How do Cochrane authors conduct web searching to identify studies? Findings from a cross-sectional sample of Cochrane Reviews

This is the final version. Available on open access from Wiley via the DOI in this recordBACKGROUND: Searching the World Wide Web using search engines and websites can be conducted to identify studies for systematic reviews. When searching to support systematic reviews, the searcher faces challenges in using the basic search interfaces of most search engines and websites. OBJECTIVES: To describe and evaluate current practice of web searching in a cross-sectional sample of Cochrane Reviews. The study also describes the stated aims of web searching, i.e. the identification of published or unpublished studies or both. METHODS: A six-month cross-sectional sample of Cochrane Reviews was identified via the Cochrane Library. Reviews were inspected for detail about web searching. Findings were described and evaluated using a framework of key principles for web searching. RESULTS: 423 Cochrane Reviews published August 2016-January 2017 were identified of which 61 (14%) reported web searching. Web searches were typically simplified versions of the bibliographic database search. Advanced and iterative approaches were not widely used. Google Search and Google Scholar were the most popular search engines. Most reports stated identification of grey literature as their aim. CONCLUSION: Basic web search interfaces necessitate simple searches. However, there is scope to use more diverse search features and techniques and a greater variety of search engines

Prospective study of biomechanical risk factors for second and third metatarsal stress fractures in military recruits

This is the author accepted manuscript. The final version is available from Elsevier via the DOI in this recordObjectives This prospective study investigated anatomical and biomechanical risk factors for second and third metatarsal stress fractures in military recruits during training. Design Prospective cohort study. Methods Anatomical and biomechanical measures were taken for 1065 Royal Marines recruits at the start of training when injury-free. Data included passive range of ankle dorsi-flexion, dynamic peak ankle dorsi-flexion and plantar pressures during barefoot running. Separate univariate regression models were developed to identify differences between recruits who developed second (n = 7) or third (n = 14) metatarsal stress fracture and a cohort of recruits completing training with no injury (n = 150) (p < 0.05). A multinomial logistic regression model was developed to predict the risk of injury for the two sites compared with the no-injury group. Multinomial logistic regression results were back transformed from log scale and presented in Relative Risk Ratios (RRR) with 95% confidence intervals (CI). Results Lower dynamic arch index (high arch) (RRR: 0.75, CI: 0.63–0.89, p < 0.01) and lower foot abduction (RRR: 0.87, CI: 0.80–0.96, p < 0.01) were identified as increasing risk for second metatarsal stress fracture, while younger age (RRR: 0.78, CI: 0.61–0.99, p < 0.05) and later peak pressure at the second metatarsal head area (RRR: 1.19, CI: 1.04–1.35, p < 0.01) were identified as risk factors for third metatarsal stress fracture. Conclusions For second metatarsal stress fracture, aspects of foot type have been identified as influencing injury risk. For third metatarsal stress fracture, a delayed forefoot loading increases injury risk. Identification of these different injury mechanisms can inform development of interventions for treatment and prevention.Funding to support this project was provided by University of Exeter and Institute of Naval Medicine

Estimated third metatarsal bending stresses are highly susceptible to variations in bone geometry

This is the author accepted manuscript. The final version is available from Taylor & Francis via the DOI in this record.Background: Third metatarsal stress fractures are relatively common during Royal Marines recruit training; however, their aetiology is poorly understood. Mathematical modelling of the third metatarsal may aid in understanding risk factors for stress fracture, particularly if the influence of footwear on peak bending stresses can be determined. This study built on previous models of metatarsal bending stress by integrating individual metatarsal geometry and gait data. Methods: Data from five males with size 11 (UK) feet were acquired. MRI images were digitised to determine cross-sectional bone parameters. Gait variables included vertical ground reaction forces, plantar pressure and foot orientation. The magnitude and location of peak bending stresses were calculated for barefoot running, before standard issue combat boots and trainers were compared. Findings: Estimated peak compressive, tensile and torsional stresses were greater in combat assault boots than in trainers (p < 0.05) with medium effect sizes but wide confidence intervals. However, differences in bone geometry between individuals had a much greater influence on estimated peak stresses. Interpretation: Results suggest that bone geometry has a greater influence on third metatarsal stress fracture risk than footwear. Future bone stress simulations should account for bone geometry. Further development of the model in a variety of participants should proceed to verify these suggestions

