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BACKGROUND: Globally, many mothers and their babies die during pregnancy and childbirth. A key element of optimizing outcomes is high- quality antenatal care. The Government of Nepal has significantly improved antenatal care and health outcomes through high-level commitment and investment; however, only 69% of patients attend the 4 recommended antenatal appointments.OBJECTIVE: This study aimed to evaluate the quality and perceptions of antenatal care in Nepal to understand compliance with the Nepalese standards.STUDY DESIGN: This cross-sectional study was conducted at a tertiary referral and private hospital in Kathmandu and a secondary hos- pital in Makwanpur, Nepal. The study recruited 538 female inpatients on postnatal wards during the 2-week data collection period from May 2019 to June 2019. A review of case notes and verbal survey of women to understand the pregnancy information they received and their sat- isfaction with antenatal care were performed. We created a summary score of the completeness of antenatal care services received ranging from 0 to 50 (50 indicating complete conformity with standards) and investigated the determinants of attending 4 antenatal care visits and patient satisfaction.RESULTS: The median antenatal care attendance was 4 visits at the secondary and referral hospitals and 8 visits at the private hospital. However, 24% of the patients attended CONCLUSION: Few women achieved full compliance with the Nepali antenatal care standards; however, some services were delivered well. To improve, each antenatal contact needs to meet its clinical aims and be respectful. To achieve this communication and counseling training for staff, investment in health promotion and delivery of core services are needed. It is important that these interventions address key issues, such as attendance in the first trimester of pregnancy, improving privacy and optimizing communication around danger signs. However, they must be designed alongside staff and service users and their efficacy tested before widespread investment or implementation.

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Background: Maternal and neonatal mortality rates remain high in many less economically developed countries, including Nepal. Good quality antenatal care can reduce adverse pregnancy outcomes; however, identifying how best to improve antenatal care can be challenging. Objectives: Our objective was to identify interventions for maternal or neonatal benefit that have been investigated in in the antenatal period in Nepal. We wanted to understand their scale, location, cost, and effectiveness. Study design: Online bibliographic databases (Cochrane Central, Medline, Embase, CINAHL Plus, British Nursing Index, PsycInfo, Allied and Complementary Medicine) and trial registries (ClinicalTrials.gov and the World Health Organization Clinical Trials Registry Platform) were searched from their inception until 24th May 2020. We included all studies reporting any maternal or neonatal outcome following an intervention in the antenatal period. We screened studies and extracted data in duplicate. Meta-analysis was not possible due to the heterogeneity of interventions and outcomes, so we performed a narrative synthesis of the included studies. Results: Twenty-five studies met our inclusion criteria. These studies showed a variety of approaches to improving antenatal care (e.g. educational programs, incentive schemes, micronutrient supplementation) in different settings (home, community or hospital-based) and with a wide variety of outcomes. Less than a quarter of the studies were randomized controlled trials, and many were single-site or reported only short-term outcomes. All studies reported having made a positive impact on antenatal care in some way but only three provided a cost-benefit analysis to support implementation. None of these studies focused on the most remote communities in Nepal. Conclusions: Our systematic review found good quality evidence that micronutrient supplementation and educational interventions can bring important clinical benefits. Iron folic acid supplementation significantly reduces neonatal mortality and maternal anaemia, while birth preparedness classes increase uptake of antenatal and postnatal care, increase compliance with micronutrient supplementation, and increase awareness of danger signs in pregnancy. Funding: Project funding through University of Bristol Global Challenges Research Fund (GCRF) and salary support from National Institute for Health and Research (NIHR).

BackgroundProstate Specific Antigen (PSA) is a commonly used test to detect prostate cancer. Attention has mostly focused on the use of PSA in screening asymptomatic patients, but the diagnostic accuracy of PSA for prostate cancer in patients with symptoms is less well understood.MethodsA systematic database search was conducted of Medline, EMBASE, Web of Science, and the Cochrane library. Studies reporting the diagnostic accuracy of PSA for prostate cancer in patients with symptoms were included. Two investigators independently assessed the titles and abstracts of all database search hits and full texts of potentially relevant studies against the inclusion criteria, and data extracted into a proforma. Study quality was assessed using the QUADAS-2 tool by two investigators independently. Summary estimates of diagnostic accuracy were calculated with meta-analysis using bivariate mixed effects regression.Results563 search hits were assessed by title and abstract after de-duplication, with 75 full text papers reviewed. 19 studies met the inclusion criteria, 18 of which were conducted in secondary care settings (one from a screening study cohort). All studies used histology obtained by Transrectal Ultrasound guided biopsy (TRUS) as a reference test, usually only for patients with elevated PSA or abnormal prostate examination. Pooled data from 14,489 patients found estimated sensitivity of PSA for prostate cancer was 0.93 (95% CI 0.88, 0.96) and specificity was 0.20 (95% CI 0.12, 0.33). The area under the receiving-operator characteristic curve was 0.72 (95% CI 0.68, 0.76). All studies were assessed as having a high risk of bias in at least one QUADAS-2 domain.ConclusionsCurrently available evidence suggests PSA is highly sensitive but poorly specific for prostate cancer detection. However, significant limitations in study design and reference test reduces the certainty of this estimate. There is very limited evidence for the performance of PSA in primary care, the healthcare setting where most PSA testing is performed.

