Malnutrition in children under 5 years is a major public health problem in developing countries. Malnutrition complex comprises of under-nutrition including multipleconditions like acute, chronic malnutrition, micronutrient deficiencies and nutrition related to obesity. Therefore, it is of interest to report data on the individualizednutritional counselling on nutritional status among mild to moderately malnourished children aged 2 - 5 years at one, three and six month follow up. Their dietary habitswill help to determine the aetiology of mild/moderate malnutrition.150 Children attending outpatient department of the Department of Paediatrics of D Y Patil MedicalCollege and admitted with mild/moderate malnutrition were included in the study after taking informed consent from their parents. The children were randomly allocatedinto 4 groups (group 1 - 4). The groups consisted of children where dedicated nutritional counselling was provided at 1 month, 1 and 3 month follow up and where-in nodedicated counselling was provided. A diet chart was provided with counselling. Group 4 followed up with routine care without any dietary intervention. Detailed dietary,socio economic history, clinical examination with anthropometry was done followed-up at 1, 3, 6 months from date of inclusion. Majority (57.3%) belonged to lowersocio-economic class according to Kuppuswamy scale. The mean birth weight was 2.4 kg, age 34.5 months and age of weaning 7.6 months. Data shows that 70% children hadmild malnutrition and 30% moderate malnutrition. At 6 month follow up amongst 105 children with mild malnutrition, 82 still had mild malnutrition, 4 normal, 19 hadmoderate malnutrition. Under-five childhood malnutrition is highly prevalent in poor socioeconomic strata of the society. Nutritional counselling provided by trainedhealthcare providers in existing settings are effective in improving nutritional status, daily calorie/protein intake, prevention of malnutrition. Prevention/treatmentof co-existing illness bears equal importance. Malnutrition in fewer than 5 children is a major public health problem in developing countries. Malnutrition has economic, health, and social consequences for futuregenerations. Malnutrition complex comprises of multiple conditions like chronic malnutrition, micronutrient deficiencies and nutrition related to obesity .ChronicDepartment of paediatrics at Dr D.Y. Patil Medical College, Hospital and Research centre, Pimpri, Pune.Period of 2 years, Ethics Committee clearance was obtained pre study.Randomized control and observational study.150 children with Mild or moderate malnutrition between 2 to 5 years admitted or attending, outpatient department in our hospital were included.[1] Severe acute malnutrition with or without complications.[2] Children with chromosomal and congenital anomalies.[3] Children lost to follow up.[4] Children with secondary cause of malnutrition.[5] Patient not consenting for the study.Children attending OPD or admitted with mild/moderate malnutrition in our hospital have been included in study after informed consent. The children were randomlyallocated as follows:Group I: Dedicated nutritional counselling was done on the day of inclusion.Group II: Dedicated nutritional counselling was done on the day of inclusion and at one month follow-up visit.Group III: Dedicated nutritional counselling was done on day of inclusion, one month and three month follow up visit.Group IV: No dedicated specific nutritional counselling done and treated as per routine care of our hospital. A diet chart was made for Group 1, 2 and 3. Group 4patients were followed up with routine care without any dietary intervention. At the time of enrolment- Detailed history with emphasis on dietary, socioeconomic, clinicalexamination, anthropometry was done. All children included in study were followed up after 1, 3 and 6 months from date of inclusion (+/-7days). At the time of followup- Clinical examination, dietary history, nutritional assessment, recorded. Records of any illness, admissions, OPD visit from the last follow up were taken.Anthropometry:[1] Weight- Weight of the child is useful for calculating the right dosage of drugs.[2] Height- Measured using Harpenden Stadiometer. The child was made to stand against a wall with bare feet touching, the heel, calf, buttock, upper back andocciput touching the wall and child looking straight.[3] Mid arm circumference- Measured with a measuring tape mid-way between the acromion process and olecranon process with arm hanging by the side of the body.More than 13.5 cm considered normal, less than 12.5 indicates malnutrition.The study includes 150 children either mildly or moderately malnourished at inclusion and was assessed at 6 months’ follow up for anthropometric indices, dailycalorie, and protein intake (Tables 1 to 4 - see PDF). An almost equal proportion of male and female patients (51.3% and 48.7% respectively) seen.57.3% childrenbelonged to the lower socio-economic class, 42.7% came from upper-lower socio-economic class according to the modified Kuppuswamy scale. Mean birth weight of the childrenin study was 2.4 kg ± 0.1 kg (range 2.4 to 2.7 kg), mean age was 34.5 months ± 7 months (range 24 to 51 months). Mean age at which weaning was started was7.6 months ± 1 month (range 5 to 9 months). Majority of the children were fed a vegetarian diet  as against only 39/150 (26%) fed non-vegetarian diet.A significant association between poor socioeconomic statuses , birth weight < 2.5 kg, predominantly vegetarian diet, andhigher prevalence of moderate malnutrition was found. The odds of a child from lower SE class being moderately malnourished were higher  ascompared to one from upper lower SE class and higher odds of being fed a vegetarian diet leading to a protein deficit . Similarly, a child hadhigher odds of being born as a low-birth-weight infant (birth weight < 2.5kg) if the child belonged to the lower SE class . Sample divided into4 groups based on timing of dedicated nutritional counselling. Amongst 150 children, groups I, II and III had 40 (26.7%) each, while group IV had 30 (20%). There are analmost equal proportion of girls/ boys in all 4 groups. Cross-tabulation using chi-squared test revealed the difference in the proportion in all the groups wasinsignificant (p=0.587).Amongst 150 children, 105 (70%) had mild and 45 (30%) had moderate malnutrition at inclusion. At 1 month 68.7% had mild malnutrition and 31.3%had moderate malnutrition. 3 months follow up- 99/150 (66%) children had mild malnutrition 48/150, (32%) had moderate malnutrition, 3 children (2%) had severemalnutrition. At 6 months, out of 105 children with mild malnutrition, 82 had mild malnutrition, 19 moderate malnutrition of which 5, 3, 2, 9 from the 1st to 4th grouprespectively. 4 children were normal of which 3 from 1st group, 1 from 2nd group. Among 45 children with moderate malnutrition, 2 became mildly malnourished, 39 remainedmoderately malnourished, 4 became severely malnourished of which 2 were from 2nd group, 1 from the 3rd, 4th group each. Using one-way ANOVA, mean daily calorie intake ofchildren was compared between Visit 1 (at inclusion) and subsequent visits at 1st, 3rd and 6th month follow up, namely Visit 2, Visit 3 and Visit 4 respectively. In GroupI, the mean daily calorie intake increased per visit, however was not statistically significant (p=0.082). Group II - A consistent increase in daily calorie intake pervisit. However, it is statistically insignificant. (p=0.066). Group III Increase was persistently high, and highly statistically significant (p=0.003). Group IV Meandaily calorie intake was low even at inclusion, however increased per visit and was statistically significant (p=0.0001). However, the mean daily calorie intake achievedat the last follow up by this group was much lower than the mean daily calorie intake of all other groups at baseline itself. Using one-way ANOVA, mean values of dailyprotein intake compared between time of inclusion (Visit 1) and per follow up, wasn't significantly different amongst 4 groups. At subsequent visits it increased per grouphowever statistically insignificant increase in all the 4 groups (p>0.005).Mean weight comparison between inclusion wasn't significantly different compared tosubsequent follow ups irrespective of allocation to any study group (p>0.05). However, the mean weight in Group IV remained lesser in comparison to three groups. Therewas an increase in the mean height of all the children per follow up visit but statistically insignificant (p>0.05).The mid-arm circumference of all the children inthe study was comparable to begin with at the time of inclusion. At subsequent follow ups no change was seen in children belonging to groups I and IV, slight increase ingroups II and III was noticed, but statistically insignificant (p>0.05).Malnutrition is defined as lack of proper nutrition caused by unavailability of food, inadequate staple dietary intake required for appropriate growth/nourishment ofchildren. Malnutrition is a major public health problem affecting more than 30% under 5 children-developing countries, 50.6 million are undernourished. Children belongingto the severely malnourished category with a illness have led to a case-fatality rate exceeding 20% ,13.The Under-five childhood malnutrition is highly prevalent in poor socioeconomic strata of the society. Nutritional counselling provided by trained healthcare providers inexisting settings is effective in improving nutritional status, daily calorie/protein intake, prevention of malnutrition. Furthermore, to enhance the nutritional conditionof families, there is a need to provide coordinated nutrition education to mothers.


