[A patient with Alice in Wonderland syndrome]. / Een patiënt met het Alice in Wonderland-syndroom.

We present the case of a 65-year-old man who was referred to the old-age department of our psychiatric hospital because of a depressed mood and inactivity. During his stay he exhibited a variety of peculiar visual perceptions and bodily experiences. We concluded that he suffered from a severe depressive disorder, as well as from symptoms that fitted largely into the clinical pattern of the Alice in Wonderland syndrome. In this case report we discuss the symptoms, etiology, and treatment options.

Inflammatory bowel disease and risk of adenocarcinoma and neuroendocrine tumors in the small bowel.

BACKGROUND: Uncertainty prevails about the magnitude of excess risk of small bowel cancer in patients with inflammatory bowel disease (IBD). PATIENTS AND METHODS: To quantify the risk of small bowel adenocarcinoma and neuroendocrine tumors in patients with ulcerative colitis (UC) and Crohn's disease (CD), we undertook a population-based cohort study of all patients with IBD diagnosed in Norway and Sweden from 1987 to 2016. Patients were followed through linkage to national registers. We calculated standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) of small bowel adenocarcinomas and neuroendocrine tumors for patients with CD and UC. We excluded the first year of follow-up to reduce reverse causality. RESULTS: Among 142 008 patients with a median follow-up of 10.0 years, we identified 66 adenocarcinomas and 57 neuroendocrine tumors in the small bowel. The SIR of small bowel adenocarcinoma was 8.3 (95% CI 5.9-11.3) in CD and 2.0 (95% CI 1.2-3.1) in UC. The incidence rates of adenocarcinomas were highest in CD with stricturing disease and extent limited to the small bowel, at 14.7 (95% CI 8.2-24.2) and 15.8 (95% CI 8.4-27.0) per 100 000 person-years, respectively. The SIR of neuroendocrine tumors was 2.5 (95% CI 1.5-3.9) in CD and 2.0 (95% CI 1.4-2.8) in UC. CONCLUSIONS: Patients with CD experienced an eightfold increased risk of small bowel adenocarcinomas, patients with both UC and CD experienced an about twofold increased risk of neuroendocrine tumors, and patients with UC experienced a twofold increased risk of small bowel adenocarcinoma. The small absolute excess cancer risk suggests that active surveillance to diagnose small intestinal cancer early is unlikely to be cost-effective.

[Somatoparaphrenia in a patient with schizophrenia and addiction problems: 'That arm is not mine, doctor']. / Somatoparafrenie bij een patiënt met schizofrenie en verslavingsproblematiek: 'Die arm is niet van mij, dokter'.

Somatoparaphrenia is a disorder of body perception, usually on the left side. One or both limbs are seen as foreign or as belonging to somebody else. In the literature this rare phenomenon has been described in patients with brain damage, usually due to an infarction or other lesion to the right parietal lobe. We describe a patient with schizophrenia and addiction problems who believed that his left forearm was not his, but rather belonged to a Spanish girl. An EEG and an MRI of the brain showed no abnormalities. Despite years of antipsychotic treatment, the delusion persisted. To rule out neurological causes we recommend auxiliary investigations in all patients with somatoparaphrenia. No evidence-based treatments are known for this monothematic delusion in the context of schizophrenia.

[Optical illusions and the work of M.C. Escher]. / Optische illusies en het werk van M.C. Escher.

BACKGROUND: The name Maurits Escher is inextricably linked with the notion of 'optical illusion', a type of illusion evoked by his 'impossible figures'. Despite the sober style in which he realised these figures, they go on to mesmerise generations of art lovers. It is unclear what causes this, and whether other factors than aesthetic ones are involved.
AIM: To gain insight into the genesis of optical illusions in Escher's work, and in the role of the perceptual system in that process.
METHOD: An explorative literature search in PubMed, Science.gov, Google Scholar, and the historical literature.
RESULTS: Since 'impossible figures' cannot be found in our natural environment, and therefore have a high novelty factor to the brain, they inevitably draw our attention. The reason that we remain captivated, is at least partly associated with the fact that the hippocampus and parahippocampal place area come into conflict with each other, and (in vain) accept the challenge to find a 'best fit'.
CONCLUSION: Fundamental research may benefit from Escher's 'impossible figures' to fathom the rules of our visual grammar. The optical illusions they evoke moreover constitute an ongoing source of inspiration for other artists, architects, and film makers.

Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: a systematic guideline review and expert consensus.

The complexity and heterogeneity of patients with multimorbidity and polypharmacy renders traditional disease-oriented guidelines often inadequate and complicates clinical decision making. To address this challenge, guidelines have been developed on multimorbidity or polypharmacy. To systematically analyse their recommendations, we conducted a systematic guideline review using the Ariadne principles for managing multimorbidity as analytical framework. The information synthesis included a multistep consensus process involving 18 multidisciplinary experts from seven countries. We included eight guidelines (four each on multimorbidity and polypharmacy) and extracted about 250 recommendations. The guideline addressed (i) the identification of the target population (risk factors); (ii) the assessment of interacting conditions and treatments: medical history, clinical and psychosocial assessment including physiological status and frailty, reviews of medication and encounters with healthcare providers highlighting informational continuity; (iii) the need to incorporate patient preferences and goal setting: eliciting preferences and expectations, the process of shared decision making in relation to treatment options and the level of involvement of patients and carers; (iv) individualized management: guiding principles on optimization of treatment benefits over possible harms, treatment communication and the information content of medication/care plans; (v) monitoring and follow-up: strategies in care planning, self-management and medication-related aspects, communication with patients including safety instructions and adherence, coordination of care regarding referral and discharge management, medication appropriateness and safety concerns. The spectrum of clinical and self-management issues varied from guiding principles to specific recommendations and tools providing actionable support. The limited availability of reliable risk prediction models, feasible interventions of proven effectiveness and decision aids, and limited consensus on appropriate outcomes of care highlight major research deficits. An integrated approach to both multimorbidity and polypharmacy should be considered in future guidelines.

Incidence of sight-threatening diabetic retinopathy in people with Type 2 diabetes mellitus and numbers needed to screen: a systematic review.

AIM: To investigate the incidence of sight-threatening diabetic retinopathy in Type 2 diabetes mellitus. BACKGROUND: In most countries, yearly or biennial screening intervals for diabetic retinopathy in people with Type 2 diabetes are recommended. Fewer screening sessions reduce the effort required of people with Type 2 diabetes and reduce healthcare costs. METHODS: We conducted a search of PubMed, Embase, Web of Science and the COCHRANE Library for studies published betweeen 1 January 2000 and 1 January 2017. Eligible studies were those that included general populations of >100 people with Type 2 diabetes mellitus. Additional study population criteria were absence of moderate diabetic retinopathy or more severe diabetic retinopathy at last screening session and at least two gradable retinal screening sessions. Outcomes of interest in the included studies were moderate and severe non-proliferative diabetic retinopathy (R2), proliferative diabetic retinopathy (R3) or maculopathy (M1), collectively known as sight-threatening or referable diabetic retinopathy. RESULTS: A total of 17 studies were included. In people with Type 2 diabetes without or with only mild diabetic retinopathy at baseline, the average incidence rates of sight-threatening diabetic retinopathy were ~1 per 100 person-years and ~8 per 100 person-years, respectively. The average numbers needed to screen to detect one case of sight-threatening diabetic retinopathy were 175 and 19 in people without and with mild retinopathy at last screening, respectively. CONCLUSION: In people with Type 2 diabetes without retinopathy at last screening, the incidence of severe sight-threatening retinopathy at the subsequent screening session was low. In people with mild retinopathy, progression to sight-threatening diabetic retinopathy was nearly 10-fold higher. This review supports lengthening of the screening interval of patients with Type 2 diabetes without retinopathy at last screening session.

