Systematic review and meta-analysis of the diagnostic accuracy of prostate-specific antigen (PSA) for the detection of prostate cancer in symptomatic patients.

BACKGROUND: Prostate-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. METHODS: A 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. RESULTS: Five hundred sixty-three search hits were assessed by title and abstract after de-duplication, with 75 full text papers reviewed. Nineteen studies met the inclusion criteria, 18 of which were conducted in secondary care settings with 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 hierarchical summary receiver 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. CONCLUSIONS: Currently available evidence suggests PSA is highly sensitive but poorly specific for prostate cancer detection in symptomatic patients. 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

The effects of interactive training of healthcare providers on the management of life-threatening emergencies in hospital

Background Preparing healthcare providers to manage relatively rare life‐threatening emergency situations effectively is a challenge. Training sessions enable staff to rehearse for these events and are recommended by several reports and guidelines. In this review we have focused on interactive training, this includes any element where the training is not solely didactic but provides opportunity for discussions, rehearsals, or interaction with faculty or technology. It is important to understand the effective methods and essential elements for successful emergency training so that resources can be appropriately targeted to improve outcomes. Objectives To assess the effects of interactive training of healthcare providers on the management of life‐threatening emergencies in hospital on patient outcomes, clinical care practices, or organisational practices, and to identify essential components of effective interactive emergency training programmes. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL and ERIC and two trials registers up to 11 March 2019. We searched references of included studies, conference proceedings, and contacted study authors. Selection criteria We included randomised trials and cluster‐randomised trials comparing interactive training for emergency situations with standard/no training. We defined emergency situations as those in which immediate lifesaving action is required, for example cardiac arrests and major haemorrhage. We included all studies where healthcare workers involved in providing direct clinical care were participants. We excluded studies outside of a hospital setting or where the intervention was not targeted at practicing healthcare workers. We included trials irrespective of publication status, date, and language. Data collection and analysis We used standard methodological procedures expected by Cochrane and Cochrane Effective Practice and Organisation of Care (EPOC) Group. Two review authors independently extracted data and assessed the risk of bias of each included trial. Due to the small number of studies and the heterogeneity in outcome measures, we were unable to perform the planned meta‐analysis. We provide a structured synthesis for the following outcomes: survival to hospital discharge, morbidity rate, protocol or guideline adherence, patient outcomes, clinical practice outcomes, and organisation‐of‐care outcomes. We used the GRADE approach to rate the certainty of the evidence and the strength of recommendations for each outcome. Main results We included 11 studies that reported on 2000 healthcare providers and over 300,000 patients; one study did not report the number of participants. Seven were cluster randomised trials and four were single centre studies. Four studies focused on obstetric training, three on obstetric and neonatal care, two on neonatal training, one on trauma and one on general resuscitations. The studies were spread across high‐, middle‐ and low‐income settings. Interactive training may make little or no difference in survival to hospital discharge for patients requiring resuscitation (1 study; 30 participants; 98 events; low‐certainty evidence). We are uncertain if emergency training changes morbidity rate, as the certainty of the evidence is very low (3 studies; 1778 participants; 57,193 patients, when reported). We are uncertain if training alters healthcare providers' adherence to clinical protocols or guidelines, as the certainty of the evidence is very low (3 studies; 156 participants; 558 patients). We are uncertain if there were improvements in patient outcomes following interactive training for emergency situations, as we assessed the evidence as very low‐certainty (5 studies, 951 participants; 314,055 patients). We are uncertain if training for emergency situations improves clinical practice outcomes as the certainty of the evidence is very low (4 studies; 1417 participants; 28,676 patients, when reported). Two studies reported organisation‐of‐care outcomes, we are uncertain if interactive emergency training has any effect on this outcome as the certainty of the evidence is very low (634 participants; 179,400 patient population). We examined prespecified subgroups and found no clear commonalities in effect of multidisciplinary training, location of training, duration of the course, or duration of follow‐up. We also examined areas arising from the studies including focus of training, proportion of staff trained, leadership of intervention, and incentive/trigger to participate, and again identified no clear mediating factors. The sources of funding for the studies were governmental, local organisations, or philanthropic donors. Authors' conclusions We are uncertain if there are any benefits of interactive training of healthcare providers on the management of life‐threatening emergencies in hospital as the certainty of the evidence is very low. We were unable to identify any factors that may have allowed us to identify an essential element of these interactive training courses. We found a lack of consistent reporting, which contributed to the inability to meta‐analyse across specialities. More trials are required to build the evidence base for the optimum way to prepare healthcare providers for rare life‐threatening emergency events. These trials need to be conducted with attention to outcomes important to patients, healthcare providers, and policymakers. It is vitally important to develop high‐quality studies adequately powered and with attention to minimising the risk of bias

