With increasing follow‐up of patients treated with minimally invasive ventral mesh rectopexy (VMR) more redo surgery can be expected for recurrent rectal prolapse, mesh erosion and pelvic pain. The aim of this study is to evaluate the 90‐day morbidity of robot‐assisted redo interventions.All robot‐assisted redo interventions after primary transabdominal repair of rectal prolapse between 2011 and 2019 were retrospectively analysed and compared with the results for patients after primary robot‐assisted VMR during the same period. The redo interventions were divided into groups based on the indication for surgery . Intraoperative complications and 90‐day postoperative morbidity were evaluated.p > 0.05). More intraoperative complications, minor and major complications were seen in redo surgery for erosion compared with primary VMR . The frequency of intraoperative complications after redo surgery for pelvic pain was 7% with minor and major morbidity rates of 14% and 7% (p > 0.05). Half of the patients with pelvic pain experienced relief of their symptoms.Three hundred and fifty nine patients were treated with primary VMR, with 73 for recurrent rectal prolapse, 12 for mesh erosion and 14 for pelvic pain. Complications of recurrent prolapse surgeries were comparable to those of primary VMR (Redo surgery for management of recurrent rectal prolapse is safe. Redo surgery for mesh erosion is associated with high morbidity rates. Redo surgery for pelvic pain can have major complications and is only effective in half of the cases. This paper provides new information regarding the safety and risks of redo surgery for recurrence, mesh erosion and pelvic pain. It will help clinicians and patients in treatment decision‐making and preoperative counselling in both primary ventral mesh rectopexy and redo surgery after previous rectal prolapse surgery.Since its introduction in the early 2000s minimally invasive laparoscopic ventral mesh rectopexy (VMR) has found wide acceptance in the treatment of rectal prolapse (RP) , 2. UnfoThe majority of redo surgery is performed in patients who develop a recurrent RP. The treatment strategy for recurrent prolapse is not uniform and a previous attempt to create a treatment algorithm was not successful . HoweverPatients with mesh erosion usually have symptoms of pain, dyspareunia, purulent or serosanguinous discharge and/or functional complaints , 14, 15.A third group consists of patients with therapy‐resistant pelvic pain, without evidence of mesh erosion, who request mesh removal. The incidence of pelvic pain is understudied and only recently a first retrospective study described de novo pelvic pain in 15% of patients . CurrentIn this study all robot‐assisted surgeries after previous surgery for RP in a tertiary referral centre were analysed. The aim was to evaluate the safety of redo interventions with regard to intraoperative complications and 90‐day morbidity in patients treated for recurrent RP, mesh erosion or pelvic pain.This study was conducted in a tertiary referral centre for pelvic floor pathology with a national referral function. The study protocol was approved by the institutional review board and requirement for informed consent was waived due to the retrospective study design. Part of the cohort has been described in previous studies with other research aims , 7.All patients undergoing a robot‐assisted intervention related to RP between March 2011 and December 2019 were included. All abdominal procedures for primary and redo interventions were performed with the Da Vinci robotic system . A redo intervention was defined as surgery to treat a complication after a previous abdominal intervention for RP and/or apical prolapse. This includes redo surgery for (1) recurrent RP, (2) mesh erosion and (3) pelvic pain.Primary outcome measurements were intraoperative complication rates and 90‐day morbidity rates. Outcomes were compared with primary robot‐assisted VMR (RVMR). Major complications were defined as Clavien–Dindo (CD) classification grade >2 . If patiPatients were assessed by a multidisciplinary team. Additional imaging and functional assessments were made on indication.The preoperative work‐up was similar to that of patients with primary complaints and has been described in detail previously . PatientPhysical examination of the rectum and/or vagina was performed in the case of complaints possibly related to mesh erosion. If the erosion was small and without signs of infection, transvaginal or transanal excision was considered. If this failed or did not seem appropriate , a robot redo intervention was planned to remove the mesh and close the defect. The possible need for a diverting stoma was discussed.In cases of chronic pelvic pain after previous VMR or other prolapse surgery with mesh implantation, other underlying causes of pain  were excluded. A redo intervention for mesh removal was performed with great reluctance and was considered if conservative pain management failed and patients requested mesh removal. Patients were counselled that surgery was not a guarantee of relief of complaints. Because of the risk of recurrence of prolapse symptoms after mesh removal, patients were additionally counselled for resection rectopexy.Techniques and materials for redo RVMR were similar to primary RVMR . PreviouRRR was performed according to previously described techniques . Old mesAll mesh was intentionally removed, and the defect was closed with transabdominal (±omentoplasty) and transvaginal and/or transrectal absorbable sutures.Depending on the location and extent of the defect, a diverting stoma was created in patients who were expected to have a high risk of development of a new rectovaginal fistula. In the case of pelvic pain all mesh and tackers were removed unless the risk of complications seemed higher than the possible gain.All patients were routinely seen at 6–12 weeks after surgery in the outpatient clinic.t‐test, the Mann–Whitney U‐test and the chi‐square or Fisher's exact test were used as appropriate. A p‐value <0.05 was considered significant. Analyses were performed using SPSS version 24 (IBM Corp.).Data are presented as mean ± standard deviation (SD) and median with interquartile range (IQR) for parametric and nonparametric continuous variables, respectively. Numbers and percentages are used for categorical variables. The independent samples A total of 462 robot‐assisted surgeries were performed: 359 were primary RVMR cases and 103 were redo interventions. Of the redo interventions, the indication for surgery was a recurrent prolapse in 76 cases (72%), mesh erosion or infection in 13 cases (12%) and pelvic pain in 14 cases (13%). Baseline characteristics of patients with primary RVMR and patients with a redo intervention per subgroup are shown in Table Seventy six robot redo surgeries were performed for recurrent RP in 72 patients. Four patients underwent a second robot redo intervention due to a re‐recurrence Figure . Redo RVA careful assessment of operation notes showed that failure of the previous VMR was thought to be related to suboptimal distal mesh positioning in 54 cases (71%), i.e. the mesh was not positioned deep enough in the rectovaginal septum, was positioned too laterally or failed to give adequate tension. In three cases (4%) the mesh was luxated from the sacral promontory. In seven cases (9%) reason for failure was unclear and 12 patients (16%) had a previous rectal suspension other than VMR . Complications and their treatment are depicted in Table After redo RVMR two patients developed a mesh erosion after the 90‐day postoperative course (after 22 and 82 months). These cases will be further elaborated on as part of the mesh erosion group.Twelve patients diagnosed with mesh erosion underwent a robot redo intervention . In one patient a second robot redo intervention was necessary after 9 months because of a rectovaginal fistula due to infection of residual mesh Figure . Only onp‐value 0.01; Table p‐value 0.06) and five patients (38%) suffered from a major complication . In four patients, major morbidity led to the creation of a loop ileostomy or colostomy (Table An intraoperative complication occurred in three patients 23%), compared with 12 patients (3%) in primary RVMR  pain was relieved to the patient's satisfaction, six patients (43%) still experienced pain and in one patient it was unclear what effect surgery had had on the preoperative complaints. The pain relief experienced was better in the group with complete mesh removal (five out of six patients with improved symptoms) compared with patients in whom mesh removal was incomplete (two out of eight patients with improved symptoms).Reasons for redo surgery after surgical repair for RP can be recurrence, mesh erosion or chronic pelvic pain resistant to conservative management. This study gives an overview of safety outcomes with regard to these three indications in patients undergoing robot‐assisted redo surgery.Symptomatic recurrence after VMR has been described in 5%–15% of cases and increases with longer follow‐up , 4, 5. TWe found that in 71% of cases failure of the primary VMR was due to suboptimal fixation of the distal side of the mesh. This is important information for surgeons performing primary VMR and shows the importance of well‐trained and dedicated surgeons. Only a small proportion showed proximal mesh detachment. The change in our clinic to absorbable sutures was made only recently and does not affect this cohort. Although this change in material might conflict with our observation of suboptimal distal mesh fixation as a reason for failure of VMR, we reckon that by the time the suture material is absorbed, ingrowth of native tissue into the mesh implant will give sufficient support and fixation to prevent luxation. Future studies comparing recurrence of VMR with mesh fixed with absorbable sutures versus nonabsorbable sutures are important to confirm this hypothesis.Laitakari et al.  recentlyMesh erosion rates after VMR have been described in 1%–2% of patients , 6, 8. IThere is no consensus regarding the treatment strategy for mesh erosion. This is reflected in the varying approaches described in previous studies. Management varies from transanal resection  , 15, 18,Ratnatunga et al.  publisheIn the multicentre study of Evans et al. , 3 of 45Although concerns about post‐VMR pelvic pain have increased, the prevalence of this complaint is understudied. Only recently a retrospective study was published describing de novo pelvic pain in 15% of patients after VMR . AlthougAn overall limitation was the retrospective study design and the small cohorts of patients with redo surgery for mesh erosion and pelvic pain. However, this is still the largest group of patients to be described in the literature thus far. This study included patients up to 90 days postoperatively. Future studies should focus on functional outcome and quality of life after longer follow‐up.In conclusion, redo surgery has been shown to be a safe procedure in the management of recurrent RP with comparable complication rates to primary VMR. In the management of mesh erosion, redo surgery is associated with a high major complication rate of 38%. Redo surgery for pelvic pain has a major complication rate of 7% and does not lead to relief of symptoms in a high percentage of patients. It should therefore be performed reluctantly. Based on these results, we strongly advise referral to a tertiary pelvic floor centre when redo surgery, and possibly even primary VMR, is being considered. In this way patients can be diagnosed and treated by an experienced and multidisciplinary team to minimize the risk of complications. This study is of great importance for clinicians and patients when considering both primary VMR and redo surgery for recurrence, mesh erosion or pelvic pain.PMV, ECJC and IAMJB are proctors for Intuitive Surgical. EMvdS has no conflicts of interest to declare that are relevant to the content of this article.All authors qualify for authorship and agree to the submission.This retrospective study involving human participants was in accordance with the ethical standards of the institutional and national research committees and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The institutional review board of Meander Medical Centre approved this study.Requirement for informed consent to participate was waived by the institutional review board due to the retrospective nature of the study.