The healthcare sector currently accounts for 4.4% of global greenhouse gas emissions. The share of the emissions in the health care system caused by the transportation sector is 7%. The study analyses the effect of video consultation on the COThe study participants were patients who obtained a video consultation in the period from June to December 2020 and voluntarily completed a questionnaire after the consultation. The type of transport, travel time and waiting time as well as patient satisfaction were recorded by questionnaire.The study comprised 51 consultations. About 70% of respondents would have travelled to the clinic by car. The reduction in greenhouse gas emissions of video consultations compared to a face-to-face presentation was 97% in our model investigation.The video consultation can be a very important part of the reduction of greenhouse gas emissions in the health care system. It also saves time for the doctor and patient and can form an essential part of individual patient care. In addition to the direct consequences of air pollution, such as respiratory diseases, the effects on health also include the indirect consequences of climate change, such as the spread of infectious diseases due to globalization, food shortages and consequently malnutrition and migration –3. For t2), methane (CH4), nitrous oxide (N2O2), chlorofluorocarbon (CFC) and water vapour  is a measure of the global warming potential of a substance or the climate-damaging effect of an activity  with that of a period with an exclusive face-to-face consultation in the outpatient clinic of the orthopaedics and traumatology surgery at a German university hospital.Some colleagues in different sectors of medicine, for example dermatology and urology, have shown that video consultations may reduce CO pending –12. The 2.2.1.n = 2), the questionnaire as well as the supervision of the examination was carried out by the legally authorised person. The study comprised 51 consultations. The gender distribution was balanced in the patient collective . The median age of the respondents was 51 years (2.7–87.9 years). In all cases of patients under 18 years of age, the consultation was conducted in the presence of the legal guardian, which also respond to the questionnaires. The video consultation are divided into spinal surgery, joint surgery, paediatric orthopaedics and accident surgery.The study participants were patients who obtained a video consultation in the outpatient clinic of the department orthopaedics and traumatology surgery at a German university hospital in the period from June to December 2020 (Beginning of the Covid-19-pandemic in Germany) and voluntarily completed a questionnaire after the consultation. In the case of underage or mentally impaired patients , means of transport in case of face-to-face consultation , reason for the consultation  and patient satisfaction. The response rate to the questionnaires was 60.71%. Only the data of those who had completed the questionnaire were analysed.2.3.2 emissions was based on the data of the German Federal Environment Agency .In order to adequately calculate the reduction of greenhouse gas emission, the emissions that occur during the performance of a video consultation were also considered . In part2e per hour of video streaming compared to the 3G network  with 90 g CO2e . Most patients (74.5%) would have chosen to travel to the outpatient clinic by car. The search for a parking space would have taken about 30 min for most patients (64.7%). About 43.1% of the respondents were dependent on an accompanying person for a visit to our outpatient clinic. The most frequent reason (35.3%) for a consultation at the outpatient clinic was a follow-up. The majority of respondents (76%) conducted the video consultation at home and 9.8% at work. Many patients (43.1%) used their computer, 23.5% their tablet and 29.4% their smartphone for the consultation. On average, a video consultation lasted about 30 min. Two thirds of the respondents said that they would spend more than 2 h at every visit in an outpatient clinic for a face-to-face-appointment. A high percentage (84.3%) of the respondents were very satisfied or satisfied with the video consultation. Half of the respondents (n = 22) who completed a video consultation were dependent on an escort.Among the 51 respondents 31% reported a travel distance less than 20 km to the clinic and 35% reported a travel distance of more than 50 km . The tra2 reduction, with a significant difference between the groups (p < 0.001). With reference to the data of the Federal Environment Agency, it was shown the implementation of the video consultation leads to a reduction in greenhouse gas emissions over 0.5 tons CO2e for the respondents compared to those patients traveling by car . This would have resulted in around 0.5 tons COltations .2e would have be produced per return journey to the university's outpatient clinic. The high emission of patients who reported they would have use public transport to get to the clinic would have caused the emission of 15,299 g CO2e. Based on the current workload of the clinic's outpatient department with about 400 consultations per week, and assuming that about 20% of the consultations can also be performed online, it would significantly reduce greenhouse gas emissions.When 78.4% of the respondents would have travelled by car (incl. taxi), a total of 586,872 g CO4.2 reduction in the implementation of video consultation.As one of the first estimates of the daily routine of the outpatient department for orthopaedics and trauma university hospital we have shown that, the implementation of video consultations can lead to a significant reduction in greenhouse gas emission. By running video consultations only, the German university clinic could reduce greenhouse gas emissions by 97% compared to face-to-face consultations. This result shows that there is a high potential for CO2e. The emissions for the health care sector should have contributed about 42.12 GtCO2e  and the transport sector in the health care sector accounts for 2.95 GtCO2e   . Thus, r sector) , 17. In  sector) , 17.Thanks to the video consultation, many patients can avoid potentially long journeys to a specialised university hospital for a second opinion or follow-up checks. A basic physical examination during a video consultation is possible or can be carried out by the general practitioner on site. Difficulties arise in particular with language barriers and pending imaging , where treatment may be delayed , 21. On In contrast to some other regions in Europe or Germany, the travel to a hospital in North Rhine-Westphalia (NRW) is within 8–12 min. for an ambulance and therefore comparatively short –29. In a2e per year  UK, Wotton et al. divided the travel section into three groups: patient travel, visitor travel, staff travel and business travel. The total travel emissions were estimated to be about 49,000 tCOper year . This stper year . Approxiper year , 33, 35.In addition to the reduction of greenhouse gas emissions from video consultation, the reduction of electricity consumption, waste production, and water pollution must also be considered to improve environmental protection –11. AccoIn various fields of medicine, such as urology and dermatology, studies have already been conducted on the influence of video consultation on emissions. Examples of this are the works of Croghan et al. and Fathy et al. , 35. Crovia video consultation (The present study refers exclusively to an outpatient clinic for orthopaedics and traumatology surgery. The feasibility must be adapted for different field of medicine , 22, 36.ultation .2 emissions. This was not yet analysed in the study, as the doctors were in the hospital during the video consultation.The video consultation offers the possibility of changing the daily routine at the clinic through the possibility of a work from home. In this way, the profession of doctor can be integrated into the modern, digital workplace. According to the research report of the German Federal Ministry of Labour and Social Affairs, mobile working leads to a significantly higher level of employee satisfaction . In addi2 emissions have such a great impact on public health, the reduction of emissions in terms of transportation, energy consumption, waste production and water pollution is of fundamental importance (Since the protection of public health is the most important task of the health care system and COportance , 10, 38.5.One point of criticism of the study could be the imprecise data on the data transfer rate of the patients, but a significant expansion of the telecommunication infrastructure can be expected in the metropolitan areas. In rural regions, access to broadband connections is often not available . It shou6.In our study, we have shown that conducting a video consultation leads to a 97% reduction in greenhouse gas emissions compared to a face-to-face presentation in our model investigation of an outpatient clinic of orthopaedics and traumatology surgery. Video consultations are an important step towards more environmental protection in medicine by significantly reducing greenhouse gas emissions. The video consultation can be an important part of the reduction of greenhouse gas emissions in the health care system, it also saves time for the doctor and patient and is an important part of individual patient care.So far, there are no guidelines and standards for the digital examination of orthopaedic and trauma surgery patients in Germany; these will have to be worked out in the near future.


