A survey of patient informational preferences when choosing between medical and surgical therapy for ulcerative colitis: a sub-study from the DISCUSS project.

AIM: People living with ulcerative colitis (UC) have two broad treatment avenues, namely medical or surgical therapy. The choice between these can depend on patient preference as well as the receipt of relevant information. The aim of this study was to define the informational needs of patients with UC. METHOD: A postal survey was designed to capture respondent demographics, treatment experienced within the previous 12 months and informational preferences by rating a long list of items. It was delivered through two hospitals that provide tertiary inflammatory bowel disease services. Descriptive analyses were performed to describe demographics and experiences. Principal component analysis was carried out using a varimax rotation to investigate informational needs. RESULTS: A total of 101 responses were returned (20.1% response rate). The median age of respondents was 45 years and the median time since diagnosis was 10 years. Control preferences skewed towards shared (42.6%) or patient-led but clinician-informed (35.6%). Decision regret was low for the population (median 12.5/100, range 0-100). Key informational needs related to medical therapy were benefits and risks of long-term therapy, burden of hospital attendance, reproductive health, need for steroid treatment and impact on personal life. For surgery, these were stoma information, effect on daily life, effect on sexual and reproductive health, risks and benefits and disruption of life due to surgery. CONCLUSION: This study has identified key areas for discussion when counselling patients about treatment decisions around medical therapy and surgery for UC.

Biochemically recurrent prostate cancer: rationalisation of the approach to imaging.

AIM: To assess the utility of magnetic resonance imaging (MRI) in addition to the additive benefit of the conventional imaging techniques, computed tomography (CT) and nuclear medicine (NM) bone scintigraphy, for investigation of biochemical recurrence (BCR) post-prostatectomy where access to prostate specific membrane antigen (PSMA) positron-emission tomography (PET)-CT is challenging. MATERIALS AND METHODS: Relevant imaging over a 5-year period was reviewed. Ethical approval was granted by the internal review board. All patients with suspected BCR, defined as a PSA ≥0.2 ng/ml on two separate occasions, underwent a retrospective imaging review. This was performed on PACS archive search database in a single centre using search terms "PSA" and "prostatectomy" in the three imaging methods; MRI, CT, and NM bone scintigraphy. All PSMA PET CT performed were recorded. RESULTS: One hundred and eighty-five patients were identified. Patients with an MRI pelvis that demonstrated distant metastases (i.e., pelvic bone metastases or lymph node involvement more cranial to the bifurcation of the common iliac arteries) were more likely to have a positive CT and/or NM bone scintigraphy. The Pearson correlation coefficient between the findings of M1 disease at MRI pelvis and the presence of distant metastases at CT thorax, abdomen, pelvis and NM bone scintigraphy was calculated at 0.81 (p<0.01) and 0.91 (p<0.01) respectively. CONCLUSION: An imaging strategy based on risk stratification and technique-specific selection criteria leads to more appropriate use of resources, and in turn, increases the yield of conventional imaging methods. MRI prostate findings can be used to predict the additive value of CT/NM bone scintigraphy allowing a more streamlined approach to their use.

Protocol for the ORION trial (RadiO fRequency ablatION for haemorrhoids): a randomised controlled trial.

BACKGROUND: Haemorrhoids are common and can significantly impact the personal and working lives of individuals. Those with more severe symptoms and those not responding to conservative management may require surgery. Current surgical techniques are associated with a degree of postoperative discomfort which may delay return to normal activity. Recurrence is lower in more radical procedures but resulting pain is higher. Radiofrequency ablation (RFA) is a new technique that is gaining popularity and has several hypothesised benefits, including reduced pain and recurrence. However, available evidence is limited. A recent overview from the National Institute for Health and Clinical Excellence recommended more research, in the form of randomised controlled trials, be carried out before further investment is made by national health services. Our aim is to assess whether RFA is at least as good in terms of recurrence as existing surgical interventions, but superior in terms of pain, for patients with symptomatic grade II and III haemorrhoids. METHODS: The RadiO fRequency ablatION for haemorrhoids (ORION) trial will be a pragmatic multicentre patient/assessor-blind parallel group-controlled trial with economic evaluation. The target sample size is 376 participants (188 per arm) and is based on two co-primary endpoints: (i) a non-inferiority design for recurrence and (ii) superiority design for pain at seven days. Participants with grade II or III haemorrhoids will be recruited in 16 National Health Service hospitals and randomised (1:1) to either RFA or surgeon's choice of surgery. CONCLUSIONS: Results will inform future practice for the treatment of grade II-III haemorrhoids and provide evidence for national health services on future investments in RFA. TRIAL REGISTRATION: ISRCTN14474552.

