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BackgroundAntenatal care (ANC) is provided for free in Tanzania in all public health facilities. Yet surveys suggested that long distances to the facilities limit women from accessing these services. Mobile health clinics (MHC) were introduced to address this problem; however, little is known about the client cost and time associated with utilizing ANC at MHC and whether these costs deter women from using the provided services.MethodsClient-exit interviews were conducted by interviewing 293 pregnant women who visited the MHC in rural Tanzania. Two subgroups were created, one with women who travelled more than 1.5 h to the MHC, and the other with women who travelled within 1.5 h. For each subgroup we estimated the direct cost in US$ and time in hours for utilizing services and they hinder service utilization. The Wilcoxon–Mann–Whitney rank sum test was performed to compare the differences between the estimated mean values in the two groups.ResultTotal direct cost per visit was: US$2.27 (SD = 0.90) for overall, US$2.29 (SD = 1.03) for those women who travelled less than 1.5 h and US$2.53 (SD = 0.63) for those who travelled more than 1.5 h (p = 0.08). Laboratory and medicine cost accounted for 70 and 16% of the total direct cost and were similar across the groups. Total time cost per visit (in hours) was: 3.75 (SD = 1.83), 2.88 (SD = 1.27) for those women who travelled less than 1.5 h and 5.02 (SD = 1.81) for those who travelled more than 1.5 h (p < 0.01). The major contributor of time cost was waiting time; 1.89 (SD = 1.29) for overall, 1.68 (SD = 1.02) for those women who travelled less than 1.5 h and 2.17 (SD = 1.57) for those who travelled more than 1.5 h (p = 0.07). Participants reported having missed their scheduled visit due to lack of money (15%) and time (9%).ConclusionWomen receiving nominally free ANC incur considerable time and direct cost, which may result in an unsteady use of maternal care. Improving availability of essential medicine and supplies at health facilities, as well as focusing on efficient utilization of community health workers may reduce these costs.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3736-z) contains supplementary material, which is available to authorized users.

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Add-on therapy with growth factors and active skin substitutes for treating uncomplicated DFU could be an alternative to SWC alone. For explicit recommendations further studies with stronger evidence are necessary.

Sensitivity and specificity of ultrasound examinations are high. Single study results show that sonographic examinations can be faster and less painful. In addition, the calculation model shows a tendency towards less-expensive ultrasound examinations.Further studies are needed with an adequate sample size calculation for assessing equivalence or non-inferiority of ultrasound and x-ray and to collect data on pain, examination time, and costs. The age of the older participants may be problematic because of the fact that epiphyseal plates close within the age from 15 to 22 years, which may influence the diagnostic accuracy of sonographic examinations. Therefore, future studies should contain age-stratified analyses. In addition, the calculation model for costs should be tested on a wider data base.

The close cooperation between the guideline group and commission for certification allowed the guideline contents to be implemented in the form of quality indicators in everyday clinical practice. Adherence to the guidelines is required and continuously evaluated as part of certification.

Study Type – Therapy (systematic review) Level of Evidence 1a What's known on the subject? and What does the study add? Numerous newer (non‐standard) procedures for the treatment of benign prostatic hyperplasia (BPH) exist; however, it is unclear whether they actually have an additional patient‐relevant benefit compared to standard treatment. As no trial investigated non‐inferiority, we defined a non‐inferiority threshold on the basis of published literature. The present systematic review found no proof of an additional benefit of non‐standard treatments for BPH; an indictation of an additional benefit was only shown for holium laser resection of the prostate (HoLRP) and thulium laser resection of the prostate (TmLRP). OBJECTIVE To assess the potential additional benefit of non‐standard vs standard surgical treatments for benign prostatic hyperplasia (BPH) and to present a new methodological approach to investigate therapeutic equivalence (non‐inferiority) regarding symptom reduction. PATIENTS AND METHODS We conducted a systematic review and searched MEDLINE, Embase and the Cochrane Library (last search: 10/2009) for randomized controlled trials (RCTs) and non‐randomized controlled clinical trials (CCTs). Eligible studies were those that included patients with symptomatic BPH requiring surgical treatment and which compared non‐standard procedures (e.g. minimally invasive technologies) with standard ones (e.g. transurethral resection of the prostate, TURP). In addition, only studies analysing patient‐relevant outcomes were considered (e.g. irritative and obstructive symptoms, length of hospital stay, quality of life and adverse events). The main outcome of interest for the present analysis was superiority or non‐inferiority for symptom reduction. As no trial investigated non‐inferiority, we defined a non‐inferiority threshold (0.25 standard deviation) on the basis of published literature. If a non‐standard procedure showed non‐inferiority for symptom reduction, additional outcomes were assessed. Meta‐analyses were conducted if feasible and meaningful. RESULTS In all, 43 mainly low‐quality trials (RCTs only) compared nine non‐standard surgical treatments with standard ones. Mean follow‐up ranged from 6 to 84 months. No non‐standard procedure was superior for symptom reduction. Non‐inferiority for symptom reduction was shown in patients who had undergone holmium laser resection of the prostate (HoLRP) or thulium laser resection of the prostate (TmLRP). As procedural advantages (e.g. no occurrence of transurethral resection syndrome) and other advantages (e.g. shortened hospital stay) were found, an indication of an additional benefit of HoLRP and TmLRP was determined. CONCLUSIONS No proof of superiority for symptom reduction has been shown for non‐standard surgical treatments in patients with BPH. There is a lack of high‐quality RCTs and trials designed to investigate non‐inferiority. Future studies should define a non‐inferiority threshold (ideally, uniform) a priori, so that results of individual studies ar...