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Introduction and hypothesis Obstructive defecation syndrome (ODS) is a common urogynaecology presentation. This study compares two questionnaires, the electronic Personal Assessment Questionnaire (e-PAQ), used in urogynaecology clinics, with the ODS-Score (ODS-S), a simple validated scoring system used in colorectal clinics for diagnosing ODS, to identify patients with an ODS-S cut-off ≥9. Methods A total of 221 paired ODS-S and e-PAQ questionnaires were completed; 80 during the second trimester of pregnancy, 73 during the third and 68 post-natally, including women sustaining obstetric anal sphincter injury (OASI). e-PAQ score and ODS-S were compared and Pearson’s correlation coefficient calculated. Areas under the curve assessed the diagnostic ability of e-PAQ scores to identify patients with ODS-S of ≥9. Results The e-PAQ and ODS-S scores showed a positive correlation in the second and third trimesters of pregnancy, post-natally and following OASI. Pearson’s correlation coefficient was calculated (0.77; p p p = 0.001 and 0.79; p 0.90 for all groups. Conclusions Comparison of e-PAQ evacuatory domain scores and ODS-S show a strong correlation, with an e-PAQ score of ≥33 promising for identifying women with an ODS score of ≥9, indicating ODS. This study will enable us to identify women during pregnancy and post-natally with ODS for whom early recognition and intervention may be beneficial.

Women with breast cancer-related genetic pathogenic variants (e.g., BRCA1 , BRCA2 ) or with a strong family history carry lifetime risks of developing breast cancer of up to 80 to 90 percent. A significant proportion of these women proceed to bilateral risk-reducing mastectomy. The authors aimed to document the surgical morbidity of risk-reducing mastectomy and establish whether a diagnosis of breast cancer at the time of surgery impacted outcomes.Clinical details of 445 women identified as having a greater than 25 percent lifetime risk of developing breast cancer who underwent risk-reducing mastectomy and breast reconstruction were interrogated for surgical outcomes such as planned, unplanned, and emergency procedures; complication rates; length of stay; and longevity of breast reconstruction. These outcome measures were recorded in women diagnosed with breast cancer perioperatively (cancer group) and those without malignancy (benign group).Median follow-up was similar in both groups (benign group, 70 months; cancer group, 73 months). Patients were older in the cancer group than in the benign group (43 years versus 39 years; p0.001). Women in the cancer group required more planned procedures to complete reconstruction than those in the benign group (four versus two; p = 0.002). Emergency procedures, unplanned surgical interventions (e.g., capsulectomy), and postreconstruction complication rates were similar between groups. One in five women overall required revision surgery. Patients with autologous reconstructions had a revision rate of 1.24 per 1000 person-years compared with 2.52 per 1000 person-years in the implant reconstruction group.Women contemplating risk-reducing mastectomy can be reassured that this is a safe and effective procedure but will likely take multiple interventions. This knowledge should be integral to obtaining informed consent.Risk, II.

Introduction: Nigeria has a large estimated burden of AIDS-related mycoses. We aimed to determine the proportion of pa- tients with AIDS-related opportunistic fungal infections (OFIs) at an urban antiretroviral treatment (ART) centre in Nigeria. Methods: A retrospective analysis of a cohort of ART-naïve, HIV-infected patients, assessed for ART eligibility and ART- experience at the PEPFAR outpatient clinic at Lagos University Teaching Hospital over a 12-year period (April 2004-Feb- ruary 2016) was conducted. Results: During this period, 7,034 patients visited the clinic: 4,797 (68.2%) were female; 6161 patients had a recorded base- line CD4 count, and the median CD4 count was 184 cells/µl (IQR, 84-328). A baseline HIV-1 viral load (VL) was recorded for 5,908 patients; the median VL was 51,194 RNA copies/ml (IQR, 2,316-283,508) and 6,179/7046(88%) had initiated ART. Some 2,456 (34.9%) had a documented opportunistic infections, of whom 1,306 (18.6%) had an opportunistic fungal infection. The total number of OFI episodes was 1,632: oral candidiasis (n=1,473, 90.3%), oesophageal candidiasis (n=118; 8%), superficial mycoses (n=23; 1.6%), Pneumocystis pneumonia (PJP) (n=13; 0.8%), and cryptococcal meningitis(CM) (n=5; 0.4%). 113 (1.6%) were known to have died in the cohort. Conclusion: Approximately 1 in 5 HIV-infected patients in this retrospective cohort, most of whom had initiated ART, were clinically diagnosed with an OFI. Improved access to simple accurate diagnostic tests for CM and PJP should be pri- oritised for this setting. Keywords: Opportunistic fungal infections; ART Adherence; Advanced HIV disease.

