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Background: globally, alcohol use rates vary by sexual orientation and gender identity (SOGI), but UK government statistics on alcohol use in the LGBTQ+ population are missing. Aim: this systematic scoping review determined the prevalence of alcohol use amongst gender and sexual minority people in the UK. Methods: empirical UK studies from 2010 onwards reporting the prevalence of alcohol use in SOGI compared with heterosexual/cisgender people were included. Searches in MEDLINE, Embase, Web of Science, PsycINFO, CINAHL, Cochrane Library, Google Scholar, Google, charity websites and systematic reviews were conducted in October 2021, using SOGI, alcohol and prevalence terms. Citation checking was done by two authors, with disagreements resolved through discussion. Data extraction was done by one author (CM) and checked by another (LZ). Quality assessment was performed by study design, sample type and statistical analysis of results. A narrative synthesis was qualitatively combined with a tabular presentation of results. Results: database and website searches found 6607 potentially relevant citations, and 505 full texts were reviewed with 20 studies included, found in 21 publications and grey literature reports. Most were on sexual orientation, including 12 from large cohort studies. Harmful alcohol use is higher in LGBTQ+ people than heterosexual people in the UK, a result similar to that found in other countries. Qualitative data reflected alcohol’s role as emotional support. Fewer asexual people drank alcohol compared with allosexual people, and there were no data available regarding intersex people. Conclusion: funded cohort studies and service providers should routinely collect SOGI data. Standardized reporting of SOGI and alcohol use would improve comparability across studies.

Conversations about research priorities with members of the public are rarely designed specifically to include people who identify as Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ+) and are not researchers. Generally, to address this gap, and specifically, to inform future research for CLS, we carried out a rapid review of published research priority sets covering LGBTQ+ topics, and an online workshop to prioritise identified themes. Rapid review: results. The rapid review identified 18 LGBTQ+ research priority sets. Some focussed on specific populations such as women or men, younger or older people or people living within families. Five addressed transgender and gender non- conforming populations. All of the research priority sets originated from English-speaking, high and middle-income countries (UK, US, Canada, and Australia), and date from 2016 onwards. Prioritization approaches were wide-ranging from personal commentary to expert workshops and surveys. Participants involved in setting priorities mostly included research academics, health practitioners and advocacy organisations, two studies involved LGBTQ+ public in their process. Research priorities identified in this review were then grouped into themes which were prioritised during the workshop. Workshop: results. For the workshop, participants were recruited using local (Cambridge, UK) LGBTQ+ networks and a national advert to a public involvement in research matching website to take part in an online discussion workshop. Those that took part were offered payment for their time in preparing for the workshop and taking part. Participants personal priorities and experiences contributed to a consensus development process and a final ranked list of seven research themes and participants’ experiences of healthcare, mental health advocacy, care homes, caring responsibilities, schools and family units added additional context. From the workshop the three research themes prioritised were: healthcare services delivery, prevention, and particular challenges / intersectionality of multiple challenges for people identifying as LGBTQ+. Research themes interconnected in many ways and this was demonstrated by the comments from workshop participants. This paper offers insights into why these priorities were important from participants’ perspectives and detail about how to run an inclusive and respectful public involvement research exercise. On a practical level these themes will directly inform future research direction for CLS. Conversations about research priorities with members of the public who identify as Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ+) and are not researchers are not common. We reviewed published research priorities covering LGBTQ+ topics and held an online workshop. The review identified 18 LGBTQ+ research published priority sets. Some focussed on specific populations such as women or men, younger or older people or people living within families. Five were on transgender and gender non- conforming populations. Priorities were achieved by different methods such as workshops and surveys. People involved in setting priorities mostly included researchers, health practitioners and advocacy organisations, two studies involved LGBTQ+ public in their process. Research priorities identified in the review were grouped into themes which were prioritised during the workshop. For the online workshop, participants were recruited using local (Cambridge, UK) LGBTQ+ networks and a national advert and offered payment for their time. Participants personal priorities and experiences contributed to agreeing a final list of seven research themes in priority order. Participants’ experiences of healthcare, mental health advocacy, care homes, caring responsibilities, schools and family units were helpful. From the workshop the three top research themes were: healthcare services delivery, prevention, and particular and multiple challenges of people identifying as lesbian, gay, bisexual, transgender or queer. Research themes interconnected in many ways as shown by the comments from workshop participants. This paper describes why these priorities were important from participants’ perspective and offers information about how to run an inclusive and respectful public involvement research exercise.

This article reports on an investigation of the effects of ‘visual arts’-based programmes on subjective well-being (SWB) outcomes for adults with mental health conditions. In a systematic review, electronic databases were searched for articles published from January 2007 to April 2017. Grey literature completed from January 2014 to April 2017 was also considered. Six published articles of mostly moderate quality and six evaluation reports (grey literature) covering a wide range of visual arts practice, population groups and settings were included. Key themes emerged connected to the concept of ‘bonding’, sense of belonging, appreciation of self-identity and the confidence that engagement in visual arts can facilitate. The overall conclusion supports that visual arts have the potential to enhance the SWB of adults with mental health conditions. The evidence is relatively limited in terms of scope and quality – increased funding across sectors should be secured to support more extensive and long-term research.

Objectives Community-based social innovations (CBSIs) are one type of intervention that may help to address the complex needs of ageing populations globally. The aim of this research was to assess evidence for the effectiveness and cost-effectiveness of CBSIs involving in such contexts. Methods We conducted a systematic review of CBSIs for healthy ageing in middle- and high-income countries, including any CBSI that aimed to empower people aged 50 and over by motivating them to take initiative for their own health and wellbeing. The protocol was registered with Prospero (CRD 42016051622). A comprehensive search was conducted in 15 academic databases and advanced search in Google. We included published studies from 2000 onwards in any language. Exploratory meta-analysis was conducted for quantitative studies reporting similar outcomes, and qualitative studies were analysed using thematic analysis. Narrative synthesis was conducted. Searches yielded 13,262 unique hits, from which 44 papers met the inclusion criteria. Results Most studies reported interventions having positive impacts on participants, such as reduced depression, though the majority of studies were classified as being at medium or high risk of bias. There was no evidence on costs or cost-effectiveness and very little reporting of outcomes at an organization or system level. CBSIs have the potential for positive impacts, but with nearly half of studies coming from high-income urban settings (particularly the United Kingdom and the United States of America), there is a lack of generalizability of these findings. Conclusions Our research highlights the need to improve reporting of CBSIs as complex interventions, and for improved conceptualization of these interventions to inform research and practice.