This cohort study uses data from the Surveillance, Epidemiology, and End Results Program to identify the most common causes of death among US men diagnosed with metastatic prostate cancer from 2000 to 2016., Key Points Question What are the most common causes of death in patients diagnosed with metastatic prostate cancer (PC)? Findings In this cohort study of 26 168 patients with metastatic PC, 16 732 died during the follow-up period. Of these deaths, 77.8% were from PC, 5.5% were from other cancers, and 16.7% were from noncancer causes, including cardiovascular diseases, chronic obstructive pulmonary disease, and cerebrovascular diseases. Meaning These findings suggest that therapy and follow-up should be tailored to the needs of each patient with metastatic PC and counseling should be provided regarding future health risks., Importance Owing to improved survival among US patients with prostate cancer (PC), patients tend to live long enough after a PC diagnosis for non–cancer-related comorbidities to be associated with their overall survival. Although studies have investigated causes of death among patients with localized PC, data are lacking regarding causes of death among patients with metastatic PC. Objective To assess causes of death among US patients with metastatic PC from 2000 to 2016. Design, Setting, and Participants This retrospective cohort study used data from the Surveillance, Epidemiology, and End Results Program database to analyze a sample of 26 168 US men who received a diagnosis of metastatic PC from January 1, 2000, to December 31, 2016. Data were analyzed from February 2 to July 28, 2020. Exposure Diagnosis of metastatic PC. Main Outcomes and Measures Standardized mortality ratios (SMRs) for different causes of death were calculated by dividing the observed number of deaths from each cause of death by the expected number of deaths in the age-matched US male population for the same period, adjusting for age and race/ethnicity. Results Of 26 168 patients with metastatic PC included in the analysis, 48.9% were aged 50 to 70 years (mean age at diagnosis, 70.83 years); 74.5% were White individuals, and 72.7% received a diagnosis of stage M1b metastatic PC. A total of 16 732 patients (63.9%) died during the follow-up period. The mean age at death was 74.13 years. Most deaths (59.0%) occurred within the latency period of 2 years after diagnosis of metastatic PC, whereas 31.6% occurred 2 to 5 years after diagnosis and 9.4% occurred more than 5 years after diagnosis. Of the total deaths, 13 011 (77.8%) were from PC, 924 (5.5%) were from other cancers, and 2797 (16.7%) were from noncancer causes. During all latency periods, the most common noncancer causes of death were cardiovascular diseases (SMR, 1.34; 95% CI, 1.26-1.42), chronic obstructive pulmonary disease (SMR, 1.19; 95% CI, 1.03-1.36), and cerebrovascular diseases (SMR, 1.31; 95% CI, 1.13-1.50). Conclusions and Relevance In this cohort study, deaths from noncancer causes, including cardiovascular disease, constituted a substantial number of deaths among men with metastatic PC. Therapy and follow-up should be tailored to the needs of each patient with metastatic PC, and counseling regarding future health risks should be provided.

ObjectiveTo evaluate whether the implementation of the FAST‐M complex intervention was feasible and improved the recognition and management of maternal sepsis in a low‐resource setting.DesignA before‐and‐after design.SettingFifteen government healthcare facilities in Malawi.PopulationWomen suspected of having maternal sepsis.MethodsThe FAST‐M complex intervention consisted of the following components: the FAST‐M maternal sepsis treatment bundle and the FAST‐M implementation programme. Performance of selected process outcomes was compared between a 2‐month baseline phase and 6‐month intervention phase with compliance used as a proxy measure of feasibility.Main outcome resultCompliance with vital sign recording and use of the FAST‐M maternal sepsis bundle.ResultsFollowing implementation of the FAST‐M intervention, women were more likely to have a complete set of vital signs taken on admission to the wards (0/163 [0%] versus 169/252 [67.1%], P P P = 0.091). In particular, women were more likely to receive antibiotics (3/12 [25.0%] versus 72/107 [67.3%], P = 0.004) within 1 hour of recognition of suspected sepsis.ConclusionImplementation of the FAST‐M complex intervention was feasible and led to the improved recognition and management of suspected maternal sepsis in a low‐resource setting such as Malawi.Tweetable AbstractImplementation of a sepsis care bundle for low‐resources improved recognition & management of maternal sepsis.

Objectives To develop a consensus statement on current best practice of active surveillance (AS) in the UK, informed by patients and clinical experts. Subjects and Methods A consensus statement was drafted on the basis of three sources of data: systematic literature search of national and international guidelines; data arising from a Freedom of Information Act request to UK urology departments regarding their current practice of AS; and survey and interview responses from men with localized prostate cancer regarding their experiences and views of AS. The Prostate Cancer UK Expert Reference Group (ERG) on AS was then convened to discuss and refine the statement. Results Guidelines and protocols for AS varied significantly in terms of risk stratification, criteria for offering AS, and protocols for AS between and within countries. Patients and healthcare professionals identified clinical, emotional and process needs for AS to be effective. Men with prostate cancer wanted more information and psychological support at the time of discussing AS with the treating team and in the first 2 years of AS, and a named healthcare professional to discuss any questions or concerns they had. The ERG agreed 30 consensus statements regarding best practice for AS. Statements were grouped under headings: ‘Inclusion/Exclusion Criteria’; ‘AS follow-up protocol’ and ‘When to stop AS’. Conclusion Significant variation currently exists in the practice of AS in the UK and internationally. Men have clear views on the level of involvement in treatment decisions and support from their treating professionals when receiving AS. The Prostate Cancer UK AS ERG has developed a set of consensus statements for best practice in AS. Evidence for best practice in AS, and the use of multiparametric magnetic resonance imaging in AS, is still evolving, and further studies are needed to determine how to optimize AS outcomes

ObjectivesTo confirm the association of previously reported prognostic factors with future progression of localised prostate cancer using primary care data and identify new potential prognostic factors for further assessment in prognostic model development and validation.DesignRetrospective cohort study, employing Cox proportional hazards regression controlling for age, prostate specific antigen (PSA), and Gleason score, was stratified by diagnostic stage.SettingPrimary care in England.ParticipantsMales with localised prostate cancer diagnosedbetween 01/01/1987 and 31/12/2016 within the Clinical Practice ResearchDatalink database, with linked data from the National Cancer Registration andAnalysis Service and Office for National Statistics.Primary and secondary outcomesPrimary outcome measure was prostate cancer mortality. Secondary outcome measures were all-cause mortality and commencing systemic therapy. Up-staging after diagnosis was not used as a secondary outcome owing to significant missing data.Results10 901 men (mean age 74.38±9.03 years) with localised prostate cancer were followed up for a mean of 14.12 (±6.36) years. 2331 (21.38%) men underwent systemic therapy and 3450 (31.65%) died, including 1250 (11.47%) from prostate cancer. Factors associated with an increased risk of prostate cancer mortality included age; high PSA; current or ex-smoker; ischaemic heart disease; high C reactive protein; high ferritin; low haemoglobin; high blood glucose and low albumin.ConclusionsThis study identified several new potential prognostic factors for prostate cancer progression, as well as confirming some known prognostic factors, in an independent primary care data set. Further research is needed to develop and validate a prognostic model for prostate cancer progression.

