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BackgroundMedical mentoring is becoming increasingly complex with the evolving needs of trainees and the complexities of their personal and social lives. The Internet is an enabling technology, which increasingly facilitates interaction with multiple people at a distance. Web 2.0 and 3.0 technology shows promise in furthering this facilitation. ObjectiveThe objective of our study was to establish opinions among doctors in postgraduate surgical training regarding mentoring and whether these doctors would readily accept virtual mentoring following a brief experience. MethodsOn the 12th of February 2012, an introductory teaching class was arranged by The London Postgraduate School of Surgery for doctors in training. Participants were introduced to a novel virtual mentoring system and asked to complete a questionnaire regarding their opinions before and after the demonstration. ResultsA total of 57 junior doctors attended. Among them, 35 completed questionnaires pre- and postdemonstration. Regarding usefulness of a 3D virtual environment for mentoring, 6/35 (17%) agreed or strongly agreed and 20/35 (57%) were unsure prior to the session. Following 20 minutes using MentorSL, this significantly increased to 14/35 (40%) agreeing or strongly agreeing with 11/35 (31%) unsure (P

A short cut review was carried out to establish whether computed tomography (CT) is useful in the management of patients with suspected acute small bowel obstruction (SBO). A total of 348 papers were found using the reported search and manually cross referencing papers, of which 16 represented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are presented in table 3. The clinical bottom line is that CT is a useful investigation in patients presenting with suspected SBO. [ABSTRACT FROM AUTHOR]

A short cut review was carried out to establish whether transthoracic ultrasound can be used to diagnose pneumothoraces in trauma patients. A total of 46 papers were found using the reported search, of which four represented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated. [ABSTRACT FROM AUTHOR]

Background: Giant cell arteritis (GCA) is a systemic, inflammatory vasculitis primarily affecting people over the age of 50 years. GCA is treated as a medical emergency due to the potential for sudden, irreversible visual loss. Temporal artery biopsy (TAB) is one of the five criteria of the American College of Rheumatology (ACR) 1990 classification, which is used to aid the diagnosis of GCA. TAB is an invasive test, and it can be slow to obtain a result due to delays in performing the procedure and the time taken for histopathologic assessment. Temporal artery ultrasonography (US) has been demonstrated to show findings in people with GCA such as the halo sign (a hypoechoic circumferential wall thickening due to oedema), stenosis or occlusion that can help to confirm a diagnosis more swiftly and less invasively, but requiring more subjective interpretation. This review will help to determine the role of these investigations in clinical practice., Objectives: To evaluate the sensitivity and specificity of the halo sign on temporal artery US, using the ACR 1990 classification as a reference standard, to investigate whether US could be used as triage for TAB. To compare the accuracy of US with TAB in the subset of paired studies that have obtained both tests on the same patients, to investigate whether it could replace TAB as one of the criteria in the ACR 1990 classification., Search Methods: We used standard Cochrane search methods for diagnostic accuracy. The date of the search was 13 September 2022., Selection Criteria: We included all participants with clinically suspected GCA who were investigated for the presence of the halo sign on temporal artery US, using the ACR 1990 criteria as a reference standard. We included studies with participants with a prior diagnosis of polymyalgia rheumatica. We excluded studies if participants had had two or more weeks of steroid treatment prior to the investigations. We also included any comparative test accuracy studies of the halo sign on temporal artery US versus TAB, with use of the 1990 ACR diagnostic criteria as a reference standard. Although we have chosen to use this classification for the purpose of the meta-analysis, we accept that it incorporates unavoidable incorporation bias, as TAB is itself one of the five criteria. This increases the specificity of TAB, making it difficult to compare with US. We excluded case-control studies, as they overestimate accuracy, as well as case series in which all participants had a prior diagnosis of GCA, as they can only address sensitivity and not specificity., Data Collection and Analysis: Two review authors independently assessed the studies for inclusion in