Declining response proportions in surveys have been observed internationally. Improving response proportions is important for the generalizability of the outcome. The aim of this study was to examine the potential of animation videos to improve response proportions and sample composition in health surveys.A randomized trial was embedded in the Danish National Health Survey 2021  where the use of animation videos in the digital invitation letter was tested as a mean to increase response proportion. The effect of both demographic-targeted videos and a general video was tested. The sample was stratified into four subsamples; (1) individuals with non-western background and a non-Danish citizenship , (2) men aged 16–24 years , (3) women aged 75 years or older  and (4) the remaining individuals . The fourth subsample was randomized into two equal sized groups; a group receiving the general video and a control group receiving no video. Each of the first three subsamples was subsequently randomized into three subgroups with 25% receiving the target group video, 25% receiving the general video and 50% receiving no video. A total of four reminders  were sent to the eligible population.The use of animation videos resulted in similar or slightly lower overall response proportion compared to the control group. The different animation videos were found to have heterogeneous effects on response proportions. A positive effect was found among men aged 16–24 years before the delivery of the postal reminder for the targeted animation video compared to no video . Overall, the targeted animation videos tended to produce higher response proportions than the general animation video.The heterogeneous effects of the videos suggest that there is some potential for the use of animation videos to improve response proportions and sample composition. The content, target group and timing of evaluation seem to be important for the animation videos to be successful. This warrants further research to better identify in which contexts, in which subgroups and under which circumstances, animation videos are useful to increase response proportions.ClinicalTrials.gov ID: NCT05520242, registered 08/26/2022.The online version contains supplementary material available at 10.1186/s12874-023-02005-4. Declining response proportions in health surveys have been observed internationally over the last decades . The genThe medium of video has many documented advantages for public health promotion compared to paper materials or spoken instructions. Video has been shown to be more effective in improving long-term knowledge retention , short-tThe aim of this study was to examine the potential of animation videos to improve response proportions and sample composition in an embedded randomized controlled trial in the Danish National Health Survey 2021 (DNHS-2021). The overall research question was whether digital invitation letters including an animation video could produce higher response proportions compared to digital letters without an animation video. The proposition was that the inclusion of animation videos in the invitation letters should increase the willingness of sample members to participate by means of increased motivation and reduced complexity, and that this would be reflected in higher response proportions. In addition, the study also examines the effect of different versions of the animation videos  on response proportions across sample subgroups.The study was conducted as a randomized trial embedded in DNHS-2021, where the population was based on six mutually exclusive random subsamples among the adult (aged 16 years or older) Danish population: one in each of the five Danish administrative regions, and one national sample. The samples were drawn from the adult population in Denmark  using the Danish Civil Registration System which contains basic information on all people who are currently residing in Denmark , 18.The data collection was conducted from February 2021 to May 2021. All invitations were distributed in the first week of February. The majority (91.3%) of the DNHS sample was invited via a secure electronical mail service  to complete a web questionnaire. Individuals who were not registered to use Digital Post  were sent an initial invitation letter via the regular postal service, inviting them to complete a web questionnaire or the enclosed paper questionnaire (mixed-mode contact). Thus, the DNHS sample in 2021 was comprised of two subsets based on the mode of initial contact: (a) individuals invited initially by Digital Post, and (b) individuals invited via the regular postal service only. The total study sample in the present study consisted of 201,200 individuals from original national sample, Capital Region, Region Zealand and North Denmark Region whereof 15,087 (7.5%) had unsubscribed digital post. Hence, the eligible study population receiving a digital invitation was 186,133 individuals. The proportion who was not registered to use Digital Post varied from 0.8% for the age group 16–24 years  to 35.8% for the age group 75 years or older .A total of four reminders, excluding the initial invitation letter, were sent to the eligible population. If the web questionnaire was not completed after one week, a digital reminder was sent to non-response individuals. After yet another two weeks of non-response, these individuals were approached by a reminder letter sent by regular postal service. Enclosed in this letter was a paper questionnaire with identical content to the web questionnaire and a pre-paid return envelope. The remaining two reminders were sent by regular postal service, the last one with an enclosed paper questionnaire and a pre-paid return envelope. An overview of the reminder procedure in the digital path is given in supplementary material. The animation videos were part of the first digital invitation letter as well as the digital reminder for those groups randomized to receive a video  in collaboration with the researchers conducting DNHS-2021, i.e., researchers from the National Institute of Public Health and the participating regions. First, a general non-targeted animation video was developed. The scientific base for the development was international literature describing design features known to affect participation – e.g., appeal to participate, use of incentives and perception of relevance [The animation videos were developed by the company elevance –7. Furthelevance . Hence, The Danish Civil Registration System was used to retrieve information on sex, age, ethnic background, and marital status. This information was used to categorize sample members in four separate subsamples; (1) sample members with non-western background and a non-Danish citizenship, (2) men aged 16–24 years, (3) women aged 75 years or older and (4) the remaining sample members. The first 3 subsamples were known to have relatively low overall response proportions in previous waves of DNHS . Ethnic Stratification into subsamples and their size as well as randomization of each subsample are illustrated in Fig. The stratification and randomization were conducted by the National Institute of Public Health in collaboration with project members from the participating regions. Due to the timing of the different processes in conduction of the survey, the randomization was conducted before the initial split into (a) members registered to receive digital post and (b) members not registered to receive digital post. Hence, all eligible individuals were included in the randomization. As mentioned previously, it was only feasible to conduct the study among sample members who were registered to receive digital post. In the present study, 7.5% of the study sample were excluded as they were not registered to receive digital post. This exclusion is mainly an issue for subsample three (women aged 75 years or older), as the proportion who have unsubscribed digital post is high in this group 41.7%). The Fig. .7%. The By the end of data collection, data on both respondents and non-respondents, intervention and control groups etc. was stored inhouse and prepared for analysis. The response proportion was calculated as the number of respondents divided by the number of invited individuals before the delivery of the first postal reminder  to prevent interference from postal respondents who have or may not have seen the digital invitation. Further, the final response proportion was calculated for all respondents by the end of the survey. Descriptive statistics and univariate logistic regression modelling of the 186,133 study participants were conducted to answer the research questions. In all analyses, the dependent variable indicates whether the sample member has  completed the questionnaire. In the first step, the independent variable was a dichotomous indicator of intervention (animation vs. no animation). This analysis will give an initial indication of whether, on average, the letters with animation videos have any overall effect on response propensity  compared to the generic invitation letters without an animation video (38.5%)  Table . HoweverThe three targeted animation videos to specific subgroups tended to produce higher response proportions compared to the non-targeted animation video Table . HoweverLooking at the demographic variables and urbanization, generally no overall effect of the intervention with animation videos was seen on response proportion by the end of the survey in most subgroups Table  The onlyIn this randomized trial, we examined whether the use of animation videos can increase participation in health surveys. At day 22 in the survey period, a slightly positive effect was observed for the animation video targeted men aged 16–24 years. When comparing the animation videos, the targeted animation videos tended to produce higher response proportions compared to the non-targeted animation video. However, only a significant difference was observed for men aged 16–24 at day 22. However, in general, a similar or slightly lower response proportion was observed in the intervention group who received an invitation letter including an animation video compared to the control group who received the generic invitation letter without an animation video. This was seen both at day 22 and by the end of the survey. When looking at the effect of the animation videos in different demographic subgroups, a slightly lower response proportion was observed in the intervention group among divorced and among sample members living in cities compared to the control group. Overall, both negative and positive effects of targeted animation videos was observed, and future surveys researcher should carefully select the target group and content in the video to gain a positive effect on response proportion and sample composition.Previous studies have documented that the use of videos has advantages for public health promotion compared to paper materials or spoken instructions –10. FurtThe major strength of the present study was the incorporation of a randomized trial in a large nationally population sample. This made is it possible to study the effect of animation videos in a real-life setting based on a highly scientific method. The study thereby adds to the scientific knowledge about the use of animation videos as a mean to reduce nonresponse in health surveys. Further, the large sample size made it possible to study the effect of both targeted and non-targeted animation videos. Yet, in cannot be rejected that lack of statistical power is the reason for the non-significant findings in subgroups. The study also had some methodological limitations. First, 7.5% of the study sample were excluded as they were not registered to receive digital post, with the majority being in the age group 75 years or older. The criteria for unsubscribing Digital Post include low technical skills and mental or physical disability . Hence, In general, invitation letters with animation videos intended to increase response-motivation resulted in a similar or lower response proportion overall compared to a generic invitation letter without a video, hence no overall improvement in sample composition was reached. However, a positive effect on the response proportion was seen for the animation video targeted men aged 16–24 years compared to the generic invitation letter. Further, the three targeted animation videos tended to produce higher response proportions compared to the general non-targeted animation video. The heterogeneous findings suggest that there is potential for targeted animation videos to improve both response proportions and sample composition. The content of the video, the target group and timing of evaluation seem to be important for the use of targeted animation videos to be successful. This warrants further research to better identify in which contexts, in which subgroups and under which circumstances, animation videos are useful to increase response proportions.Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2Supplementary Material 3Supplementary Material 4Supplementary Material 5Supplementary Material 6Supplementary Material 7