Atrial fibrillation after resection: a PROGRESS III study.

AIM: Atrial fibrillation (AF) is a common cardiac arrhythmia, and is associated with worsening quality of life and complications such as stroke. Previous work showed that 8% of patients develop new-onset AF following colonic resection and highlighted factors that might predict the development of postoperative AF. The development of a new arrhythmia may have a negative effect on longer-term quality of life as well as cancer survivorship. The aim of this study is to accurately quantify the incidence of AF following colorectal cancer surgery and to validate a model to predict its development. METHOD: The Atrial Fibrillation After Resection (AFAR) study will recruit 720 patients aged 65 or over undergoing resection of colorectal cancer with curative intent. The primary outcome is development of AF within 90 days of surgery. Assessment of cardiac rhythm will be performed using 24-h Holter monitors at baseline, 30 and 90 days after surgery. An electrocardiogram (ECG) will be performed on the day of discharge. Baseline descriptors including model variables and quality of life will be recorded using EQ-5D-5L. The occurrence of complications and other key surgical outcomes will be recorded. An additional blood test for N-terminal pro B-type natriuretic peptide (NT-proBNP) will be performed prior to surgery. Statistical analysis will validate a previously derived model and will test the incremental value of added variables such as NT-proBNP. Finally, an exploratory analysis will assess whether changes in ECG measures between baseline and postoperative ECG can predict subsequent new-onset AF. CONCLUSION: This study will provide data that may allow us to stratify the risk of developing AF following colorectal cancer surgery. This may inform screening or prophylactic approaches.

A systematic review and meta-analysis of outcomes after elective surgery for ulcerative colitis.

AIM: Approximately 20%-30% of patients with ulcerative colitis (UC) will undergo surgery during their disease course, the vast majority being elective due to chronic refractory disease. The risks of elective surgery are reported variably. The aim of this systematic review and meta-analysis is to summarize the outcomes after elective surgery for UC. METHODS: A systematic review was conducted that analysed studies reporting outcomes for elective surgery in the modern era (>2002). It was prospectively registered on the PROSPERO database (ref: CRD42018115513). Searches were performed of Embase and MEDLINE on 15 January 2019. Outcomes were split by operation performed. Primary outcome was quality of life; secondary outcomes were early, late and functional outcomes after surgery. Outcomes reported in five or more studies underwent a meta-analysis of incidence using random effects. Heterogeneity is reported with I2 , and publication bias was assessed using Doi plots and the Luis Furuya-Kanamori index. RESULTS: A total of 34 studies were included (11 774 patients). Quality of life was reported in 12 studies, with variable and contrasting results. Thirteen outcomes (eight early surgical complications, five functional outcomes) were included in the formal meta-analysis, all of which were outcomes for ileal pouch-anal anastomosis (IPAA). A further 71 outcomes were reported (50 IPAA, 21 end ileostomy). Only 14 of 84 outcomes received formal definitions, with high inter-study variation of definitions. CONCLUSION: Outcomes after elective surgery for UC are variably defined. This systematic review and meta-analysis highlights the range of reported incidences and provides practical information that facilitates shared decision making in clinical practice.

A systematic review of the quality of reporting of interventions in the surgical treatment of Crohn's anal fistula: an assessment using the TIDiER and Blencowe frameworks.

BACKGROUND: Crohn's anal fistula is a challenging condition, and may require multiple surgical procedures. To replicate successful procedures, these must be adequately reported in the literature. The aim of this study was to review the quality of reporting of components of surgical interventions for Crohn's anal fistula. METHODS: A systematic review was conducted. It was registered with PROSPERO (CRD:42019135157). The Medline and EMBASE databases were searched for studies reporting interventions intended to close fistula in patients with Crohn's disease, published between 1999 and August 2019. Abstracts and full texts were screened for inclusion by two reviewers. Dual extraction of data was performed to compare reporting to the TIDiER and Blencowe frameworks for reporting of interventions. RESULTS: Initial searches identified 207 unique studies; 38 full texts were screened for inclusion and 33 were included. The most common study design was retrospective cohort (17/33), and the most frequently reported interventions were anal fistula plug (n = 8) and fibrin glue (n = 6). No studies showed coverage of all domains of TIDieR. Reporting was poor among domains related to who provided an intervention, where it was provided, and how it was tailored. Reporting of domains in the Blencowe framework was poor; the majority of studies did not report the component steps of procedures or efforts to standardise them. CONCLUSIONS: This study demonstrates that reporting on technical aspects of interventions for Crohn's anal fistula is poor. Surgeons should aim to improve reporting to allow accurate reproduction of techniques both in clinical practice and in clinical trials.