Progression in tumor assessments is often detected at a follow‐up appointment rather than when actual change in progression has occurred, which can bias PFS outcomes.We sought to evaluate the frequency of tumor assessment scans in clinical trials of anti‐cancer interventions and to compare this to recommended  and real‐world frequencies of tumor assessments.In a cross‐sectional analysis, we searched for articles published in the three top oncology journals between July 2017 and June 2020. We included articles that were RCTs of patients that had unresectable or metastatic solid tumors and used an intervention that was designed to be anti‐tumor. We abstracted median PFS survival for each group, the PFS hazard ratio, frequency of tumor assessment scans, tumor type, intervention type, and information regarding the study.p < .0001) and the control group (p < .0001). PFS hazard ratios for studies scanning for tumors every 10 or more weeks were no different than for studies scanning for tumors more frequently (p = .88). Data on the frequency of tumor assessments in the real world is sparse.We found that, in the 182 comparisons (163 articles), less frequent tumor assessment (occurring more than 9 weeks between assessments) was associated with higher median PFS values for both the intervention group (We found that less frequent tumor assessment frequency was associated with longer median PFS in both intervention and control groups of clinical oncology trials but was not associated with differences in PFS hazard ratios. Future research is needed to compare real world to trial assessment. The US National Comprehensive Cancer Network has issued recommended scan frequencies for some cancers, and the frequency of scans varies by cancer type and treatment type, recommending every 2–6 months for women with breast cancer treated with endocrine therapy and every 6–12 weeks for women treated with cytotoxic chemotherapy, and as frequently as every 6–16 weeks for kidney cancer.It is with this background that we sought to evaluate the frequency of tumor assessment scans in clinical trials of anti‐cancer interventions for solid tumors and to compare this to recommended and real‐world frequencies of tumor assessments. We further sought to assess the association between tumor assessment frequency and PFS measurements.2We sought to characterize the frequency of tumor assessments in the literature and to see if there is an association between tumor assessment frequency and either PFS or overall survival indices in oncology studies.2.1Articles published in the three top oncology journals  between July 2017 and June 2020 were considered for inclusion. We included articles that were RCTs of patients with cancers that were unresectable or metastatic solid tumors and used an intervention that was designed to be anti‐tumor. Studies that did not report PFS hazard ratio, median PFS, or tumor assessment frequency, were pooled analyses, were dose‐optimization studies (no comparator), or the intervention was to prevent cancer were excluded. For studies that had more than two arms, we analyzed each comparison separately.We abstracted median PFS survival for each group, the PFS hazard ratio, frequency of tumor assessment scans, tumor type, intervention type, whether the tumor assessments were blinded (double blind or masked tumor assessment vs. open and unmasked tumor assessments), and information regarding the study . Because a number of studies did not report a PFS hazard ratio, we calculated a risk ratio from the reported median PFS control and intervention values for all studies. Both the risk ratio and the PFS hazard ratio were used as separate outcomes. For the three studies where median PFS was not reached, we used the time the study participants were followed in place of the median PFS. Most studies assessed the tumor response at regular intervals, but for those that had varying frequencies, we used the frequency first used lasting 6 months or longer. We then categorized tumor assessment frequency by <8 weeks, 8–9 weeks, and >9 weeks.We then compared the tumor assessment frequency with guideline recommendations  for the frequency of tumor assessments. We also searched on Google Scholar and PubMed for studies that reported on the frequency of tumor assessment in real‐world clinical practice. For search terms, we used the cancer type (for the five most common) and “frequency of tumor assessment real world”. For this search, we did not include articles that reported frequency in clinical trials.2.2We calculated descriptive statistics for included studies. We calculated differences in PFS and overall survival indices by tumor assessment frequency category using analysis of covariance. We ran separate models for PFS hazard ratio, PFS risk ratio, and overall survival hazard ratio. To examine the effects of blinding and tumor type on PFS outcomes, we calculated differences in PFS indices by tumor assessment frequency, stratified by whether the study was blinded or not and by the most common tumor types. We did not include one study in the model analyses because it was found to be an outlier when we checked model residuals. We checked model assumptions by using a QQ plot for normality and the residuals versus fits plot for homogeneity of variance. All data were publicly available and non‐identifiable to patients or study participants, so no institutional review board approval was required. All analyses were done using R statistical software.3We reviewed 1484 articles. Among excluded articles, 947 were not RCTs; 171 trials did not include patients with unresectable or metastatic cancer; 54 did not include PFS outcomes; 55 used interventions that were not anti‐tumor; 40 involved non‐solid tumors; 26 were subgroup or secondary analyses; 17 were pooled analyses; 6 had interventions designed to prevent cancer (not treat), and one was a dose‐finding study. We further excluded two articles ‐ one article was retracted, and another article reported that the median PFS was not reached in either arm and did not report a hazard ratio, and therefore we had no numbers to use in the analysis. We then excluded two additional studies because they did not report a tumor assessment frequency. The remaining 163 articles were included in the data analysis. Sixteen articles had multiple arms, which resulted in 182 total comparisons.n = 29 studies; 18%); breast ; colorectal cancer ; prostate ; ovarian ; melanoma ; and gastric . Most studies were phase 3 , followed by phase 2 , phase 4  and phase 1 , with three studies not indicating the phase (2%). Ninety‐seven studies (60%) did not use a blinded tumor assessment, while 66 studies (40%) did.The most common cancers studied were: non‐small cell lung cancer (p = .93).The percentage of studies with blinded tumor assessments by tumor assessment category was as follows: 38% of studies had tumor assessments being done every 12 weeks or longer; 36% studies had tumor assessments being done every 8 weeks; and 45% of studies had tumor assessments done less than every 8 weeks . Figure p < .0001; Table p < .0001). Median overall survival times were higher for studies that had tumor assessment every 10 or more weeks for both the intervention group . Both PFS  and overall survival  hazard ratios for studies scanning for tumors every 10 or more weeks were numerically higher than for studies scanning for tumors more frequently, but the differences were not significant (Table We found that less frequent tumor assessment (occurring more than 9 weeks between assessments) was associated with higher median PFS values for both the intervention group , but there was no indication of interaction between scan frequency and blinded status of the study (p = .16). We did not find any differences in PFS hazard ratio tumor between categories of tumor assessment frequency in either blinded studies or (p = .62) or unblinded studies (p = .50). When looking at the association between tumor scan frequency and PFS hazard ratio in each of the three most common cancer types, there was no association .We found that PFS hazard ratios were higher in studies with unblinded assessments than studies that had blinded assessments  more often occurred in tumor types and settings where PFS was longer, either due to the natural biology of the disease or the treatment. This did not translate into significantly different PFS hazard ratios between categories of tumor assessment frequency. Several authors have suggested the possibility of biased PFS outcomes due to the timing of tumor assessment,We should be careful to say that our study cannot exclude the possibility that the frequency of scanning can result in varying PFS hazard ratios. In all these trials, the sponsor and investigators chose the frequency with the knowledge of the underlying biology, and some prediction of the putative efficacy . That knowledge may lead to the choice of PFS assessment interval. Put another way, the PFS assessment interval is not randomly selected. As such, we cannot draw a firm causal conclusion that alternative intervals would not alter the observed hazard rations; Instead, we merely observe the phenomenon, that as conducted, our study failed to find such differences.We also found that that median overall survival was longer in studies that assessed tumor frequency less often, which may be a result of less aggressive or slower growing tumors needing assessments less frequently. Because survival is a hard outcome, survival status should not be biased by treatment status like softer outcomes, such as PFS might be. One possible explanation for this is attrition bias or informative censoring from incomplete follow‐up when there are longer intervals between tumor assessments.We were not able to find much data on the frequency of tumor assessments in the real world, and it was difficult to determine tumor assessment