Copyright: © 2021 by the authors. The paper reports an evidence synthesis of how loneliness is conceptualised in qualitative studies in adults. Using PRISMA guidelines, our review evaluated exposure to or experiences of loneliness by adults (aged 16+) in any setting as outcomes, processes, or both. Our initial review included any qualitative or mixed-methods study, published or unpublished, in English, from 1945 to 2018, if it employed an identified theory or concept for understanding loneliness. The review was updated to include publications up to November 2020. We used a PEEST (Participants, Exposure, Evaluation, Study Design, Theory) inclusion criteria. Data extraction and quality assessment (CASP) were completed and cross-checked by a second reviewer. The Evidence of Reviews of Qualitative Research (CERQual) was used to evaluate confidence in the findings. We undertook a thematic synthesis using inductive methods for peer-reviewed papers. The evidence identified three types of distinct but overlapping conceptualisations of loneliness: social, emotional, and existential. We have high confidence in the evidence conceptualising social loneliness and moderate confidence in the evidence on emotional and existential loneliness. Our findings provide a more nuanced understanding of these diverse conceptualisations to inform more effective decision-making and intervention development to address the negative wellbeing impacts of loneliness. Economic and Social Research Council (ES/NOO3721/1).

Same-sex female couples who wish to become pregnant can choose donor insemination or in-vitro fertilization (IVF)—a technique intended for infertile women. In general, women in same-sex female partnerships are no more likely to be infertile than those in opposite sex partnerships. This article investigates data available from the Government Regulator of UK fertility clinics—the Human Fertilization and Embryology Authority, which is the only data available worldwide on same-sex female couples and their fertility choices. IVF is increasing both in absolute numbers and relative proportions year on year in the UK, compared to licensed donor insemination for same-sex female couples. As IVF has greater human and financial costs than donor insemination, policies should not encourage it as the first choice for fertile women requiring sperm. Commercial transactions are taking place where fertile lesbians receive cut price, and arguably unnecessary, IVF intervention in exchange for selling their eggs to be used for other infertile customers. If women are not told about the efficacy of fresh vs. frozen semen, and the risks of egg ‘sharing’ or intra-couple donation, exploitation becomes possible.

BackgroundEpidemiological evidence for specific long-term conditions is required to inform best practices regarding the substantial health inequalities experienced by sexual minority individuals compared with heterosexual peers.AimTo describe inequalities in long-term conditions among sexual minority (lesbian, gay, and bisexual [LGB]) adults.Design & settingCross-sectional analysis of 1 341 339 nationally representative survey responses from the English GP Patient Survey (GPPS).MethodStratifying by sex, the weighted prevalence and covariate-adjusted association of 15 long-term conditions were calculated, comparing sexual minority and heterosexual adults, considering variation by sexual orientation and variation in sexual orientation inequalities by deprivation, ethnic group, region, and age.ResultsAfter adjusting for deprivation, ethnic group, region, and age, 13 long-term conditions (all except cancer and hypertension) were more prevalent among sexual minority women than their heterosexual peers, with the largest inequalities for mental health problems (odds ratio [OR] 2.8, 95% confidence interval [CI] = 2.7 to 3.0), neurological conditions (OR 1.7, 95% CI = 1.5 to 1.8), dementia (OR 1.6, 95% CI = 1.3 to 1.9), and back problems (OR 1.4, 95% CI = 1.3 to 1.5). It was found that nine long-term conditions were also more prevalent among sexual minority men including mental health problems (OR 2.3, 95% CI = 2.2 to 2.4), 'all other conditions' (OR 1.8, 95% CI = 1.7 to 1.8), neurological conditions (OR 1.5, 95% CI = 1.4 to 1.6), and kidney or liver disease (OR 1.4, 95% CI = 1.3 to 1.5); inequalities were often largest for bisexual adults. Inequalities did not vary significantly by deprivation, ethnic group, or region except for mental health problems. Inequalities in multimorbidity were highest at younger ages; for example, LGB women aged 18–24 years had multimorbidity at the same level (approximately 20%) as heterosexual women aged 45–54 years.ConclusionSexual minority adults, especially bisexual adults, are at elevated risk for many long-term conditions and multimorbidity; this risk spans socioeconomic status and ethnic group, representing a significant healthcare challenge.

ObjectiveTo systematically review all published and unpublished evidence on the impact of the COVID-19 pandemic on the health and well-being of UK sexual and gender minority (LGBT+; lesbian, gay, bisexual, transgender, non-binary, intersex and queer) people.MethodsAny relevant studies with or without comparator were included, with outcomes of: COVID-19 incidence, hospitalisation rates, illness severity, death rates, other health and well-being. Six databases (platforms) were searched—CINAHL Plus (Ovid), Cochrane Central (Cochrane Library), Medline (Ovid), Embase (Ovid), Science Citation Index (Web of Science) and Scopus between 2019 and 2020 in December 2020, using synonyms for sexual and gender minorities and COVID-19 search terms. Data extraction and quality assessment (using the relevant Joanna Briggs checklist) were in duplicate with differences resolved through discussion. Results were tabulated and synthesis was through narrative description.ResultsNo published research was found on any outcomes. Eleven grey literature reports found to be of low quality were included, mostly conducted by small LGBT+ charities. Only four had heterosexual/cisgender comparators. Mental health and well-being, health behaviours, safety, social connectedness and access to routine healthcare all showed poorer or worse outcomes than comparators.ConclusionsLack of research gives significant concern, given pre-existing health inequities. Social and structural factors may have contributed to poorer outcomes (mental health, well-being and access to healthcare). Paucity of evidence is driven by lack of routinely collected sexual orientation and gender identity data, possibly resulting from institutional homophobia/transphobia which needs to be addressed. Men are more at risk of serious illness from COVID-19 than women, so using data from trans women and men might have started to answer questions around whether higher rates were due to sex hormone or chromosomal effects. Routine data collection on sexual orientation and gender identity is required to examine the extent to which COVID-19 is widening pre-existing health inequalities.PROSPERO registration numberCRD42020224304.

COVID-19 infection rates and severity are worse in marginalised groups, although, for sexual and gender minorities, there are no data on infections, hospitalisations or deaths, but there may be worse rates. This study uses information from Understanding Society: The UK Household Longitudinal Study (UKHLS) to derive COVID-19 symptoms and positive tests by sexual orientation. Data came from all seven UKHLS COVID-19 survey waves in 2020 and 2021, and sexual orientation in main UKHLS waves 3 and 9. Numbers ranged from 17,800 to 12,000. Covariates in the regression models were gender, age, highest educational qualification, ethnicity, diagnosed medical condition, and key worker status. Compared to heterosexual individuals, more sexual minorities experienced symptoms, and bisexual individuals reported a greater number of symptoms. Gays and lesbians were no more or less likely to have been tested, but a larger proportion of bisexual individuals were tested. Regression models showed that differences mostly disappeared when other characteristics were considered. A small sample size means that principal questions remain, so health inequalities have been largely unnoticed and therefore not addressed. Suitable action should be taken to minimise their future risks. Why sexual and gender minorities have been omitted needs to be explored, and action needs to be taken to ensure this does not happen again.