Circulating serum miR-223-3p and miR-16-5p as possible biomarkers of early rheumatoid arthritis.

Small non-coding RNAs have emerged as possible biomarkers for various diseases including autoimmune diseases. A number of studies have demonstrated that the expression of specific microRNAs (miRNAs) is dysregulated in rheumatoid arthritis (RA). So far, all studies on miRNAs in RA patients have been performed using either microarray or reverse transcription-quantitative polymerase chain reaction (RT-qPCR) analyses. Compared to RT-qPCR and microarray analyses, next-generation sequencing (NGS) allows the genome-wide analysis of small RNAs and the differentiation between miRNAs that differ by a single nucleotide. The application of NGS to the analysis of small RNAs circulating in sera of RA patients has not been reported. This study provides a global overview of the circulating small RNAs in the sera of RA patients and healthy subjects and identifies differences between these groups using NGS. Several classes of small RNAs, including hY RNA-derived fragments, tRNA-derived fragments and miRNAs, were determined. Differentially expressed individual small RNAs were verified by RT-qPCR. The levels of two miRNAs, miR-223-3p and miR-16-5p, were significantly lower in the sera from early RA patients than in those from established RA patients and healthy controls. In contrast, the serum level of miR-16-5p was higher in patients with established RA than in healthy control samples. These miRNAs may not only serve as biomarkers, but may also shed more light on the pathophysiology of RA.

Auditory hallucinations, not necessarily a hallmark of psychotic disorder.

Auditory hallucinations (AH) are often considered a sign of a psychotic disorder. This is promoted by the DSM-5 category of Other Specified Schizophrenia Spectrum And Other Psychotic Disorder (OSSSOPD), the diagnostic criteria for which are fulfilled with the sole presence of persistent AH, in the absence of any other psychotic symptoms. And yet, persistent AH are not synonymous with having a psychotic disorder, and should therefore not be uncritically treated as such. Many people who seek treatment for persistent AH have no other psychotic symptoms, have preserved reality-testing capacities, and will never develop a schizophrenia spectrum disorder. Instead, hallucinations may be the result of many different causes, including borderline personality disorder, post-traumatic stress disorder (PTSD), hearing loss, sleep disorders or brain lesions, and they may even occur outside the context of any demonstrable pathology. In such cases, the usage of the DSM-5 diagnosis of OSSSOPD would be incorrect, and it may prompt unwarranted treatment with antipsychotic medication. We therefore argue that a DSM-5 diagnosis of Schizophrenia Spectrum Disorder (or any other type of psychotic disorder) characterized by AH should require at least one more symptom listed under the A-criterion (i.e. delusions, disorganized speech, disorganized or catatonic behavior or negative symptoms). Adhering to these more stringent criteria may help to distinguish between individuals with persistent AH which are part of a psychotic disorder, for whom antipsychotic medication may be helpful, and individuals with AH in the absence of such a disorder who may benefit from other approaches (e.g. different pharmacological interventions, improving coping style, trauma-related therapy).

The frail older person does not exist: development of frailty profiles with latent class analysis.

BACKGROUND: A fundamental issue in elderly care is targeting those older people at risk and in need of care interventions. Frailty is widely used to capture variations in health risks but there is no general consensus on the conceptualization of frailty. Indeed, there is considerable heterogeneity in the group of older people characterized as frail. This research identifies frailty profiles based on the physical, psychological, social and cognitive domains of functioning and the severity of the problems within these domains. METHODS: This research was a secondary data-analysis of older persons derived from The Older Person and Informal Caregiver Minimum Dataset. Selected respondents were 60 years and older (n = 43,704; 59.6% female). The following variables were included: self-reported health, cognitive functioning, social functioning, mental health, morbidity status, and functional limitations. Using latent class analysis, the population was divided in subpopulations that were subsequently discussed in a focus group with older people for further validation. RESULTS: We distinguished six frailty profiles: relatively healthy; mild physically frail; psychologically frail; severe physically frail; medically frail and multi-frail. The relatively healthy had limited problems across all domains. In three profiles older people mostly had singular problems in either the physical or psychological domain and the severity of the problems differed. Two remaining profiles were multidimensional with a combination of problems that extended to the social and cognitive domains. CONCLUSIONS: Our research provides an empirical base for meaningful frailty profiles. The profiles showed specific patterns underlying the problems in different domains of functioning. The heterogeneous population of frail older people has differing needs and faces different health issues that should be considered to tailor care interventions. Evaluation research of these interventions should acknowledge the heterogeneity of frailty by profiling.

