Summary Whilst previously rare, some surveys indicate substantial increases in the population with body mass index (BMI) ≥40 kg/m2 since the 1980s. Clinicians report emerging care challenges for this population, often with high resource demands. Accurate prevalence data, gathered using reliable methods, are needed to inform health care practice, planning, and research. We searched digitally for English language sources with measured prevalence data on adult BMI ≥40 collected since 2010. The search strategy included sources identified from recent work by NCD‐RisC (2017), grey sources, a literature search to find current sources, and digital snowball searching. Eighteen countries, across five continents, reported BMI ≥40 prevalence data in surveys since 2010: 12% of eligible national surveys examined. Prevalence of BMI ≥40 ranged from 1.3% (Spain) to 7.7% (USA) for all adults, 0.7% (Serbia) to 5.6% (USA) for men, and 1.8% (Poland) to 9.7% (USA) for women. Limited trend data covering recent decades support significant growth of BMI ≥40 population. Methodological limitations include small samples and data collection methods likely to exclude people with very high BMIs. BMI ≥40 data are not routinely reported in international surveys. Lack of data impairs surveillance of population trends, understanding of causation, and societal provision for individuals living with higher weights.

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.

The psychosocial aspects of multiple sclerosis are far-reaching and may have devastating effects on individuals and carers alike. Issues such as the impact of uncertainty, the need to maintain hope and control, and a person's ability to adjust his/her lifestyle to the disease progression are highlighted by recent research. The individualized nature of this chronic illness experience makes comprehensive and ongoing assessment crucial. Evidence from practice suggests that the district nurse's contribution to psychosocial support is hindered by poor role definition. Similarly, while the literature acknowledges the benefits of empowerment, difficulties exist in practice. Collaboration between district nurses and clinical nurse specialists is advocated as a means of integrating best practice and clinical knowledge with community expertise. The need for improved research methodology is identified.

Aims The number of people with severe obesity (BMI ⩾40 kg/m2) is increasing rapidly, but is poorly documented, partly as a result of inappropriate standard anthropometric measurement methods for community-based people. Methods As part of a broader study, people receiving care services and with severe obesity were visited at home. The people were assessed for measurements using different weighing scales and a standard portable stadiometer. If the stadiometer could not be used, their half arm span and knee height were measured to estimate their height using standard predictive equations. Results Measurements were taken for 15 women and 10 men ( n = 25) aged 40–87 years (mean 62 years). Weights ranged from 98.4 to 211.8 kg (mean 150 kg), with 16 participants requiring bariatric scales. For the six people who were unable to stand, we used wheelchair scales ( n = 1), bed weighing scales ( n = 2), routine weights from care home records ( n = 2) or weight data from hospital records ( n = 1). The standard portable stadiometer could only be used for one person; the others required alternative measures from which to estimate height. Large body habitus obscured bony landmarks, meaning alternative measures gave diverse heights. Fourteen participants had a ⩾8 cm difference in height between estimates from half arm span and knee height measurements. Conclusions Standard practice commonly does not provide reliable measurements for people with severe obesity, particularly those with mobility difficulties. An inability to measure weight and height accurately can exclude people from appropriate care, obscuring the true numbers affected and the effectiveness of future service planning. Safe community care requires the availability of specialist scales and standardised methods for height estimation appropriate for older and disabled people with severe obesity.

Background: Front-line professionals are uniquely placed to identify evidence gaps and the way routinely-collected data can help address them. This knowledge can enable incisive, clinically-relevant research. Aim: To document an example of the real-world approvals journey within the current NHS/Higher Education regulatory landscape, from the perspective of an experienced nurse undertaking doctoral study as a clinical academic. Methods: An instrumental case-study approach is used to explore the approvals process for a mixed-methods study. Relevant context is highlighted to aid understanding, including introduction of the General Data Protection Regulation and the integration of health and social care services. Results: Formal approvals by nine separate stakeholders from four different organisations took nearly 3 years, including 15 initial or revised applications, assessments or agreements. Obstacles included: conflicting views on what constitutes ‘research’ or ‘service evaluation’; isolated decision-making; fragmented data systems; multiple data controllers and a changing data governance environment. The dual perspectives of being both clinician and academic using routine data are explored. Conclusions: Practitioners face a complex approvals process to use data they routinely collect, for research or evaluation purposes. Use of data during the COVID-19 pandemic has demonstrated the need for streamlining of data governance processes. Practical recommendations are outlined.

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