BackgroundMost cancers in sub-Saharan Africa (SSA) are diagnosed at advanced stages, with limited treatment options and poor outcomes. Part of this may be linked to various events occurring in patients’ journey to diagnosis. Using the model of pathways to treatment, we examined the evidence regarding the routes to cancer diagnosis in SSA.Design and settingsA systematic review of available literature was performed.MethodsThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Between 30 September and 30 November 2019, seven electronic databases were searched using terms relating to SSA countries, cancer and routes to diagnosis comprising the population, exposure and outcomes, respectively. Citation lists of included studies were manually searched to identify relevant studies. Furthermore, ProQuest Dissertations & Theses Global was searched to identify appropriate grey literature on the subject.Results18 of 5083 references identified met the inclusion criteria: eight focused on breast cancer; three focused on cervical cancer; two each focused on lymphoma, Kaposi’s sarcoma and childhood cancers; and one focused on colorectal cancer. With the exception of Kaposi’s sarcoma, definitive diagnoses were made in tertiary healthcare centres, including teaching and regional hospitals. The majority of participants initially consulted within primary care, although a considerable proportion first used complementary medicine before seeking conventional medical help. The quality of included studies was a major concern, but their findings provided important insight into the pathways to cancer diagnosis in the region.ConclusionThe proportion of patients who initially use complementary medicine in their cancer journey may explain a fraction of advanced-stage diagnosis and poor survival of cancer in SSA. However, further research would be necessary to fully understand the exact role (or activities) of primary care and alternative care providers in patient cancer journeys.

Background Active surveillance (AS) is a management option for men diagnosed with lower risk prostate cancer. There is wide variation in all aspects of AS internationally, from patient selection to investigations and follow-up intervals, and a lack of clear evidence on the optimal approach to AS. This study aimed to provide guidance for clinicians from an international panel of prostate cancer experts. Methods A modified Delphi approach was undertaken, utilising two rounds of online questionnaires followed by a face-to-face workshop. Participants indicated their level of agreement with statements relating to patient selection for AS via online questionnaires on a 7-point Likert scale. Factors not achieving agreement were iteratively developed between the two rounds of questionnaires. Draft statements were presented at the face-to-face workshop for discussion and consensus building. Results 12 prostate cancer experts (9 Urologists, 2 academics, 1 radiation oncologist) participated in this study from a range of geographical regions (4 USA, 4 Europe, 4 Australia). Complete agreement on statements presented to the participants was 29.4% after Round One and 69.5% after Round Two. Following robust discussions at the face-to-face workshop, agreement was reached on the remaining statements. Conclusions The lack of consistency in the practice of AS for men with lower risk prostate cancer between and within countries was reflected in this modified Delphi study. There are, however, areas of common practice and agreement from which clinicians practicing in the current environment can use to inform their clinical practice to achieve the best outcomes for patients.

Non-invasive prenatal testing is regularly used to screen for aneuploidies and Rhesus status of a fetus. Since 1997 when free fetal DNA (ffDNA) in the maternal circulation was first identified, it has been hypothesized that it may be possible to use non-invasive prenatal testing (NIPT) to identify high-risk pregnancies including pre-eclampsia, growth restriction and preterm birth. Since then there has been much interest in this area as a way to identify and understand disease processes. This review presents the current evidence for this approach. For pre-eclampsia the hypothesis is that ffDNA would increase but the evidence for this is heterogenous across studies and trimesters. There is however increasing agreement between studies that by the third trimester ffDNA is more likely to be raised in pre-eclamptic patients than controls. For preterm birth, again, the main hypothesis is that ffDNA should increase. The results are also heterogenous, with some studies finding increased ffDNA prior to preterm birth, and others finding no change. For fetal growth restriction, there are competing theories for reduced and increased ffDNA and some studies suggest that levels are raised and some reduced. There are complexities in interpreting all of this evidence as the studies' designs, patient populations, and especially in the context of growth restriction, the definitions are not clear. Furthermore, authors use different biochemical tests and different units to describe their results, making meta-analysis difficult. All of these issues and conflicting findings lead us to the conclusion that currently there is yet no definitive place in clinical practice for NIPT to support the diagnosis and management of high-risk pregnancies. However, it is vital that this research continues as it could open the door to better understanding of the disease process and novel approaches to management.

ObjectiveTo implement a modified obstetric early warning system (MOEWS) to promote identification and stabilization of unwell women.MethodsA before-and-after study of MOEWS implementation took place between April 2013 and January 2014 in a government referral hospital in Bulawayo, Zimbabwe. After piloting MOEWS, cesarean case files were retrospectively assessed to compare preoperative stabilization. A longitudinal “spot-check” study measured use of MOEWS and action taken on abnormal results. A quality indicator was introduced to assess ongoing implementation.ResultsAnalysis of women undergoing cesarean before (n=79) and after (n=85) MOEWS implementation showed that preoperative stabilization improved significantly post-intervention (odds ratio 2.78, 95% confidence interval 1.39–5.54). The longitudinal analysis of women at baseline (n=43) and after (n=85) MOEWS implementation also showed a significant improvement in action taken (1/24 [4%] vs 28/45 [62%]; P=0.001). The 6-month aggregated quality indicator revealed that 78 (62%) of 125 patients had a completed MOEWS chart, with appropriate stabilization of 65 (93%) of 70 women.ConclusionImplementation of MOEWS improved women's care through action being taken on abnormal observations. Before whole-scale adoption of MOEWS in low-resource settings, the study should be scaled up and repeated to ensure replicable findings.

Angina pectoris is chest pain due to insufficient coronary artery blood flow and/or increased myocardial oxygen demand. In 2012, angina affected 3.05% of men and 1.79% of women in the UK. Stable angina is a chronic disease that can progress to unstable angina or myocardial infarction. Lifestyle modification, medications, and cardiac intervention/cardiothoracic surgery all play a part in its management. Patients with angina are mostly managed in primary care, where the focus of care is on maintaining quality of life and preventing disease progression.

> Ted is a 65-year-old retired arts teacher. He was recently diagnosed with localised prostate cancer. He has been to see the urologist to discuss his prognosis and treatment options. Men and clinicians face difficult decisions with regards to treatments for prostate cancer. For our patients, they can be faced with a choice of radical treatments, which carry a high risk of incontinence and sexual dysfunction, or active surveillance, which can be perceived to go against the strong public cancer narrative of ‘find it early and treat it’. Although studies such as the PROTECT trial suggest minimal reductions in mortality from aggressive treatments when compared with active surveillance,1 prostate cancer still causes a significant number of cancer-related deaths. Predicting the long-term outcomes for men with a diagnosis of localised disease is difficult, although new methods for understanding a man’s risk and informing treatment decisions are being developed and refined. Clearly communicating the potential risks, benefits, and uncertainties with men is vital to help them navigate these difficult choices, which can be made easier with their GP by their side. > Ted hasn’t come to a decision about whether to undergo radical treatment for his prostate cancer or active surveillance. He makes an appointment to see you to run through his options. Most patients …