[Hallucinations and art]. / Hallucinaties en kunst1.

BACKGROUND Hallucinations and art appear to be inextricably connected, and yet the question remains in how far artists make use of hallucinations for their work in daily practice.
AIM: To chart the ways in which the fine arts are influenced by hallucinations, an explorative literature search was carried out. METHOD The search was carried out in PubMed, Google, and the historical literature.
RESULTS: Some famous examples of artists who drew on hallucinations for their work, are Hildegard of Bingen, William Blake, and Yayoi Kusama. Especially among the surrealists, we also find indications of the use of pareidolias, metamorphopsias, and other positive disorders of visual perception.
CONCLUSION: In the art literature, the term hallucination is often used in a broader sense than in medicine. As a consequence, the suggestion that hallucinations would be lying at the basis of many works of art cannot be confirmed, even though some spectacular examples can certainly be pointed out.

[Brua and psychiatry: A pilot study among Dutch-Antillean patients in the Netherlands]. / Brua en psychiatrie: een pilotstudie onder patiënten in Nederland afkomstig van de voormalige Nederlandse Antillen.

BACKGROUND: Individuals native to Aruba, Bonaire, and Curaçao, the abc islands of the former Netherlands Antilles, often attribute their complaints to brua, although they seldom discuss this with health professionals. This may have a negative influence on the therapeutic relationship and diagnostic processes.
AIM: To explore the role of brua in the illness perception of psychiatric patients in the Netherlands who were originally from the abc islands.
METHOD: A random sample of patients under treatment at Parnassia Psychiatric Institute in The Hague were interviewed with the aid of a semi-structured questionnaire.
RESULTS: Of the 18 psychiatric patients interviewed, 10 (56%) believed in brua, and 3 (17%) considered it the cause of their disease. Although none of the interviewees admitted to an active involvement in brua, 8 (44%) had been in touch with a traditional healer and 9 (50%) possessed artifacts meant to provide protection against evil. Regarding the usefulness of discussing brua with health professionals, opinions were divided.
CONCLUSION: Psychiatric patients in the Netherlands native to the abc islands are all knowledgeable of brua, with more than half of them believing in it. Despite the fear and shame that people often experience, making brua fit for discussion in clinical practice would improve the relationship between health professional and patient, yielding further opportunities for diagnosis and treatment.

Protistan predation interferes with bacterial long-term adaptation to substrate restriction by selecting for defence morphotypes.

Bacteria that are introduced into aquatic habitats face a low substrate environment interspersed with rare productive 'hotspots', as well as high protistan grazing. Whereas the former condition should select for growth performance, the latter should favour traits that reduce predation mortality, such as the formation of large cell aggregates. However, protected morphotypes often convey a growth disadvantage, and bacteria thus face a trade-off between investing in growth or defence traits. We set up an evolutionary experiment with the freshwater isolate Sphingobium sp. strain Z007 that conditionally increases aggregate formation in supernatants from a predator-prey coculture. We hypothesized that low substrate levels would favour growth performance and reduce the aggregated subpopulation, but that the concomitant presence of a flagellate predator might conserve the defence trait. After 26 (1-week) growth cycles either with (P+) or without (P-) predators, bacteria had evolved into strikingly different phenotypes. Strains from P- had low numbers of aggregates and increased growth yield, both at the original rich growth conditions and on various single carbon sources. By contrast, isolates from the P+ treatment formed elevated proportions of defence morphotypes, but exhibited lower growth yield and metabolic versatility. Moreover, the evolved strains from both treatments had lost phenotypic plasticity of aggregate formation. In summary, the (transient) residence of bacteria at oligotrophic conditions may promote a facultative oligotrophic life style, which is advantageous for survival in aquatic habitats. However, the investment in defence against predation mortality may constrain microbial adaptation to the abiotic environment.

