Aim The purpose of this systematic review was to use the Appraisal of Guidelines for Research and Evaluation tool to assess the methodological quality of clinical practice guidelines (CPGs) for the workup and management of paediatric neck masses. Methods MEDLINE, Embase, Cochrane and grey literature were searched to identify CPG incorporating paediatric neck masses. Four authors with previous training of the Appraisal of Guidelines for Research and Evaluation tool evaluated the included studies. Results Nine studies met inclusion criteria. The highest scoring domains were ‘Scope and Purpose’ (74.0 ± 4.5) and ‘Clarity of Presentation’ (72.9 ± 6.3). The lowest scoring domains were ‘Rigour and Development’ (18.8 ± 7.5) and ‘Applicability’ (23.7 ± 6.1). One study was ‘High’ quality, three received scores of ‘Average’ and five were found to be ‘Low’ quality. Conclusion The majority of paediatric neck mass CPGs were low to average quality. The domains in need of greatest improvement were ‘Rigour and Development’ and ‘Applicability’, suggesting significant concerns in current CPGs focused on paediatric neck masses.
To develop and validate on a simulator a learnable technique to decrease deviation of biopsied cores from the template schema during freehand, side-fire systematic prostate biopsy (sPBx) with the goal of reducing prostate biopsy (PBx) falsenegatives, thereby facilitating earlier sampling, diagnosis and treatment of clinically significant prostate cancer. Participants and MethodsUsing a PBx simulator with real-time three-dimensional visualization, we devised a freehand, pitch-neutral (0°, horizontal plane), side-fire, transrectal ultrasonography (TRUS)-guided sPBx technique in the left lateral decubitus position. Thirtyfour trainees on four Canadian and US urology programmes learned the technique on the same simulator, which recorded deviation from the intended template location in a double-sextant template as well as the TRUS probe pitch at the time of sampling. We defined deviation as the shortest distance in millimeters between a core centre and its intended template location, template deviation as the mean of all deviations in a template, and mastery as achieving a template deviation ≤5.0 mm. ResultsAll results are reported as mean AE SD. The mean absolute pitch and template deviation before learning the technique (baseline) were 8.2 AE 4.1°and 8.0 AE 2.7 mm, respectively, and after mastering the technique decreased to 4.5 AE 2.7°(P = 0.001) and 4.5 AE 0.6 mm (P < 0.001). Template deviation was related to mean absolute pitch (P < 0.001) and increased by 0.5 mm on average with each 1°increase in mean absolute pitch. Participants achieved mastery after practising 3.9 AE 2.9 double-sextant sets. There was no difference in time to perform a double-sextant set at baseline (277 AE 102 s) and mastery (283 AE 101 s; P = 0.39). ConclusionA pitch-neutral side-fire technique reduced template deviation during simulated freehand TRUS-guided sPBx, suggesting it may also reduce PBx false-negatives in patients in a future clinical trial. This pitch-neutral technique can be taught and learned; the University of Florida has been teaching it to all Urology residents for the last 2 years.
nmCRPC, demonstrated that APA added to androgen deprivation therapy (ADT) prolonged metastasis-free survival (MFS) by > 2 yrs (median 40.5 vs 16.2 mo; HR, 0.28; p < 0.0001) and provided a 55% reduction in the risk of symptomatic progression (HR, 0.45; 95% CI, 0.32-0.63; p < 0.0001) (Smith et al. N Engl J Med 2018). We examined whether treatment with APA, a next-generation androgen receptor inhibitor, provided the same benefit and safety profile in pts with or without prior RP and/or XRT (RP/XRT).METHODS: Pts with nmCRPC and a high risk of developing metastasis (prostate-specific antigen doubling time [PSADT] 10 mo) were randomized 2:1 to APA (240 mg QD) þ ADT or PBO þ ADT. Pt outcomes were evaluated based on any RP/XRT prior to the study. Cox proportional hazard analysis was used to estimate the HR and 95% CI for MFS.RESULTS: 41% of pts in each arm (334/806 APA; 166/401 PBO) had prior RP/XRT. Pts with prior RP/XRT were younger with longer time since diagnosis, had lower PSA values, lower ECOG and Gleason scores, and were less likely to have renal impairment. Despite these baseline advantages in the PBO group, pts with prior RP/XRT had poorer outcomes. MFS was significantly shorter for PBO pts with vs without prior local therapy (HR, 1.73; p [ 0.0002). This negative prognosis for pts with prior RP/XRT was overcome with APA (HR, 0.80; p [ 0.13), which delayed development of metastases by 68%-84% vs PBO (Table ). The relative magnitude of improvement with APA vs PBO was highest in pts with prior local therapy. No impact of prior local therapy was observed on incidence of grade 3/4 treatment-emergent adverse events with APA and PBO. Incidence of falls, fractures, hypothyroidism, seizures, and skin rash was similar in pts with or without prior RP/XRT. CONCLUSIONS: Regardless of prior local therapy, pts received highly significant MFS benefit from treatment with APA. Prior therapy did not have an impact on tolerability of APA.
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