A mapping review of sacrococcygeal pilonidal sinus disease.

BACKGROUND: Pilonidal sinus is a hole in the natal cleft which may cause severe pain and become infected. The evidence base for management of pilonidal sinus is said to be poor quality, poorly focused and rapidly proliferating. We undertook a systematic mapping review to provide a broad overview of the field and support the identification of research priorities. METHODS: We searched MEDLINE, CINAHL, and EMBASE from inception to 22nd Nov 2020 for primary research studies focused on the management of pilonidal sinus. We extracted data on study design and categorised studies under five major headings ('non-surgical treatment', 'surgical treatment', 'aftercare' and 'other'), producing frequency counts for different study designs. Gaps in research were identified from published systematic reviews and tabulated. RESULTS: We identified 983 eligible studies, of which 36 were systematic reviews and/or meta-analyses; 121 were randomised controlled trials), and 826 observational studies of various design. The majority of studies evaluated surgical techniques (n = 665), or adjuvant medical interventions (n = 98). The literature on wound care has developed most recently, and the evidence base includes 30% randomised controlled trials. Gaps analysis highlighted comparison of surgical techniques including flaps, laser depilation, and wound care interventions as potential areas for randomised controlled trials. CONCLUSIONS: This mapping review summarises eight decades of research on the management of pilonidal sinus. Further research is needed to identify front-running interventions, understand variation in practice and patient values, and to prioritise future research.

Variation in descriptors of patient characteristics in randomized clinical trials of peptic ulcer repair: a systematic review.

BACKGROUND: The ability to compare findings across surgical research is important. Inadequate description of participants, interventions or outcomes could lead to bias and inaccurate assessment of findings. The aim of this study was to assess consistency of description of participants using studies comparing laparoscopic and open repair of peptic ulcer as an example. METHODS: This systematic review is reported in line with the PRISMA checklist. Searches of MEDLINE and Embase databases were performed to identify studies comparing laparoscopic and open repair of perforated peptic ulcer in adults, published in the English language. Manuscripts were dual-screened for eligibility. Full texts were retrieved and dual-screened for inclusion. Data extracted from studies included descriptors of participants in studies from tables and text. Descriptors were categorized into conceptual domains by the research team, and coverage of each domain by study was tabulated. RESULTS: Searches identified 2018 studies. After screening, 37 full texts were retrieved and 23 studies were included in the final synthesis. A total of 76 unique descriptors were identified. These were classified into demographics (11 descriptors), vital signs (9 descriptors), disease-specific characteristics (10 descriptors), presentation and pathway factors (4 descriptors), risk factors (8 descriptors), laboratory tests (14 descriptors) and baseline health (28 descriptors). The number of descriptors in a single study ranged from three to 31. All studies reported at least one demographic descriptor. Laboratory tests was the least frequently described domain. CONCLUSION: Study participants are described inconsistently in studies of a single example surgical condition.