[The Alice in Wonderland syndrome. What do we know after 60 years?]. / Het Alice in Wonderland-syndroom; wat weten wij na 60 jaar?

BACKGROUND: The Alice in Wonderland syndrome (AIWS) was conceptualised in 1955 as a group of distortions of visual perception, the body schema and the experience of time. Although 60 years have passed since then, very little is known yet about the syndrome. This is surprising since the AIWS has important diagnostic and therapeutic implications. AIM: To provide an overview of the literature on the AIWS. METHOD: For this review, a literature search was carried out in PubMed and the historical literature. RESULTS: The search yielded 70 papers with a total of 169 case descriptions. As these papers indicate, the AIWS has many causes, the main ones being neurological, infectious and substance-related; sometimes the causes are psychiatric. Among adults and elderly patients the disorders described are mainly neurological; among young people encephalitis is fairly common. Treatment needs to be directed at the (assumed) underlying condition, although in almost half of the cases the patient's main requirement is reassurance rather than treatment. Prevalence rates are unknown, but studies in the general population indicate that the symptoms of the AIWS occur more frequently than previously assumed. CONCLUSION: Clinical suspicion of an AIWS warrants careful auxiliary investigations and - whenever necessary - treatment. The AIWS should not be confused with schizophrenia spectrum disorders and other perceptual disorders, and it deserves to be included in the research agenda of international classifications such as the DSM and ICD.

[Auditory verbal hallucinations in patients with borderline personality disorder]. / Auditieve verbale hallucinaties bij patiënten met een borderline-persoonlijkheidsstoornis.

BACKGROUND: Traditionally, auditory verbal hallucinations (AVH) experienced by patients with a borderline personality disorder (BPD) are considered to be rare, to have a 'pseudo'-quality, and to cause little distress. AIM: To provide an overview of studies of the prevalence and phenomenological characteristics of AVHs in patients with a BPD, and of the ensuing degree of suffering. METHOD: We performed a systematic literature search using PubMed and the Ovid database. RESULTS: 27% of patients with a BPD experience AVH. Phenomenologically, these percepts are indistinguishable from those experienced by patients with a schizophrenia spectrum disorder. Hallucinations in several modalities were present in 50% of the patients with BPD. The mean time-span in which AVH were experienced was 17 years, the mean frequency was several minutes per day. The degree of suffering was high and the patient's life was interrupted to a moderate degree. CONCLUSION: AVH and other hallucinations are common in BPD. We advise clinicians to inquire directly whether patients experience them and to provide treatment whenever possible. However, one of the problems is, that evidence-based treatment methods such as antipsychotics, cognitive-behavioural therapy and transcranial magnetic stimulation have not yet been studied systematically for this specific patient group.

[Red tape in psychiatry: on bureaucracy, bureaucratism, and our secret fondness for procedures]. / De paarse krokodil in de psychiatrie: over bureaucratie, bureaucratisme en onze heimelijke liefde voor procedures.