Objective To identify and characterize patient-centered outcomes (PCOs) relating to multiparametric MRI (mpMRI) and MRI-guided biopsy as diagnostic tests for possible prostate cancer. Methods Medline via OVID, EMBASE, PsycInfo, and the Cochrane Central register of Controlled Trials (CENTRAL) were searched for relevant articles. Hand searching of reference lists and snowballing techniques were performed. Studies of mpMRI and MRI-guided biopsy that measured any PCO were included. There were no restrictions placed on year of publication, language, or country for study inclusion. All database search hits were screened independently by two reviewers, and data were extracted using a standardized form. Results Overall, 2,762 database search hits were screened based on title and abstract. Of these, 222 full-text articles were assessed, and 10 studies met the inclusion criteria. There were 2,192 participants featured in the included studies, all of which were conducted in high-income countries. Nineteen different PCOs were measured, with a median of four PCOs per study (range 1-11). Urethral bleeding, pain, and urinary tract infection were the most common outcomes measured. In the four studies that compared mpMRI or MRI-guided biopsy to transrectal ultrasound biopsy, most adverse outcomes occurred less frequently in MRI-related tests. These four studies were assessed as having a low risk of bias. Discussion PCOs measured in studies of mpMRI or MRI-guided biopsy thus far have mostly been physical outcomes, with some evidence that MRI tests are associated with less frequent adverse outcomes compared with transrectal ultrasound biopsy. There was very little evidence for the effect of mpMRI and MRI-guided biopsy on emotional, cognitive, social, or behavioral outcomes.

BACKGROUND: Surgical intervention is needed in some cases of spontaneous abortion to remove retained products of conception. Antibiotic prophylaxis may reduce the risk of pelvic infection, which is an important complication of this surgery, particularly in low-resource countries.METHODS: We conducted a double-blind, placebo-controlled, randomized trial investigating whether antibiotic prophylaxis before surgery to complete a spontaneous abortion would reduce pelvic infection among women and adolescents in low-resource countries. We randomly assigned patients to a single preoperative dose of 400 mg of oral doxycycline and 400 mg of oral metronidazole or identical placebos. The primary outcome was pelvic infection within 14 days after surgery. Pelvic infection was defined by the presence of two or more of four clinical features (purulent vaginal discharge, pyrexia, uterine tenderness, and leukocytosis) or by the presence of one of these features and the clinically identified need to administer antibiotics. The definition of pelvic infection was changed before the unblinding of the data; the original strict definition was two or more of the clinical features, without reference to the administration of antibiotics.RESULTS: We enrolled 3412 patients in Malawi, Pakistan, Tanzania, and Uganda. A total of 1705 patients were assigned to receive antibiotics and 1707 to receive placebo. The risk of pelvic infection was 4.1% (68 of 1676 pregnancies) in the antibiotics group and 5.3% (90 of 1684 pregnancies) in the placebo group (risk ratio, 0.77; 95% confidence interval [CI], 0.56 to 1.04; P = 0.09). Pelvic infection according to original strict criteria was diagnosed in 1.5% (26 of 1700 pregnancies) and 2.6% (44 of 1704 pregnancies), respectively (risk ratio, 0.60; 95% CI, 0.37 to 0.96). There were no significant between-group differences in adverse events.CONCLUSIONS: Antibiotic prophylaxis before miscarriage surgery did not result in a significantly lower risk of pelvic infection, as defined by pragmatic broad criteria, than placebo. (Funded by the Medical Research Council and others; AIMS Current Controlled Trials number, ISRCTN97143849.).

Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Prophylactic uterotonic drugs can reduce blood loss and are routinely recommended. There are several uterotonic drugs for preventing PPH, but it is still debatable which drug or combination of drugs is the most effective.To identify the most effective and cost-effective uterotonic drug(s) to prevent PPH, and generate a ranking according to their effectiveness and side-effect profile.The Cochrane Pregnancy and Childbirth's Trials Register (1 June 2015), ClinicalTrials.gov and the World Health Organization (WHO)'s International Clinical Trials Registry Platform (ICTRP) were searched for unpublished trial reports (30 June 2015). In addition, reference lists of retrieved studies (updated October 2017) were searched for randomised trials evaluating uterotonic drugs for preventing PPH. The study estimated relative effects and rankings for preventing PPH, defined as blood loss of ≥ 500 ml and ≥ 1000 ml. Pairwise meta-analyses and network meta-analysis were performed to determine the relative effects and rankings of all available drugs and combinations thereof [ergometrine, misoprostol (CytotecFrom 137 randomised trials and 87,466 women, ergometrine plus oxytocin, carbetocin and misoprostol plus oxytocin were found to reduce the risk of PPH blood loss of ≥ 500 ml compared with the standard drug, oxytocin [ergometrine plus oxytocin: risk ratio (RR) 0.69, 95% confidence interval (CI) 0.57 to 0.83; carbetocin: RR 0.72, 95% CI 0.52 to 1.00; misoprostol plus oxytocin: RR 0.73, 95% CI 0.6 to 0.9]. Each of these three strategies had 100% cumulative probability of being ranked first, second or third most effective. Oxytocin was ranked fourth, with an almost 0% cumulative probability of being ranked in the top three. Similar rankings were noted for the reduction of PPH blood loss of ≥ 1000 ml (ergometrine plus oxytocin: RR 0.77, 95% CI 0.61 to 0.95; carbetocin: RR 0.70, 95% CI 0.38 to 1.28; misoprostol plus oxytocin: RR 0.90, 95% CI 0.72 to 1.14), and most secondary outcomes. Ergometrine plus oxytocin and misoprostol plus oxytocin had the poorest ranking for side effects. Carbetocin had a favourable side-effect profile, which was similar to oxytocin. However, the analysis was restricted to high-quality studies, carbetocin lost its ranking and was comparable to oxytocin. The relative cost-effectiveness of the alternative strategies is inconclusive, and the results are affected by both the uncertainty and inconsistency in the data reported on adverse events. For vaginal delivery, when assuming no adverse events, ergometrine plus oxytocin is less costly and more effective than all strategies except carbetocin. The strategy of carbetocin is both more effective and more costly than all other strategies. When taking adverse events into consideration, all prevention strategies, except oxytocin, are more costly and less effective than carbetocin. For delivery by caesarean section, with and without adverse events, the relative cost-effectiveness is different, again because of the uncertainty in the available data.There was considerable uncertainty in findings within the planned subgroup analyses, and subgroup effects cannot be ruled out.Ergometrine plus oxytocin, carbetocin and misoprostol plus oxytocin are more effective uterotonic drug strategies for preventing PPH than the current standard, oxytocin. Ergometrine plus oxytocin and misoprostol plus oxytocin cause significant side effects. Carbetocin has a favourable side-effect profile, which was similar to oxytocin. However, most carbetocin trials are small and of poor quality. There is a need for a large high-quality trial comparing carbetocin with oxytocin; such a trial is currently being conducted by the WHO. The relative cost-effectiveness is inconclusive, and results are affected by uncertainty and inconsistency in adverse events data.This study is registered as PROSPERO CRD42015020005; Cochrane Pregnancy and Childbirth Group (substudy) reference number 0871; PROSPERO-Cochrane (substudy) reference number CRD42015026568; and sponsor reference number ERN_13-1414 (University of Birmingham, Birmingham, UK).Funding for this study was provided by the National Institute for Health Research Health Technology Assessment programme in a research award to the University of Birmingham and supported by the UK charity Ammalife (UK-registered charity 1120236). The funders of the study had no role in study design, data collection, data synthesis, interpretation or writing of the report.Postpartum haemorrhage (PPH) is the most common reason why mothers die in childbirth worldwide. Although most healthy women can cope well with blood loss after birth, some do not, and this can pose a serious risk to their health and even life. To reduce blood loss after birth, the routine administration of a drug to contract the uterus (uterotonic) has become standard practice across the world. This research seeks to identify which is the most effective and cost-effective drug. Different drugs have been used for reducing the occurrence of PPH. They include oxytocin, misoprostol, ergometrine, carbetocin, and combinations of these drugs, each with different effectiveness and side effects. The study synthesised the available evidence to compare all of these drugs and combinations thereof. After putting the results of all available comparisons together in a network, a ranking among them was calculated, and provided robust effectiveness and side-effect profiles for each drug and their associated costs. The study included 137 randomised trials, involving a total of 87,466 women. The results suggested that ergometrine plus oxytocin, carbetocin and misoprostol plus oxytocin are the most effective strategies for preventing PPH and are more effective than the currently recommended drug, oxytocin. Each of these three strategies had almost 100% probability of being ranked first, second or third most effective. Oxytocin was ranked fourth with an almost 0% probability of being ranked in the top three. Ergometrine plus oxytocin and misoprostol plus oxytocin were the worst drug combinations for side effects, with carbetocin having the most favourable side-effect profile. Carbetocin could prevent approximately one further event of PPH out of three in comparison with oxytocin. However, existing carbetocin studies were small and of poor quality. There is need for a large high-quality study comparing carbetocin with the current standard treatment of oxytocin for the prevention of PPH. The cost analyses of the alternative drug strategies remain inconclusive.

