Our results indicate that PAE provides a clinically and statistically significant improvement in symptoms and QoL, although some of these improvements were greater in the TURP arm. The safety profile and quicker return to normal activities may be seen as highly beneficial by patients considering PAE as an alternative treatment to TURP, with the concomitant advantages of reduced length of hospital stay and need for admission after PAE. PAE is an advanced embolization technique demanding a high level of expertise, and should be performed by experienced interventional radiologists who have been trained and proctored appropriately. The use of cone-beam computed tomography is encouraged to improve operator confidence and minimize non-target embolizations. The place of PAE in the care pathway is between that of drugs and surgery, allowing the clinician to tailor treatment to individual patients' symptoms, requirements and anatomical variation.

ObjectiveTo determine if postnatal transfer or birth in a non-tertiary hospital is associated with adverse outcomes.DesignObservational cohort study with propensity score matching.SettingNational health service neonatal care in England; population data held in the National Neonatal Research Database.ParticipantsExtremely preterm infants born at less than 28 gestational weeks between 2008 and 2015 (n=17 577) grouped based on birth hospital and transfer within 48 hours of birth: upward transfer (non-tertiary to tertiary hospital, n=2158), non-tertiary care (born in non-tertiary hospital; not transferred, n=2668), and controls (born in tertiary hospital; not transferred, n=10 866). Infants were matched on propensity scores and predefined background variables to form subgroups with near identical distributions of confounders. Infants transferred between tertiary hospitals (horizontal transfer) were separately matched to controls in a 1:5 ratio.Main outcome measuresDeath, severe brain injury, and survival without severe brain injury.Results2181 infants, 727 from each group (upward transfer, non-tertiary care, and control) were well matched. Compared with controls, infants in the upward transfer group had no significant difference in the odds of death before discharge (odds ratio 1.22, 95% confidence interval 0.92 to 1.61) but significantly higher odds of severe brain injury (2.32, 1.78 to 3.06; number needed to treat (NNT) 8) and significantly lower odds of survival without severe brain injury (0.60, 0.47 to 0.76; NNT 9). Compared with controls, infants in the non-tertiary care group had significantly higher odds of death (1.34, 1.02 to 1.77; NNT 20) but no significant difference in the odds of severe brain injury (0.95, 0.70 to 1.30) or survival without severe brain injury (0.82, 0.64 to 1.05). Compared with infants in the upward transfer group, infants in the non-tertiary care group had no significant difference in death before discharge (1.10, 0.84 to 1.44) but significantly lower odds of severe brain injury (0.41, 0.31 to 0.53; NNT 8) and significantly higher odds of survival without severe brain injury (1.37, 1.09 to 1.73; NNT 14). No significant differences were found in outcomes between the horizontal transfer group (n=305) and controls (n=1525).ConclusionsIn extremely preterm infants, birth in a non-tertiary hospital and transfer within 48 hours are associated with poor outcomes when compared with birth in a tertiary setting. We recommend perinatal services promote pathways that facilitate delivery of extremely preterm infants in tertiary hospitals in preference to postnatal transfer.

Word count: Abstract (300 /300w) Background: Necrotising enterocolitis (NEC), a feared neonatal gastrointestinal inflammatory disease with high mortality and morbidity, is growing in global relevance as birth rates and early survival of low gestational age (GA) infants increases. Population data are scant and pathogenesis is incompletely understood but enteral feed exposures are believed to influence risk. Methods:We conducted a two-year national surveillance study to quantify the total population burden of severe NEC (confirmed at laparotomy and/or leading to death) in England, and a propensity score analysis of the impact of early feeds of maternal milk (MM), and avoidance of bovine-origin formula (BOF) and milk fortifier (BMF), on NEC risk in very preterm infants. Findings:During the study period 118,073 infants (14,678 <32w GA) were admitted to 163 neonatal units across 23 networks; 531 (462 <32w GA) developed severe NEC; 247 died, 139 following laparotomy. Among infants <32w GA the adjusted network incidence ranged from 2·51% to 3·85% with no evidence of unusual variation in relation to the national incidence of 3·13% (95%CI 2·85, 3·42) despite variation in feeding practices. Also among infants <32w GA, commencing any MM within seven postnatal days resulted in an Absolute Risk Difference (ARD) of -0·88% (95% CI -1·15, -0·61), Relative Risk (RR) 0·69 (95% CI 0·60, 0·78), and Number Needed to Treat (NNT) 114 (95% CI 87, 136); equivalent figures for infants receiving no, compared to any bovine-origin products within 14 postnatal days were ARD -0·65% (95% CI -1·01, -0·29), RR 0·61 (95% CI 0·39, 0·83), NNT 154 (95% CI 94, 345). Interpretation:Commencing MM early and avoiding bovine-origin products may reduce NEC but absolute risk reductions appear small. The rarity of severe NEC requires national and international collaboration for adequately powered preventive trials.Funding: This study represents independent research funded by the National Institute for Health Research (NIHR). Research in contextEvidence before this study Necrotising enterocolitis (NEC) is a feared, acute neonatal gastrointestinal inflammatory disease with high mortality and morbidity. Reliable population incidence data are necessary for designing preventive and treatment studies. Enteral feeding stratagems are widely believed to influence NEC risk. When maternal milk (MM) is insufficient or unavailable some clinicians prefer pasteurised human donor milk (HDM) over bovine-origin formula (BOF) in the hope that avoidance of bovine-origin products will be protective and/or pasteurised HDM will retain some of the protective properties of MM. Others prefer BOF to HDM as the composition of the former is consistent, nutrient density is higher, and costs are lower. Other uncertainties relate to the timing of introduction of milk feeds in very preterm infants, and use of bovineorigin fortifier (BMF) (additional vitamins, minerals, and nutrients added to human milk).We conducted a systematic search of studies from the 34 countries in the Organisation fo...