BACKGROUND: A frequent complaint in psychiatry is that the psychiatrist-patient relationship and the quality of care are hampered by bureaucratic processes. AIM: To provide an analysis of various types of bureaucracy in psychiatry that can serve as a starting-point for the improvement of care and the performance of qualitative studies. METHOD: We conducted an exploratory study using PubMed, Google, and various Dutch medical journals. RESULTS: Contemporary psychiatry is characterised by a bureaucratic organization structure. Mental, somatic, and social problems are translated in a standardised manner into medical jargon which gives rise to a DSM diagnosis, a cost-price, and outcome measures. This medical-bureaucratic system has important virtues, provided it is applied efficiently and the patient-psychiatrist relationship remains intact. In the Netherlands, however, this balance has been disturbed. Future research can be facilitated if distinctions are made between various types of bureaucracy (referred to here as Hippocratic, Weberian, and Kafkaesque bureaucracy). In addition, we discuss various national initiatives which aim to counter bureaucracy, including initiatives of the Dutch government. CONCLUSION: If the patient-psychiatrist relationship is to regain its central role, bureaucracy needs to be countered constantly. The government can facilitate this process, but healthcare providers can also play a key role and meanwhile help to bring about a substantial reduction in the costs of care.

Estimating genetic parameters for fertility in dairy cows from in-line milk progesterone profiles.

The aim of this study was to define endocrine fertility traits from in-line milk progesterone (P4) records and to estimate genetic parameters for these traits. Correlations of classical fertility (calving interval and calving to first service) and milk production traits with endocrine fertility traits were also estimated. In-line milk P4 records (n=160,952) collected from June 2009 through November 2013 for 2,273 lactations of 1,561 Holstein-Friesian cows in 12 commercial herds in the Netherlands were analyzed for (the log of) the number of days from calving till commencement of luteal activity (lnC-LA), proportion of samples between 25 and 60 d in milk with luteal activity (PLA), presence or absence of luteal activity for a cow between 25 and 60 d in milk, interval from commencement of luteal activity to first service (CLAFS), first luteal phase length, length of first interluteal interval, and length of first interovulatory interval. Milk P4 records were sampled, on average, every 2 d. Genetic parameters were estimated using a mixed linear animal model. Heritability estimates (±SE) of endocrine fertility traits were 0.12±0.05 for lnC-LA, 0.12±0.05 for PLA, and 0.11±0.06 for CLAFS, and their repeatability estimates were 0.29±0.04, 0.21±0.04, and 0.15±0.06, respectively. The genetic correlation of lnC-LA with PLA was -0.91±0.06 and with CLAFS was -0.56±0.25. The genetic correlations of lnC-LA were 0.26±0.33 with calving interval and 0.37±0.21 with calving to first service. Genetic correlations of the milk production traits with lnC-LA ranged from 0.04 to 0.18 and 0.07 to 0.65 with classical fertility traits. The phenotypic correlations of all endocrine fertility traits with milk production traits were close to zero (0.01 to 0.07). This study shows that in-line P4 records can be used to define and explore several heritable endocrine fertility traits in dairy cows and might help in selection for improved fertility.

[The delusion of world catastrophe. Is this classic symptom still relevant today?]. / De wereldondergangswaan; een klassiek symptoom met actuele relevantie?

BACKGROUND: The delusion of world catastrophe was conceptualised by classic authors such as Jaspers and Conrad as a specific expression of acute psychosis that deserved special attention in psychiatric diagnosis. We need to find out whether this approach is still relevant today. AIM: To provide an overview of the literature about the delusion of world catastrophe. METHOD: The literature was searched and historical literature was also consulted. RESULTS: A patient's delusion of world catastrophe often begins with a phase known as the 'Wahnstimmung' which may be accompanied by subtle positive disorders of perception. This is followed by frank psychosis, with hallucinations, formal thought disorders, and, in exceptional cases, can lead to suicidality and/or homicidality. Prevalence rates derived from populations of patients diagnosed with a schizophrenia spectrum disorder vary from 1% to 8%, with a single outlier of 63.5%. Wetzel was the first to conceptualise the delusion of world catastrophe as an attempt of the brain to make sense of a world on which it had lost its grip due to the psychotic process. The link Wetzel established between subtle disorders of perception and possible organic causes is still relevant today. CONCLUSION: Patients who are beginning to have delusions of world catastrophe deserve not only to get an early diagnosis of the neurobiological correlates of their perceptual disorders, but also to receive adequate treatment for their psychosis.