Treatment options for alcohol use disorders (AUDs) have minimally advanced since 2004, while the annual deaths and economic toll have increased alarmingly. Phosphodiesterase type 4 (PDE4) is associated with alcohol and nicotine dependence. PDE4 inhibitors were identified as a potential AUD treatment using a bioinformatics approach. We prioritized a newer PDE4 inhibitor, apremilast, as ideal for repurposing  and tested it using multiple animal strains and models, as well as in a human phase IIa study. We found that apremilast reduced binge-like alcohol intake and behavioral measures of alcohol motivation in mouse models of genetic risk for drinking to intoxication. Apremilast also reduced excessive alcohol drinking in models of stress-facilitated drinking and alcohol dependence. Using site-directed drug infusions and electrophysiology, we uncovered that apremilast may act to lessen drinking in mice by increasing neural activity in the nucleus accumbens, a key brain region in the regulation of alcohol intake. Importantly, apremilast (90 mg/d) reduced excessive drinking in non–treatment-seeking individuals with AUD in a double-blind, placebo-controlled study. These results demonstrate that apremilast suppresses excessive alcohol drinking across the spectrum of AUD severity. Alcohol use disorder (AUD) is a complex psychiatric disease with far reaching impacts on society, including more than 95,000 associated deaths annually in the United States and a net economic cost of $249 billion annually  . DespiteA central goal of the present study was to determine whether apremilast reduced ethanol drinking across the progression of AUD by testing its efficacy in relevant preclinical drinking paradigms, genetic animal models, and human participants. Specifically, the effects of apremilast were evaluated in 5 clinically relevant animal models of excessive alcohol drinking (listed in order of increasing chronicity): (a) binge-like drinking , (b) motWe further studied the role of PDE4 in the nucleus accumbens (NAc) in drinking behavior and physiology using genetic mouse models. An extensive body of literature supports the NAc as a critical regulator of alcohol drinking and its candidacy as a neural target in the treatment of AUD –21. Therhttps://doi.org/10.1172/JCI159103DS1).To test whether PDE4 inhibition reduces binge-like alcohol drinking, we administered apremilast to selectively bred “High Drinking in the Dark” (replicate HDID-1 and HDID-2) mice of both sexes prior to measuring limited access drinking using the widely adopted “Drinking in the Dark” (DID) assay . HDID miNext, we found that 2 clinically relevant doses of apremilast, 20 and 40 mg/kg (i.p.) reduced binge drinking and BALs (below 80 mg% — the level of intoxication), in female and male HDID-1 mice . The abiAUDs are characterized by a chronic history of harmful drinking. To determine the efficacy of apremilast in reducing chronic alcohol intake, we tested whether 40 mg/kg (i.p.) of apremilast would reduce binge drinking in HDID-1 mice (of both sexes) over a 4-week period, as compared to baseline drinking levels. Here we saw that 40 mg/kg of apremilast reduced chronic binge-like ethanol intake of female and male HDID-1 mice , with noTo determine whether PDE4 inhibition reduces the motivation for alcohol drinking, we next tested the effects of apremilast in inbred HDID-1 (iHDID-1) mice of both sexes during 2 operant ethanol self-administration tasks: (a) operant responding under a progressive ratio (PR) schedule of reinforcement and (b) quinine-adulterated alcohol responding , 29, 30.To ascertain whether apremilast would reduce compulsive-like responding to alcohol , mice were tested for quinine-adulterated alcohol responding  and cellular excitability. Inhibitory synaptic drive overall was suppressed by apremilast treatment  per day over an 11-day period of ad libitum drinking than those treated with placebo. To further clarify whether any such effect was a result of reduction in heavy drinking specifically, numbers of heavy drinking days  were similarly examined over this same period. Earlier PDE4 inhibitors like rolipram and ibudilast are associated with side effects, particularly nausea and vomiting, that may significantly reduce treatment retention . ApremilStudy admission criteria specified non–treatment-seeking male and female paid volunteers 18 to 65 years of age with AUD of moderately severe or greater, as defined by the Diagnostic and Statistical Manual for Mental Disorders – Fifth Edition (DSM-5) criteria . The Conn = 26) and placebo (n = 25) groups did not differ in baseline demographic, clinical, or physiological variables, as summarized in t test P values were all >0.40).The rate of study completion (84%) was equivalent across groups and is detailed in n = 43) were included in hypothesis testing that employed latent growth modeling (LGM) (P < 0.05) reduced the number of drinks per day relative to placebo, as well as the probability of a heavy drinking day . Calculations from the LGM show an average change from day 1 to day 11 of 2.74 drinks per day for apremilast and 0.48 for placebo and yields a Cohen’s d value of 0.77, which is consistent with a “large” effect of apremilast on decreasing drinking . The analogously calculated effect size of treatment was 0.39 for apremilast and 0.05 for placebo, with a Cohen’s d of 0.26, or “small-medium,” suggesting that some but not all of the decrease in drinking involved attenuation of heavy drinking. There was no evidence of rebound drinking differences in the 2 groups during the 2-week posttreatment follow-up period. No baseline demographic, clinical, or physiological variable contributed significantly to drinking outcome. A trend was noted (P < 0.09) that individuals in the apremilast group with higher baseline craving scores reduced their drinking at a faster rate than placebo (results not shown), and subjective reports also referenced decreased craving (All participants completing the protocol n =  were incng (LGM) . Apremildrinking . Supplem craving . No seri craving .We leveraged gene expression profiles of drinking to intoxication to identify compounds that might be repurposed to reduce excessive alcohol drinking characteristic of AUD. The FDA-approved PDE4 inhibitor apremilast was identified as the most promising target for repurposing, given a lower likelihood of severe PDE4 adverse effects associated with treatment discontinuation than earlier PDE4 inhibitors. We propose it is imperative to test potential therapeutics across multiple drinking paradigms, species, and strains to reduce the number of clinical study failures. The present work determined whether apremilast would reduce harmful alcohol drinking in male and female mice from 4 different strains with high risk for excessive drinking . Strikingly, we found that apremilast reduced excessive drinking across a spectrum of clinically relevant drinking models for binge-like, motivational, compulsive-like, and stress- and non–stress-induced facilitation of dependence-like drinking. Although follow-up testing suggests that apremilast acts through central means , it is possible that either or both central and peripheral actions of apremilast are necessary for reducing harmful drinking. Therefore, future work should address the importance of such central and peripheral mechanisms. In a human POC study, we employed a double-blind, placebo-controlled study in non–treatment-seeking individuals with AUD and found that oral apremilast was robustly effective at reducing the number of daily drinks consumed. PDE4b, a target of apremilast, has been associated with both alcohol and nicotine dependence. We show that a gene identified from a genome-wide association study , successPde4 subtypes, Pde4a and Pde4b. Notably, heightened expression of the Pde4b isoform has been genetically associated with chronic ethanol intake in humans  and importantly, in humans, we sought to determine the neural mechanisms by which PDE4 inhibition reduces harmful drinking. The NAc is a critical brain region for many behaviors and is well studied for its role in alcohol drinking. Structural and molecular changes in the NAc following both acute and chronic ethanol drinking are thought to play a role in further aberrant drinking patterns . Deep brn humans . We furtn humans , 51. PDEn humans . PDE inhn humans . The preThe extent to which PDE4 inhibition, and in particular apremilast, alters input to, and output of, subpopulations of MSNs in the NAc helps to identify potential critical neurobiological mechanisms and may in part explain the observed reduction in harmful alcohol drinking across drinking models. Decreased alcohol drinking seen with chemogenetic manipulation of the NAc likely engages different signaling pathways that may be dependent on drinking paradigm, sex, and/or distinct cell types , 53, 54.The above double-blind, placebo-controlled POC study found a large effect of apremilast (90 mg/d) on decreasing drinking relative to placebo in 51 non–treatment-seeking men and women with severe AUD. The observed effect size for apremilast was more than double that reported in a comprehensive meta-analysis of randomized controlled trials of the FDA-approved treatments for AUD, acamprosate and naltrexone . IbudilaThis collaborative set of studies from 6 independent laboratories and universities highlights apremilast as a powerful AUD treatment option and further identifies mechanisms by which apremilast may reduce harmful alcohol drinking.Further information can be found in The drinking, behavioral, gene expression, and electrophysiological data supporting the findings of this study have been deposited and are available in the Figshare digital repository (10.6084/m9.figshare.14687358).α value of 0.05. Behavioral experiments were analyzed with either a 1- or 2-way ANOVA, followed by either Dunnett’s or Newman-Keuls post hoc test. Two-tailed Student’s t test was used to analyze data from the intra-NAc apremilast and NAc mRNA studies. For electrophysiology experiments, data were analyzed using 2- or 3-way ANOVA. Changes in drinks per day and the probability of a heavy drinking day in the clinical study were analyzed using 2-tailed mixed-effect LGMs.Significance was set at an Guide for the Care and Use of Laboratory Animals . Human laboratory testing was approved by the Scripps Research Institutional Review Board (protocol 16-6821), was conducted under an investigator-initiated IND (no. 135813), and is registered on ClinicalTrials.gov (NCT03175549). All participants provided written informed consent prior to study inclusion.For animal studies, all procedures were approved by the local Institutional Animal Care and Use Committee and were conducted in accordance with the NIH Preclinical: ARO, KBG, RA Mangieri, RA Morrisett, AJR, and MFL conceived and performed the preclinical experiments, performed analyses, and wrote the manuscript. EJF, AT, KGT, and HCA performed the preclinical experiments. PM analyzed preclinical data. JCC, MR, and HCB conceived the preclinical experiments and edited the manuscript. Clinical: BJM conceived and conducted the clinical study, interpreted results, and wrote the manuscript. JML analyzed the clinical data, interpreted results, and wrote the manuscript. AB, JB, JM, SQ, FS, and MS conducted the clinical study. TKE and JJM analyzed the physiological data and interpreted results.