Conversations about research priorities with members of the public are rarely designed specifically to include people who identify as Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ+) and are not researchers. We carried out a rapid review of published research priority sets covering LGBTQ+ topics, and an online workshop. The rapid review identified 18 LGBTQ+ research priority sets. Some focussed on specific populations such as women or men, younger or older people or people living within families. Five addressed transgender and gender non- conforming populations. All of the research priority sets originated from English-speaking, high and middle-income countries (UK, US, Canada, and Australia), and date from 2016 onwards. Prioritization approaches were wide-ranging from personal commentary to expert workshops and surveys. Participants involved in setting priorities mostly included research academics, health practitioners and advocacy organisations, two studies involved LGBTQ+ public in their process. Research priorities identified in this review were then grouped into themes which were prioritised during the workshop. For the workshop, participants were recruited using local (Cambridge, UK) LGBTQ+ networks and a national advert to a public involvement in research matching website to take part in an online discussion workshop. Those that took part were offered payment for their time in preparing for the workshop and taking part. Participants personal priorities and experiences contributed to a consensus development process and a final ranked list of seven research themes. Participants’ experiences of healthcare, mental health advocacy, care homes, caring responsibilities, schools and family units added additional contexts. These ranged from living with neurodiversity, and disability as well as experiencing social and economic inequalities and multigenerational health issues. From the workshop the three research themes prioritised were: healthcare services delivery, prevention, and particular challenges /intersectionality of people identifying as lesbian, gay, bisexual, transgender or queer. Research themes interconnected in many ways and this was demonstrated by the comments from workshop participants. This paper offers insights into why these priorities were important from participants’ perspectives and detail about how to run an inclusive and respectful public involvement research exercise. The workshop outcomes are currently being used to inform research funding applications by CLS.

ObjectivesTo systematically review the evidence base for a systems approach to healthcare design, delivery or improvement.DesignSystematic review with meta-analyses.MethodsIncluded were studies in any patients, in any healthcare setting where a systems approach was compared with usual care which reported quantitative results for any outcomes for both groups. We searched Medline, Embase, HMIC, Health Business Elite, Web of Science, Scopus, PsycINFO and CINAHL from inception to 28 May 2019 for relevant studies. These were screened, and data extracted independently and in duplicate. Study outcomes were stratified by study design and whether they reported patient and/or service outcomes. Meta-analysis was conducted with Revman software V.5.3 using ORs—heterogeneity was assessed using I2statistics.ResultsOf 11 405 records 35 studies were included, of which 28 (80%) were before-and-after design only, five were both before-and-after and concurrent design, and two were randomised controlled trials (RCTs). There was heterogeneity of interventions and wide variation in reported outcome types. Almost all results showed health improvement where systems approaches were used. Study quality varied widely. Exploratory meta-analysis of these suggested favourable effects on both patient outcomes (n=14, OR=0.52 (95% CI 0.38 to 0.71) I2=91%), and service outcomes (n=18, OR=0.40 (95% CI 0.31 to 0.52) I2=97%).ConclusionsThis study suggests that a systems approaches to healthcare design and delivery results in a statistically significant improvement to both patient and service outcomes. However, better quality studies, particularly RCTs are needed.PROSPERO registration numberCRD42017065920.

Objectives To describe cervical cancer screening participation among women who have sex exclusively with women (WSEW) and women who have sex with women and men (WSWM) compared with women who have sex exclusively with men (WSEM), and women who have never had sex and compare this with bowel (colorectal) and breast screening participation. To explore whether there is evidence of differential stage 3 cervical intraepithelial neoplasia (CIN3) or cervical cancer risk. Methods We describe cervical, bowel and breast cancer screening uptake in age groups eligible for the national screening programmes, prevalent CIN3 and cervical cancer at baseline, and incident CIN3 and cervical cancer at five years follow-up, among 218,674 women in UK Biobank, a cohort of healthy volunteers from the UK. Results Compared with WSEM, in adjusted analysis [odds ratio (95% confidence interval)], WSEW 0.10 (0.08–0.13), WSWM 0.73 (0.58–0.91), and women who have never had sex 0.02 (0.01–0.02) were less likely to report ever having attended cervical screening. There were no differences when considering bowel cancer screening uptake ( p = 0.61). For breast cancer screening, attendance was lower among WSWM 0.79 (0.68 to 0.91) and women who have never had sex 0.47 (0.29–0.58), compared with WSEM. There were incident and prevalent cases of both CIN3 and cervical cancer among WSEW and WSWM. Compared with WSEM with a single male partner, among WSEW there was a twofold increase in CIN3 1.91 (1.01 to 3.59); among WSWM with only one male partner, this was 2.25 (1.19 to 4.24). Conclusions These findings highlight the importance of improving uptake of cervical screening among all women who have sex with women and breast screening among WSWM and women who have never had sex.

Copyright © 2020 The Author(s). Background: Social capital is often cited as shaping impacts of participatory arts, although the concept has not been systematically mapped in arts, health and wellbeing contexts. In wider health inequalities research, complex, differential, and sometimes negative impacts of social capital have been recognised. Methods: This paper maps of social capital concepts in qualitative research as part of the UK What Works for Wellbeing evidence review programme on culture, sport and wellbeing. Results: Studies often cite positive impacts of bonding and, to a lesser extent, bridging social capital. However, reported challenges suggest the need for a critical approach. Forms of linking social capital, such as reframing and political engagement to address social divisions, are less often cited but may be important in participatory arts and wellbeing. Conclusions: Future research should further specify dimensions of social capital as well as their nuanced effects in arts, and wellbeing contexts. Economic & Social Research Council grant number ES/N003721/1, as part of the evidence review programme for the UK What Works Centre for Wellbeing.

Lesbian and bisexual women may have different levels of sex hormones compared to heterosexual women. We systematically reviewed comparative studies measuring any sex hormones. A protocol was prospectively registered (PROSPERO—CRD42017072436) and searches conducted in six databases. Any relevant empirical studies published within the last 50 years reporting any circulating sex hormones in sexual minority women compared to heterosexual women were included, with no language or setting restrictions. Inclusions, data extraction, and quality assessment were conducted in duplicate. Random-effects meta-analyses of hormone levels, using standardized-mean-differences (SMD) were conducted where five or more studies reported results. From 1236 citations, 24 full papers were examined and 14 studies of mixed designs included, 12 in women without known ovarian problems. Hormones were measured in plasma (n = 9), saliva (n = 4), and urine (n = 2) and included androstenedione, luteinizing hormone, estradiol, pregnanediol, progesterone, testosterone, and several other hormones. Most studies were small, biased, and had considerable heterogeneity. Few found statistically significant differences between groups. All-sample meta-analysis showed increased testosterone in sexual minority women compared to heterosexual women (n = 9; SMD = 0.90; 95% Confidence interval (CI) 0.22, 1.57, I2 = 84%). This was the only difference found. We conclude that the small amount of heterogeneous research, from 50 years to date, suggests little discernable difference in sex hormone levels between lesbian, bisexual, and heterosexual women excepting possibly higher testosterone. A large-scale primary study would be required before placing any certainty in the findings or their implications.