[The incubus phenomenon: A sleep-related condition, not to be confused with psychosis]. / Het incubusfenomeen: een slaapgerelateerde stoornis, niet te verwarren met psychose.

BACKGROUND: The incubus phenomenon is a paroxysmal condition characterised by sleep paralysis coinciding with a sensed presence and the frightening sensation that something or somebody is exerting pressure on the thorax. AIM: To present an overview of the literature on the incubus phenomenon and to provide practical advice regarding diagnosis and treatment. METHOD: To obtain information for our paper we carried out a search in PubMed and the historical literature. RESULTS: The incubus phenomenon is a relatively unknown condition, even though, world-wide, it has a lifetime prevalence rate of 30% in the general population. The prevalence is even higher among students, psychiatric patients and patients with narcolepsy. It is attributed to a dissociation of the rem sleep phase and the subsequent intrusion of endogenously mediated percepts. The condition rarely requires treatment because it is self-limiting, and generally occurs only once in a lifetime. Repeated attacks, however, may warrant additional diagnostic testing with the aid of polysomnography and may require treatment with anxiolytics, antidepressants, anticholinergics or anti-epileptics. CONCLUSION: The incubus phenomenon is an intrusive condition, but, as far as we currently know, it is benign. Nevertheless, it is important that the condition is recognised and not confused with a psychotic disorder or any other type of severe mental illness. When necessary, it should be treated lege artis.

[Brua as an explanatory model for diseases]. / Brua als verklaringsmodel voor ziekten.

A 26-year-old woman from the island of Aruba who had been living in the Netherlands for ten years felt she was misunderstood by the various health professionals she had consulted because of her fear that she was being poisoned and would soon die. Due to her background en her belief in brua, she attributed her symptoms and her illness to 'voodoo', allegedly practiced by members of her husband's family in connection with relationship problems. A culture-sensitive approach to the patient, along with thorough psychiatric and neurological tests, yielded a surprising result. Our findings emphasise how important it is for us as health professionals to acquaint ourselves with explanatory models of the diseases of our patients, and how vital it is for us to be aware of a patient's background, particularly if the patient is of foreign descent.

Results of collagen plug occlusion of anal fistula: a multicentre study of 126 patients.

AIM: The Biodesign(®) anal fistula plug was introduced as a means of obliterating the fistula tract and promoting healing through biocompatibility. The results demonstrated unexplained variations from good to bad. This report analysed the results of a retrospective multicentre study. METHOD: All plug procedures performed in four Stockholm hospitals between June 2006 and June 2010 were identified and studied using a common protocol. The outcome after the first plug-insertion procedure was assessed by chart review performed a minimum of 8 months after plug insertion. Cox proportional-hazards models were used to assess the associations of various factors with fistula healing. RESULTS: One-hundred and twenty-six patients (mean age 47 years) were deemed suitable for the plug procedure. Eighty-five per cent of fistulae were cryptoglandular, 64% of patients were male and a mean of 2.9 previous fistulae procedures had been performed. All patients, except four, had an indwelling seton at the time of the plug procedure, which was performed in accordance with previously established principles of day surgery. After a median of 13 months, 30 (24%) fistulae had closed with no discomfort or secretion reported. The outcome in the four hospitals varied from 13% to 33% with similar numbers of patients in each hospital. A success rate of 12% was observed for patients with anterior fistula compared with 32% for those with posterior tracks [hazard ratio (HR) for successful healing = 2.98; 95% CI: 1.01-8.78) and 41% for those with a lateral internal opening (HR = 3.76; 95% CI: 1.03-13.75). Age, sex and number of previous procedures were not associated with healing. CONCLUSION: Four independent patient groups showed low success rates after the first plug-insertion procedure. Anterior fistulae were much less likely to heal compared with fistulae in other locations.