ObjectiveYouTube  is used as a primary resource for many patients looking to gain healthcare knowledge. Recently, YouTube made efforts to increase the quality of posted content by accrediting trusted healthcare sources. With an increasing emphasis being placed on minimally invasive options, this study was done to investigate the quality of YouTube videos on MitraClip™  with respect to patient education. Methods YouTube was searched using the keyword “MitraClip”. A total of 66 videos were evaluated, with 32 of those videos being included for final analysis after applying exclusionary criteria. Three independent reviewers separately scored the videos using the Global Quality Scale. Likes, dislikes, views, comments, and dates of upload were also recorded. Two-tailed t-tests were used to determine statistical significance.Results MitraClip videos on YouTube proved to be of medium quality, receiving an average Global Quality Scale score of 3.39. When stratified by the new YouTube accreditation process, those with accreditation had a significantly higher Global Quality Scale score of 4.11, while non-accredited videos had an average Global Quality Scale score of 3.12 (p<0.01). Shorter and more patient-friendly videos were also significantly lower in quality (p<0.05).ConclusionThe YouTube accreditation process has demonstrated initial success at regulating the quality of MitraClip content, thereby reducing the spread of misinformation. However, this progress is undermined by the lack of unique videos present on the platform. Increasing the amount of original content about MitraClip may allow viewers to diversify their educational sources and ultimately gain a better understanding of the procedure.  Internet usage in people of all age groups has dramatically increased in the past decade, with many of these online searches pertaining to healthcare information for themselves or loved ones ,2. RatheCurrently, over two million Americans are afflicted by mitral regurgitation, a condition that is often overlooked and undertreated ,14. MitrSearch strategywww.youtube.com) was searched for the key term “MitraClip” on November 5, 2021. To avoid customized search results, the inquiry was done on Google Chrome  in "incognito" mode. The search results were then set to "filter by view count" on YouTube’s advanced search parameters. This organizes videos from most viewed to least viewed, thereby ensuring the relevance of the videos included in the study. Videos with <3,000 views were excluded, leaving 66 videos for analysis. Next, content that was less than one minute (n=2), not in English (n=13), or a duplicate (n=19) was also excluded from the study. Videos less than one minute were excluded as these did not contain sufficient information to accurately assess. Content that was not narrated or captioned in English was excluded as this is the universally accepted language in many countries [The study methodology was based on that of multiple previous studies regarding online healthcare content ,20. YouTVideo assessmentEach video was independently analyzed by three authors  to minimize personal bias. All three reviewers were third-year medical students who were well-versed in the MitraClip procedure. Content quality was judged using the Global Quality Scale (GQS), a five-point DISCERN score adapted to video content, as described in previous studies -25. EachDescriptive video characteristics including likes, dislikes, comments, view count, duration, modality, and date of upload were recorded. The new YouTube accreditation process was used to separate videos that were accredited versus those that were not. Videos were also stratified by the presence or absence of a board-certified physician substantiating the information at any point. Finally, video modality was used to categorize content into "Patient Friendly" or "Clinician Friendly" groups. Patient accounts of their experience with MitraClip, physician interviews, and animations were included in the "Patient Friendly" group. These required minimal health literacy to comprehend and were designed to educate the general public on the procedure. In contrast, academic presentations and live surgeries were categorized into the "Clinician Friendly" group. Prior medical knowledge was essential to understand this content as it was oriented toward practicing physicians looking to further their education on MitraClip.View ratio and a like-to-dislike ratio were used to assess video popularity, as noted in previous studies . The vieStatistical analysisStatistical analysis was performed with IBM SPSS Statistics for Windows, Version 26.0 . The normality of the data was tested using the Shapiro-Wilks test. The intraclass correlation coefficient (ICC) was used to assess score reliability among the three independent reviewers. Pairwise comparisons between average GQS scores and video categories were evaluated using the Mann-Whitney U test. A p-value of <0.05 was considered statistically significant. Continuous variables were reported as mean and standard deviation while categorical variables were reported as frequency. The Pearson correlation coefficient was used to analyze relationships between GQS score and video characteristics. Numerical results were rounded to two decimal places.MitraClip videos on YouTube proved to be of moderate quality, receiving an average GQS score of 3.39. However, of the 66 videos evaluated, 51.52% (34/66) were excluded, with the majority of those being duplicates of the same exact animation (n=19). MitraClip videos were an average of 1,661.81 days (4.55 years) old and garnered an average of 19,712 views per video. Videos about MitraClip were, on average, 920.72 seconds or 15.35 minutes in length. This is about four minutes longer than the average 11.7-minute video length on YouTube as a whole . The vieWhen categorized by target audience, 17 videos (53%) were patient friendly and 15 videos (47%) were clinician friendly. Patient friendly videos included six animations (19%), six physician interviews (19%), and five patient accounts (16%). Clinician friendly videos included 11 academic presentations (34%), and four live MitraClip procedures 12%)   MitraClip videos were labeled as reliable by the newly implemented YouTube accreditation process, while the remaining 23 (71.87%) videos were not. MitraClip videos with accreditation had a significantly higher GQS score of 4.11, while non-accredited videos had an average GQS score of 3.12 (p<0.01)  in length received an average GQS score of 2.84, while those longer than five minutes (n=17) had an average GQS score of 3.88 (p<0.05). No significant correlation was found between average GQS Scores and days since upload (R2 =0.07). There was no significant difference in average GQS scores between videos with view ratios higher than 6 (n=15) and those lower than 6 (n=17) (p=0.2). This was also the case when videos were separated by those above and below a view ratio of 10 (p=0.18). When stratified by accreditation status, videos did not have significantly different view ratios (p=0.56). No significant difference was found when comparing average GQS scores between groups with (n=24) and without (n=8) a physician present to substantiate the claims made in the video at any point (p=0.08). The ICC for GQS scores was 0.92, which indicated excellent agreeability among the three independent reviewers .Amazon.com, Inc., Seattle, Washington, United States), and Instagram  to take down inaccurate information regarding the pandemic. These efforts were able to mitigate a substantial amount of misinformation in circulation [YouTube is the most prominent video platform on the internet and an increasingly popular source of healthcare information ,4. Howevculation . Howeverculation .Additionally, due to the commercial interests of YouTube, there are numerous difficulties in ensuring adequate quality content moderation . TherefoIn response to these growing concerns, numerous studies have been published to define the educational value of healthcare content on YouTube ,26. HoweThe insufficient quantity of original MitraClip videos on YouTube undermines patients’ ability to properly educate themselves on the subject. Over half (56%) of the videos excluded from analyses were duplicates of the same exact MitraClip animation. This is troublesome as previous studies have highlighted the importance of diverse visual representations of data when learning . ViewersThe educational value of MitraClip videos is not only hindered by content quantity, but content comprehensibility as well. This becomes apparent when stratifying videos by the target audience. Clinician-friendly videos contained academic presentations and live procedures that were clearly intended for viewers with a background in healthcare. Although this content contained significantly higher quality information than patient-friendly videos, they were often unsuitable for educating those with low health literacy. One possible reason for this discrepancy may be a lack of trained professionals present in patient-friendly content. However, stratifying by the presence or absence of a board-certified physician in the video failed to produce significant results when compared to average GQS scores (p=0.08). An alternative explanation is the oversimplification of the MitraClip procedure in patient-friendly videos. To appeal to a broader audience, video creators often omit important details, thus lowering the video’s educational quality. One such detail that was often omitted from patient-friendly videos was information regarding areas of uncertainty such as the relative risks and benefits of the MitraClip procedure. These omissions are troublesome as individuals with low health literacy are highly susceptible to online misinformation . TherefoIn response to growing concerns about online healthcare misinformation, YouTube implemented a new accreditation process on January 26, 2021 . AccrediBesides accreditation status, several additional video characteristics were compared with GQS scores to elucidate factors related to content quality. Of these, only video duration yielded significant results. On average, content over five minutes in length was higher in quality than content shorter than five minutes. This result is likely because longer videos had ample time to provide a sufficiently detailed explanation of the MitraClip procedure. Therefore, physicians should urge their patients to avoid videos shorter than five minutes to obtain the highest quality information.Notably, no significant correlation was found between the date of video upload and GQS scores. This indicates a stagnant trend in content quality and emphasizes the need for expansion of the current MitraClip YouTube catalog. View ratios were not significantly different between videos with and without accreditation status. However, this finding may be due to a lack of sufficient time for accredited videos to gain significantly more views than non-accredited content. Similarly, average GQS scores were not significantly different between videos with high versus low view ratios. Previous studies have found mixed results regarding viewership and content quality , indicatLimitationsThe primary limitation of this study was the small sample size as noted previously. Less stringent exclusionary criteria and an increased quantity of MitraClip YouTube content are necessary for more robust analyses in the future. Additionally, an unavoidable limitation of this study is the profit-driven business model of YouTube as a platform. YouTube's main source of revenue is through advertisements on their videos and is thereby subjected to influences from their investors who place an emphasis on profit . Every tFuture studyThis study, to the best of our knowledge, was the first to evaluate the YouTube accreditation process. Future research in this field must account for this policy change to reveal its long-term implications. Furthermore, MitraClip content on popular video platforms besides YouTube, such as TikTok  and Facebook (Meta Platforms LLC), should also be analyzed.The YouTube accreditation process has demonstrated initial success at regulating the quality of MitraClip content, thereby reducing the spread of misinformation. However, this progress is undermined by the lack of unique and high-quality patient-friendly videos currently on the platform. Increasing the amount of original, patient-centered content regarding MitraClip may allow viewers to diversify their education sources and ultimately gain a better understanding of the procedure.