Improving the health of particular populations is an important objective for public health service planners, policymakers and care delivery staff. This is especially important for disadvantaged minority groups such as people of minority sexual orientation and gender identity populations, where robust evidence to show considerable health inequities is developing. Improving health and wellbeing is an important objective for all who aspire to reduce health inequities (inequalities that are considered preventable). It is important to understand various factors that contribute to lesbian, gay, bisexual, trans and similar (LGBT+) groups’ mental and physical health and the mediators and moderators of these relationships. This Special Issue was open to any subject area related to sexual orientation, gender identity, and physical or mental health and wellbeing, and considered systematic reviews as well as primary qualitative or quantitative research. The result is an interesting collection of published papers from around the world. They showed how health inequities in LGBT+ groups of people were found across a wide variety of political environments and health and wellbeing topics. Several focussed on healthcare delivery and its inadequacies regarding the treatment and care of LGBT+ people. The increasing interest in health and wellbeing research for minority sexual orientation and gender identity populations, which have been neglected in the past, shows its growing importance. It is hoped that this collection will contribute to the growing body of evidence around LGBT+ health and wellbeing that can be used by service planners, policymakers and the general public. Includes chapter: The power of recognition: a qualitative study of social connectedness and wellbeing through LGBT sporting, creative and social groups in Ireland.

Introduction: This study determined the prevalence of child abuse in first year medical students in a Turkish university using the ICAST-R, as well as the relationships between sociodemographic data and abuse. Materials&Methods: First-year medical students in a Turkish university were surveyed between 15th-30th June 2012, using ISPCAN Child Abuse Screening Tool-Retrospective Version (ICAST-R) and a questionnaire to collect sociodemographic data. Data analysis was performed with SPSS 15.0. Results: The study included 192 students, 56.8% female and 43.2% male. Physical, emotional and sexual abuse were found in 14.6%; 32.3%; and 8.9% of participants, respectively. No significant relation between gender and emotional abuse was found (p= 0.775), whereas both physical and sexual abuse were more common in males (p= 0.04; p= 0.018 respectively). There was a statistically significant relation between emotional abuse and parental separation (p= 0,014). Conclusion: Abuse is not rare among the medical student participants, and several preventable factors could worsen it. The findings have implications on how medical students are taught about these issues.

Background The NHS Health Check programme is a prevention initiative offering cardiovascular risk assessment and management advice to adults aged 40–74 years across England. Its effectiveness depends on uptake. When it was introduced in 2009, it was anticipated that all those eligible would be invited over a 5-year cycle and 75% of those invited would attend. So far in the current cycle from 2013 to 2018, 33.8% of those eligible have attended, which is equal to 48.5% of those invited to attend. Understanding the reasons why some people do not attend is important to maximise the impact of the programmes. Aim To review why people do not attend NHS Health Checks. Design and setting A systematic review and thematic synthesis of qualitative studies. Method An electronic literature search was carried out of MEDLINE, Embase, Health Management Information Consortium, Cumulative Index to Nursing and Allied Health Literature, Global Health, PsycINFO, Web of Science, OpenGrey, the Cochrane Library, NHS Evidence, Google Scholar, Google, ClinicalTrials.gov, and the ISRCTN registry from 1 January 1996 to 9 November 2016, and the reference lists of all included papers were also screened manually. Inclusion criteria were primary research studies that reported the views of people who were eligible for but had not attended an NHS Health Check. Results Nine studies met the inclusion criteria. Reasons for not attending included lack of awareness or knowledge, misunderstanding the purpose of the NHS Health Check, aversion to preventive medicine, time constraints, difficulties with access to general practices, and doubts regarding pharmacies as appropriate settings. Conclusion The findings particularly highlight the need for improved communication and publicity around the purpose of the NHS Health Check programme and the personal health benefits of risk factor detection., This work was funded by a grant from Public Health England. Juliet A Usher-Smith was funded by a National Institute for Health Research (NIHR) Clinical Lectureship and Fiona M Walter by an NIHR Clinician Scientist award (RG 68235). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health. All researchers were independent of the funding body and the funder had no role in data collection, analysis and interpretation of data; in the writing of the report; or decision to submit the article for publication.

Background: There is greater dissatisfaction with health services by LGBT people compared to heterosexual and cisgender people and some of this is from lack of equality and diversity training for health professionals. Core training standards in sexual orientation for health professionals have been available since 2006. The purpose of this project is to systematically review educational materials for health and social care professionals in lesbian, gay, bisexual, and transgender (LGBT) issues. Methods: A protocol was developed and searches conducted in six databases. Selection criteria: any studies reporting delivery or evaluation of UK education of health and/or social care professionals in LGBT issues, with no language or setting restrictions. Inclusions and data extraction were conducted in duplicate. Narrative synthesis of educational evaluations was used. Educational materials were assessed using thematic synthesis. Results: From the searches, 165 full papers were evaluated and 19 studies were included in the narrative synthesis. Three were successful action-research projects in cancer services and in residential care. Sixteen sets of educational/training materials have been available since 2010. These varied in length, scope, target audience, and extent of development as classroom-ready materials. Conclusions: Despite the availability of appropriate training programmes for post-qualifying staff, recommendations to undertake training, best practice examples, and statements of good intent, LGBT people continue to report that they are experiencing discrimination or direct prejudice from health and/or social care services. Better training strategies using behaviour change techniques are needed.

Sexual minority women (SMW) experience worse health and disproportionate behavioural risks to health than heterosexual women. This mixed-methods systematic review evaluated recent studies on health experiences of UK SMW, published 2010–2018. Analysis was through narrative thematic description and synthesis. Identified were 23,103 citations, 26 studies included, of which 22 provided qualitative and nine quantitative results. SMW had worse health experiences that might impact negatively on access, service uptake and health outcomes. Findings highlighted significant barriers facing SMW, including heteronormative assumptions, perceptions and experiences of negative responses to coming out, ignorance and prejudice from healthcare professionals, and barriers to raising concerns or complaints. Little information was available about bisexual and trans women’s issues. Findings highlighted the need for explicit and consistent education for healthcare professionals on SMW issues, and stronger application of non-discrimination policies in clinical settings.

