ERPs are patient-reported outcome measures, patients with complex needs and assessment of factors pertaining to successful ERP implementation. The next generation of ERP studies should seek to develop our understanding in these key areas

Experiences of Interventions Aiming to Improve the Mental Health and Wellbeing of Children and Young People with a Long-Term Physical Condition: A Systematic Review and Meta-ethnography

This is the author accepted manuscript. The final version is available from Wiley via the DOI in this recordBackground Children and young people with long term physical health conditions are at increased risk of experiencing mental health and wellbeing difficulties. However, there is a lack of research that explores the experiences of, and attitudes towards interventions aiming to improve their mental health and wellbeing. This systematic review seeks to address this gap in the literature by exploring what children and young people with long term conditions, their caregivers and health practitioners perceive to be important aspects of interventions aiming to improve their mental health and wellbeing. Methods An information specialist searched five academic databases using pre‐defined criteria for qualitative evaluations of interventions aiming to improve the mental health or wellbeing of children with long term physical conditions. Reviewers also performed supplementary citation and grey literature searches. Two reviewers independently screened titles, abstracts and full texts which met the inclusion criteria and conducted data extraction and quality assessment. Meta‐ethnography was used to synthesise the findings. Results Screening identified 60 relevant articles. We identified five overarching constructs through the synthesis: i) Getting In and Staying In, ii) Therapeutic Foundation, iii) Social Support, iv) A Hopeful Alternative and v) Empowerment. The line of argument which links these constructs together indicates that when interventions can provide an environment that allows young people to share their experiences and build empathetic relationships; it can enable participants to access social support and increase feelings of hope and empowerment. Conclusion These findings may provide a framework to inform the development of mental health interventions for this population, and evaluate existing interventions which already include some of the components or processes identified by this research. Further research is needed to establish which of the constructs identified by the line of argument are most effective in improving the mental wellbeing of young people living with long term conditions.National Institute for Health Research (NIHR

Evidence for specialist treatment of people with acquired brain injury in secure psychiatric services: systematic review and narrative synthesis

This is the final version. Available from NIHR Journals Library via the DOI in this recordThe protocol for this systematic review is available in ORE at http://hdl.handle.net/10871/40286Patients with acquired brain injury (ABI) may experience various physical, cognitive or emotional sequelae and are at increased risk of mental health difficulties. They may display aggressive, sexually inappropriate or disinhibited behaviour which challenges those supporting them and poses a risk to themselves or others. Such individuals may need assessment, care and/or treatment within secure settings. There is limited availability of secure placements and referral must be based on the patient meeting certain criteria. Objectives To systematically review evidence that can inform the arrangements for the specialist care of adults with ABI who may require secure psychiatric services. Data sources Seven bibliographic databases (CINAHL, HMIC, MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, Social Policy & Practice, ASSIA) were searched on 27th June 2019, date-limited to 2000. Database searches were supplemented with citation searching; inspecting relevant reviews; searching ClinicalTrials.gov and WHO International Clinical Trials Registry Platform, searching relevant websites; liaising with clinical experts and affiliation searches. Review methods We sought evidence about adults with non-degenerative ABI placed in, eligible for referral to, or being assessed for eligibility for referral to secure psychiatric services in any highincome country. Eligibility for referral to secure services was based on assessment or observation of challenging behaviours. Psychometric studies of tools used in assessments were eligible for inclusion. Study selection, data extraction and quality assessment were completed independently by two reviewers. Given the heterogeneity of studies, outcomes and data, a narrative synthesis approach was used. We were interested in identifying patient, diagnostic or symptom characteristics associated with requiring care in secure settings. Findings 6297 unique titles and abstracts were screened against inclusion criteria, leading to full-text screening of 325 papers. Forty-six observational and case-control studies and one systematic review were included; however none were set in, or referred explicitly to secure settings. Thirty-eight of the primary studies evaluated patient characteristics associated with challenging behaviour. Eight primary studies and the systematic review evaluated the psychometric properties of measures used to assess challenging behaviour. Narrative synthesis indicated a highly heterogeneous set of studies providing uncertain evidence about patient characteristics which may be associated with challenging behaviours. Whilst tentative associations were found between certain patient characteristics and occurrence of challenging behaviour, the conflicting nature of this evidence reduces confidence in these findings. There was no strong evidence to recommend the use of specific patient assessment tools. Limitations We found no evidence regarding referrals to secure treatment settings and thus were not able to directly answer our research questions. Studies investigating associations between patient characteristics and challenging behaviours varied in methodological rigour and evidence was highly heterogeneous. Conclusions There is no direct evidence to support decisions about the suitable setting for the care of adults with ABI who display challenging behaviour. There is tentative evidence about patient characteristics associated with risk of challenging behaviour. Future work Primary research is needed to inform evidence-based decisions on the appropriate setting for the care of people with ABI who display challenging behaviour.National Institute for Health Research (NIHR

Experiences of interventions to reduce hospital stay for older adults following elective treatment: Qualitative evidence‐synthesis

This is the final version. Available on open access from Wiley via the DOI in this record. Data availability statement: Data available from corresponding author upon reasonable request.Background and Objectives: Hospitals streamline treatment pathways to reduce the length of time older adults admitted for planned procedures spend in hospital. However patient perspectives have been poorly evaluated. This systematic review aimed to understand the experiences of older patients, carers, families and staff of multi-component interventions intended to improve recovery following elective treatment. Research Design and Methods: Bibliographic databases searched in June 2021 included MEDLINE ALL, HMIC, CENTRAL, CINAHL, AMED and ProQuest Dissertations and Theses. We conducted citation searching and examined reference lists of reviews. Two reviewers independently undertook screening and data extraction, resolving disagreements through discussion. We used an adapted Wallace checklist for quality appraisal and meta-ethnography to synthesise data. Clinician, carer and patient views were incorporated throughout the review. Results: Thirty-five papers were included in the synthesis. Thirteen studies were conducted in the UK, with patient views the most frequently represented. We identified six overarching constructs: ‘Home as preferred environment for recovery’, ‘Feeling safe’, ‘Individualisation of structured programme’, ‘Taking responsibility’, ‘Essential care at home’ and ‘Outcomes’. Discussion and Implications: Findings explore the support patients, families and carers need throughout hospital admission, and may inform commissioning of services to ensure patients and carers receive appropriate follow-up support after hospital discharge. The findings may help hospital and community-based health and social care staff provide person-centred care based upon assessments of emotional and physical wellbeing of patients and family/carers. Research is needed to establish a core-set of patient-reported outcome measures which capture aspects of recovery which are meaningful to patients.National Institute for Health and Care Research (NIHR