ispartof: LANCET ONCOLOGY vol:19 issue:12 pages:E665-E665 ispartof: location:England status: published

Background:Nodal metastasis is an important prognostic factor in head and neck squamous cell carcinoma. This study aimed to determine the average nodal basin yield per level of neck dissection, and to investigate if age, gender, body mass index, tumour size, depth of tumour invasion and p16 status influence nodal yield.Method:A retrospective review of 185 patients with head and neck squamous cell carcinoma generated 240 neck dissection specimens.Results:The respective mean nodal yields for levels I, II, III, IV and V were 5.27, 9.43, 8.49, 7.43 and 9.02 in non-cutaneous squamous cell carcinoma patients, and 4.2, 7.57, 9.65, 4.33 and 12.29 in cutaneous squamous cell carcinoma patients. Multiple regression analysis revealed that p16-positive patients with mucosal squamous cell carcinoma yielded, on average, 2.4 more nodes than their p16-negative peers (p = 0.04, 95 per cent confidence interval = 0.116 to 4.693). This figure was 3.84 (p = 0.008, 95 per cent confidence interval = 1.070 to 6.605) for p16-positive patients with oral cavity squamous cell carcinoma.Conclusion:In mucosal squamous cell carcinoma, p16-positive status significantly influenced nodal yield, with the impact being more pronounced in oral cavity squamous cell carcinoma patients.

Background Maternal mortality is high in Loreto, Peru, but can be reduced by high quality antenatal care. Indicators for the quality of antenatal care received include the timing (with respect to gestational age) and number of antenatal appointments attended, the delivery of antenatal services and health information, and women’s perceptions about their care. This study investigated these indicators amongst women receiving antenatal care in predominantly the San Juan Bautista district of Iquitos, Loreto. This was to identify areas for improvement through comparison with antenatal guidelines published by the Ministry of Health, Peru, and the World Health Organization. Methods A total of 134 women were recruited at the Centro de Salud, San Juan—a primary care centre in Iquitos. Information about the delivery of antenatal services and the number of and gestational ages at appointments attended was collected from 121/134 women’s hand-held antenatal cards. The delivery of health information and women’s perceptions about their antenatal care were investigated through questionnaires (133/134 completed). Descriptive statistics, such as frequencies and valid percentages, were determined. Results Hand-held antenatal cards revealed that 52.9% of participants began their antenatal care in the first trimester. Compared to national guidelines, 42.1% attended appointments at recommended gestational ages and no women received all recommended antenatal services. Most women received information about identifying complications in pregnancy and health and lifestyle topics. Over 85% of women reported satisfaction with their antenatal care. Conclusions Timely antenatal attendance and delivery of services should be encouraged to meet national and global standards. Although all services were not delivered in a combined manner according to national guidelines, individual services were mostly delivered to a high standard and therefore a high proportion of women were satisfied with their antenatal care.

Background: Stillbirth has a profound impact on women, families, and healthcare workers. The burden is highest in low- and middle-income countries (LMICs). There is need for respectful and supportive care for women, partners, and families after bereavement. Objective: To perform a qualitative meta-summary of parents’ and healthcare professionals’ experiences of care after stillbirth in LMICs. Search strategy: Search terms were formulated by identifying all synonyms, thesaurus terms, and variations for stillbirth. Databases searched were AMED, EMBASE, MEDLINE, PsychINFO, BNI, CINAHL. Selection criteria: Qualitative, quantitative, and mixed method studies that addressed parents’ or healthcare professionals’ experience of care after stillbirth in LMICs. Data collection and analysis: Studies were screened, and data extracted in duplicate. Data were analysed using the Sandelowski meta-summary technique that calculates frequency and intensity effect sizes (FES/IES). Main results: In all, 118 full texts were screened, and 34 studies from 17 countries were included. FES range was 15–68%. Most studies had IES 1.5–4.5. Women experience a broad range of manifestations of grief following stillbirth, which may not be recognised by healthcare workers or in their communities. Lack of recognition exacerbates negative experiences of stigmatisation, blame, devaluation, and loss of social status. Adequately developed health systems, with trained and supported staff, are best equipped to provide the support and information that women want after stillbirth. Conclusions: Basic interventions could have an immediate impact on the experiences of women and their families after stillbirth. Examples include public education to reduce stigma, promoting the respectful maternity care agenda, and investigating stillbirth appropriately. Tweetable abstract: Reducing stigma, promoting respectful care and investigating stillbirth have a positive impact after stillbirth for women and families in LMICs.