The impact of losing a limb in military service extends well beyond initial recovery and rehabilitation, with long-term consequences and challenges requiring health-care commitments across the lifecourse. This paper presents a systematic review of the current state of knowledge regarding the long-term impact of ageing and limb-loss in military veterans. Key databases were systematically searched including: ASSIA, CINAHL, Cochrane Library, Medline, Web of Science, PsycArticles/PsychInfo, ProQuest Psychology and ProQuest Sociology Journals, and SPORTSDiscus. Empirical studies which focused on the long-term impact of limb-loss and/or health-care requirements in veterans were included. The search process revealed 30 papers relevant for inclusion. These papers focused broadly on four themes: (a) long-term health outcomes, prosthetics use and quality of life; (b) long-term psycho-social adaptation and coping with limb-loss; (c) disability and identity; and (d) estimating the long-term costs of care and prosthetic provision. Findings present a compelling case for ensuring the long-term care needs and costs of rehabilitation for older limbless veterans are met. A dearth of information on the lived experience of limb-loss and the needs of veterans’ families calls for further research to address these important issues.

Background Chronic pain, considered to be pain lasting more than three months, is a common and often difficult to treat condition that can significantly impact upon function and quality of life. Treatment typically includes pharmacological and non‐pharmacological approaches. Transcutaneous electrical nerve stimulation (TENS) is an adjunct non‐pharmacological treatment commonly recommended by clinicians and often used by people with pain. Objectives To provide an overview of evidence from Cochrane Reviews of the effectiveness of TENS to reduce pain in adults with chronic pain (excluding headache or migraine). To provide an overview of evidence from Cochrane Reviews of the safety of TENS when used to reduce pain in adults with chronic pain (excluding headache or migraine). To identify possible sources of inconsistency in the approaches taken to evaluating the evidence related to TENS for chronic pain (excluding headache or migraine) in the Cochrane Library with a view to recommending strategies to improve consistency in methodology and reporting. To highlight areas of remaining uncertainty regarding the effectiveness of TENS for chronic pain (excluding headache or migraine) with a view to recommending strategies to reduce any uncertainty. Methods Search methods We searched the Cochrane Database of Systematic Reviews (CDSR), in the Cochrane Library, across all years up to Issue 11 of 12, 2018. Selection of reviews Two authors independently screened the results of the electronic search by title and abstract against inclusion/exclusion criteria. We included all Cochrane Reviews of randomised controlled trials (RCTs) assessing the effectiveness of TENS in people with chronic pain. We included reviews if they investigated the following: TENS versus sham; TENS versus usual care or no treatment/waiting list control; TENS plus active intervention versus active intervention alone; comparisons between different types of TENS; or TENS delivered using different stimulation parameters. Data extraction and analysis Two authors independently extracted relevant data, assessed review quality using the AMSTAR checklist and applied GRADE judgements where required to individual reviews. Our primary outcomes included pain intensity and nature/incidence of adverse effects; our secondary outcomes included disability, health‐related quality of life, analgesic medication use and participant global impression of change. Main results We included nine reviews investigating TENS use in people with defined chronic pain or in people with chronic conditions associated with ongoing pain. One review investigating TENS for phantom or stump‐associated pain in people following amputation did not have any included studies. We therefore extracted data from eight reviews which represented 51 TENS‐related RCTs representing 2895 TENS‐comparison participants entered into the studies. The included reviews followed consistent methods and achieved overall high scores on the AMSTAR checklist. The evidence reported within each review was consistently rated as very low quality. Using review authors' assessment of risk of bias, there were significant methodological limitations in included studies; and for all reviews, sample sizes were consistently small (the majority of studies included fewer than 50 participants per group). Six of the eight reviews presented a narrative synthesis of included studies. Two reviews reported a pooled analysis. Primary and secondary outcomes One review reported a beneficial effect of TENS versus sham therapy at reducing pain intensity on a 0 to 10 scale (MD −1.58, 95% CI −2.08 to −1.09, P < 0.001, I² = 29%, P = 0.22, 5 studies, 207 participants). However the quality of the evidence was very low due to significant methodological limitations and imprecision. A second review investigating pain intensity performed a pooled analysis by combining studies that compared TENS to sham with studies that compared TENS to no intervention (SMD −0.85, 95% CI −1.36 to −0.34, P = 0.001, I² = 83%, P < 0.001). This pooled analysis was judged as offering very low quality evidence due to significant methodological limitations, large between‐trial heterogeneity and imprecision. We considered the approach of combining sham and no intervention data to be problematic since we would predict these different comparisons may be estimating different true effects. All remaining reviews also reported pain intensity as an outcome measure; however the data were presented in narrative review form only. Due to methodological limitation and lack of useable data, we were unable to offer any meaningful report on the remaining primary outcome regarding nature/incidence of adverse effects, nor for the remaining secondary outcomes: disability, health‐related quality of life, analgesic medication use and participant global impression of change for any comparisons. We found the included reviews had a number of inconsistencies when evaluating the evidence from TENS studies. Approaches to assessing risk of bias around the participant, personnel and outcome‐assessor blinding were perhaps the most obvious area of difference across included reviews. We also found wide variability in terms of primary and secondary outcome measures, and inclusion/exclusion criteria for studies varied with respect to including studies which assessed immediate effects of single interventions. Authors' conclusions We found the methodological quality of the reviews was good, but quality of the evidence within them was very low. We were therefore unable to conclude with any confidence that, in people with chronic pain, TENS is harmful, or beneficial for pain control, disability, health‐related quality of life, use of pain relieving medicines, or global impression of change. We make recommendations with respect to future TENS study designs which may meaningfully reduce the uncertainty relating to the effectiveness of this treatment in people with chronic pain., Transcutaneous electrical nerve stimulation (TENS) for chronic pain ‐ an overview of Cochrane Reviews Bottom line For people with chronic pain, this overview of Cochrane Reviews found it was not possible to confidently state whether TENS is effective in relieving pain compared to sham TENS, usual care/no treatment or when TENS is combined with another active treatment versus the active treatment alone. We were unable to find any reliable evidence that the effectiveness of TENS varies when using different delivery modes (e.g. different frequency, intensity or electrode placement). Background Chronic pain (pain for longer than three months) is associated with a range of common conditions and can be difficult to treat effectively. TENS is a common treatment for pain conditions and involves using a small battery‐operated unit to apply low‐intensity electrical current to the body using electrodes attached to the skin. This is suggested to relieve pain. TENS has been previously investigated by a number of Cochrane Reviews. Review question By identifying relevant Cochrane Reviews on TENS for common chronic pain conditions, we investigated whether TENS is effective in reducing pain in adults with chronic pain (excluding headache or migraine). Study characteristics As of November 2018, we found nine reviews eligible for inclusion. Seven reviews specifically investigated TENS for the treatment of pain/function in a variety of chronic conditions in adults. We also included one review investigating a range of electrotherapy modalities for neck pain and one review examining non‐pharmacological interventions in people with spinal cord injury. Both of these reviews included studies investigating TENS. Though the included reviews were of high quality, we found the quality of the evidence presented within the reviews to be very low. Key findings We are unable to confidently state whether TENS is effective in relieving pain in people with chronic pain. This is due to the very low quality of the evidence, and the overall small numbers of participants included in studies in the reviews. Issues with quality, study size and lack of data meant we were unable to draw any conclusion on TENS‐associated harms or side‐effects or the effect of TENS on disability, health‐related quality of life, use of pain‐relieving medicines or people's impression of how much TENS changed their condition.