ANTECEDENTES: La capacidad de comparar los hallazgos en la investigación quirúrgica es importante. Una descripción inadecuada de los participantes, las intervenciones o los resultados podría conllevar sesgos y una evaluación incorrecta de los hallazgos. El objetivo de este estudio fue evaluar la consistencia en la descripción de los participantes utilizando los estudios comparativos de la cirugía laparoscópica con la cirugía abierta en el tratamiento de la úlcera péptica, como modelo. MÉTODOS: Esta revisión sistemática se presenta de acuerdo con la lista de verificación PRISMA. Se realizaron búsquedas en las bases de datos MEDLINE y EMBASE para identificar estudios, publicados en inglés, que compararan el tratamiento quirúrgico laparoscópico y abierto de la úlcera péptica perforada en adultos. Los artículos elegibles fueron sometidos a un doble cribaje para su selección. Se recuperaron los textos completos de los artículos y se evaluaron por partida doble para su inclusión. Los datos extraídos correspondían a los términos que describían las poblaciones de estudio en el texto y en las tablas de los artículos. Dichos términos descriptores fueron clasificados por el equipo de investigación en dominios conceptuales, registrándose la cobertura de cada dominio en cada estudio. RESULTADOS: Las búsquedas bibliográficas identificaron 2.018 estudios. Después de la selección, se recuperaron 37 artículos de texto completo y se incluyeron 23 estudios en la síntesis final. Se identificaron un total de 76 descriptores únicos. Dichos descriptores se clasificaron en demográficos (11 variables), signos vitales (9 variables), características específicas de la enfermedad (10 variables), factores de presentación y del proceso (4 variables), factores de riesgo (8 variables), pruebas de laboratorio (14 variables) y estado de salud basal (28 variables). El número de descriptores en un solo estudio varió de 3 a 31. Todos los estudios presentaron al menos un descriptor demográfico. Las pruebas de laboratorio fueron el dominio descrito con menor frecuencia. CONCLUSIÓN: Esta revisión demuestra que los participantes en los estudios se describen de manera inconsistente, tras haber tomado como modelo los estudios de una sola patología quirúrgica.

Blindness increases the risk for hip fracture and vertebral fracture but not the risk for distal radius fracture: a longitudinal follow-up study using a national sample cohort.

The risks for hip fracture and vertebral fracture, but not the risk for distal radius fracture, were significantly higher in the blindness group than in the control group with a maximum 12-year follow-up. PURPOSE: To evaluate the influence of visual impairment on the risk for osteoporotic fractures at common sites: hip, thoracic/lumbar vertebra, and distal radius. METHODS: This longitudinal follow-up study used a database of a national sample cohort from 2002 to 2013 provided by the Korean National Health Insurance Service. Of a total of 1,125,691 subjects, 3918 patients with visual impairment and age ≥ 50 years were enrolled in a 1:4 ratio; 15,672 control participants were matched for age, sex, income, and region of residence. Stratified Cox proportional-hazards models were used to evaluate the crude and adjusted (for steroid medication, rheumatoid arthritis, depression, osteoporosis, diabetes mellitus, and stroke history) hazard ratios (HRs) for each fracture site. Fracture diagnoses were based on the ICD-10 codes: hip fracture (S720, S721, S722), vertebral fracture (S220, S320), and distal radius fracture (S525). RESULTS: The HRs for hip and vertebral fracture were significantly higher in the blindness group (adjusted HR = 2.46, p < 0.001 for hip fracture; adjusted HR = 1.42, p = 0.020 for thoracic/lumbar vertebral fracture) than in the matched control group. However, the HR for distal radius fracture was not higher in the blindness group. The HRs for all three fracture sites were not significantly higher in the non-blindness visual impairment group after adjustment. CONCLUSION: The risks for hip fracture and vertebral fracture were significantly higher in the blindness group. However, the risk for distal radius fracture was not related to visual impairment including blindness.

The informational and decisional preferences of patients undergoing surgery for Crohn's anal fistula: a qualitative study.

AIM: One in three patients with Crohn's disease will develop a perianal fistula, but only a few achieve long-term healing. Treatment is both medical and surgical. Since there is no 'best' surgical procedure, patient preference is important in selecting the appropriate treatment for this condition. The aim of this study was to investigate the informational and decisional preferences of patients when surgical treatment is being considered. METHOD: Patients who had undergone surgery for Crohn's anal fistula underwent face-to-face semi-structured interviews. These explored the experience of treatments for fistula, of receiving information and of participation in decision-making. Transcripts were analysed by two investigators through inductive thematic analysis. Saturation was assessed for at 12 interviews and then after each subsequent interview. RESULTS: Seventeen patients completed interviews, and saturation was achieved. Five themes were identified, of which two (desired information and decision-making) were relevant to this study. Other themes included experience of Crohn's disease, experience of receiving information and procedure-specific comments. Participants wanted to have information on any risks, high-level outcomes (e.g. success), impact on day-to-day life and aftercare. Participants felt they did not always receive the information they needed to select the best treatment option. Participants felt uninvolved in treatment decisions and would have liked to trade off operations to reach their treatment goal. CONCLUSION: Information provided to patients about surgical treatment of Crohn's perianal fistula does not meet their needs. Clinicians should address aftercare, impact on quality of life and the risks and benefits of the any proposed procedure.