Time to go global: a consultation on global health competencies for postgraduate doctors

BACKGROUND: Globalisation is having profound impacts on health and healthcare. We solicited the views of a wide range of stakeholders in order to develop core global health competencies for postgraduate doctors. METHODS: Published literature and existing curricula informed writing of seven global health competencies for consultation. A modified policy Delphi involved an online survey and face-to-face and telephone interviews over three rounds. RESULTS: Over 250 stakeholders participated, including doctors, other health professionals, policymakers and members of the public from all continents of the world. Participants indicated that global health competence is essential for postgraduate doctors and other health professionals. Concerns were expressed about overburdening curricula and identifying what is 'essential' for whom. Conflicting perspectives emerged about the importance and relevance of different global health topics. Five core competencies were developed: (1) diversity, human rights and ethics; (2) environmental, social and economic determinants of health; (3) global epidemiology; (4) global health governance; and (5) health systems and health professionals. CONCLUSIONS: Global health can bring important perspectives to postgraduate curricula, enhancing the ability of doctors to provide quality care. These global health competencies require tailoring to meet different trainees' needs and facilitate their incorporation into curricula. Healthcare and global health are ever-changing; therefore, the competencies will need to be regularly reviewed and updated

Applying a genetic risk score for prostate cancer to men with lower urinary tract symptoms in primary care to predict prostate cancer diagnosis : a cohort study in the UK Biobank

Background Prostate cancer is highly heritable, with >250 common variants associated in genome-wide association studies. It commonly presents with non-specific lower urinary tract symptoms that are frequently associated with benign conditions. Methods Cohort study using UK Biobank data linked to primary care records. Participants were men with a record showing a general practice consultation for a lower urinary tract symptom. The outcome measure was prostate cancer diagnosis within 2 years of consultation. The predictor was a genetic risk score of 269 genetic variants for prostate cancer. Results A genetic risk score (GRS) is associated with prostate cancer in symptomatic men (OR per SD increase = 2.12 [1.86-2.41] P = 3.5e-30). An integrated risk model including age and GRS applied to symptomatic men predicted prostate cancer (AUC 0.768 [0.739-0.796]). Prostate cancer incidence was 8.1% (6.7-9.7) in the highest risk quintile. In the lowest quintile, prostate cancer incidence was Conclusions This study is the first to apply GRS in primary care to improve the triage of symptomatic patients. Men with the lowest genetic risk of developing prostate cancer could safely avoid invasive investigation, whilst those identified with the greatest risk could be fast-tracked for further investigation. These results show that a GRS has potential application to improve the diagnostic pathway of symptomatic patients in primary care.Peer reviewe

A modified Delphi study to develop a practical guide for selecting patients with prostate cancer for active surveillance

This is the final version. Available on open access from BMC via the DOI in this recordAvailability of data and materials: The datasets generated and/or analysed during the current study are not publicly available as consent was not sought from participants to make data publically available. Data may be available from the corresponding author on reasonable request.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 69.0% after Round Two. Following robust discussions at the face-to-face workshop, agreement was reached on the remaining statements. PSA, PSA density, Multiparametric MRI, and systematic biopsy (with or without targeted biopsy) were identified as minimum diagnostic tests required upon which to select patients to recommend AS as a treatment option for prostate cancer. Patient factors and clinical parameters that identified patients appropriate to potentially receive AS were agreed. Genetic and genomic testing was not recommended for use in clinical decision-making regarding AS. 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

Best practice in active surveillance for men with prostate cancer: a Prostate Cancer UK consensus statement.

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

Uterotonic agents for preventing postpartum haemorrhage:a network meta-analysis (Protocol)