Background Few data exist regarding pregnancy in lesbian and bisexual (LB) women. Objectives To determine the likelihood of LB women becoming pregnant, naturally or assisted, in comparison with heterosexual women Search strategy Systematic review of papers published 1 January 2000 to 23 June 2015. Selection criteria Studies contained details of pregnancy rates among LB women compared with heterosexual women. No restriction on study design. Data collection and analysis Inclusion decisions, data extraction and quality assessment were conducted in duplicate. Meta-analyses were carried out, with subgroups as appropriate. Main results Of 6859 papers identified, 104 full-text articles were requested, 30 papers (28 studies) were included. The odds ratio (OR) of ever being pregnant was 0.19 (95% CI 0.18–0.21) in lesbian women and 1.22 (95% CI 1.15–1.29) in bisexual women compared with heterosexual women. In the general population, the odds ratio for pregnancy was nine-fold lower among lesbian women and over two-fold lower among bisexual women (0.12 [95% CI 0.12–0.13] and 0.50 [95% CI 0.45–0.55], respectively). Odds ratios for pregnancy were higher for both LB adolescents (1.37 [95% CI 1.18–1.59] and 1.98 [95% CI 1.85, 2.13], respectively). There were inconsistent results regarding abortion rates. Lower rates of previous pregnancies were found in lesbian women undergoing artificial insemination (OR 0.17 [95% CI 0.11–0.26]) but there were higher assisted reproduction success rates compared with heterosexual women (OR 1.56 [95% CI 1.24–1.96]). Conclusions Heterosexuality must not be assumed in adolescents, as LB adolescents are at greater risk of unwanted pregnancies and terminations. Clinicians should provide appropriate information to all women, without assumptions about LB patients’ desire for, or rejection of, fertility and childbearing. Tweetable abstract Review of likelihood of LB women becoming pregnant: LB teenagers at greater risk of unwanted pregnancies.

Summary Background Music is a non-invasive, safe, and inexpensive intervention that can be delivered easily and successfully. We did a systematic review and meta-analysis to assess whether music improves recovery after surgical procedures. Methods We included randomised controlled trials (RCTs) of adult patients undergoing surgical procedures, excluding those involving the central nervous system or head and neck, published in any language. We included RCTs in which any form of music initiated before, during, or after surgery was compared with standard care or other non-drug interventions. We searched MEDLINE, Embase, CINAHL, and Cochrane Central. We did meta-analysis with RevMan (version 5.2), with standardised mean differences (SMD) and random-effects models, and used Stata (version 12) for meta-regression. This study is registered with PROSPERO, number CRD42013005220. Findings We identified 4261 titles and abstracts, and included 73 RCTs in the systematic review, with size varying between 20 and 458 participants. Choice of music, timing, and duration varied. Comparators included routine care, headphones with no music, white noise, and undisturbed bed rest. Music reduced postoperative pain (SMD −0·77 [95% CI −0·99 to −0·56]), anxiety (−0·68 [–0·95 to −0·41]), and analgesia use (−0·37 [–0·54 to −0·20]), and increased patient satisfaction (1·09 [0·51 to 1·68]), but length of stay did not differ (SMD −0·11 [–0·35 to 0·12]). Subgroup analyses showed that choice of music and timing of delivery made little difference to outcomes. Meta-regression identified no causes of heterogeneity in eight variables assessed. Music was effective even when patients were under general anaesthetic. Interpretation Music could be offered as a way to help patients reduce pain and anxiety during the postoperative period. Timing and delivery can be adapted to individual clinical settings and medical teams. Funding None.

Objectives: The objective of this study was to collate the level of sexual and reproductive health knowledge, awareness, attitudes, and behavior among female university students, in addition to identifying their sources of information in Middle Eastern and North African countries. Methods: A systematic review was conducted with a search in Medline, EMBASE, Web of Knowledge, PsycINFO, and CINAHL from inception to February 2013. Included were studies in any language describing sexual and reproductive health knowledge and attitudes among female university students. Results: Nine studies were included, and all were cross-sectional surveys. There was a general lack of knowledge of sexual and reproductive health. The highest knowledge levels reported were for HIV. Conclusions: There are deficiencies in sexual and reproductive health knowledge and behavior in Middle Eastern and North African countries. Studies are needed to evaluate how to provide culturally sensitive sexual and reproductive health infor...

ObjectiveTo review and assess effectiveness of sport and dance participation on subjective well-being outcomes among healthy young people aged 15–24 years.DesignSystematic review.MethodsWe searched for studies published in any language between January 2006 and September 2016 on PsychINFO, Ovid MEDLINE, Eric, Web of Science (Arts and Humanities Citation Index, Social Science and Science Citation Index), Scopus, PILOTS, CINAHL, SPORTDiscus and International Index to Performing Arts. Additionally, we searched for unpublished (grey) literature via an online call for evidence, expert contribution, searches of key organisation websites and the British Library EThOS database, and a keyword Google search. Published studies of sport or dance interventions for healthy young people aged 15–24 years where subjective well-being was measured were included. Studies were excluded if participants were paid professionals or elite athletes, or if the intervention was clinical sport/dance therapy. Two researchers extracted data and assessed strength and quality of evidence using criteria in the What Works Centre for Wellbeing methods guide and GRADE, and using standardised reporting forms. Due to clinical heterogeneity between studies, meta-analysis was not appropriate. Grey literature in the form of final evaluation reports on empirical data relating to sport or dance interventions were included.ResultsEleven out of 6587 articles were included (7 randomised controlled trials and 1 cohort study, and 3 unpublished grey evaluation reports). Published literature suggests meditative physical activity (yoga and Baduanjin Qigong) and group-based or peer-supported sport and dance has some potential to improve subjective well-being. Grey literature suggests sport and dance improve subjective well-being but identify negative feelings of competency and capability. The amount and quality of published evidence on sport and dance interventions to enhance subjective well-being is low.ConclusionsMeditative activities, group and peer-supported sport and dance may promote subjective well-being enhancement in youth. Evidence is limited. Better designed studies are needed.Trial registration numberCRD42016048745; Results.