A narrow bimalleolar width is a risk factor for ankle inversion injury in male military recruits: A prospective study

This is the author accepted manuscript. The final version is available from the publisher via the DOI in this record.Background: Ankle inversion injuries are one of the most common and burdensome injuries in athletic populations. Research that prospectively identifies characteristics associated with this injury is lacking. This prospective study compared baseline anthropometric and biomechanical gait characteristics of military recruits who sustained an ankle inversion injury during training, with those who remained injury-free. Methods: Bilateral plantar pressure and three-dimensional lower limb kinematics were recorded in 1065 male, injury-free military recruits, during barefoot running. Injuries that occurred during the 32-week recruit training programme were subsequently recorded. Data were compared between recruits who sustained an ankle inversion injury during training (n=27) and a sample (n=120) of those who completed training injury-free. A logistic regression analysis was used to identify risk factors for this injury. Findings: A narrower bimalleolar width and an earlier peak pressure under the fifth metatarsal were predictors of ankle inversion injury. Those who sustained an ankle inversion injury also had a lower body mass, body mass index, and a smaller calf girth than those who completed training injury-free. Interpretation: Anthropometric and dynamic gait characteristics have been identified that may predispose recruits to an ankle inversion injury during Royal Marine recruit training, allowing identification of recruits at higher risk at the start of training

Individual risk factors associated with exertional heat illness: A systematic review

This is the final version. Available on open access from Wiley via the DOI in this record. Despite the widespread knowledge of exertional heat illness (EHI) and clear guidance for its prevention, the incidence of EHI remains high. We carried out a systematic review of available literature evaluating the scientific evidence underpinning the risk factors associated with EHI. Medline, PsycINFO, SportDiscus and Embase were searched from inception to January 2019 with no date limitation, with supplementary searches also being performed. Search terms included permutations of risk and heat illness, with only studies in English included. Study selection, data extraction and quality assessment, using the QUALSYST tool, were performed by two independent reviewers. Of 8898 articles identified by the searches, 42 were included in the systematic review as primary evidence demonstrating a link between a risk factor and EHI. The quality scores ranged from 57.50 to 100%, and studies were generally considered to be of strong quality. The majority of risks attributable to EHI were categorized as those associated with lifestyle factors. The findings from the systematic review suggest complex manifestation of EHI through multiple risk factors rather than any one factor in isolation. Further research is needed to explore the accumulation of risk factors to help in development of effective preventative measures

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

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

Boot-insole effects on comfort and plantar loading at the heel and fifth metatarsal during running and turning in soccer

Plantar loading may influence comfort, performance and injury risk in soccer boots. This study investigated the effect of cleat configuration and insole cushioning levels on perception of comfort and in-shoe plantar pressures at the heel and fifth metatarsal head region. Nine soccer academy players (age 15.7 ± 1.6 years; height 1.80 ± 0.40 m; body mass 71.9 ± 6.1 kg) took part in the study. Two boot models (8 and 6 cleats) and two insoles (Poron and Poron/gel) provided four footwear combinations assessed using pressure insoles during running and 180° turning. Mechanical and comfort perception tests differentiated boot and insole conditions. During biomechanical testing, the Poron insole generally provided lower peak pressures than the Poron/gel insole, particularly during the braking step of the turn. The boot model did not independently influence peak pressures at the fifth metatarsal, and had minimal influence on heel loads. Specific boot-insole combinations performed differently (P < 0.05). The 8-cleat boot and the Poron insole performed best biomechanically and perceptually, but the combined condition did not. Inclusion of kinematic data and improved control of the turning technique are recommended to strengthen future research. The mechanical, perception and biomechanical results highlight the need for a multi-faceted approach in the assessment of footwear

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