We aimed to assess male circumcision for the prevention of human immunodeficiency virus (HIV) acquisition in heterosexual and homosexual men using all available data. A systematic literature review was conducted searching for studies that assessed male circumcision as a method to prevent HIV acquisition in homosexual and/or heterosexual men. PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrials.gov were searched in March 2017. A random effects model was used to calculate a pooled risk ratio (RR) and its associated 95% confidence interval (CI). In total, 49 studies were included in this meta-analysis. The overall pooled RR for both homosexual and heterosexual men was 0.58 (95% CI 0.48-0.70), suggesting that circumcision was associated with a reduction in HIV risk. Circumcision was found to be protective for both homosexual and heterosexual men (RR: 0.80, 95% CI 0.69-0.92 and 0.28, 95% CI 0.14-0.59, respectively). Heterosexual men had a greater RR reduction (72% compared with 20% for homosexual men). There was significant heterogeneity among the studies (χ = 1378.34, df = 48; I = 97%). This meta-analysis shows that male circumcision was effective in reducing HIV risk for both heterosexual and homosexual men.

To assess how UK General Practitioners (GPs) and Practice Managers (PMs) have coped with the challenges posed by the coronavirus disease-19 (COVID-19) pandemic and whether they felt adequately supported by the wider National Health Service (NHS). Methods This is a cross-sectional survey. All GPs and PMs (total 1,354) in Leicester, Leicestershire, and Rutland (LLR) were invited to participate in an online questionnaire. Results A total of 95 invitees completed the survey. Over a quarter had required time off work due to COVID symptoms or contact. All respondents described either introducing or increasing the use of remote patient consultations. Most striking was the rise in video consultations from just 3% to 95% during the pandemic. Almost half of the feedback on the usefulness of remote consultations were positive, 16% were negative and 17% were mixed. The most commonly cited benefit was time efficiency. Drawbacks of remote consultations included technical difficulties and poor patient communication. Practice premises, systems and processes also required significant modifications during the pandemic to ensure the provision of safe clinical care, including reception screens, one-way patient flow, greater infection prevention measures. However, despite their ability to introduce such widescale change virtually overnight, over 10% of respondents reported that the strain had placed their practice at risk of closure. Over half of respondents felt they were not provided with adequate personal protective equipment (PPE) for the safety of their staff. Perception of the support provided by NHS England and the Clinical Commissioning Groups (CCGs) was rather mixed, although additional guidelines were broadly welcomed. The most requested enduring changes related to remote patient consultations (59%) and remote triage (19%). However, in order to support such largescale permanent change, study respondents felt that a different funding and financial structure is required together with improved IT infrastructure, greater patient education and a more supportive regulatory environment. Conclusions COVID-19 has substantially accelerated the pace of change within NHS primary care. The long-1 2 3 4 5 6

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Use of cutting type spinal needle is associated with a greater decrease in mean hearing levels compared to the non-cutting type.