the review. They extracted data using a standardised data collection form and employed the QUADAS-2 tool to assess methodological quality. As not enough studies reported data at our prespecified halo threshold of 0.3 mm, we fitted hierarchical summary receiver operating characteristic (ROC) models to estimate US sensitivity and also to compare US with TAB. We graded the certainty of the evidence using the GRADE approach., Main Results: Temporal artery ultrasound was investigated in 15 studies (617 participants with GCA out of 1479, 41.7%), with sample sizes ranging from 20 to 381 participants (median 69). There was wide variation in sensitivity with a median value of 0.78 (interquartile range (IQR) 0.45 to 0.83; range 0.03 to 1.00), while specificity was fair to good in most studies with a median value of 0.91 (IQR 0.78 to 1.00; range 0.40 to 1.00) and four studies with a specificity of 1.00. The hierarchical summary receiver operating characteristic (HSROC) estimate of sensitivity (95% confidence interval (CI)) at the high specificity of 0.95 was 0.51 (0.21 to 0.81), and 0.84 (0.58 to 0.95) at 0.80 specificity. We considered the evidence on sensitivity and specificity as of very low certainty due to risk of bias (-1), imprecision (-1), and inconsistency (-1). Only four studies reported data at a halo cut-off > 0.3 mm, finding the following sensitivities and specificities (95% CI): 0.80 (0.56 to 0.94) and 0.94 (0.81 to 0.99) in 55 participants; 0.10 (0.00 to 0.45) and 1.00 (0.84 to 1.00) in 31 participants; 0.73 (0.54 to 0.88) and 1.00 (0.93 to 1.00) in 82 participants; 0.83 (0.63 to 0.95) and 0.72 (0.64 to 0.79) in 182 participants. Data on a direct comparison of temporal artery US with biopsy were obtained from 11 studies (808 participants; 460 with GCA, 56.9%). The sensitivity of US ranged between 0.03 and 1.00 with a median of 0.75, while that of TAB ranged between 0.33 and 0.92 with a median of 0.73. The specificity was 1.00 in four studies for US and in seven for TAB. At high specificity (0.95), the sensitivity of US and TAB were 0.50 (95% CI 0.24 to 0.76) versus 0.80 (95% CI 0.57 to 0.93), respectively, and at low specificity (0.80) they were 0.73 (95% CI 0.49 to 0.88) versus 0.92 (95% CI 0.69 to 0.98). We considered the comparative evidence on the sensitivity of US versus TAB to be of very low certainty because specificity was overestimated for TAB since it is one of the criteria used in the reference standard (-1), together with downgrade due to risk of bias (-1), imprecision (-1), and inconsistency (-1) for both sensitivity and specificity., Authors' Conclusions: There is limited published evidence on the accuracy of temporal artery US for detecting GCA. Ultrasound seems to be moderately sensitive when the specificity is good, but data were heterogeneous across studies and either did not use the same halo thickness threshold or did not report it. We can draw no conclusions from accuracy studies on whether US can replace TAB for diagnosing GCA given the very low certainty of the evidence. Future research could consider using the 2016 revision of the ACR criteria as a reference standard, which will limit incorporation bias of TAB into the reference standard., (Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Communities of practice (CoPs) are defined as "groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise by interacting on an ongoing basis". They are an effective form of knowledge management that have been successfully used in the business sector and increasingly so in healthcare. In May 2023 the electronic databases MEDLINE and EMBASE were systematically searched for primary research studies on CoPs published between 1st January 1950 and 31st December 2022. PRISMA guidelines were followed. The following search terms were used: community/communities of practice AND (healthcare OR medicine OR patient/s). The database search picked up 2009 studies for screening. Of these, 50 papers met the inclusion criteria. The most common aim of CoPs was to directly improve a clinical outcome, with 19 studies aiming to achieve this. In terms of outcomes, qualitative outcomes were the most common measure used in 21 studies. Only 11 of the studies with a quantitative element had the appropriate statistical methodology to report significance. Of the 9 studies that showed a statistically significant effect, 5 showed improvements in hospital-based provision of services such as discharge planning or rehabilitation services. 2 of the studies showed improvements in primary-care, such as management of hepatitis C, and 2 studies showed improvements in direct clinical outcomes, such as central line infections. CoPs in healthcare are aimed at improving clinical outcomes and have been shown to be effective. There is still progress to be made and a need for further studies with more rigorous methodologies, such as RCTs, to provide further support of the causality of CoPs on outcomes., Competing Interests: Usman Jaffer is co-founder and CEO of health-shared.com an online platform that hosts communities of practice. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Noar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Duplex ultrasound (DUS) is the most widely used method for surveillance of arteriovenous fistulae (AVF) created for dialysis. However, DUS is poor at predicting AVF outcomes and there is a need for novel methods that can more accurately evaluate multidirectional AVF flow. In this study we aimed to evaluate the feasibility of detecting AVF stenosis using a novel method combining tensor-decomposition of B-mode ultrasound cine loops (videos) of blood flow and machine learning classification. Classification of stenosis was based on the DUS assessment of blood flow volume, vessel diameter size, flow velocity, and spectral waveform features. Real-time B-mode cine loops of the arterial inflow, anastomosis, and venous outflow of the AVFs were analysed. Tensor decompositions were computed from both the 'full-frame' (whole-image) videos and 'cropped' videos (to include areas of blood flow only). The resulting output were labelled for the presence of stenosis, as per the DUS findings, and used as a set of features for classification using a Long Short-Term Memory (LSTM) neural network. A total of 61 out of 66 available videos were used for analysis. The whole-image classifier failed to beat random guessing, achieving a mean area under the receiver operating characteristics (AUROC) value of 0.49 (CI 0.48 to 0.50). In contrast, the 'cropped' video classifier performed better with a mean AUROC of 0.82 (CI 0.66 to 0.96), showing promising predictive power despite the small size of the dataset. The combined application of tensor decomposition and machine learning are promising for the detection of AVF stenosis and warrant further investigation., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Poushpas et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Diabetic foot ulceration (DFU) is a common and challenging complication of diabetes. Risk stratification can guide further management. We aim to evaluate the prognostic performance of bedside tests used for peripheral arterial disease (PAD) diagnosis to predict DFU healing., Research Design and Methods: Testing for Arterial Disease in Diabetes (TrEAD) was a prospective observational study comparing the diagnostic performance of commonly used tests for PAD diagnosis. We performed a secondary analysis assessing whether these could predict DFU healing. Follow-up was performed prospectively for 12 months. The primary outcome was sensitivity for predicting ulcer healing. Secondary endpoints were specificity, predictive values, and likelihood ratios for ulcer healing., Results: 123 of TrEAD participants with DFU were included. In 12 months, 52.8% of ulcers healed. The best negative diagnostic likelihood ratio (NDLR) was observed for the podiatry ankle duplex scan (PAD-scan) monophasic or biphasic with adverse features(NDLR 0.35, 95% CI 0.14-0.90). The highest positive likelihood ratios were observed for toe brachial pressure index of ≤0.2 (positive diagnostic likelihood ratio (PDLR) 7.67, 95% CI 0.91-64.84) and transcutaneous pressure of oxygen of ≤20 mm Hg (PDLR 2.68, 95% CI 0.54-13.25). Cox proportional hazards modeling demonstrated significantly greater probabilities of healing with triphasic waveforms (HR=2.54, 95% CI 1.23-5.3, p=0.012) and biphasic waveforms with non-adverse features (HR=13.67, 95% CI 4.78-39.1, p<0.001) on PAD-scan., Conclusions: No single test performed well enough to be used in isolation as a prognostic marker for the prediction of DFU healing., Trial Registration Number: NCT04058626., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In this narrative review, we present the evidence on nucleotide-binding and oligomerization (NOD) domain-like receptor (NLR) family pyrin domain (PYD)-containing 3 (NLRP3) inflammasome activation for its putative roles in the elusive pathomechanism of aging-related cerebral small vessel disease (CSVD). Although NLRP3 inflammasome-interleukin (IL)-1β has been implicated in the pathophysiology of coronary artery disease, its roles in cerebral arteriothrombotic micro-circulation disease such as CSVD remains unexplored. Here, we elaborate on the current manifestations of CSVD and its' complex pathogenesis and relate the array of activators and aberrant activation involving NLRP3 inflammasome with this condition. These neuroinflammatory insights would expand on our current understanding of CSVD clinical (and subclinical) heterogenous manifestations whilst highlighting plausible NLRP3-linked therapeutic targets.