frequency in clinical practice compared to the frequency in clinical studies or in clinical guidelines. Future studies need to be done to better characterize tumor assessment frequency in real world practice. The frequency of scans in clinical studies was often more frequent than NCCN guidelines, but the recommended frequencies have recently been updated – suggesting less frequent tumor assessments.4.1There are three limitations to our analysis. First, not all studies reported a PFS hazard ratio, which may have biased out results. As a sensitivity analysis, we also used a calculated risk ratio of median PFS for control participants and intervention participants, which resulted in similar results as results using the PFS hazard ratio. Second, our results may not be generalizable to all oncology studies since we used studies from only three oncology journals. While the number of journals was small, the journals are high‐impact journals that publish high‐quality publications on the larger oncology studies. Third, our categorization of tumor assessment frequency could not fully capture the multiple assessment frequencies used in some of the studies. In assigning a frequency category, we tried to select the frequency used for the longest duration, and the one in which progression was most likely to occur, as these were studies on metastatic tumors.5In conclusion, we document the frequency of scans in a range of contemporary randomized controlled trials. We found that less frequent tumor assessment frequency was associated with longer median PFS in both intervention and control groups of clinical oncology trials, but was not associated with differences in PFS hazard ratios. This may be explained by deliberate choices made by investigators to assess progression less frequently based on lower event rates. Future research is needed to compare real world to trial assessment.Dr. Prasad reports receiving royalties from his books, Ending Medical Reversal and Malignant; that his work is funded by the Arnold Ventures; that he has received honoraria for grand rounds/lectures from several universities, medical centers, and professional societies and payments for contributions to Medscape; Dr. Prasad hosts the podcast Plenary Session, which has Patreon backers. Dr. Haslam and Ms. Gill have no disclosures to report.Alyson Haslam: Data curation (lead); formal analysis (lead); methodology . Jennifer Gill: Data curation (supporting); validation (supporting); writing‐review & editing (supporting). Vinay Prasad: Conceptualization ; funding acquisition (lead); methodology ; supervision ; writing‐review & editing .All data were publicly available and non‐identifiable to patients or study participants, so no institutional review board approval was required, nor was individual informed consent.


The purpose of the study was to explore nurse practitioner perceptions of integration practices in acute hospitals across one health care region in Ireland.A recent Department of Health National policy towards developing a critical mass of nurse practitioners was implemented across Ireland. Successful integration of nurse practitioner roles is integral to the success of the service and sustainability of the roles for the long term.An electronic survey was circulated to a convenience sample of 85 nurse practitioners across a single, acute health care region in Ireland.Sixty‐six (78%) of nurse practitioners participated. A standardized governance structure was reported by 24 (36%) participants. Thirty‐two (48%) participants expressed their job description clearly defined their role. Consultant physicians were identified as the most supportive stakeholder by participants.This research identifies that nurse practitioner integration is not currently structured. A framework to support nurse practitioner integration is required to ensure ongoing support for the role. This research identifies that integration is not currently optimized.Failure to successfully integrate the nurse practitioner role risks the long‐term sustainability of the role and is a missed opportunity to demonstrate the success of advanced clinical leadership to health care. The email included an anonymous link and QR code to the online survey. A reminder email was sent every 2 weeks over an 8‐week period.4.4Quantitative data were exported directly from Qualtrics® to SPSS 24® for statistical analysis. Data were checked and cleaned. The researchers concluded that three questions related to caseloads were not clearly defined therefore the data provided was excluded in the analysis. Descriptive statistics were used to describe, compare and summarize participant responses. Chi‐square statistics were used to establish an association between categorical variables.5A declaration of exemption from full ethical review was accepted by the University human research ethics committee (LS‐E‐21‐175‐Ryder). The survey was accessed using an anonymous link or QR code. A participant information letter was provided upon accessing the survey. Participants were required to select an option ‘consent to participate’ to proceed to the survey questions. The first question required participants to identify their registration or candidate status. Selection of candidate practitioner resulted in automatic exit from the remainder of the survey.6α = .720 for 13 variables, eliminating two referral pattern questions.Data were analysed using descriptive and analytical testing. Given the assumption of content and face validity based on the development of the survey. There is preliminary evidence of reliability Cronbach's 6.1n = 17; 26%), followed by older person care . The majority of participants came into post in 2019 . Forty‐three (65%) of participants were appointed as nurse practitioners since 2018.One hundred and four participants accessed the survey. A total of 34 candidate/student nurse practitioners were identified and excluded from analysis. Four additional blank survey responses were eliminated. A total of 66 responses from eligible nurse practitioners were included for analysis. Table 6.2n = 47; 71%) and the medical physician (Consultant) in specialist area  as the key stakeholders who identified an opportunity for the nurse practitioner role  provided an annual report primarily to the DON   have an agreed process to discuss opportunities for expansion of their service. A similar number  reported having their caseload (workload reviewed) at defined times, which varied from 3 to 72 months. Eight participants (12%) reported their organisation had an agreed process to review their role and workload. The largest proportion of participants  identified the consultant physician as the most significant support person in their role  reported the existence of a nurse practitioner network in their organisation. This was described as a professional supportive network, led primarily by nurse practitioners.The majority  reported having a specific agreed job description. Three key stakeholders were identified by participants as contributing to the job description, Consultants, DON, and a nurse practitioner in a similar role  expressed that their job description specified work that was autonomous and collaborative in nature. The majority reported having agreed organisational referral processes to access their service  and to refer to other services . More than half of the participants reported having agreed external  referral processes for their service.The language collaboration and referral relate to the process of agreeing autonomous and collaborative caseloads and referral process for the nurse practitioner service. Most participants  understood their performance indicators reflected access to their service and that they captured the quality of care provided. A small number of participants  believed performance indicators accurately captured their workload. Reporting timelines for performance indicators have been identified for 12 (18%) participants.Outcomes demonstrate the value of a service and are a requirement in the Irish context  = 4.889, p = .087.Chi‐square statistical analysis identified that having agreed performance indicators for nurse practitioner roles is dependent on having a standardized governance structure in an organisation; however, the relationship was not significant, χ6.7Participants were provided with an opportunity to provide any comments in the final question. Twelve participants expressed a need for additional support in both the establishment and meeting the ongoing requirements of their role.7There was a large response from nurse practitioners to the survey. This research has identified a recent increase in nurse practitioner roles in areas outside the Emergency Departments, focusing on older person services in response to a strategic centralized approach from the Department of Health. Identifying a gap in service can be best served by nurse practitioners was a joint effort by Directors of Nursing and Consultant physicians. Participants reported a lack of governance structures for these senior nursing clinical positions across the health care region. The nurse practitioners in this research reported rich collaborations and referral processes both within their own organisations and externally. Less than half of participants identified having performance indicators associated to their services. Fewer than one quarter reported their performance indicators were aligned to recent health care policy, and most participants expressed that they did not capture the nature of their work. Ongoing role and service review was reported as lacking by participants. Consultant physicians were identified as the key stakeholder supporting nurse practitioners in their roles.Support from policy makers is essential to the development of nurse practitioner initiatives .Data S1. Supporting InformationClick here for additional data file.