Many pouch complications following ileoanal pouch surgery have an inflammatory or mechanical nature, and specialist colorectal surgeons are required to assess the anatomy of the ileoanal pouch in multiple settings. In this study, we report our stepwise clinical and endoscopic assessment of the patient with an ileoanal pouch.The most common configuration of the ileoanal pouch is a J-pouch, and the stapled anastomosis is more frequently performed than a handsewn post-mucosectomy. A structured clinical and endoscopic assessment of the ileoanal pouch must provide information on 7 critical areas: anus and perineum, rectal cuff, pouch anal anastomosis, pouch body, blind end of the pouch, pouch inlet and pre-pouch ileum.We have developed a structured pro forma for step-wise assessment of the ileoanal pouch, according to 7 essential areas to be evaluated, biopsied and reported. The structured assessment of the ileoanal pouch in 102 patients allowed reporting of abnormal findings in 63 (61.7%). Strictures were diagnosed in 27 patients (26.4%), 3 pouch inlet strictures, 21 pouch anal anastomosis strictures, and 3 pre-pouch ileum strictures. Chronic, recurrent pouchitis was diagnosed in 9 patients, whilst 1 patient had Crohn’s disease of the pouch.Detailed clinical history, assessment of symptoms and multidisciplinary input are all essential for the care of patients with an ileoanal pouch. We present a comprehensive reporting pro forma for initial clinical assessment of the patient with an ileoanal pouch, with the aim to guide further investigations and inform multidisciplinary decision-making. Ileal pouch-anal anastomosis (IPAA) following restorative proctocolectomy is the surgical procedure of choice for ulcerative colitis (UC) and familial adenomatous polyposis (FAP), as an alternative to permanent end ileostomy and when ileorectal anastomosis is not appropriate. The multidisciplinary management for ileoanal pouch patients involves dedicated colorectal surgeons and gastroenterologists throughout the course of the disease, working synergistically with specialist nurses, radiologists and dietitians, to maintain a healthy pouch and to treat short- and long-term complications .Many pouch complications have an inflammatory or mechanical nature and can be successfully treated if promptly diagnosed. The ability to perform an endoscopic assessment of the pouch “pouchoscopy” is an essential skill required of the pouch surgeon, who will be reviewing pouch patients in the outpatient clinic or in the operating theatre under general anesthetics. Specialist colorectal surgeons are required to assess the anatomy of the ileoanal pouch in multiple settings: right after the ileal pouch-anal anastomosis fashioning, during surveillance endoscopic follow-up, to detect inflammatory disorders of the pouch and to exclude any mechanical conditions associated with pouch dysfunction .Gaining experience in pouch surgery is difficult as the procedure is performed infrequently across many hospitals, as evident from the UK Pouch registry, reporting that the average number of pouches performed in English institutions was just three cases per year, and one quarter of the pouch surgeons undertaking this surgery had performed only one case over the last 5 years .In this study, we report our stepwise clinical and endoscopic assessment of the patient with an ileoanal pouch and present a dedicated reporting pro forma we have developed.The most common configuration of the ileoanal pouch is a J-pouch Figure , and theIn view of the complexity of the pouch anatomy, we believe that a structured clinical and endoscopic assessment of the ileoanal pouch must provide information on 7 critical areas.The observation of anal and perianal skin irritation can be an indirect sign of poor pouch function. The perianal region is inspected for previous surgical incisions and scars and for signs of fistulating disease or collections. The presence and location of external openings is noted, and inspection of the skin extending towards the scrotum and groins is essential, as it is to perform a vaginal examination to rule out pouch-vaginal fistulae.Anal canal stricture is a common condition after an IPAA, usually diagnosed with digital examination and requiring dilation. According to Prudhomme, the anal strictures can be subdivided into non-rigid or rigid depending on the presence of palpable fibrosis .The anal transition zone (AZT) is an area in the anal canal between the squamous epithelium of the anoderm and dentate line below and the uninterrupted rectal columnar epithelium above; it extends for a variable length  and is best represented in stapled anastomosis. Along with the retained rectal cuff, it has a potential risk for inflammation, dysplasia and cancer .This step of pouch assessment is completed by evaluating the tone of the anal sphincter complex and the squeeze pressure at digital rectal examination. The presence of anal canal problems, such as fissures, skin tags and haemorrhoids, is also reported.The inflammation of the rectal cuff or cuffitis is one of the long-term complications of IPAA. Correct division of the rectum at the level of the levators remains a significant challenge in minimally invasive pouch surgery, with inappropriately retained long rectal cuffss, leading to bleeding, tenesmus, urgency and a risk of dysplasia or cancer.Rectal examination allows for detection of any intra-anal-rectal lesions, appreciating the distance of the anastomosis from the anal verge. Particularly during intraoperative evaluation, care must be taken in evaluating possible discrepancies in the length of rectal cuff, which can be left longer anteriorly and shorter posteriorly, as for the possible presence of “dog-ears” remnants of the double stapled anastomosis.Up to 15% of ileoanal pouches will develop a symptomatic leak . The cliA pouch sinus is another late presentation of an undetected IPAA anastomotic leak, and it is described as a blind-ended pouch tract connected to a pelvic abscess. This condition affects from 3 to 8% of patients undergoing IPAA and when not timely treated leads to pouch failure in one patient out of 3 [Fistulas at the IPAA can involve the vagina, skin, urethra, prostate or gluteal muscles such as in pouch-vaginal or pouch-cutaneous fistula, the two most common types. Multiple classifications for pouch fistulas have been proposed, based on etiology, location of the primary orifice or target organ. The height of the internal opening can guide the differentiation between anastomotic dehiscence and cryptoglandular which are typically below the anastomosis.The diagnosis of pouch fistula is mainly based on patient’s symptoms and clinical history, and suspect should always lead the surgeons to perform an evaluation under anesthesia (EUA) with pouchoscopy and a pelvic MRI to delineate the anatomy and evaluate possible undrained abscesses in the area. Pouch-vaginal fistula (PVF) is a challenging complication with devastating effect on women quality of life, not as rare since it has been reported in up to 16% of pouch patients and represents one of the main causes leading to pouch failure .IPAA strictures are among the most common sequelae of pouch surgery, occurring in around 11–12% in UC and FAP patients. Strictures in pouch surgery may happen in multiple sites, like at the IPAA, at the mid-pouch or pouch body, at the pouch inlet and in the afferent limb of the pouch. The presence of a stricture at the IPAA level or lower may impair the possibility to perform pouchoscopy.In the S-pouch configuration, an efferent limb will connect the pouch body to the ileaoanal pouch anastomosis, and its length needs to be reported, as limbs longer than 2 cm can be responsible for obstructed defecation or efferent limb syndrome.The pouch body is the main segment of the J-pouch in terms of volume, enclosed between the pouch anal anastomosis (pouch outlet) and the pouch inlet. Right after exploring the anastomosis, the endoscope will reach the pouch body, and by insufflating, it will be possible to assess the size and distensibility of the pouch. Pouch compliance is among the most important features for pouch function, being necessary for its activity as a reservoir for stool and its ability to empty during the defecation. A severely contracted pouch can be due to pelvic sepsis, or occasionally to a low volume pouch at the time of construction. Conversely, a large and dilated pouch can be the result of chronic obstruction, leading to incomplete defecation and need for self-catheter insertion.Pouch inflammation or Pouchitis is more common in UC than in FAP, with about 25 to 50% of pouch patients experiencing at least one episode in the first 10 years from the index surgery. Diagnosis and assessment rely on pouchoscopy and biopsies, with scores as the Pouchitis Disease Activity Index  or inflammatory  pouch problems.Pre-pouch ileitis (PI) was first described in 1994 as an inflammatory complication targeting the distal afferent limb of the J-pouch, with a reported incidence of around 5% . PouchosFace and content validity and ease of use of the developed pro forma were evaluated by survey feedback from colorectal surgeons, gastroenterologists and trainees. Construct validity for the presence of strictures was obtained by comparing the structured assessment of the pouch with MRI imaging, when available. Completeness of the reporting by using the pro forma was evaluated by identifying the number of items documented on pouchoscopies reports retrospectively available for the same patients, prior to the introduction of the pro forma .We have developed a structured pro forma for step-wise assessment of the ileoanal pouch, according to 7 essential areas to be evaluated, biopsied and reported Table .Table 1SWe have applied the reporting pro forma in all the new referrals to our specialist ileoanal pouch clinic where we are able to offer multidisciplinary counselling, imaging and endoscopic procedures on the same appointment . The “onFrom August 2020 to March 2023, we have evaluated 102 patients with our structured clinical and endoscopic assessment, with all procedures performed by the same colorectal surgeon. Approximately 35% of the referrals originated from outside the Trust . The structured assessment