Prostate cancer is a common malignancy seen worldwide. The incidence has risen in recent decades, mainly fuelled by more widespread use of prostate-specific antigen (PSA) testing, although prostate cancer mortality rates have remained relatively static over that time period. A man's risk of prostate cancer is affected by his age and family history of the disease. Men with prostate cancer generally present symptomatically in primary care settings, although some diagnoses are made in asymptomatic men undergoing opportunistic PSA screening. Symptoms traditionally thought to correlate with prostate cancer include lower urinary tract symptoms (LUTS), such as nocturia and poor urinary stream, erectile dysfunction and visible haematuria. However, there is significant crossover in symptoms between prostate cancer and benign conditions affecting the prostate such as benign prostatic hypertrophy (BPH) and prostatitis, making it very challenging to distinguish between them on the basis of symptoms. The evidence for the performance of PSA in asymptomatic and symptomatic men for the diagnosis of prostate cancer is equivocal. PSA is subject to false positive and false negative results, affecting its clinical utility as a standalone test. Clinicians need to counsel men about the risks and benefits of PSA testing to inform their decision-making. Digital rectal examination (DRE) by primary care clinicians has some evidence to show discrimination between benign and malignant conditions affecting the prostate. Patients referred to secondary care for diagnostic testing for prostate cancer will typically undergo a transrectal or transperineal biopsy, where a number of samples are taken and sent for histological examination. These biopsies are invasive procedures with side effects and a risk of infection and sepsis, and alternative tests such as multiparametric magnetic resonance imaging (mpMRI) are currently being trialled for their accuracy and safety in diagnosing clinically significant prostate cancer.

Background The estimated annual global burden of miscarriage is 33 million out of 210 million pregnancies. Many women undergoing miscarriage have surgery to remove pregnancy tissues, resulting in miscarriage surgery being one of the most common operations performed in hospitals in low-income countries. Infection is a serious consequence and can result in serious illness and death. In low-income settings, the infection rate following miscarriage surgery has been reported to be high. Good quality evidence on the use of prophylactic antibiotics for surgical miscarriage management is not available. Given that miscarriage surgery is common, and infective complications are frequent and serious, prophylactic antibiotics may offer a simple and affordable intervention to improve outcomes. Methods Eligible patients will be approached once the diagnosis of miscarriage has been made according to local practice. Once informed consent has been given, participants will be randomly allocated using a secure internet facility (1:1 ratio) to a single dose of oral doxycycline (400 mg) and metronidazole (400 mg) or placebo. Allocation will be concealed to both the patient and the healthcare providers. A total of 3400 women will be randomised, 1700 in each arm. The medication will be given approximately 2 hours before surgery, which will be provided according to local practice. The primary outcome is pelvic infection 2 weeks after surgery. Women will be invited to the hospital for a clinical assessment at 2 weeks. Secondary outcomes include overall antibiotic use, individual components of the primary outcome, death, hospital admission, unplanned consultations, blood transfusion, vomiting, diarrhoea, adverse events, anaphylaxis and allergy, duration of clinical symptoms, and days before return to usual activities. An economic evaluation will be performed to determine if prophylactic antibiotics are cost-effective. Discussion This trial will assess whether a single dose of doxycycline (400 mg) and metronidazole (400 mg) taken orally 2 hours before miscarriage surgery can reduce the incidence of pelvic infection in women up to 2 weeks after miscarriage surgery. Trial registration Registered with the ISRCTN (international standard randomised controlled trial number) registry: ISRCTN 97143849. (Registered on April 17, 2013). Electronic supplementary material The online version of this article (10.1186/s13063-018-2598-3) contains supplementary material, which is available to authorized users.

Background Patient–doctor continuity is valued by both parties, yet the effect of the depth of the patient–doctor relationship on the content of consultations in general practice is unknown. Aim To assess whether differences in the depth of relationship between a patient and their GP affects the length of consultations, and the number and type of problems and issues raised during a consultation. Design and setting Cross-sectional study in 22 GP practices in the UK. Method GP consultations (n = 229) were videotaped and the number of problems and aspects of those problems and issues identified. Patients completed the Patient–Doctor Depth of Relationship (PDDR) and General Practice Assessment Questionnaire-communication (GPAQc) scales. Associations were explored using multivariable linear and logistic regression. Results Complete data were available on 190 participants consulting 30 GPs. In unadjusted analysis, patients with a deep relationship with their GP discussed more problems (mean 2.8) and issues (mean 4.7) compared with those with a moderate (2.4 problems; 4.0 issues) or shallow (2.3 problems; 3.8 issues) relationship. Patients with deep relationships had consultations that were on average 118 seconds (95% CI = 1 to 236) longer than those with shallow relationships. Adjustment for participant and GP factors attenuated these relationships, although the main trends persisted. Conclusion A greater number of problems and issues may be raised in a consultation when patients have a deeper relationship with their GP. Over several clinical encounters each year, this may be associated with significant benefits to patients and efficiencies in GP consultations and warrants further investigation.

Background: Clinical trials in low- and middle-income countries (LMICs) are necessary to develop evidence-based approaches to improve women's health. Understanding what research is currently being conducted will allow the identification of research gaps, avoidance of duplication, planning of future studies, collaboration amongst research groups, and geographical targeting for research investments. Objectives:To provide an overview of active women's health trials in LMICs. Search strategy: The World Health Organization's International Clinical Trials Registry Platform was searched for trials registered between 1 April 2012 and 31 March 2014. Selection criteria: Selected trials were randomised, conducted in LMICs, active, and with a women's health intervention or a significant outcome for the woman. Data collection and analysis: Two reviewers extracted data. Analysis included geographical spread, speciality areas, pre-enrolment registration, study size, and funders. Main results: Of the 8966 records, 509 were eligible for inclusion. Gynaecology trials made up 57% of the research, whereas the remaining 43% of trials were in obstetrics. Research activity focused on fertility (17%), the antenatal period (15%), benign gynaecology (14%), intrapartum care (9%), and pre-invasive disease and cancers (8%). The majority of trials (84%) took place in middle-income countries (MICs). In low-income countries (LICs) 83% of research investigated obstetrics, and in MICs 60% of research investigated gynaecology. Most trials (80%) had a sample size of 500 or fewer participants. The median size of trials in LICs was 815 compared with 128 in MICs. Pre-enrolment registration occurred in 54% of trials. The majority (62%) of trials were funded locally. Authors' conclusions: Many LMICs are active in women's health research. The majority of registered trials are located in MICs; however, the trials in LICs are often larger. The focus of research in MICs may be driven by local priorities and funding, with fertility being highly researched. In LICs, pregnancy is the focus, perhaps reflecting the international prioritisation of maternal health.