Non-randomized studies should be considered for assessing surgical techniques in rectal prolapse: prospective cohort study.

AIM: Randomized trials comparing surgical techniques for rectal prolapse are not always feasible. We assessed whether non-randomized comparisons of those who have had surgery with those still waiting would be confounding baseline health status. METHOD: This was a prospective cohort study in seven UK hospitals. Participants were ≥ 18 years and listed for surgical interventions of equivalent intensity for rectal prolapse. They were defined as short or long waiters (≤ 18 or > 18 weeks, respectively). Time on the waiting list was compared with baseline comorbidity (Charlson comorbidity index) and change from baseline in health status (EQ-5D-5L) at the time of surgery. RESULTS: In all, 203 patients were analysed. Median (interquartile range) waiting time was 13.7 weeks (8.1, 20.4) varying across sites. Baseline comorbidity was not an important predictor of waiting time. Median Charlson comorbidity index was 2 (0, 3) for short and 1 (0, 3) for long waiters. A change in waiting time by a week was associated with negligible improvement in the EQ-5D-5L index of 0.001 (95% CI -0.000 to 0.003, P = 0.106). CONCLUSION: Negligible change in patient reported health status while on the waiting list and lack of effect of comorbidities in influencing waiting time support the use of non-randomized pre-/post-studies to compare the effects of surgical interventions for rectal prolapse.

Association of low skeletal muscle mass with the presence of advanced colorectal neoplasm: integrative analysis using three skeletal muscle mass indices.

AIM: This study aimed to evaluate an association between colorectal neoplasm (CRN) and skeletal muscle mass using three widely accepted skeletal muscle mass indices (SMIs) in a large population at average risk. METHOD: We performed a cross-sectional study using a screening colonoscopy database of 33 958 asymptomatic subjects aged 40-75 years. Appendicular skeletal muscle mass (ASM) was measured using a bioelectrical impedance analyser. ASM adjusted for height squared (ASM/ht2 ), weight (ASM/wt) and body mass index (ASM/BMI) were used as indices for muscle mass. Logistic regression models were used to evaluate the association between SMIs and CRN. RESULTS: In a multivariable-adjusted model, the risk of an advanced CRN increased linearly with decreasing quartiles for all three SMIs. The adjusted odds ratios (ORs) for advanced CRN in quartiles 1, 2 and 3 of ASM/wt compared with that in quartile 4 were 1.279, 1.196 and 1.179, respectively (Ptrend  = 0.017); for ASM/BMI, ORs were 1.307, 1.144 and 1.091, respectively (Ptrend  = 0.002); and for ASM/ht2 , ORs were 1.342, 1.169 and 1.062, respectively (Ptrend  = 0.002). The risk of distally located advanced CRN was higher in quartile 1 than in quartile 4 for all three SMIs (ASM/wt, OR = 1.356; ASM/BMI, OR = 1.383; ASM/ht2 , OR = 1.430). CONCLUSION: Our study demonstrated that low skeletal muscle mass was consistently associated with the presence of advanced CRN in a population at average risk regardless of the operational definition of the SMI, and it was particularly associated with distal advanced CRN.

Establishing core outcome sets for gastrointestinal recovery in studies of postoperative ileus and small bowel obstruction: protocol for a nested methodological study.

INTRODUCTION: Gastrointestinal recovery describes the restoration of normal bowel function in patients with bowel disease. This may be prolonged in two common clinical settings: postoperative ileus and small bowel obstruction. Improving gastrointestinal recovery is a research priority but researchers are limited by variation in outcome reporting across clinical studies. This protocol describes the development of core outcome sets for gastrointestinal recovery in the contexts of postoperative ileus and small bowel obstruction. METHOD: An international Steering Group consisting of patient and clinician representatives has been established. As overlap between clinical contexts is anticipated, both outcome sets will be co-developed and may be combined to form a common output with disease-specific domains. The development process will comprise three phases, including definition of outcomes relevant to postoperative ileus and small bowel obstruction from systematic literature reviews and nominal-group stakeholder discussions; online-facilitated Delphi surveys via international networks; and a consensus meeting to ratify the final output. A nested study will explore if the development of overlapping outcome sets can be rationalized. DISSEMINATION AND IMPLEMENTATION: The final output will be registered with the Core Outcome Measures in Effectiveness Trials initiative. A multi-faceted, quality improvement campaign for the reporting of gastrointestinal recovery in clinical studies will be launched, targeting international professional and patient groups, charitable organizations and editorial committees. Success will be explored via an updated systematic review of outcomes 5 years after registration of the core outcome set.

