Health systems invest significant resources in leadership development for physicians and other health professionals. Competent leadership is considered vital for maintaining and improving quality and patient safety. We carried out this systematic review to synthesise new empirical evidence regarding medical leadership development programme factors which are associated with outcomes at the clinical and organisational levels. Using Ovid MEDLINE, we conducted a database search using both free text and Medical Subject Headings. We then conducted an extensive hand-search of references and of citations in known healthcare leadership development reviews. We applied the Medical Education Research Study Quality Indicator (MERSQI) and the Joanna Briggs Institute (JBI) Critical Appraisal Tool to determine study reliability, and synthesised results using a meta-aggregation approach. 117 studies were included in this systematic review. 28 studies met criteria for higher reliability studies. The median critical appraisal score according to the MERSQI was 8.5/18 and the median critical appraisal score according to the JBI was 3/10. There were recurring causes of low study quality scores related to study design, data analysis and reporting. There was considerable heterogeneity in intervention design and evaluation design. Programmes with internal or mixed faculty were significantly more likely to report organisational outcomes than programmes with external faculty only (p=0.049). Project work and mentoring increased the likelihood of organisational outcomes. No leadership development content area was particularly associated with organisational outcomes. In leadership development programmes in healthcare, external faculty should be used to supplement in-house faculty and not be a replacement for in-house expertise. To facilitate organisational outcomes, interventions should include project work and mentoring. Educational methods appear to be more important for organisational outcomes than specific curriculum content. Improving evaluation design will allow educators and evaluators to more effectively understand factors which are reliably associated with organisational outcomes of leadership development.

We present the case of a patient with Lynch syndrome and metastatic colorectal carcinoma (mCRC). The initial immunohistochemistry (IHC) test for deficient mismatch repair gave a false negative result. However, the same mutation has accurately has been detected with IHC in other cancers with microsatellite instability (MSI) This supports the determining role of somatic missense mutations in MMR IHC. MSI-PCR testing confirmed MSI and the patient benefited from nivolumab with a complete metabolic response. We explain the rationale for immunotherapy in mCRC, current testing strategies and discuss future developments in MSI testing. We advocate for upfront testing using both IHC and MSI-PCR to direct therapy in mCRC, and a greater understanding of IHC and MSI-PCR testing pitfalls.

Radiolabelled prostate-specific membrane antigen (PSMA)-based Positron emission tomography-computed tomography (PET-CT) has been shown in numerous studies to be superior to conventional imaging in the detection of nodal or distant metastatic lesions. 68Ga-PSMA PET-CT is now recommended by many guidelines for the detection of biochemically relapsed disease after radical local therapy. PSMA radioligands can also function as radiotheranostics, namely Lu-PSMA has been shown to be a potential new line of treatment for metastatic castrate resistant prostate cancer. W hole-body MRI (WB-MRI) has been shown to have a high diagnostic performance in the detection and monitoring of metastatic bone disease. Prospective, randomized, multi-centre studies comparing 68 Ga-PSMA PET-CT and WB-MRI for pelvic nodal and metastatic disease detection are yet to be performed. Challenges for interpretation of PSMA include tracer trapping in non-target tissues and urinary excretion of tracers confounding image interpretation at the vesicoureteral junction. Additionally , studies have described how long-term androgen deprivation therapy (ADT) affects PSMA expression and could, therefore, reduce tracer uptake and visibility of PSMA-positive lesions . Furthermore, ADT of short duration might increase PSMA expression, leading to the PSMA flare phenomenon, which makes it challenging to accurately monitor treatment response to ADT with PSMA-PET. Scan duration, detection of incidentalomas and presence of metallic implants are some of the major challenges with WB-MRI. Emerging data supports the wider adoption of PSMA-PET and WB-MRI for diagnosis, staging, disease burden evaluation and response monitoring, though their relative roles in the standard of care management of patents is yet to be fully defined.. Key points• Next-generation imaging techniques have been found to affect prostate cancer disease state classifications as their increased sensitivity can result in stage migration.

Out‐of‐area placements (OAPs) are heavily relied upon by the NHS to meet growing demand but they are expensive, disruptive for patients, and may reduce quality of care and outcomes for patients. Here, the authors compared 50 patients who used acute OAPs with 50 patients admitted to an acute bed locally as regards length of stay, readmission rates, contact with services and levels of self‐harm in the following 12 months. The results were substantially worse in key respects for patients who go to OAPs, raising further questions about their quality and the economic impact to the NHS.