Multidisciplinary training has improved maternity outcomes when the training has been well attended, regular, in house, used high-fidelity simulators, and integrated teamwork training. If these principles were used in other settings, better clinical care may result. This before-after study sought to establish whether a short multidisciplinary training intervention can improve recognition of the deteriorating patient using an aggregated physiological parameter scoring system (Early Warning Score [EWS]). Nursing, medical, and allied nursing staff participated in an hour-long training session, using real-life scenarios with simple tools and structured debriefing. After training, staff were more likely to calculate EWS scores correctly (68.02% vs 55.12%; risk ratio [RR] = 1.24, 95% confidence interval [CI] = 1.07-1.44), and observations were more likely to be performed at the correct frequency (78.57% vs 68.09%; RR = 1.20, 95% CI = 1.09-1.32). Multidisciplinary training, according to core principles, can lead to more accurate identification of deteriorating patients, with implications for subsequent care and outcome.

Human papillomavirus (HPV) vaccination programmes in the UK were established in 2008, and targeted females aged 12–13 years. This decision was based on recommendations from the Joint Committee for Vaccination and Immunisation (JCVI), after assessing the available evidence for the impact and cost effectiveness of HPV vaccination programmes. The theory was that reducing HPV rates in females would result in lower infection rates in males of a similar age. This herd immunity did not extend to men-who-have-sex-with-men (MSM) or heterosexual men having sex abroad. Public Health England (PHE) undertook a trial of a targeted HPV vaccination programme for MSM in 2016–2017. The 12-month pilot involved MSM up to 45 years of age being offered Gardasil® 4, a quadrivalent HPV vaccine, through genitourinary medicine (GUM) and HIV clinics across England. GPs were not included in the pilot as there was insufficient evidence of acceptability and effective delivery. The pilot was reported as a success, and PHE has recommended rolling out this programme across England.1 The JCVI issued an interim statement regarding extending HPV immunisation to adolescent males in July 2017, again concluding that there was insufficient evidence for benefit in males.2 However, after strong responses through stakeholder consultations, continued pressure from lobby groups such as HPV Action (www.hpvaction.org), and further analysis of the latest research, the JCVI recently (18 July 2018) recommended extending the HPV vaccination programme to adolescent males.3 HPV is a major cause of infection-related cancers. It is associated with cervical, anal, oropharyngeal, penile, vulval and vaginal …

Importance The current diagnostic pathway for patients with suspected prostate cancer (PCa) includes prostate biopsy. A large proportion of individuals who undergo biopsy have either no PCa or low-risk disease that does not require treatment. Unnecessary biopsies may potentially be avoided with prebiopsy imaging. Objective To compare the performance of systematic transrectal ultrasonography–guided prostate biopsy vs prebiopsy biparametric or multiparametric magnetic resonance imaging (MRI) followed by targeted biopsy with or without systematic biopsy. Data Sources MEDLINE, Embase, Cochrane, Web of Science, clinical trial registries, and reference lists of recent reviews were searched through December 2018 for randomized clinical trials using the terms “prostate cancer” and “MRI.” Study Selection Randomized clinical trials comparing diagnostic pathways including prebiopsy MRI vs systematic transrectal ultrasonography–guided biopsy in biopsy-naive men with a clinical suspicion of PCa. Data Extraction and Synthesis Data were pooled using random-effects meta-analysis. Risk of bias was assessed using the revised Cochrane tool. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. All review stages were conducted by 2 reviewers. Main Outcomes and Measures Detection rate of clinically significant and insignificant PCa, number of biopsy procedures, number of biopsy cores taken, and complications. Results Seven high-quality trials (2582 patients) were included. Compared with systematic transrectal ultrasonography–guided biopsy alone, MRI with or without targeted biopsy was associated with a 57% (95% CI, 2%-141%) improvement in the detection of clinically significant PCa, a 33% (95% CI, 23%-45%) potential reduction in the number of biopsy procedures, and a 77% (95% CI, 60%-93%) reduction in the number of cores taken per procedure. One trial showed reduced pain and bleeding adverse effects. Systematic sampling of the prostate in addition to the acquisition of targeted cores did not significantly improve the detection of clinically significant PCa compared with systematic biopsy alone. Conclusions and Relevance In this meta-analysis, prebiopsy MRI combined with targeted biopsy vs systematic transrectal ultrasonography–guided biopsy alone was associated with improved detection of clinically significant PCa, despite substantial heterogeneity among trials. Prebiopsy MRI was associated with a reduced number of individual biopsy cores taken per procedure and with reduced adverse effects, and it potentially prevented unnecessary biopsies in some individuals. This evidence supports implementation of prebiopsy MRI into diagnostic pathways for suspected PCa.

ObjectivesMen who have sex with men (MSM) are at greater risk for human papillomavirus (HPV)-associated cancers. Since 2016, MSM have been offered the HPV vaccination, which is most effective when received prior to sexual debut, at genitourinary medicine clinics in the UK. In September 2019, the national HPV vaccination programme will be extended to boys. This study aimed to understand young MSM’s (YMSM) knowledge and attitudes towards HPV vaccination.DesignQuestionnaires assessed YMSM demographics, sexual behaviour, culture, knowledge and attitudes towards HPV vaccination and stage of vaccine decision-making using the precaution adoption process model. Focus groups explored sexual health information sources, attitudes, barriers and facilitators to vaccination and strategies to support vaccination uptake. Questionnaire data were analysed using descriptive statistics and focus group data were analysed thematically.SettingQuestionnaires were completed online or on paper. Focus groups were conducted within Lesbian Gay Bisexual Transgender Queer organisational settings and a university student’s union in England and Northern Ireland.ParticipantsSeventeen YMSM (M=20.5 years) participated in four focus groups and 51 (M=21.1 years) completed questionnaires.ResultsOver half of YMSM were aware of HPV (54.9%), yet few (21.6%) had previously discussed vaccination with a healthcare professional (HCP). Thematic analyses found YMSM were willing to receive the HPV vaccine. Vaccination programmes requiring YMSM to request the vaccine, particularly prior to sexual orientation disclosure to family and friends, were viewed as unfeasible. Educational campaigns explaining vaccine benefits were indicated as a way to encourage uptake.ConclusionsThis study suggests that to effectively implement HPV vaccination for YMSM, this population requires clearer information and greater discussion with their HCP. In support of the decision made by the Joint Committee on Vaccination and Immunisation, universal vaccination is the most feasible and equitable option. However, the absence of a catch-up programme will leave a significant number of YMSM at risk of HPV infection.