Previous studies focusing on high‐income countries have shown that young people often face greater barriers to accessing healthcare than older adults. However, in low‐middle income countries (LMICs), there have been a paucity of cross‐country, quantitative studies highlighting these barriers.This exploratory study aims to provide a scoping review of the publicly available Demographic and Heath Survey (DHS) data with a view to form the basis for further work.Data on insurance coverage, agency, and access to evidence‐based family planning from 30 countries in the DHS were compared between age groups. Data on 586,250 participants 15–24 years  and 854,660 participants 25–49 years  from 30 LMICs were analyzed.Significantly greater barriers to accessing healthcare were observed across six variables in younger population when compared to older adults across all survey questions with an average of 8.4% point difference. Also, there was wide country‐level variation: the maximum differences between age groups were 33% points; Rwanda was the only country with no age differences.This study highlights several possible themes for future research into improving access to healthcare for young people. These themes include more detailed evaluation of country‐specific policies to reduced barriers to healthcare for young people and further research into the causative factors that can influence healthcare utilization by young people.Our analysis showcases increased barriers to healthcare access for young people in LMICs. We argue that they can only be improved by targeted policies and direct community engagement. An example of this inequality can be seen in the rates of mortality decline within different age groups. A robust cross‐country study identified that mortality in infants  has fallen by 75% since 1980. However, during the same time period, the mortality of young people (10–24) fell significantly less in the same countries.A major reason for these poor health outcomes can be attributed to the fact that young people are less likely to access healthcare compared to other age groups, and present later when they seek care which results in poor prognosis.A healthcare barrier is something that restricts the use of a health service, either through access or utilization.Current literature indicates that this may be due to health services not meeting the specific needs of this age group, and this group facing additional barriers to accessing healthcare.Published reports clearly indicate that the unmet need for healthcare and receipt of low‐quality healthcare in adolescence are important predictors of poor health outcomes in adulthood.There is a significant body of literature across many LMICs which describe the presence of barriers to healthcare. These relate both to young peopleThe purpose of this exploratory work is to highlight the existence of these barriers using publicly available Demographic and Health Surveys (DHS) dataset to form the basis for further work. Using variables that are comparable to those used within the published literature, this study intends to provide a basis for policy intervention in these countries. We performed an exploratory cross‐country quantitative analysis of the prevalence of healthcare barriers amongst young people (15–24) and older adults (25–49) across 30 LMICs to identify if young people face additional healthcare barriers compared to older adults.2https://www.statcompiler.com/en/) and compared the prevalence of healthcare barriers in different age groups by country, using the most recent available survey  across all countries sampled. DHS methodology uses a mixture of survey tools including four model questionnaires including separate surveys for men, women, and household, as well as biomarker collection. Methods are uniform and standardized across countries and survey years, allowing direct comparisons to be made between countries. All surveys were nationally representative and had large enough sample sizes to allow meaningful comparisons between age groups. Definitions of the study variables and wider description of the data is provided in Supporting Information: Material 3Previous literature in this field was reviewed, with a focus on cross country studies that compared healthcare access between younger and older adults or between adolescents in different countries. This was conducted to find methods to identify unmet need and poorer health outcomes and build a conceptual framework to search the DHS database as a part of this exploratory phase. Based on this conceptual framework, we identified the survey questions which were adapted from the World Health Organization accelerated action for the health of adolescents action plan, informed by previous work.The DHS database was systematically searched to find survey questions and countries. Data extraction from the DHS database was conducted using the DHS STATcompiler program. The extracted data were then cleaned and standardized for analysis. The average household response rate to survey questions across all countries was 97%,The inclusion criteria for a survey question was to meet one aspect of the conceptual framework and to have age disaggregation between young people (10–24) and an older age group (25+). Any country selected needed to have data on at least half of the questions during the period of 2005–2018. Applying this selection criteria left six questions and 30 countries (full list of these questions and countries are provided in the Supporting Information).Final say in own healthcare (women)*.Final say on own healthcare (men)*.Unmet need for family planning*.Demand for family planning satisfied by modern methods*.No health insurance (men).No health insurance (women).A healthcare barrier was defined as something that restricts the use of a health service and/or reflects lack of access to evidence‐based care. We selected six variables which reflected such barriers and had high levels of complete data across a wide range of countries:*Denotes that questions were only addressed to married participants.z‐test. Next, data from all countries were aggregated, weighted so that each country contributed equally to the overall proportions. The mean values across all countries for each survey question were calculated and compared between age groups. Comparisons between the two groups (15–24) and (25–49) were conducted using the two‐proportion z‐test.p < 0.05. The first set of analyses were standardized so that each country was given equal weight. The (15–24) and (25–49) group were then compared, to look at any differences between younger and older age groups across all questions. Countries were then compared to each other in each respective survey question, to look for differences between countries. To facilitate comparisons between questions that looked at positive and negative outcomes, the questions that showed a negative outcome  were inverted to present the proportion of participants giving a positive response  and (35–49) were weighted by proportion and aggregated to produce a (25–49) “older adults” category. No other specific data reduction or homogenization techniques were used. For each country, the proportion of respondents in each age group  reporting healthcare barriers were calculated; age groups were then compared using the two‐proportion 4Data were analyzed on 586,250 participants 15–24 years  and 854,660 participants 25–49 years .p < 0.01), “final say in own healthcare – married men” , “need for family planning met” , “demand for family planning satisfied by modern methods” , “health insurance – all men” , and “health insurance – all women” .Figure p < 0.01). In contrast, Rwanda was one of three countries  where young women had significantly better access than older adults .When each survey question was analyzed individually, wide variations were seen between countries. For example, the proportion of young women in India who reported being able to access modern methods of family planning was 33% points lower than among older women . These trends are seen a variety of countries with different levels of economic development, which indicate that some barriers that young people face may be independent of the economic development of the LMIC. This theory is supported by how Rwanda has $57 health spending per capita but appears to perform better in giving young people equal access healthcare compared to Sao Tome and Principe which spends triple this amount.These included cost barriers , lack of agency  and unmet need for modern family planning methods. These findings extend previous qualitative and single‐country studies in LMICs and cross‐country studies in HICs which have also reported more barriers to accessing healthcare among young people. However, the wide variation between countries reinforces the message that such age differences are far from inevitable: they can be mitigated or even avoided by using targeted strategies. Certain countries such as Rwanda had no differences between age groups across multiple survey questions, indicating that healthcare barriers for young people are not inevitable Figure .21, 2Also, young people display country specific health behaviors and attitudes based on a number of ethnographic factors. However, this does not appear to influence the inequalities young people face in healthcare access compared to older adults, with many countries with varying geographic distribution showing similar health barriers. Furthermore, it is interesting to note that the patterns seen are very similar to those seen in young people in HICs, suggesting how this is a worldwide problem.The DHS survey questions with data availability were focused on married women, with half of the final survey questions focusing only on this subgroup. It is also important to note there is a multiyear gap between surveys in different countries due to data availability, and healthcare barriers could have changed over this period. This means that we cannot infer the magnitude of these barriers young people face in other LMICs. It is also possible that differences between age group and/or countries may reflect different understanding of the question or different expectations of agency, insurance coverage, or access to family planning. Also, the definition for unmet need for family planning was changed over the period of sampling years reported within this paper. However, as outlined within the DHS program website, this has been accounted for and the reported data estimates the total demand for family planning, the satisfied share of this demand and the unmet need for sexually active unmarried women.In addition to the data available from the DHS, studies such as the Research on Early Life and Aging Trends and EffectsAlthough one could argue that the country selection and the variables used within this study does not provide an overall picture, this report is driven by immediate data availability to highlight the gap in this area. One needs to understand that there are several other available variables in the DHS surveys concerning access to healthcare such as the access to antenatal care, access to institutional delivery and skilled worker, and distance to the healthcare facilities. While these could provide a richer picture there have been gaps across countries and selection dates in these variables.One of the perceived limitations of the current paper relates to the cluster effect and correlation that may exist among the samples from each specific country. Access to health services across age groups and gender might be different in various countries and one could use mathematical techniques such as generalized linear models models to account for such clustering effects when using merged datasets to compare data between different countries.The main purpose to explore the validity of the methodological approaches to form the basis of further work. The large differences in responses between countries suggest that there are multiple external factors that affect healthcare barriers, and these can be targeted by health systems. Interventions such as prioritizing youth friendly services as done in Rwanda Figure  provide 6This study highlights several possible themes for future research into improving access to healthcare for young people. These themes include more detailed evaluation of country‐specific policies to reduced barriers to healthcare for young people and further research into the causative factors that can influence healthcare utilization by young people.Nitish Nachiappan: Conceptualization; data curation; investigation; methodology; writing – original draft; and writing – review and editing. Shona Mackinnon: Writing – original draft; and writing – review and editing. Jean P. Ndayizeye: Writing – original draft; and writing – review and editing. Geva Greenfield: Writing – original draft; and writing – review and editing. Dougal Hargreaves: Conceptualization; data curation; investigation; methodology; supervision; and writing – review and editing.The authors declare no conflict of interest.The lead author (NN) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.Supporting information.Click here for additional data file.Supporting information.Click here for additional data file.Supporting information.Click here for additional data file.Supporting information.Click here for additional data file.Supporting information.Click here for additional data file.Supporting information.Click here for additional data file.Supporting information.Click here for additional data file.Supporting information.Click here for additional data file.