Contemporary endovascular management of splenic vascular pathologies.

The spleen is a commonly injured organ and the splenic vasculature is also susceptible to inflammation and trauma, often resulting in aneurysm formation. Splenic artery aneurysms carry a high risk of rupture and are associated with high mortality and morbidity. Due to the advances in endovascular techniques and devices, endovascular management of splenic vascular pathologies is now considered a first-line strategy. Endovascular embolisation and advance techniques including balloon- or stent-assisted coil embolisation enables minimally invasive management option while preserving splenic function.

Women in interventional radiology: insights into Australia's gender gap.

AIM: To assess differences in the exposure, teaching, knowledge, appreciation, and interest in interventional radiology (IR) between male and female doctors prior to specialisation and to identify potential predisposing factors to the gender inequality in interventional radiology. MATERIALS AND METHODS: A prospective cross-sectional multicentre study was conducted using in-person and web-based distribution of a voluntary, anonymous questionnaire to junior doctors yet to commence specialisation at 11 health services across two Australian states. RESULTS: Complete responses were provided by 333 junior doctors (21.9% response rate). Women were significantly less likely than men to consider a career in IR (13.1% versus 29.7%, p < 0.001). No other statistically significant gender disparities were identified, as both men and women reported low levels of prior teaching and exposure to IR, strong belief in the importance of IR, and suboptimal knowledge of IR. CONCLUSIONS: The gender gap amongst practising Australian interventional radiologists is perpetuated by a consistent gender gap in upcoming junior doctors' desire to pursue IR. This disparity exists despite junior doctors receiving the same exposure and opportunities in interventional radiology, possibly suggesting that preconceived stereotypes or psychosocial factors deter females from pursuing this procedural, male-dominated subspecialty. Future qualitative studies are required to confirm this hypothesis, in conjunction with prospective, experimental trials to determine whether changes in education, mentorship, and advocacy can promote gender equality.

A validated severity score for haemorrhoids as an essential prerequisite for future haemorrhoid trials.

BACKGROUND: There is a lack of standardised outcomes for haemorrhoidal disease making comparison between trials difficult. A need for a very well validated severity score is essential to facilitate meta-analysis of comparative studies, enabling evidence-based clinical practice. METHODS: The Hubble trial provides a large cohort of patients with haemorrhoidal disease randomised to rubber band ligation (RBL) or haemorrhoidal artery ligation. The haemorrhoid severity score (HSS) was collected on each patient at baseline, 6 weeks and 1 year after intervention. This allows for the responsiveness of the HSS instrument to be examined and compared with a more specific instrument, the Vaizey incontinence score (also collected). Responsiveness was tested using four methods (effect size, standardised response means (SRM), significance of change, and responsiveness statistic). RESULTS: The four tests of responsiveness demonstrated that the HSS was more responsive to changes in the patient's health status following both of the interventions compared to the Vaizey questionnaire. For example, between baseline and 6 weeks, the RBL intervention effect size scores and SRM calculations indicated a non-significant small amount of change (0.20 and 0.16 respectively). However, using the HSS, the effect size and SRM demonstrated a large magnitude of change (1.12 and 1.01, respectively) which was significant. Similar results were observed at 1 year. Significance of change scores and the index of responsiveness were also higher for the HSS questionnaire than the Vaizey across both treatment modalities. CONCLUSIONS: The HSS is a highly responsive tool for the detection of changes in haemorrhoid symptoms. It should form an essential patient-reported outcome tool for future studies on haemorrhoidal disease.

A systematic review of classification systems for pilonidal sinus.