Background One in five British children are overweight or obese when entering primary school but most parents fail to recognise child overweight. Health-care professionals are expected to manage childhood overweight, but initiating conversations with parents is difficult. The aim of this study was to inform the development of a visual and language toolbox to support health-care professionals in initiating sensitive conversations about weight with parents of overweight preschool children. Methods Three focus group discussions were conducted with health-care professionals (total n=29) recruited from general practices in London and Bristol, UK, and 15 semi-structured interviews were undertaken with parents of preschool children ( Findings Health-care professionals perceived parents as being unconcerned about child overweight; parents were apprehensive about health-care professionals criticising their parenting skills. Some health-care professionals did not consider child overweight to be their responsibility. General practitioners were reluctant to discuss weight with parents because of shortage of time, fear of damaging patient–practitioner relationships, and insufficient training; nurses were more willing. Both health-care professionals and parents were positive about the potential for body image scales to facilitate conversations, generally preferring scales based on three-dimensional body scans over artists' drawings. Parents thought that language used by health-care professionals needed to be clear and impactful, but not stigmatising—eg, overweight, very overweight (but not fat, heavy, or obese). Interpretation The findings suggest that a visual and language toolbox would be well received by parents and health-care professionals. Anatomically accurate preschool body image scales are needed for use in consultations. Practice nurses may be better placed than general practitioners to initiate conversations with parents. Health-care professionals should consider parents' conceptions of health and blame when conducting consultations, to encourage parental recognition of preschool overweight, with the ultimate aim of facilitating appropriate behaviour change. Funding This study is funded by a Cancer Research UK/Bupa Foundation Innovation award. The funders had no role in the writing of the abstract or the decision to submit it for publication.

Objective To assess the effectiveness of telehealth interventions in the primary prevention of cardiovascular disease in adult patients in community settings. Methods Systematic literature review of randomised controlled trials comparing the effectiveness of telehealth interventions to reduce overall cardiovascular disease (CVD) risk and/or to reduce multiple CVD risk factors compared with a non-telehealth control group was conducted in June 2013. Study quality was assessed using the Cochrane Risk of Bias tool. Fixed and random effects models were combined with a narrative synthesis for meta-analysis of included studies. Results Three of 13 included studies measured Framingham 10-year CVD risk scores, and meta-analysis showed no clear evidence of reduction in overall risk (SMD − 0.37%, 95% CI − 2.08, 1.33). There was weak evidence for a reduction in systolic blood pressure (SMD − 1.22 mm Hg 95% CI − 2.80, 0.35) and total cholesterol (SMD − 0.07 mmol/L 95% CI − 0.19, 0.06). There was no change in High-Density Lipoprotein cholesterol or smoking rates. Conclusion There is insufficient evidence to determine the effectiveness of telehealth interventions in reducing overall CVD risk. More studies are needed that consistently measure overall CVD risk, directly compare different telehealth interventions, and determine cost effectiveness of telehealth interventions for prevention of CVD.

Background Prostate cancer is the second most common cancer in the UK, with 39 741 cases diagnosed in 2014. The National Cancer Registration and Analysis Service (NCRAS) collects data about cancer (including prostate cancer) in England. The CAP study is a cluster-randomised controlled trial investigating the effectiveness and cost-effectiveness of prostate-specific antigen (PSA) testing. The value of cancer registries is high if they receive and process quality data, which can be evaluated in various domains, including completeness and validity. This study aimed to compare the completeness and accuracy of the NCRAS registry with data from the CAP study. Methods We compared the percentage completeness and agreement of prostate cancer diagnosis by Union Internationale Contre le Cancer (UICC) TNM stage and Gleason grade in the NCRAS cancer registry with information collected via independent medical record review on participants in CAP. CAP study participants were matched to NCRAS registry entries by their National Health Service number. Agreement was assessed with Cohen's κ. Findings 1356 men were included in this study (mean age 75·1 years, SD 5·1). Both the NCRAS registry (97·9%) and CAP study (98·5%) had high levels of completeness for date of diagnosis. Agreement was high for combined Gleason score (κ=0·90, 95% CI 0·89–092) and low for American Joint Committee on Cancer (AJCC) group (0·48, 0·43–0·53) overall. TNM staging agreement was 0·35 (0·31–0·37) for T, 0·51 (0·45–0·57) for N, and 0·58 (0·51–0·66) for M stage. Agreement was moderate when considering local (T1–3N0M0) versus metastatic disease (T4NxMx/TxN1Mx/TxNxM1) (0·54, 0·44–0·64). Interpretation The NCRAS prostate cancer registry has a high level of completeness for case registration, and strong accuracy for Gleason grade. Agreement of exact TNM staging and AJCC group seems low, which could be explained if staging data were collected from different sources (ie, pathological vs imaging staging methods), and needs to be explored further. Prostate cancer stage and accuracy of grade data for the NCRAS registry need repeated assessment to drive improvements in data quality. Funding None.

1 (“Cardiovascular disease” or CVD or “myocardial infarction” or “acute myocardial infarction” or MI or AMI or “coronary heart disease” or CHD or “coronary artery disease” or CAD or “ischaemic heart disease” or IHD or “acute coronary syndrome” or ACS or “heart attack” or “heart disease” or atherosclerosis or stroke or CVA or “cerebrovascular accident” or “occlusive stoke” or “haemorrhagic stroke” or “hemorrhagic stroke” or “hypertensive stroke”). mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] 618,168

This paper reports on a study that examined the financial impact of an endoluminalgrafting procedure for an abdominal aortic aneurysm using the Mialhe EndoluminalAortic Stentor. Clinical outcomes were not a focus of this study. The results of the studysuggest that financial impacts of new clinical procedures can be understood andaddressed through planning and greater liaison between clinicians, codingprofessionals and clinical costing staff.

BACKGROUND The association between hypoalbuminaemia and a new diagnosis of cancer is as yet unknown. OBJECTIVE This study aimed to assess whether unexplained hypoalbuminaemia was associated with an increased risk of subsequent new cancer diagnosis within the next 12 months. METHODS A cohort study was performed using a large UK database of adult primary care patients. Patients with a serum albumin test, either low or normal, were followed for 12 months for a new diagnosis of non-skin cancer. Logistic regression was used to assess for relationships between hypoalbuminaemia and cancer diagnoses. RESULTS A total of 100 122 participants had at least one albumin test result. Of these, 5753 (5.75%) had a result