of the ileoanal pouch allowed reporting of abnormal findings in 63 patients (61.7%). Strictures were diagnosed in 27 patients (26.4%), 3 pouch inlet strictures, 21 pouch anal anastomosis strictures and 3 pre-pouch ileum strictures. Afferent limb syndrome due to adhesions at the level of the pouch inlet was found in 1 patient. Chronic, recurrent pouchitis was diagnosed in 9 patients (8.8%), whilst 1 patient had Crohn’s disease of the pouch.Fistulae were present in 7 patients (6.8%): 3 pouch-vaginal fistulae, 4 pouch anal fistulae. Pouch anal anastomotic leak was diagnosed in 4 patients (3.9%), whilst 2 patients had a chronic pouch sinus, and 1 patient had a chronic leak at the blind end of the pouch.A rectal cuff longer than 2 cm was diagnosed in 11 patients (10.1%), whilst cuffitis in 15 patients (14.7%). No cases of invasive cancer were diagnosed, whilst one patient had a rectal polyp with low grade dysplasia, and another had diffuse high-grade dysplasia in the rectal cuff and anal transition zone.The pro forma demonstrated acceptable face and content validity. Two gastroenterologists, 2 colorectal surgeons and 3 surgical trainees were surveyed on the use of the newly developed pouch pro forma for reporting of the clinical and endoscopic ileoanal pouch assessment. The median time needed to complete the report was 5 minutes (range 3–10), with all users satisfied that all required items were present in the pro forma. Validity of the test was confirmed by the fact that all strictures in the pre-pouch ileum and pouch inlet were also detected by MRI imaging, whilst of the 21 anastomotic strictures, only 17 (81%) were identified at MRI. Of the 102 patients included in the study, only 19 had a retrospective pouchoscopy report available.We present a comprehensive reporting pro forma for initial clinical assessment of the patient with an ileoanal pouch, with the aim to guide further investigations and inform timely multidisciplinary decision-making. Detailed clinical history, assessment of symptoms and multidisciplinary input are all essential for the care of patients with an ileoanal pouch. Similar to inflammatory bowel diseases, diagnosis of pouch disorders is multifactorial and must involve clinical, radiological, endoscopic and pathological results. Clinical assessment and pouchoscopy should not be used in isolation but complementarily to all these other diagnostic tools. Nevertheless, pouchoscopy has a crucial role in intraoperative decision-making and in detecting complications of the ileoanal pouch that can benefit from surgical treatment. Our study provides a pro forma to help colorectal surgeons investigating pouch disorders, with the aim to minimise unstructured reporting. Unfortunately, it does not provide a score able to stratify the severity of the pouch complications or the response to treatment. We believe that a structured assessment of the ileoanal pouch must report routinely on both positive and negative findings, allowing retrospective review of patients who develop new symptoms during the long-term follow-up. Such a structured report could also facilitate inter-hospital communication, as not infrequently pouch patients can be followed in a tertiary centre away from the local hospital.We routinely inspect intraoperatively the ileoanal pouch during restorative surgery, obtaining information on the completeness of the anastomosis, the presence of bleeding  or the suspect of ischaemic changes with the aid of indocyanine green. It is also a helpful feedback for direct visualisation of the dentate line to orientate if the appropriate level of rectal transection has been achieved. We also perform an intraoperative pouchoscopy at the time of the loop ileostomy reversal, despite preoperative contrast studies, due to the known risk of missing subclinical leaks or strictures.There are known technical challenges surrounding the IPAA procedure, with significant focus around minimally invasive approaches, plane of rectal dissection and 3-stage versus 2-stage (and modified 2-stage) restorative proctocolectomy. These challenges are reflected in inconsistencies in IPAA surgery practice, with need for consensus on what is considered safe and appropriate .Our study represents a single pouch centre experience, and the validity of our results, and replicability of the pouch reporting pro forma, must be further evaluated. Comparing the completeness of pouchoscopy reports since the introduction of the reporting tool would have also been deemed necessary but was not possible in our cohort due to the limited number of reports available retrospectively. However, we correlated the results of our clinical and endoscopic assessment with the imaging findings in the patients who had an MRI of the pouch available. Whilst our pouch assessment reporting pro forma is not yet validated for pouch assessment by multiple specialists or different hospitals, we believe that providing a routine structured framework for description of findings in pouch patients could lead to standardisation of reports, with more complete information available to clinicians.


AimTM videos on MRI claustrophobia.Magnetic resonance imaging (MRI)-induced anxiety is not infrequent with a reported incidence as high as 37% and the rate of failed MRI imaging due to claustrophobia ranges between 0.5% and 14.5%. The objective of this study was to evaluate the quality and reliability of YouTubeMethodsSixty-five videos were included in the final analysis. Video information analyzed included video length (minutes), video content, qualification of the video uploaders, time of upload, time since upload, the number of total views and the mean daily views, and like counts. We divided the videos according to the uploaders into professional and non-professional groups and further grouped the videos as useful and misleading. Data obtained from the videos were evaluated with three tools including subjective evaluation, Quality Criteria for Consumer Health Information (DISCERN), and Global Quality Scale (GQS) tools.ResultsThe mean video duration was found as 4.14±4.45 minutes. The mean view count was 104.59±408,788.68 and the mean like count was found as 272.55±1096.25. Seventeen (26.15%) videos were uploaded by professionals and 48 (73.85%) by non-professionals. Twenty-eight (43.08%) of the videos were useful and 37 (56.92%) were useless. The mean DISCERN and GQS scores were statistically significantly higher in the professional videos compared to the non-professional videos and in useful videos compared to non-useful videos .ConclusionTM videos concerning MRI claustrophobia were uploaded by non-professionals. Physicians and other healthcare personnel should be encouraged to provide useful and accurate videos and to direct patients appropriately.A majority of the YouTube Magnetic resonance imaging (MRI) was introduced in the field of medicine in the 1980s, and since then has become a popular, non-invasive imaging modality . Today, Claustrophobia is defined as a marked, excessive, or unreasonable fear of being trapped in an enclosed space . For a cTM (www.youtube.com) is the most frequently visited video-sharing platform. In 2021, there were approximately 1.86 billion global YouTubeTM users and this figure is estimated to increase to 210 million in 2022. More than 500 hours of videos are uploaded to YouTubeTM every minute. Videos can be uploaded to YouTubeTM at any time, by any person, and free of charge, making YouTubeTM a source of health-related information [TM. These concerns are much more intense relative to misleading YouTubeTM videos on the ongoing coronavirus disease 2019 (COVID-19) pandemic. In addition, YouTubeTM has no filtering options or a clear policy for health-related misleading videos, prompting many studies of the quality and reliability of YouTubeTM videos in several diseases and medical conditions [TM video content specific to fear of MRI. The objective of this study was to evaluate the quality and reliability of YouTubeTM videos on MRI claustrophobia.As in many diseases and medical conditions, patients and/or their relatives tend to search for information from various sources before seeking professional healthcare aid. The internet is the leading source of information for this purpose with millions of health-related websites and a great number of sharing platforms, including social media. With the increasingly widespread use of sharing platforms on the Internet, today it is common for a physician to encounter patients who have already done their research on the Internet to find treatment options for their disease . Currentormation . Howevernditions . To the Study design and search strategyTM videos on fear of MRI, namely MRI claustrophobia, on January 24, 2023. In the case of disagreement, a third colleague (15 years) was invited, and the decision was made by the three. The search terms were determined by the two radiologists as “Fear of MRI,” “MRI phobia,” and “MRI claustrophobia.” The terms were entered into the search box of YouTubeTM and from the filtering feature, the “relevance” option was chosen. The first 100 videos returned by the search were subjected to the analysis because it has been reported that most YouTubeTM searchers view the first of the yielded results. Most previous studies have used the first 50 or 100 videos for YouTubeTM analysis [TM videos is shown in Figure This study was conducted by two independent experienced radiologists (14 years and three years) on the quality and reliability of YouTubeanalysis . Althouganalysis . Among tData collection and evaluationTM has removed the dislike count and so we could not include VPI in our analysis.In order to extract information from the videos and make the assessment, a Microsoft Excel sheet was prepared by the researcher. Links to the 65 videos were entered into this file. Video information analyzed in this study included video length (minutes), video content, qualification of the video uploaders, time of upload, time since upload, the number of total views and the mean daily views, and similar counts. In order to make a more accurate comparison, the average daily view counts of the videos were calculated by dividing the number of total views by the time (in days) since the video was uploaded. In previous studies, Video