ObjectivesTo assess the association between tobacco and hazardous alcohol use and sexual orientation and whether such an association could be explained by other sociodemographic characteristics.DesignCross-sectional household survey conducted in 2014–2016.SettingEngland, UK.ParticipantsRepresentative English population sample (pooled n=43 866).Main outcomesSexual orientation identity (lesbian/gay, bisexual, heterosexual, prefer-not-to-say); current tobacco and hazardous alcohol use (defined as Alcohol Use Disorders Identification Test Score ≥8). All outcomes were self-reported.ResultsDue to interactions between sexual orientation and gender for substance use, analyses were stratified by gender. Tobacco use prevalence was significantly higher among lesbian/gay (women: 24.9%, 95% CI 19.2% to 32.6%; men: 25.9%, 95% CI 21.3% to 31.0%) and bisexual participants (women: 32.4%, 95% CI 25.9% to 39.6%; men: 30.7%, 95% CI 23.7% to 30.7%) and significantly lower for prefer-not-to-say participants in women (15.5%, 95% CI 13.5% to 17.8%) but not men (22.7%, 95% CI 20.3% to 25.3%) compared with heterosexual participants (women: 17.5%, 95% CI 17.0% to 18.0%; men: 20.4%, 95% CI 19.9% to 21.0%; pConclusionsIn England, higher rates of tobacco use among sexual minority men and women appear to be attributable to other sociodemographic factors. Higher rates of hazardous alcohol use among sexual minority men may also be attributable to these factors, whereas this is not the case for sexual minority women.

BackgroundSince 2009, all eligible persons in England have been entitled to an NHS Health Check. Uncertainty remains about who attends, and the health-related impacts.AimTo review quantitative evidence on coverage (the proportion of eligible individuals who attend), uptake (proportion of invitees who attend), and impact of NHS Health Checks.Design and settingA systematic review and quantitative data synthesis. Included were studies or data reporting coverage or uptake and studies reporting any health-related impact that used an appropriate comparison group or before- and-after study design.MethodEleven databases and additional internet sources were searched to November 2016.ResultsTwenty-six observational studies and one additional dataset were included. Since 2013, 45.6% of eligible individuals have received a health check. Coverage is higher among older people, those with a family history of coronary heart disease, those living in the most deprived areas, and some ethnic minority groups. Just under half (48.2%) of those invited have taken up the invitation. Data on uptake and impact (especially regarding health-related behaviours) are limited. Uptake is higher in older people and females, but lower in those living in the most deprived areas. Attendance is associated with small increases in disease detection, decreases in modelled cardiovascular disease risk, and increased statin and antihypertensive prescribing.ConclusionPublished attendance, uptake, and prescribing rates are all lower than originally anticipated, and data on impact are limited, with very few studies reporting the effect of attendance on health-related behaviours. High-quality studies comparing matched attendees and non-attendees and health economic analyses are required.

ObjectiveTo review the experiences of patients attending NHS Health Checks in England.DesignA systematic review of quantitative and qualitative studies with a thematic synthesis of qualitative studies.Data sourcesAn electronic literature search of Medline, Embase, Health Management Information Consortium, Cumulative Index of Nursing and Allied Health Literature, Global Health, PsycInfo, Web of Science, OpenGrey, the Cochrane Library, National Health Service (NHS) Evidence, Google Scholar, Google, Clinical Trials.gov and the ISRCTN registry to 09/11/16 with no language restriction and manual screening of reference lists of all included papers.Inclusion criteriaPrimary research reporting experiences of patients who have attended NHS Health Checks.Results20 studies met the inclusion criteria, 9 reporting quantitative data and 15 qualitative data. There were consistently high levels of reported satisfaction in surveys, with over 80% feeling that they had benefited from an NHS Health Check. Data from qualitative studies showed that the NHS Health Check had been perceived to act as a wake-up call for many who reported having gone on to make substantial lifestyle changes which they attributed to the NHS Health Check. However, some had been left with a feeling of unmet expectations, were confused about or unable to remember their risk scores, found the lifestyle advice too simplistic and non-personalised or were confused about follow-up.ConclusionsWhile participants were generally very supportive of the NHS Health Check programme and examples of behaviour change were reported, there are a number of areas where improvements could be made. These include greater clarity around the aims of the programme within the promotional material, more proactive support for lifestyle change and greater appreciation of the challenges of communicating risk and the limitations of relying on the risk score alone as a trigger for facilitating behaviour change.

Background: Lower limb lymphoedema is a recognised complication of cancer commonly encountered in palliative care, associated with reduced mobility and poor quality of life. Aim: To evaluate the available evidence for the treatment of secondary lower limb lymphoedema in patients with malignancies. Design: A systematic review of the literature. Data sources: The MEDLINE, Embase, LILACS, Science Citation Index, Cochrane Databases and conference proceedings for published data from date of inception to July 2014 were searched. Relevant unpublished studies via relevant databases, Internet searches and hand-searches of the bibliographies of relevant papers were performed. Results: From 1617 citations, 32 papers were selected for full-text assessment. Two randomised trials and five observational studies were identified. The two randomised controlled trials evaluated graded compression stockings and Coumarin capsules, respectively. The five observational studies evaluated lymphovenous microsurgical shunts, pneumatic compression devices, compression bandages alone, manual lymphatic drainage with compression and a herbal remedy combining Coumarin, Ginkgo and Melitoto (with or without manual lymphatic drainage), respectively. The extracted studies showed substantial heterogeneity. Hence, a meta-analysis was inappropriate and not performed. Conclusion: Few studies have evaluated the clinical effectiveness and potential side effects of treatments for lower limb lymphoedema. Moreover, symptoms and quality-of-life assessments were inconsistently reported. All included studies report lower limb volume reduction after treatment, which includes complex decongestion therapy, graded compression stockings and lymphovenous microsurgical shunts. Adequately powered randomised controlled trials of these interventions are recommended. Effort should be made to establish standardised outcomes, to minimise bias and to improve reporting quality in future trials of treatment for lower limb lymphoedema.