Objective: To evaluate the cost-effectiveness of point-of-care duplex ultrasound (PAD-scan) and other bedside tests for the diagnosis of peripheral arterial disease (PAD) in people with diabetes., Background: PAD is a risk factor for cardiovascular disease, diabetic foot ulceration (DFU), and amputation in diabetic patients. Diagnosis enables optimization of therapies to manage these risks. PAD-scan can be performed by frontline staff and has been shown to be the most accurate bedside test. However, its cost-effectiveness has not been investigated., Methods: A Markov model was constructed to estimate the health outcomes and costs over 5 years of different testing strategies applied to a cohort of diabetic patients. Bedside tests investigated were PAD-scan, ankle-brachial pressure index, toe-brachial pressure index, audible and visual Doppler, transcutaneous pressure of oxygen, and pulse palpation. Health outcomes were incidence of new DFU, major cardiovascular events, amputation, death, and DFU healing rates. Sensitivity analyses were performed., Results: PAD-scan was the most cost-effective bedside test with an incremental cost-effectiveness ratio of £11,391/quality-adjusted life years. PADscan had the highest probability (78.7%) of having the greatest net benefit at a willingness to pay threshold of £20,000 per quality-adjusted life years. It reduced the number of amputations by 24% and the number of cardiovascular deaths by 10% over 5 years, compared to toe-brachial pressure index (next best alternative). PAD-scans superiority in incremental cost-effectiveness ratio occurred at a PAD prevalence threshold of 0.24., Discussion: PAD-scan is a cost-effective test for the detection of PAD in patients with diabetes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Quality of intraoperative teamwork may have a direct impact on patient outcomes. Heart rate variability (HRV) synchrony may be useful for objective assessment of team cohesion and good teamwork. The primary aim of this study was to investigate the feasibility of using HRV synchrony in surgical teams. Secondary aims were to investigate the association of HRV synchrony with length of procedure (LOP), complications, number of intraoperative glitches and length of stay (LOS). We also investigated the correlation between HRV synchrony and team familiarity, pre- and intraoperative stress levels (STAI questionnaire), NOTECHS score and experience of team members. Methods: Ear, nose and throat (ENT) and vascular surgeons (consultant and registrar team members) were recruited into the study. Baseline demographics including level of team members’ experience were gathered before each procedure. For each procedure, continuous electrocardiogram (ECG) recording was performed and questionnaires regarding pre- and intraoperative stress levels and non-technical skills (NOTECHS) scores were collected for each team member. An independent observer documented the time of each intraoperative glitch. Statistical analysis was conducted using stepwise multiple linear regression. Results: Four HRV synchrony metrics which may be markers of efficient surgical collaboration were identified from the data: 1. number of HRV synchronies per hour of procedure, 2. number of HRV synchrony trends per hour of procedure, 3. length of HRV synchrony trends per hour of procedure, 4. area under the HRV synchrony trend curve per hour of procedure. LOP was inversely correlated with number of HRV synchrony trends per hour of procedure (p < 0.0001), area under HRV synchrony trend curve per hour of procedure (p = 0.001), length of HRV synchrony trends per hour of procedure (p = 0.002) and number of HRV synchronies per hour of procedure (p < 0.0001). LOP was positively correlated with: FS (p = 0.043; R = 0.358) and intraoperative STAI score of the whole team (p = 0.007; R = 0.493). Conclusions: HRV synchrony metrics within operating teams may be used as an objective marker to quantify surgical teamwork. We have shown that LOP is shorter when the intraoperative surgical teams’ HRV is more synchronised.