Power Index (VPI) based on like and dislike counts has been used to evaluate the popularity of the videos. However, YouTubeWe divided the videos into two principal groups according to whether the uploaders were professional or non-professional and further grouped the videos as useful and useless and/or misleading. Useful videos are those with scientifically accurate content helping patients to make an informed decision about treatment. Useless or misleading videos are those with scientifically inaccurate content that mislead patients regarding decisions for treatment. Professional videos consisted of the videos uploaded directly by doctors, MRI technicians, and hospital channels. Most of the hospital videos were narrated by doctors. Non-professional videos included those uploaded by patients, health channels, and others. Videos uploaded by health channels were included in this group because they mostly include informative content rather than focusing on the fear of MRI.TM videos on the fear of MRI were further evaluated using the Quality Criteria for Consumer Health Information (DISCERN) and Global Quality Scale (GQS) tools. The two authors independently rated each video in separate rooms, but at the same time interval in order to prevent the influence of one author by the other author during scoring.Data obtained from the videos were evaluated with three tools. First was a subjective evaluation made by mutual consensus of the two authors and the reviewed videos were classified as useful or misleading. YouTubeDISCERN scoringThe DISCERN is a scoring system used for the evaluation of the reliability of consumer healthcare information on treatment options. In this study, the modified DISCERN tool that was developed by Singh et al. was used . The DISGQS scoringThe GQS, which was developed first by Bernard et al. , is a scEthics considerationsTM was also waived, since all videos used in this study were publicly available. However, the study was conducted in line with the ethical principles of the Declaration of Helsinki.Ethics approval was waived because no humans or animals were included in the study. In addition, permission from YouTubeStatistical analysisThe data obtained in this study were analyzed using SPSS version 25.0  statistical software. The normality of the data was analyzed with the Kolmogorov-Smirnov test. Since the variables were non-normally distributed, a comparison of the continuous variables between the two groups was made using the Mann-Whitney U test. Categorical variables were compared using the Chi-square test. The continuous variables were expressed as the mean ± standard deviation and the categorical variables as frequency . Cronbach alpha coefficients were used to calculate the agreement between the two raters. p<0.05 values were considered statistically significant.TM videos on MRI claustrophobia were analyzed and evaluated in terms of quality and reliability by two radiologists, independently of each other. Video content was found as general information on MRI in 20 (30.77%), sharing experience in 17 (26.25%), and overcoming fear of MRI in 28 (43.08%) videos. The mean video duration was found as 4.14±4.45 minutes. The mean view count was 104.59±408,788.68. The oldest video was uploaded on February 10, 2010 and the latest one on December 6, 2021. The mean like count was found as 272.55±1,096.25. The most liked video was uploaded by a health channel to relate general information on MRI and received 8,200 likes, while eight (4.85%) received no like. The main characteristics of the reviewed videos are given in Table After the excluded videos, the remaining 65 YouTubeQualifications of the video uploaders are given in Figure The video providers were assigned to two groups - professionals and non-professionals. The professionals group included doctors, MRI technicians, and hospitals. Hospitals were included in this group because the vast majority of these videos were narrated by doctors. Health channels were included in the non-professional group because the videos uploaded by these channels mostly involved general information on MRI and did not direct patients for coping with anxiety occurring due to MRI. Accordingly, 17 (26.15%) videos were uploaded by professionals and 48 73.85%) by non-professionals. The videos were divided into two groups as useful and useless through a subjective assessment made by mutual consensus of the two authors. Accordingly, 28 (43.08%) of the videos were useful and 37 (56.92%) were useless . The mean view count was 99,655.81±193,330.10 in the professional and 106,236.50±460,495.76 in the non-professional videos (p=0.317). The mean like count was 273.69±762.03 in the professional and 272.17±1,193.96 in the non-professional videos (p=0.920).The mean video length was found as 3.27±3.69 minutes in the useful and 5.02±5.01 minutes in the useless videos, with no statistically significant difference found between the groups (p=0.233). The mean view count was 184,630.79±603,435.15 in the useful videos and 41,195.38±102,611.27 minutes in the useless videos (p=0.827). The mean like count was 405.11±1,558.40 in the useful videos and 164.92±508.02 minutes in the useless videos (p=0.279).The mean DISCERN and GQS scores were statistically significantly higher in the professional videos compared to the non-professional videos and in useful videos compared to non-useful videos . The mean DISCERN and GQS scores according to the groups are given in Table Figure According to DISCERN scale, the reliability of the reviewed videos was considered poor in 21 32.31%) videos, moderate in 18 (27.69%), and good in 27 (41.54%) videos. Agreement between the two radiologists in the evaluation of the videos was assessed using the Cronbach alpha coefficient. There was an excellent agreement between the two researchers  many non-open MRI devices remain in use and (2) some people who have fear of MRI and experience panic attack and/or anxiety during MRI procedure. In our study, the mean length of videos was found as 4.14 minutes. Looking at recent YouTubeTM analysis studies in the literature, the mean video length was reported as 7.56 minutes by Kuru and Erken [TM videos on rotator cuff tears, 8.10 minutes by Ku et al. [In this study, we evaluated the quality and reliability of YouTubend Erken  for YouTu et al.  for videu et al.  for videTM analysis studies [In our study, the most common video content was directed at overcoming fear of MRI or MRI claustrophobia followed by general information and sharing experience. It is obvious that video content widely differs among studies depending on the objectives and the topic of study. We think that experience sharing is a common content item among YouTube studies ,23. In tTM videos on psoriatic arthritis, the videos were evaluated as useful and misleading. Jamleh et al. [TM videos on periradicular surgery and examined the videos with usefulness scores as poor, moderate, and good. Kocyigit and Akyol [TM videos on COVID‑19 vaccination in rheumatic diseases and divided the videos into three groups based on the quality scores as low, intermediate, and high-quality videos.We divided the videos into two groups as the videos were uploaded by professionals  and those uploaded by non-professionals . In addition, we divided the videos into further two groups as useful and useless videos based on consensus subjective evaluation by the two authors. Similarly, in a study by Onder and Zengin  evaluatih et al.  analyzednd Akyol  investigTM analysis study on gout, Onder and Zengin [TM videos on Compensated Maneuvers for Dysphagia. In a study analyzing YouTubeTM videos on the Surgical Treatment of Uterine Leiomyomas, Ergul [In the present study, we evaluated videos through DISCERN and GQS scales. Both scores were statistically significantly higher in the professional group compared to the non-professional group and in the useful group compared to the useless group . There are several reasons for these findings. First, videos uploaded by patients mostly contained experience sharing, explanations of fearful times during MRI and even increasing fear of the audience. Videos uploaded by health channels did not give information on how to overcome MRI claustrophobia; instead, they introduced the modern MRI devices that they use, and although these videos were not ads or misleading, they were useless for the topic of our study . In a Yod Zengin  reporteds, Ergul  reportedTM videos about Behçet’s disease, 46% of the videos were found to have low-to-moderate reliability and 56% good quality. In the present study, as high as 73.85% of videos pertaining to the fear of MRI were uploaded by non-professionals with most of them being patients. This suggests a significant difference in quality and reliability for videos uploaded by professionals and non-professionals. Studies on YouTubeTM videos in the literature are largely consistent with the present study.Finally, according to DISCERN scale, the reliability of the reviewed videos was considered poor in 21 (32.31%) videos, moderate in 18 (27.69%), and good in 27 (41.54%) videos. In a study by Karakoyun and Yildirim  evaluatiStudy limitationsTM videos on MRI claustrophobia.This study has some limitations. The study involved a snap-shot assessment of the reviewed videos at a certain period of time. Whereas these videos can be uploaded or removed at any time. In order to minimize subjective bias in video scoring process, further studies may include different observers of various backgrounds such as different age groups and healthcare consumers, i.e., patients. However, we think that our results will be a preliminary guide for future studies in terms of patient education on imaging methods and this is the first study to evaluate YouTubeTM videos concerning fear of MRI or MRI claustrophobia were uploaded by non-professionals with poor quality and reliability. Physicians and other healthcare personnel should be encouraged to provide useful and accurate videos and to direct patients appropriately. Healthcare-related YouTubeTM videos should be supervised by YouTubeTM and regulatory bodies and be classified as professional or non-professional videos before they are made accessible to the public. According to the findings of our study, a majority of the YouTube