Background:The purpose of this study was to determine the accuracy of sentinel lymph node (SLN) biopsy with technetium 99 (99mTc) and/or blue dye-enhanced lymphoscintigraphy in vulval cancer.Methods:Sensitive searches of databases were performed upto October 2013. Studies with at least 75% of women with FIGO stage IB or II vulval cancer evaluating SLN biopsy with 99mTc, blue dye or both with reference standard of inguinofemoral lymphadenectomy (IFL) or clinical follow-up were included. Meta-analyses were performed using Meta-Disc version 1.4.Results:Of the 2950 references, 29 studies (1779 women) were included; most of them evaluated 99mTc combined with blue dye. Of these, 24 studies reported results for SLN followed by IFL, and 5 reported clinical follow-up only for SLN negatives. Pooling of all studies was inappropriate because of heterogeneity. Mean SLN detection rates were 94.0% for 99mTc, 68.7% for blue dye and 97.7% for both. SLN biopsy had pooled sensitivity of 95% (95% CI 92-98%) with negative predictive value (NPV) of 97.9% in studies using 99mTc/blue dye, ultrastaging and immunohistochemistry with IFL as reference. Pooled sensitivity for SLN with clinical follow-up for SLN-negatives was 91% (85-95%) with NPV 95.6%. Patients undergoing SLN biopsy experienced less morbidity than those undergoing IFL.Conclusions:Sentinel lymph node biopsy using 99mTC, blue dye and ultrastaging with immunohistochemistry is highly accurate when restricted to carefully selected patients, within a rigorous protocol, with close follow-up and where sufficient numbers for learning curve optimisation exist. Patients must make an informed choice between the slightly higher groin recurrence rates of SLN biopsy vs the greater morbidity of IFL. © 2014 Cancer Research UK. Funded by Health technology assessment, National Institute of Health Research, United Kingdom – project number 09/112/03

OBJECTIVE: To undertake a cost-effectiveness analysis that compares positron emission tomography - computed tomography (PET-CT) imaging plus standard practice with standard practice alone in the diagnosis of recurrent or persistent cervical cancer during routine surveillance and follow-up of women who have previously been diagnosed and treated. DESIGN: Model-based economic evaluation using data from a systematic review, supplemented with data from other sources, and taking a UK National Health Service (NHS) perspective. SETTING: Secondary Care in England. POPULATION: Women at least 3 months after the completion of treatment, with either recurrent or persistent cervical cancer. METHODS: A state transition (Markov) model was developed using TreeAge Pro 2011. The structure of the model was informed by the reviews of the trials and clinical input. In the model, two diagnostic strategies were examined. A one-way sensitivity analysis, probabilistic sensitivity analysis, and a value of information analysis were also carried out. MAIN OUTCOME MEASURES: Cost-effectiveness based on incremental cost per quality-adjusted life year (QALY). RESULTS: Adding PET-CT to the current treatment strategy of clinical examination and scanning [magnetic resonance imaging (MRI) and/or CT scan] during the routine surveillance and follow-up of women with recurrent or persistent cervical cancer is significantly more costly, with only a minimal increase in effectiveness. The incremental cost-effectiveness ratio (ICER) for the strategy of PET-CT as an adjunct to the standard treatment strategy that included clinical examination, MRI, and/or CT scan, compared with the usual treatment alone, was over £1 million per QALY. CONCLUSION: The results of the current analysis suggest that use of PET-CT in the diagnosis of recurrent or persistent cervical cancer is not cost-effective. Current guidelines recommending imaging using PET-CT as a diagnostic or surveillance tool need to be reconsidered in light of these results. This study did not specifically investigate the use of PET-CT in women with symptoms and radiological suspicion of recurrence where exenteration was considered. More research in that specific area is required.

Background Positron emission tomography–computed tomography (PET-CT) is recommended to triage women for exenterative surgery and surveillance after treatment for advanced cervical cancer. Objective To evaluate diagnostic accuracy of additional whole body PET-CT compared with CT/magnetic resonance imaging (MRI) alone in women with suspected recurrent/persistent cervical cancer and in asymptomatic women as surveillance. Design Systematic reviews. Subjective elicitation to supplement diagnostic information. Search strategy/Selection criteria/Data collection and analysis Searches of electronic databases were performed to June 2013. Studies in women with suspected recurrent/persistent cervical cancer and in asymptomatic women undergoing follow up with sufficient numeric data were included. We calculated sensitivity, specificity and corresponding 95% confidence intervals. Meta-analyses employed a bivariate model that included a random-effects term for between-study variations (CT studies) and univariate random effects meta-analyses (PET-CT studies) for sensitivity and specificity separately. Subjective elicitation Prevalence of recurrence and the accuracy of imaging elicited using the allocation of points technique. Coherence of elicited subjective probabilities with estimates in the literature examined. Results We identified 15 relevant studies; none directly compared additional PET-CT with MRI or CT separately. Most CT and MRI studies used older protocols and the majority did not distinguish between asymptomatic and symptomatic women. Meta-analysis of nine PET-CT studies in mostly symptomatic women showed sensitivity of 94.8 (95% CI 91.2–96.9), and specificity of 86.9% (95% CI 82.2–90.5). The summary estimate of the sensitivity of CT for detection of recurrence was 89.64% (95% CI 81.59–94.41) and specificity was 76% (95% CI 43.68–92.82). Meta-analysis for MRI test accuracy studies was not possible because of clinical heterogeneity. The sensitivity and specificity of MRI in pelvic recurrence varied between 82 and 100% and between 78 and 100%, respectively. Formal statistical comparisons of the accuracy of index tests were not possible. Subjective elicitation provided estimates comparable to the literature. Subjective estimates of the increase in accuracy from the addition of PET-CT were less than elicited increases required to justify the use in PET-CT for surveillance. Conclusion Evidence to support additional PET-CT is scarce, of average quality and does not distinguish between application for surveillance and diagnosis. Guidelines recommending PET-CT in recurrent cervical cancer need to be reconsidered in the light of the existing evidence base.

Background: This study examines the cost-effectiveness of sentinel lymph node biopsy, a potentially less morbid procedure, compared with inguinofemoral lymphadenectomy (IFL) among women with stage I and stage II vulval squamous cell carcinoma. Methods: A model-based economic evaluation was undertaken based on clinical evidence from a systematic review of published sources. A decision tree model was developed with the structure being informed by clinical input, taking the perspective of the health-care provider. Results: For overall survival for 2 years, IFL was found to be the most cost-effective option and dominated all other strategies, being the least costly and most effective. For morbidity-free related outcomes for 2 years, sentinel lymph node (SLN) biopsy with 99mTc and blue dye and haematoxylin & eosin (H&E) histopathology, with ultrastaging and immunohistochemistry reserved for those that test negative following H&E is likely to be the most effective approach. Conclusion: SLN biopsy using 99mTc and blue dye with ultrastaging may be considered the most cost-effective strategy based on the outcome of survival free of morbidity for 2 years. The findings here also indicate that using blue dye and H&E for the identification of the SLN and the identification of metastasis, respectively, are not sensitive enough to be used on their own.