While it is known that histologically involved margins lead to a higher local recurrence rate, re-excision of anterior margins is less common than that of radial margins. However, there are minimal long-term data on the oncological safety of non-surgical management of anterior margins. A retrospective study was performed of all patients who underwent breast conserving surgery for breast cancer between 2000 and 2008 at two tertiary referral centres. A close margin was defined as disease within two mm of the resection margin (including disease at the margin). 6922 patients underwent surgery for invasive or in situ breast cancer of whom 277 patients had a close anterior margin alone after breast conserving surgery. Two hundred and twenty patients had non-surgical management of their margins, while 57 had re-excision surgery. Overall, there were 4/57 local recurrences in the surgical management group and 12/220 in the non-surgical management group. The local recurrence-free survival rate at 5 years was 98.2% (1 recurrence, 95% CI 87.8–99.7) in the surgical management group and 97.2% (6 recurrences, 95% CI 93.8–98.7) in the non-surgical management group. At 10 years, the rates were 92.2% (4 recurrences, 95% CI 80.3–97.0) in the surgical management group and 93.9% (12 recurrences, 95% CI 89.4–96.5) in the non-surgical management group. There was no significant difference found in the local recurrence rate between management groups (HR 1.24, 95% CI 0.40, 3.85; p = 0.71). Local recurrence rates are acceptable and similar in both the surgically and non-surgically managed groups. Non-surgical management of close anterior margins appears oncologically safe when combined with appropriate adjuvant therapy.

Health interventions should be tested before being introduced into clinical practice, to find out whether they work and whether they are harmful. However, research studies will only provide reliable answers to these questions if they are appropriately designed and analysed. But these are not trivial tasks. We review some methodological challenges that arise when evaluating fertility interventions and explain the implications for a non-statistical audience. These include flexibility in outcomes and analyses; use of surrogate outcomes instead of live birth; use of inappropriate denominators; evaluating cumulative outcomes and time to live birth; allowing each patient or couple to contribute to a research study more than once. We highlight recurring errors and present solutions. We conclude by highlighting the importance of collaboration between clinical and methodological experts, as well as people with experience of subfertility, for realising high-quality research. Lay summary We do research to find out whether fertility treatments are beneficial and to make sure they don’t cause harm. However, research will only provide reliable answers if it is done properly. It is not unusual for researchers to make mistakes when they are designing research studies and analysing the data that we get from them. In this review, we describe some of the mistakes people make when they do research about fertility treatments and explain how to avoid them. These include challenges which arise due to the large number of things that can be measured and reported when looking to see if fertility treatments work; failure to check whether the treatment increases the number of live births; failing to include all study participants in calculations;challenges in studies where participants may have more than one treatment attempt. We conclude by highlighting the importance of collaboration between clinical and methodological experts, as well as people with experience of fertility problems.

Ivacaftor was the first therapy licensed to address the underlying defect in cystic fibrosis (CF). The improvements in lung function, nutritional status and pulmonary exacerbations in patients carrying aWe conducted a 5-year single-centre retrospective study of people with CF carrying the35 people were included. After commencing ivacaftor, FEVThe addition of ivacaftor provides acute benefits for people with the

Objective To assess the effectiveness of patient decision aids to facilitate shared decision making in obstetrics and gynecology. Data sources We searched ClinicalTrials.gov, MEDLINE, CENTRAL, Cochrane Gynaecology and Fertility specialized register, CINAHL, and EMBASE from 1946 to July 2019. Methods of study selection We selected randomized controlled trials comparing patient decision aids with usual clinical practice or a control intervention. Tabulation, integration, and results Thirty-five randomized controlled trials, which reported data from 9,790 women, were included. Patient decision aids were evaluated within a wide range of clinical scenarios relevant to obstetrics and gynecology, including contraception, vaginal birth after cesarean delivery, and pelvic organ prolapse. Study characteristics and quality were recorded for each study. The meta-analysis was based on random-effects methods for pooled data. A standardized mean difference of 0.2 is considered small, 0.5 moderate, and 0.8 large. When compared with usual clinical practice, the use of patient decision aids reduced decisional conflict (standardized mean difference -0.23; 95% CI -0.36, to -0.11; 19 trials; 4,624 women) and improved patient knowledge (standardized mean difference 0.58; 95% CI 0.44 to 0.71; 17 trials; 4,375 women). There was no difference in patient anxiety (standardized mean difference -0.04; 95% CI -0.14 to 0.06; 12 trials; 2,714 women) or satisfaction (standardized mean difference 0.17; 95% CI 0.09 to 0.24; 6 trials; 2,718 women). Conclusion Patient decision aids are effective in facilitating shared decision making and can be helpful in clinical practice to support patient centered care informed by the best evidence. Systematic review registration PROSPERO International Register of Systematic Reviews, www.crd.york.ac.uk/prospero/89953, CRD42018089953.

BackgroundScreening with cardiac non-invasive stress studies (NISS) prior to listing for kidney transplantation can help in identifying treatable coronary disease and is considered an integral part of pre-kidney transplant evaluation. However, few studies assessed their effectiveness in all patients evaluated for transplantation in clinical practice. To evaluate the role of NISS in pre-kidney transplant evaluation we analyzed their impact prior to waitlisting in 1053 adult CKD-5 patients consecutively evaluated in Greater Manchester, UK during a 6-year period.Methods918 waitlisted patients were grouped based on presence or absence of Diabetes or Cardio-Vascular Disease (CVD): Group-1 (255 DM-/CVD-/NISS-), Group-2 (368 DM-/CVD-/NISS+) and Group-3 (295 with DM or CVD).ResultsGroup-2 patients had longer 'time-to-listing' (5.5months in Group-1 vs 6.9months in 'Normal-NISS' vs 9.9months in 'Abnormal-NISS', pConclusionsPre-kidney transplant evaluation with NISS influenced clinical management in 19 of 1053 (2%) patients. Screening with NISS added limited benefit but contributes to significant delays in listing and adding resource implications. Further studies are needed to assess clinical and cost effectiveness of NISS in pretransplant evaluation to optimize outcomes and resources.