The aim of this paper is focused on expanding medical students' knowledge and understanding of a non‐core curricular subject not normally offered in the medical curriculum. The critical juncture explored how to introduce a health‐related subject into medical education that complements without competing for space/time in medical students' core studies. Using dental trauma as an example, this paper supports the opportunity for medical students to learn online about managing dental injuries and to raise their awareness of the need for accurate diagnosis and treatment of traumatic dental injuries before they graduate as medical doctors. Online learning allows students to self‐learn anywhere, at any time.The underlying premise of introducing a non‐curricular topic into medical education was that if learning the topic of dental trauma is presented as an interesting and important topic using an online course approach,In creating a framework for developing online learning platforms for medical students, medical educators will be able to introduce the topic of dental trauma by encouraging self‐learning outside the formal medical timetable.2The overarching aim was to find an alternative way to expand medical students' theoretical knowledge of dental trauma, a non‐core curricular topic, by introducing it into medical education without occupying formal teaching hours. The proposal to use an online dental trauma course provided a pathway for cross‐disciplinary learning in medical education.Australian Government Research Training Program (RTP) Scholarship.No potential conflict of interest relevant to this article was reported.


To measure whether the prevalence of use and real‐world effectiveness of different smoking cessation aids has changed in England since the coronavirus disease 2019 (COVID‐19) pandemic.Representative monthly cross‐sectional surveys, January 2015–June 2021.England.A total of 7300 adults (≥18 y) who had smoked within the previous 12 months and had made ≥1 quit attempt during that period.The independent variable was the timing of the COVID‐19 pandemic (pre‐pandemic [January 2015–February 2020] vs pandemic [April 2020–June 2021]). We analysed (i) the association between the pandemic period and self‐reported use (vs non‐use) during the most recent quit attempt of: prescription medication (nicotine replacement therapy [NRT]/varenicline/bupropion), NRT bought over‐the‐counter, e‐cigarettes, traditional behavioural support and traditional remote support  and (ii) the interaction between the pandemic period and use of these cessation aids on self‐reported abstinence from quit date to survey. Covariates included age, sex, social grade, level of cigarette addiction and characteristics related to the quit attempt.After adjustment for secular trends, there was a significant increase from the pre‐pandemic to pandemic period in the prevalence of use of traditional remote support by past‐year smokers in a quit attempt ; specifically telephone support  and websites . There was also an increase in the prevalence of use of prescription medication ; specifically varenicline . There were no significant changes in prevalence of use of other cessation aids after adjustment for secular trends. People who reported using prescription medication  and e‐cigarettes  had greater odds of reporting abstinence than people who did not. There were no significant interactions between the pandemic period and use of any cessation aid on abstinence, after adjustment for covariates and use of the other aids, although data were insensitive to distinguish no change from meaningful modest (OR = 1.34) effects (Bayes factors 0.72–1.98).In England, the COVID‐19 pandemic was associated with an increase in use of remote support for smoking cessation and varenicline by smokers in a quit attempt up to June 2021. The data were inconclusive regarding an association between the pandemic and changes in the real‐world effectiveness of popular smoking cessation aids. Smoking prevalence in England has declined steadily over the past decade , and theEngland has among the most extensive and comprehensive coverage, as well as highest rates of use, of medications and behavioural support for smoking cessation in the world . PharmacThe United Kingdom (UK) government responded to the COVID‐19 pandemic by implementing a national lockdown with work, travel and social contact restrictions enforceable by law on 23 March 2020. This had an immediate impact on the ways in which smokers were able to access support for quitting. Vape shops were classed as ‘non‐essential retail’ and were forced to close; online shops remained open . This san < 200), limiting statistical power to explore changes in use of specific aids separately. With more data now available, it is possible to undertake a more detailed assessment of changes in use of cessation aids during the pandemic.It is possible that the changes in smokers' access to popular forms of cessation support brought about by the COVID‐19 pandemic may have affected the prevalence of their use in a quit attempt. We previously analysed changes in smoking and quitting outcomes during the first month of lockdown in England . ResultsThe pandemic may also have affected the real‐world effectiveness of popular cessation aids in helping smokers to quit successfully. For example, as the closure of vape shops drove consumers to purchase their supplies elsewhere, with less specialised support and a more limited range of products, there was also a shift in the types of devices being purchased away from open‐system devices to closed‐system pod devices . StudiesAmong smokers making a quit attempt in England, to what extent has the prevalence of use of prescription medication , NRT OTC, e‐cigarettes, traditional behavioural support and traditional remote support  changed since the COVID‐19 pandemic, relative to the 5 years before the pandemic?Among smokers making a quit attempt in England, has the association between use of the above cessation aids and success in the quit attempt been moderated by the COVID‐19 pandemic?This study aimed to examine whether the prevalence of use and real‐world effectiveness of different smoking cessation aids has changed in England since the COVID‐19 pandemic. This information will provide important context around previous findings documenting a substantial increase in the success rate of quit attempts by smokers in England during the early stages of the pandemic , 30. SpeData were drawn from the ongoing Smoking Toolkit Study, a monthly cross‐sectional survey of a representative sample of adults in England designed to provide insights into population‐wide influences on smoking and cessation by monitoring trends on a range of variables relating to smoking . The stuData are usually collected monthly through face‐to‐face computer assisted interviews. However, social distancing restrictions under the COVID‐19 pandemic meant that no data were collected in March 2020 and data from April 2020 onward were collected via telephone, and the lower age bound for participation was increased from 16 to 18 years because of changes in consenting procedures. The telephone‐based data collection relied on the same combination of random location and quota sampling, and weighting approach as the face‐to‐face interviews and previous diagnostic analyses conducted on the first month of telephone data indicate good comparability between the two data collection modalities , 30.For the present study, we used aggregated individual‐level data from respondents age ≥18 years (to match the age range of participants surveyed since the pandemic) to the survey in the period from January 2015 (during this time use of different cessation aids has been relatively stable following a rapid increase in use of e‐cigarettes) to June 2021 . Our sample comprised respondents who reported: (i) smoking cigarettes (including hand‐rolled) or any other tobacco product (e.g. pipe or cigar) daily or occasionally at the time of the survey or during the preceding 12 months (‘past‐year smokers’), and (ii) having made at least one quit attempt in the preceding 12 months, assessed with the question ‘How many serious attempts to stop smoking have you made in the past 12 months? By serious, I mean you decided that you would try to make sure you never smoked again.’Use of smoking cessation aids was assessed with the question: ‘Which, if any, of the following did you try to help you stop smoking during the most recent serious quit attempt?’ Respondents were asked to indicate all that apply, and data for each of the following were coded 1 if chosen and 0 if not: (i) prescription NRT ; (ii) NRT OTC (NRT bought over the counter without a prescription); (iii) varenicline; (iv) bupropion; (v) e‐cigarettes; (vi) traditional behavioural support ; (vii) telephone support (phoned a smoking helpline); (viii) written self‐help materials (a book or booklet); and (ix) websites. For analysis, we combined variables relating to prescription medication  and traditional remote support  because we anticipated the numbers of participants reporting using these aids to be small . Where sSuccessful smoking cessation was defined as self‐reported continuous abstinence from the start of the most recent quit attempt up to the time of survey. Respondents were asked ‘How long did your most recent quit attempt last before you went back to smoking?’ Responses were coded 1 for those who responded that they were still not smoking and 0 otherwise.Timing of the COVID‐19 pandemic was coded 1 for April 2020 through June 2021  and 0 for January 2015 through February 2020 .Sociodemographic covariates were age, sex and occupational social grade . This occupational measure of social grade is a valid classification that is widely used in research in UK populations .Level of cigarette addiction was assessed by self‐reported ratings of the strength of urges to smoke over the last 24 hours . This question was also coded ‘0’ for smokers who responded ‘not at all’ to the (separate) question ‘How much of the time have you spent with the urge to smoke?’ . This meVariables relating to the most recent quit attempt were also included, including time since the quit attempt started, the number of prior quit attempts in the past year , whether the quit attempt was planned or occurred immediately when the decision to quit was made and whether the respondent cut down first or stopped abruptly.The month of survey was also included to take account of seasonal variation in quit attempts (e.g. in January or ‘Stoptober’).https://osf.io/y5c8w/). We made two amendments to the analyses following peer review: (i) we reran our analysis of changes in the prevalence of use of cessation aids during the pandemic period relative to the pre‐pandemic period adjusting for survey wave to take account of secular trends; and (ii) we added a sensitivity analysis in which we restricted the sample to those whose quit attempt began >6 months ago.The analysis plan was pre‐registered on Open Science Framework  and traditional remote support .We used logistic regression to compare the mean prevalence of use of each aid during the pandemic period relative to the pre‐pandemic period, with and without adjustment for survey wave (coded January 2015 = 1 through June 2021 = 78) to take account of underlying linear trends. We plotted the quarterly prevalence of use of each smoking cessation aid to show trends over the study period.We then constructed a series of logistic regression models in which we tested the two‐way interaction between each cessation aid (use of a specific aid vs no use of that specific aid) and the timing of the pandemic (pre‐pandemic vs pandemic period) on abstinence (abstinent yes vs no). Each model was fully adjusted for all other cessation aids (to estimate the unique association between each cessation aid and abstinence) and the covariates outlined above. In an unplanned sensitivity analysis added following peer review, we repeated these analyses restricting the sample to smokers whose most recent quit attempt began more than 6 months ago to assess whether the pattern of results differed when we focused on longer‐term cessation.Bayes factors (BF) were calculated to determine whether interaction results were supportive of the alternative hypothesis , the null hypothesis or were insensitive. We used a half‐normal distribution, the mode at 0 (no effect), and the SD equal to the expected effect size, which we set at OR = 1.34  on the basis that this is the documented difference between using no cessation support and the lowest intensity effective cessation support  and woulA total of 133 536 participants aged ≥18 years took part in the Smoking Toolkit Study between January 2015 and June 2021. Of these, 24 454 (18.3%) were past‐year smokers, of whom 7574 (32.0%) reported having made at least one serious attempt to quit in the past 12 months. We excluded 274 participants (3.6%) with missing data on one or more variables of interest. The analysed sample, therefore, comprised 7300 participants, 5750 (78.8%) of whom completed the survey before the pandemic (January 2015–February 2020) and 1550 (21.2%) during the pandemic (April 2020–June 2021).Table Table Relative to the pre‐pandemic period, there was an increase in the prevalence of use of traditional remote support (+68.6%) Figure —specificAlthough simple pre‐post comparisons of the prevalence of use of prescription medications indicated little change during the pandemic, a significant increase in the prevalence of use of prescription medication Figure —specificPrescription NRT followed a similar pattern, but the increase did not reach statistical significance Figure , Table 2There was a reduction in the prevalence of use of e‐cigarettes −13.8%) and an increase in unaided quitting (+18.6%), but these changes were largely attributable to a continuation of the underlying trends rather than step‐level changes in prevalence when the pandemic started  were significantly more likely than those surveyed before the pandemic (January 2015–February 2020) to report using traditional remote support for smoking cessation, in particular telephone support and websites. They were also significantly more likely to report using prescription medication, particularly varenicline. Across the entire study period, use of e‐cigarettes and varenicline were associated with the highest odds of successful cessation. No significant difference in real‐world effectiveness during the pandemic relative to before the pandemic was observed for any cessation aid, although the data were insensitive.During the early stages of the pandemic in England, there were marked increases both in the proportion of smokers who made a quit attempt and the proportion that were successful in achieving abstinence . Given lIn terms of changes in prevalence of use, we found that despite potential barriers to accessing many of the commonly used aids  was not assessed, so we cannot comment on whether this changed during the pandemic. Finally, sample sizes were relatively small for certain cessation aids, reducing statistical power. BFs indicated the data were insensitive to detect anything other than large significant associations between the pandemic and real‐world effectiveness of cessation aids, meaning we were unable to draw firm conclusions on this research question.In conclusion, in England, the COVID‐19 pandemic was associated with an increase in use of remote support for smoking cessation and varenicline by smokers in a quit attempt up to June 2021. The data were inconclusive regarding an association between the pandemic and changes in the real‐world effectiveness of popular smoking cessation aids.Ethical approval for the STS was granted originally by the UCL Ethics Committee (ID 0498/001). The data are not collected by UCL and are anonymized when received by UCL.J.B. has received unrestricted research funding from Pfizer, who manufacture smoking cessation medications. L.S. has received honoraria for talks, an unrestricted research grant and travel expenses to attend meetings and workshops from Pfizer and has acted as paid reviewer for grant awarding bodies and as a paid consultant for health care companies. All authors declare no financial links with tobacco companies or e‐cigarette manufacturers or their representatives.Sarah Jackson: Conceptualization; formal analysis; investigation; methodology; visualization. Sharon Cox: Conceptualization; investigation; methodology. Lion Shahab: Conceptualization; funding acquisition; investigation; methodology. Jamie Brown: Conceptualization; data curation; funding acquisition; investigation; methodology; resources; supervision.Table S1 Interactions between timing of the COVID‐19 pandemic (pre‐pandemic vs pandemic) and use of cessation aids on abstinence: sensitivity analysis restricting the sample to smokers whose quit attempt began >6 months agoTable S2 Association between use of cessation aids and abstinence, January 2015–June 2021: sensitivity analysis restricting the sample to smokers whose quit attempt began >6 months agoClick here for additional data file.


The Patient Concerns Inventory (PCI) is a condition specific prompt list that was initially developed for head and neck cancer (HNC) and is referred to as the PCI–HN. There have been numerous publications regarding the PCI–HN, since it was first published in 2009. To date, there has not been a review of its development, validation and clinical implications. A collation of relevant papers into key sections allows multidisciplinary teams and researchers to have an overview of the PCI–HN’s background, evaluation and utility. This is essential if colleagues are to have confidence in the tool and be able to reflect on how to optimise its use in clinical practice.Five search engines were used: EMBASE, Medline, PubMed, CINAHL and Handle-on-QOL for the specific term ‘Patient Concerns Inventory’ up to and including 1st February 2022. In addition, an accumulation of PCI–HN data of 507 HNC patients was drawn from previous studies in Liverpool and Leeds between 2007 and 2020 and was analysed specifically for this paper.54 papers relating to the PCI–HN were identified. The review is structured into eight sections: (1) What is the PCI–HN and how does it work; (2) Feasibility and acceptability; (3) Psychometrics; (4) Items selected and frequency (5) Associations with Health-Related Quality of Life (HRQOL) and casemix; (6) Other observational studies; (7) Randomised trial evaluation; (8) General discussion and further research.As the term PCI is quite ubiquitous and produces many hits when searching the literature, this review provides a very concise and convenient historical context for the PCI–HN and collates the current literature. The treatment for head and neck cancer (HNC) can have a detrimental effect on appearance, speech and swallowing, emotional well-being and social integration . The HNC“Head and cancer” OR “Head and neck carcinoma’’“questionnaire” OR “patient-reported outcome”Five search engines were utilized—EMBASE, PubMed, Medline, CINAHL and HaNDLE-On-QOL. Searches were assisted by Leeds Teaching Hospitals NHS Trust and Liverpool University Hospitals NHS Foundation Trust in September 2021. The search terms were ‘Patient Concerns Inventory’ and ‘questionnaire’; however, these terms were expanded to achieve the most thorough results possible:Preferred reporting items for systematic reviews and meta-analyses guidelines were followed for this systematic review . Figure We looked at papers from 2009 to 2022 inclusively involving humans of any age, where full text was available in English, including those with non-validated, study-specific questionnaires. The research team included all authors. Results of the literature search were downloaded into an Excel spreadsheet and screened by all three authors  who separately analysed search results. Each paper was categorised by year of publication, title, author(s), cohort, design of study, theme and type of pathology, and then documented as “included, excluded, or unable to decide” from the abstract/title information.An accumulation of PCI data for 507 HNC patients was drawn from previous studies in Liverpool and Leeds between 2007 and 2020 and was analysed specifically for this paper. Core clinical data  was required and some patients had several PCI–HN records. For this paper the closest available PCI–HN record to 24 months after diagnosis was selected, so long as it was at least 9 months after, median (IQR) 23 (17–41) months. The Mann–Whitney test (2 groups) or Kruskal–Wallis test (3 or more groups) was used to test for differences in the number of PCI–HN items by gender, age at diagnosis group, primary tumour site, stage and treatment. Spearman’s correlation coefficient was used to measure the strength of correlation of the number of PCI–HN items with the six-point overall QOL question scale of the University of Washington QOL questionnaire (UW–QOL) and with the UW–QOL social–emotional and physical function subscale scores.The data were collected as part of the clinical audit process and this part of data was approved by Liverpool University Hospital NHS Foundation Trust Audit Department (CAMS reference number 9939).Following the removal of duplicates 207 articles were identified, of which 153 were excluded (not related to head and neck cancer). 