BACKGROUND: Pilonidal sinus disease (PSD) is a simple chronic inflammatory condition resulting from loose hairs forcibly inserted into vulnerable tissue in the natal cleft. It is an acquired disease with a slight familial tendency. There is no agreement on optimum treatment and the multitude of therapeutic options cannot be compared due to the lack of a universally adopted classification of the disease. The aim of our study was to perform a systematic review of the literature to determine how presentations of PSD are classified and reported. METHODS: A systematic review of the English language literature was undertaken searching studies published after 1980. RESULTS: Eight classification systems of PSD were identified. Most classification systems were based on anatomical pathology hypotheses. The location and number of sinuses were the main factors defining classification systems. No articles were retrieved that assessed the validity and/or reliability of the classification system employed. Furthermore, there was no evidence to suggest a correlation between prognosis outcome and subgroup. CONCLUSIONS: Based on the evidence available from the literature reviewed we have no recommendations regarding the use of the current classification of PSD. A well-recognised and practical classification system to guide clinical practice is required.

eDoctor: machine learning and the future of medicine.

Machine learning (ML) is a burgeoning field of medicine with huge resources being applied to fuse computer science and statistics to medical problems. Proponents of ML extol its ability to deal with large, complex and disparate data, often found within medicine and feel that ML is the future for biomedical research, personalized medicine, computer-aided diagnosis to significantly advance global health care. However, the concepts of ML are unfamiliar to many medical professionals and there is untapped potential in the use of ML as a research tool. In this article, we provide an overview of the theory behind ML, explore the common ML algorithms used in medicine including their pitfalls and discuss the potential future of ML in medicine.

Chemsex and new HIV diagnosis in gay, bisexual and other men who have sex with men attending sexual health clinics.

OBJECTIVES: The aim of the study was to analyse associations between chemsex and new HIV and sexually transmitted infection (STI) diagnoses among gay, bisexual and other men who have sex with men (GBMSM) accessing sexual health clinics. METHODS: A retrospective case note review was carried out for all GBMSM attending two London sexual health clinics between 1 June 2014 and 31 July 2015. RESULTS: Chemsex status was documented for 1734 of 1840 patients. Overall, 27.1% (n = 463) disclosed current recreational drug use, of whom 286 (16.5%) disclosed chemsex participation and 74 of 409 (18.1%) injected drugs. GBMSM who were already HIV positive were more likely to disclose chemsex participation [adjusted odds ratio (AOR) 2.55; 95% confidence interval (CI) 1.89-3.44; P < 0.001]. Those disclosing chemsex participation had higher odds of being newly diagnosed with HIV infection (AOR 5.06; 95% CI 2.56-10.02; P < 0.001), acute bacterial STIs (AOR 3.94; 95% CI 3.00-5.17; P < 0.001), rectal STIs (AOR 4.45; 95% CI 3.37-6.06; P < 0.001) and hepatitis C (AOR 9.16; 95% CI 2.31-36.27; P = 0.002). HIV-negative chemsex participants were also more likely to have accessed post-exposure prophylaxis for HIV in the study period and to report sex with a discordant HIV- or hepatitis C virus-infected partner (P < 0.001). CONCLUSIONS: Chemsex disclosure in sexual health settings is associated with higher rates of STI diagnoses, including HIV infection and hepatitis C. GBMSM attending sexual health services should therefore be assessed for chemsex participation and disclosure should prompt health promotion, harm minimization and wellbeing interventions.

Different functional genes of upper airway microbiome associated with natural course of childhood asthma.

BACKGROUND: Microbial colonization of the airway plays a role in the pathogenesis of asthma; however, the effect of the upper airway microbiome on childhood asthma is not fully understood. We analyzed the metagenome of airway microbiome to understand the associated role of upper airway microbiome with the natural course of childhood asthma. METHODS: Nasopharyngeal swabs were collected from children with asthma, those in asthma remission, and control groups. High-throughput sequencing was used to examine the structure and functional dynamics of the airway microbiome with respect to asthma phenotypes. RESULTS: The composition of microbiota differed among healthy control, asthma, and remission groups. The relative abundance of Streptococcus was negatively associated with FEV1% predicted (P = .023) and that of Staphylococcus was negatively associated with methacholine PC20 (P = .013). Genes related to arachidonic acid metabolites, lysine residues, and glycosaminoglycans in the microbiome could be associated with airway inflammation. In particular, genes related to synthesis of anti-inflammatory prostaglandin E2 (PGE2 ) were not detected from the airway microbiome in the asthma group. CONCLUSIONS: These data suggest that alterations in the composition and function of the upper airway microbiome could be related with the natural course of asthma in children.