Importance: Necrotising Enterocolitis (NEC) is a major cause of neonatal morbidity and mortality. Preventive and therapeutic research, surveillance and quality improvement initiatives, are hindered by variations in case-definitions. Objective: To develop a gestational age (GA) specific case-definition for NEC. Design, Setting, and Participants: We conducted a prospective 34 month population study using clinician-recorded findings between December 2011 and September 2014 across all 163 neonatal units in England. Exposure: Abdominal X-ray (AXR) performed to investigate clinical concerns. Main outcomes and measures: Ordinal NEC likelihood score, dichotomous casedefinition, and GA-specific probability plots. We secured clinician commitment to record data prospectively into each infant's Electronic Patient Record (EPR). We obtained study data from the UK National Neonatal Research Database that holds information extracted regularly from the neonatal EPR. We split study data into test and validation datasets. We entered GA, birth-weight z score, clinical and AXR findings as candidate variables in a logistic regression model, performed model fitting 1000 times, averaged the predictions, and used estimates from the fitted model to develop an ordinal NEC score, and cut-points to develop a dichotomous case-definition based upon the highest area under the receiver operating characteristic curves and positive predictive values. Results: We included data from 3866 infants (2978 without and 888 with NEC). Less mature infants were less likely to present with pneumatosis, blood or mucus in stools, and were more likely to have a gasless AXR. In the ordinal NEC score analysis we allocated three points to pneumatosis, two points to blood in stools. One point each was allocated to: abdominal tenderness;abdominal discolouration; the composite of increased and/or bilious aspirates AND abdominal distension;one or more of pneumoperitoneum, fixed loop and portal venous gas. The cutoff scores for the dichotomous gestational age-specific case-definition were ≥2 (<30 weeks GA); ≥3 (30 to <37 weeks); ≥4 (≥37 weeks). The ordinal NEC score and dichotomous case-definition discriminated well between infants with and without NEC (AUC 87% and 80% respectively). Conclusions and relevance: NEC risk and clinical presentation are related to GA. Adoption of a consistent GA-specific case-definition would strengthen global efforts to reduce the population burden of this devastating neonatal disease.

A service evaluation of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) testing and result notification in patients attending a rapid testing service (Dean Street Express [DSE]) compared with those attending an existing ‘standard’ sexual health clinic (56 Dean Street [56DS]), and modelling the impact of the new service from 1 June 2014 to 31 May 2015. Primary outcome: time from patients’ sample collection to notification of test results at DSE compared with 56DS. Secondary outcomes estimated using a model: number of transmissions prevented and the number of new partner visits avoided and associated cost savings achieved due to rapid testing at DSE. In 2014/15, there were a total of 81,352 visits for CT/NG testing across 56DS (21,086) and DSE (60,266). Rapid testing resulted in a reduced mean time to notification of 8.68 days: 8.95 days for 56DS (95% CI 8.91–8.99) compared to 0.27 days for DSE (95% CI 0.26–0.28). Our model estimates that rapid testing at DSE would lead to 196 CT and/or NG transmissions prevented (2.5–97.5% centile range = 6–956) and lead to annual savings attributable to reduced numbers of partner attendances of £124,283 (2.5–97.5% centile range = £4260–590,331). DSE, a rapid testing service for asymptomatic infections, delivers faster time to result notification for CT and/or NG which enables faster treatment, reduces infectious periods and leads to fewer transmissions, partner attendances and clinic costs.