54 papers were included in this study.The PCI–HN was first published in 2009  and is aThe PCI–HN approach is not a conventional screening process with cutoff and case-ness rather it provides opportunities for patients to raise issues they feel are important and that they want to discuss. Reduction techniques, to achieve optimal discriminatory properties with minimal input required from patients, are inappropriate. Content is what really matters with the PCI–HN and any item of concern selected by a patient is important. In selecting items some patients inevitably will under-estimate and others will over-estimate the gravity of what it is that concerns them. While it is unlikely that patients would select items for discussion that they did not want to discuss it is possible that some patients decline items that they feel they ought to discuss, because of embarrassment , inappropriate environment or clinician. As far as is known no important aspect has been omitted, and there has been no obvious need to revise the PCI–HN since 2012. Content and face validity are thus relevant and all that is required is to understand the meaning of each item. The involvement of patient groups in the original design and updating of the PCI–HN argues in favour of such validity. The fact that the PCI–HN can be used as a screening tool [A survey of British Association of Head and Neck Oncology Nurses found that they preferred the PCI–HN with most (60%) feeling that, as a head and neck specific tool, the PCI–HN was most appropriate . ResearcPre-consultation PCI prompt lists can be completed electronically using touch screen technology (TST) or on paper. The prompt information is then available to the clinician and patient in real-time for use during the consultation. For our studies the PCI–HN was almost exclusively completed by electronic means. The TST approach is embedded into clinical practise at Aintree, with patients being approached in the waiting room by a hospital volunteer trained in administering the PCI, and it is very unusual for a patient to refuse. Most patients are willing and able to complete the PCI–HN on their own in the waiting room with others requiring the help of the volunteer in a designated room in the outpatient area. TST data is retrieved in real time by the clinician in another room in clinic immediately before the patient consultation. On the rare occasion of technology failure a paper version of the PCI can be completed and taken by the patient into the consultation. The first research paper about the PCI–HN  reportedA recent randomised trial of the PCI–HN involving 15 consultants from two separate units (Aintree & Leeds) and 288 HNC patients  treated 2017–2019  evaluatiAn accumulation of PCI–HN data for 507 patients were analysed specifically for this paper, with data from various studies ranging from the first patients seen in 2007 . The cloResults from 140 PCI–HN patients within the PCI–HN trial  involvinIn an international study involving 19 units from across the globe , with 21Data from 2007 to 2017 for one consultant (SNR) showed that patients at risk of specific adverse outcomes could be screened within appointments without any need for extra resources, staff or time . FifteenOne paper  reportedp ≤ 0.001) of treatment, tumour site and clinical stage with the number of items overall and the number of items in the Physical and functional well-being domain . Patients with advanced tumours were significantly more likely to have selected the fatigue item (36% vs 18%), as were those patients treated with radiotherapy/chemotherapy (39% vs 11%). Patients selecting PCI–HN fatigue/tiredness reported significantly worse overall quality of life, social–emotional and physical function composite scores (UWQOL), as well as worse Distress Thermometer scores and European Quality-of-Life Five Dimension Five level (EQ-5D-5L) scores. PCI fatigue was more often observed in those patients with sleeping, nausea, mood, depression, mobility, breathing, and energy level concerns.For consecutively diagnosed patients 2008–2012, median (IQR) months to first clinic 4 (2–10) , there wr =  − 0.43) and a positive correlation with the mean scores for general (r = 0.49) and for head and neck symptoms (r = 0.45). A similar tendency, not statistically significant, was seen for correlations between QoL scores and the number of staff members selected by patients. Gender (p = 0.002) was associated with the number of patient concerns, and patient age (p = 0.003) with the number of staff members selected.Elaldi et al. , used a Numerous research papers have reported on the accumulating data set arising from the use of the PCI–HN and UW–QOLv4 by the same consultant (SNR) at Aintree since 2007, each paper with a separate distinct focus. Several papers investigated the concurrent use of the PCI–HN and UW–QOL as a means of identifying concerns and case-ness for mood and anxiety , swallowThe notion that routine screening for unmet needs prompts larger numbers of referrals and greater burden on healthcare services is unfounded . The firA study of ORN patients with follow-up clinic data 2008–2020 indicated that HNC patients with ORN progression reported an average of nine issues , double One study successfully translated the PCI–HN into the Brazilian Portuguese language, culturally validated it and evaluated in a consecutive series of Brazilian patients .In anothAlthough the PCI–HN had been well received by patients and was being adapted for use with other conditions, a trial was needed to demonstrate its efficacy because of the power and robustness level 1 evidence gives to inform, shape and transform clinical practice and patient care. The main aim of the trial was to explore whether the routine use of the PCI–HN in review clinics during the first year following head and neck cancer treatment could improve patients’ quality of life , 41, 42.Research so far on using the PCI–HN strongly suggests that it has a positive impact on outcome. Patients definitely perceive the benefit and appreciate the approach especially when having a consultation with someone unfamiliar or less experienced. The PCI approach is a driver for improvement in patient–clinician communication in routine practice. The prompt list has increased awareness amongst clinicians of the needs of patients post-treatment, with a keen focus on improving the patient experience and the understanding of person-centred practice.Limitations of this work include that many of the papers analysed data from just two UK centres (Liverpool and Leeds) and is possible that these results may not apply worldwide, though one study did involve patients from 19 units in 16 countries. To globalise the benefits of the PCI–HN one of the most important steps is the cultural validation , as someVarious research and clinical teams have contributed with papers Table  relating


What is the topic of this review?The nutritional strategies that athletes use during competition events to optimize performance and the reasons they use them.What advances does it highlight?A range of nutritional strategies can be used by competitive athletes, alone or in combination, to address various event‐specific factors that constrain event performance. Evidence for such practices is constantly evolving but must be combined with understanding of the complexities of real‐life sport for optimal implementation.High‐performance athletes share a common goal despite the unique nature of their sport: to pace or manage their performance to achieve the highest sustainable outputs over the duration of the event. Periodic or sustained decline in the optimal performance of event tasks, involves an interplay between central and peripheral phenomena that can often be reduced or delayed in onset by nutritional strategies. Contemporary nutrition practices undertaken before, during or between events include strategies to ensure the availability of limited muscle fuel stores. This includes creatine supplementation to increase muscle phosphocreatine content and consideration of the type, amount and timing of dietary carbohydrate intake to optimize muscle and liver glycogen stores or to provide additional exogenous substrate. Although there is interest in ketogenic low‐carbohydrate high‐fat diets and exogenous ketone supplements to provide alternative fuels to spare muscle carbohydrate use, present evidence suggests a limited utility of these strategies. Mouth sensing of a range of food tastants  may provide a central nervous system derived boost to sports performance. Finally, despite decades of research on hypohydration and exercise capacity, there is still contention around their effect on sports performance and the best guidance around hydration for sporting events. A unifying model proposes that some scenarios require personalized fluid plans while others might be managed by an ad hoc approach (ad libitum or thirst‐driven drinking) to fluid intake. Despite the unique features of their sport, all athletes share a common goal: to pace or manage their performance to achieve the highest sustainable outputs or speeds, with technical and tactical proficiency, over the duration of the event. Although many athletes target competitions to showcase maximum performance to break world records or achieve personal bests, for others, success simply involves a performance that is superior to those of other competitors. Regardless, competition success is commonly determined by the athlete's ability to manage a decline in some performance metrics, intermittently and/or towards the end of the event. A periodic or sustained decline in the ability to optimally perform the tasks required of the specific event involves interplay between central and peripheral phenomena that constrain power or force production, increase ratings of fatigue/pain or reduce skill and cognitive abilities. Common causes of these physiological constraints include depletion of the substrate(s) needed to support the muscle turnover of adenosine triphosphate (ATP) or changes in body homeostasis , the overlay of the environment , the competition schedule  and the need for travel  adds further physiological and practical challenges. Therefore, there is always a need to evolve new and bespoke strategies for different versions of the same event.Second, in most sports, performance is limited by a number of interdependent factors, which need to be addressed by a coordinated plan. The interplay between performance‐limiting factors or the strategies used as countermeasures could involve redundancy, amplification, attenuation or competition between effects Burke, . Inadequdomestique teammates, who consumed 500 g CHO during a 5‐h cycling stage towards a daily CHO intake of 18 g kg−1 body mass (BM); Fordyce, −1 from aid stations placed at every 5 km; Beis et al., Third, even when beneficial nutritional strategies can be identified, the implementation of these strategies before, during and between events is dependent on the rules, logistical considerations and cultures that exist in sport  comes from psychological factors ranging from familiarity to a placebo or expectancy effect  or as a longer maintenance dose (4 weeks @ 3 g day−1) to achieve a typical increase of ∼20% in muscle PCr and creatine stores  is interspersed with short recovery intervals , which fail to allow complete restoration of PCr between bouts  or events involving combinations of both, such as intermittent team/racket sports or stochastic endurance events including critical ‘breakaway’ pieces interspersed between more moderate intensity workloads . The features and regulation of CHO metabolism are elegantly suited to fuel such events, since CHO can be used for both aerobic and oxygen‐independent production of ATP, with rapid activation of these pathways being able to meet fuel needs across the whole range of power demands and the transitions between them  can also enhance performance, via a number of centrally and peripherally derived effects including increased neural drive associated with mouth sensing, maintenance of euglycaemia, hepatic and muscle glycogen sparing and the maintenance of high rates of CHO oxidation in the face of dwindling muscle glycogen stores  exercise  meals in the hours or days before an event) have proved unsuccessful in enhancing performance even in endurance‐trained participants with enhanced capacity for FA oxidation ‐3‐hydroxybutyl (R)‐3‐hydroxy‐butyrate , acetone, acetoacetate and β‐hydroxybutyrate (βHB) are chemicals produced by the liver during periods of low energy or low CHO availability, with high circulating levels seen during starvation, prolonged fasting and ketogenic LCHF diets. Their contribution to metabolism and performance changes associated with the latter ‘keto‐adaptation’ is unclear from the currently available studies of short to medium LCHF exposure. Indeed, while ketone oxidation is proposed to have an advantage in terms of free energy liberation, it also appears to make only a minor contribution to fuel use during exercise, even when blood concentrations are increased  can enhance performance; here, it may alter traditional strategies of timing and sources of intake of these nutrients during competitive events to optimize their CNS benefits  does hypohydration impair sports performance? How should athletes approach hydration strategies for their event? Since sweat is typically hypotonic with respect to plasma, exercise‐associated sweat losses lead to hypertonic hypovolaemia . Indeed, it is noted that case histories of hyponatraemia have included athletes who claimed to be following thirst‐driven drinking practices (Hew‐Butler et al., 6High‐performance sport challenges the athlete to counter the limitations to their ability to be swifter, higher and/or stronger across the duration of their sporting event. Sports performance involves a complex interaction between physiological, biomechanical and psychological factors, with some of factors that cause a decrement in outputs being underpinned by nutritional issues. Dietary strategies undertaken in training or in the immediate period before, during or between competitive events can reduce or delay the onset of such performance constraints, leading to enhanced performance. The science and practice of sports nutrition continues to evolve and includes strategies to provide an ongoing supply of key fuels, to promote CNS approaches to enhanced pacing and to solve differences in the interpretation of data and observations around hydration and performance. Although there is a need for a sound understanding of the theoretical basis of exercise capacity, nutritional strategies need to be developed to suit the logistical features of sporting competitions. Future endeavours should focus on better understanding the interaction of different nutritional strategies within the same event, individual differences in response to nutrition strategies and the athlete's capacity to implement strategies in real‐life conditions including harsh environments and multi‐day or multi‐event programmes.None declared.Sole author.


As the pace of environmental change increases, there is an urgent need for quantitative data revealing the temporal dynamics of local communities in tropical areas. Here, we quantify the stability of avian assemblages in the highly threatened, but poorly studied, Andean biodiversity hot spot. We evaluated the temporal variation in species richness and community composition of local bird assemblages in three habitat types  using a unique, relatively long‐term data series from Cajas National Park and Mazán Reserve in the southern Andes of Ecuador. We sampled birds with mist nets using a standardized protocol over 11 years, from 2006 to 2016. Species richness remained stable over time across habitats, but community composition changed in the native forest. In particular, we observed taxonomic reordering in the native forest, in which the evenness in the distribution of abundances of taxa decreased over time. This finding is consistent with other studies where species richness remained constant over time while community composition changed. Our study highlights the value of long‐term studies in the tropical Andes as we show that species composition of birds in a montane forest is changing, consistent with global trends in biodiversity change. We evaluated the temporal variation in species richness and community composition of local bird assemblages over 11 years in Cajas National Park and Mazán Reserve in the Southern Andes of Ecuador. Species richness remained stabled over time, but we observed taxonomic reordering in the undisturbed native forest, in which the evenness in the distribution of abundances of taxa decreased over time. This trend, resulting in increased dominance of some species, while others became rare in the native forest, is of conservation concern because it indicates that biodiversity could be changing over time even in the absence of local disturbances. Specifically, we analyzed changes in local communities to ask the following three questions: (1) Is taxonomic richness changing over time? Given the previous evidence of decline in richness in the study area  of mostly native montane forest, with páramo grasslands occupying the upper ridges of the valley , and early successional vegetation (hereafter native shrub) , with isolated taller trees mainly along small creeks that crossed our sampling area. There has been little change in the structure of the vegetation in all habitat types over the period of this study , mixed stands of mature ) Figure . The nat2.2At each sampling station, we captured birds by placing 20 mist nets (12 m × 32 mm mesh) along edges of narrow trails (1 m approximately) in fixed locations for two consecutive days  was estimated with a Jackknife estimator, obtained by using observed species richness of each of the three sampling periods within each year  has been previously shown to follow abrupt changes in the abundance curve of species found in Amazonian communities  were used to check for potential temporal autocorrelations, and they did not indicate temporal autocorrelation of residuals. All of the analyses were performed using software R .Observed annual species richness did not change in any of the habitats over time Figure . These rThe time‐lag analysis revealed a significant temporal rate of change in community composition only in the native forest Figure ; the othThere was no temporal trend in the rate of taxonomic turnover in any of the habitats Figure , Table 2Metallura tyrianthina and Coeligena iris increased in abundance over time relative to other species, while Basileuterus coronatus decreased in dominance. In the native shrub habitat, Eriocnemis luciani increased in dominance over time.Rank abundance distribution plots over time in each habitat showed that in native forest and native shrub habitats, the proportional abundance of the highest ranked species had increased from 2006 to 2016 Figure . Heat ma4Using a unique dataset from the tropical Andes, we examined how species richness and community composition of birds changed over 11 years in three habitats located in high‐elevation protected areas. Taxonomic richness remained constant in native forest, shrub, and introduced forest habitats. However, we detected taxonomic reordering in the native forest, where evenness of the distribution of species decreased over the studied period. This trend, resulting in increased dominance of some species, while others became rare in the native forest, is of conservation concern because it indicates that biodiversity could be changing over time even in the absence of local disturbances. Changes in avian diversity in the absence of local disturbances have been found previously in other tropical ecosystems (Blake & Loiselle, Hemispingus verticalis and Cnemathraupis eximia, for example, are among those rare species that were detected in the 1994–1995 study period, but have not been recorded since we started sampling in the native forest in 2006. Therefore, since 2006, we might be monitoring an already impoverished avian community already suffering from the loss of species. This same factor could explain the stability in taxonomic turnover we detected in all habitats, where avian communities in the region are currently composed of multiple‐disturbance‐tolerant species that are able to maintain populations over time in different habitat types (Tinoco et al., Constant species richness over time across all habitats agrees with global analyses that suggest that at the local scale species richness is relatively stable (Blowes et al., Our time‐lag analysis showed that species composition is becoming more dissimilar over time in the native forest. This change in the native forest is likely determined by taxonomic reordering of the community. Although the decline in evenness over time was marginally significant, our results suggest that some species became more dominant over time in this habitat. We expected that the most undisturbed site would have the lowest rates of change in community composition because the internal dynamics of undisturbed forests should be governed by stochastic demographic variation in populations (Jackson & Sax, Several interacting environmental factors may have influenced the change in evenness in the native forest, including successional processes in the local vegetation, regional land‐use change, and global climate change. Detailed measures of forest structure in the native forest showed little variation in canopy cover, and number of trees and shrubs between 2007 and 2013 (Tinoco et al., Temporal changes in evenness signal an assemblage that is undergoing a transitional phase (Smith et al., Exploring temporal changes in biodiversity across different habitats in the tropical Andes is necessary for predicting the long‐term consequences of global environmental change, as this region harbors a large proportion global diversity (Laurance et al., Fig S1Click here for additional data file.