Brathys e Trigynobrathys (88 e 59 representantes, respectivamente) são as duas maiores seções do gênero Hypericum que são distribuídos principalmente na América Central e América do Sul. Das mais de 100 espécies sul-americanas de Hypericum quase 65 são endêmicas dos Páramos, ecossistemas de alta altitude, caracterizados por uma vegetação composta principalmente de plantas de roseta gigantes, arbustos e gramíneas, nos quais Hypericum é um componente importante. Tendo em vista o escasso conhecimento da fitoquímica destas espécies de Hypericum, o presente estudo teve como objetivo estudar a composição fitoquímica e algumas bioatividades de seis espécies de Hypericum nativas do Peru (H. aciculare, H. andinum, H. brevistylum, H. decandrum, H. laricifolium e H. silenoides). O material vegetal, seco ao ar, das seis espécies (partes aéreas, caules, folhas e flores), e material vegetal subterrâneo de H. andinum (raízes e caules), foram moídas e extraídas por maceração à temperatura ambiente com n-hexano. Além disso, foram obtidos extrato etanólicos a partir de quatro espécies (H. andinum, H. brevistylum, H. laricifolium e H. silenoides). Os extratos n-hexano foram fracionados e as frações foram sometidas a processos cromatográficos obtendo-se cinco derivados de floroglucinol diméricos conhecidos, uliginosina A, uliginosina B, isouliginosina B, hiperbrasilol B e isohiperbrasilol B. Além disso, foram identificadas duas estruturas monoméricas e duas diméricas inéditas em H. andinum (raízes) e em H. laricifolium, andinina A, hiperlaricifolina A, laricifolina A e laricifolina B. Andinina A mostrou potencial atividade antidepressiva no teste de natação forçada. Do mesmo modo, a atividade antidepressiva dos extratos etanólicos foi avaliada. Estes quatro extratos apresentaram potencial atividade antidepressiva. As análises fitoquímicas por TLC, HPLC-DAD e UPLC-DAD/Q-TOF-MS revelaram que estes extratos são ricos em flavonoides, principalmente hiperosídeo. Os extratos n-hexano foram também analisados por um novo método de HPLC-DAD associado a LC-MS e UPLC-Q-TOF-MS . A presença de homólogos superiores M + 14 e regioisómeros foi determinada. A ocorrência natural destes cinco floroglucinois homólogos superiores M + 14 é descrita e a presença de outros compostos identificados pelo padrão de fragmentação MS é apresentada. Estes extratos e o seu principal componente foram capazes de inibir potencialmente a quimiotaxia induzida por LPS. Estes resultados sugerem que os extratos de espécies de Hypericum das seções Brathys e Trigynobrathys são fontes potenciais de novos anti-inflamatórios e antidepressivos.Brathys and Trigynobrathys (88 and 59 representatives, respectively) are the two largest sections of the genus Hypericum that are principally distributed in Central and South America. Of the more than 100 South American species of Hypericum almost 65 are endemic to the Páramos, high-altitude grassland ecosystems characterized by vegetation composed mainly of giant rosette plants, shrubs and grasses, in which Hypericum is a prominent component. In view of the scare knowledge on the phytochemistry of these Hypericum species, the present research aimed to study the phytochemical composition and some bioactivities of six Peruvian Hypericum species (H. aciculare, H. andinum, H. brevistylum, H. decandrum, H. laricifolium and H. silenoides). The air-dried aerial plant material of those six species (stems, leaves and flowers), and underground plant material of H. andinum (roots and stems), were ground and extracted by maceration at room temperature with n-hexane. Additionally crude ethanolic extracts were obtained from four species (H. andinum, H. brevistylum, H. laricifolium and H. silenoides). The n-hexane extracts were fractionated, and fractions were further processed by chromatographic procedures to yield five known dimeric acylphloroglucinol derivatives uliginosin A, uliginosin B, isouliginosin B, hyperbrasilol B and isohyperbrasilol B. In addition, two monomeric and two dimeric acylphloroglucinol structures were identified in H. andinum (roots extract) and H. laricifolium for the first time, andinin A, hyperlaricifolin A, laricifolin A and laricifolin B. Andinin A showed potential antidepressant-like activity in the forced swimming test. Similarly, the antidepressant-like activity of the crude ethanolic extracts was assessed. These four extracts possessed a potential antidepressant-like activity. The phytochemical analyses by TLC, HPLC-DAD and UPLCDAD/Q-TOF-MS revealed that the extracts were rich in flavonoids, principally hyperoside. The n-hexane extracts were also analyzed by a new HPLC-DAD fingerprint method associated with LC-MS and UPLC-Q-TOF-MS. The presence of M + 14 higher homologues and regioisomers could be distinguished. The natural occurrence of these five M + 14 higher homologues is described and the presence of other compounds identified by their MS fragmentation pattern is presented. These extracts and their main dimeric acylphloroglucinol component were able to potently inhibit the LPS-induced chemotaxis on rat PMN. These results suggest that extracts of Hypericum species from sections Brathys and Trigynobrathys are potential sources of new anti-inflammatory and antidepressant molecules