Introduction: Peripheral arterial disease (PAD) is a key risk factor for cardiovascular disease, foot ulceration and lower limb amputation in people with diabetes. Early diagnosis of PAD can enable optimisation of therapies to manage these risks. Its diagnosis is fundamental, though challenging in the context of diabetes. Although a variety of diagnostic bedside tests are available, there is no agreement as to which is the most accurate in routine clinical practice.The aim of this study is to determine the diagnostic performance of a variety of tests (audible waveform assessment, visual waveform assessment, ankle brachial pressure index (ABPI), exercise ABPI and toe brachial pressure index (TBPI)) for the diagnosis of PAD in people with diabetes as determined by a reference test (CT angiography (CTA) or magnetic resonance angiography (MRA)). In selected centres, we also aim to evaluate the performance of a new point-of-care duplex ultrasound scan (PAD-scan)., Methods and Analysis: A prospective multicentre diagnostic accuracy study (ClinicalTrials.gov Identifier NCT05009602). We aim to recruit 730 people with diabetes from 18 centres across the UK, covering primary and secondary healthcare. Consenting participants will undergo the tests under investigation. Reference tests (CTA or MRA) will be performed within 6 weeks of the index tests. Imaging will be reported by blinded consultant radiologists at a core imaging lab, using a validated scoring system, which will also be used to categorise PAD severity. The presence of one or more arterial lesions of ≥50% stenosis, or tandem lesions with a combined value of ≥50%, will be used as the threshold for the diagnosis of PAD. The primary outcome measure of diagnostic performance will be test sensitivity., Ethics and Dissemination: The study has received approval from the National Research Ethics Service (NRES) (REC reference 21/PR/1221). Results will be disseminated through research presentations and papers., Trial Registration Number: NCT05009602., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objective: We compared the diagnostic performance of a novel point-of-care duplex ultrasound test (podiatry ankle duplex scan; PAD-scan) against commonly used bedside tests for the detection of PAD in diabetes., Background: PAD is a major risk factor for diabetic foot ulceration and amputation. Its diagnosis is fundamental though challenging. Although a variety of bedside tests are available, there is no agreement as to which is the most useful. PAD-scan may be advantageous over current tests as it allows for vessel visualization and more accurate arterial waveform assessment. However, its accuracy has not been previously evaluated., Methods: From March to October 2019, we recruited 305 patients from 2 diabetic foot clinics. The diagnostic performance of ankle-brachial pressure index, toe-brachial pressure index, transcutaneous pressure of oxygen, pulse palpation, and ankle waveform assessment using PAD-scan and Doppler devices (audible and visual waveform assessment) were assessed. The reference test was a full lower limb duplex ultrasound., Results: Based on the reference test, 202 (66.2%) patients had evidence of PAD. PAD-scan had a significantly higher sensitivity [95%, confidence interval (CI) 90%-97%) as compared to all other tests. Particularly low sensitivities were seen with pulse palpation (43%, CI 36%-50%) and transcutaneous pressure of oxygen (31%, CI 24%-38%). PAD-scan had a lower specificity (77%, CI 67%-84%) compared to toe-brachial pressure index (86%, CI 78%-93%; P < 0.001), but not statistically different when compared to all other tests., Conclusions: PAD-scan has superior diagnostic utility and is a valid first line investigation., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Point-of-care duplex ultrasound has emerged as a promising test for the diagnosis of peripheral artery disease (PAD). However, the interpretation of morphologically diverse Doppler arterial spectral waveforms is challenging and associated with wide inter-observer variation. The aim of this study is to evaluate the utility of machine learning techniques for the diagnosis of PAD from Doppler arterial spectral waveforms sampled at the level of the ankle in patients with diabetes., Methods: In two centres, 590 Doppler arterial spectral waveform images (PAD 369, no-PAD 221) from 305 patients were prospectively collected. Doppler arterial spectral waveform signals were reconstructed. Blinded full lower-limb reference duplex ultrasound results were used to label waveform according to PAD status (i.e., PAD, no-PAD). Statistical metrics and multiscale wavelet variance were extracted as discriminatory features. A long short-term memory (LSTM) network was used for the classification of raw signals, and logistic regression (LR) and support vector machines (SVM) were used for classification of extracted features. Signals and feature vectors were randomly divided into training (80%) and testing (20%) sets., Results: The highest overall accuracy was achieved using a logistic regression model with a combination of statistical and multiscale wavelet variance features, with 88% accuracy, 92% sensitivity, and 82% specificity. The area under the receiver operating characteristics curve (AUC) was 0.93., Conclusion: We have constructed a machine learning algorithm with high discriminatory ability for the diagnosis of PAD using Doppler arterial spectral waveforms sampled at the ankle vessels.

Introduction: The aim of this study was to identify factors associated with primary graft patency 1 year following open lower limb revascularisation (LLR) at a tertiary referral vascular service., Methods: A retrospective analysis of patients undergoing infra-inguinal bypass surgery between January 2016 and May 2017 at a tertiary vascular centre (St Mary's Hospital, London) was performed. Data regarding patient demographics, comorbidities, type of operation and post-operative anti-thrombotic strategy were collected. Quality of run-off score was assessed from pre-operative imaging., Results: Seventy-seven cases were included in the analysis. Overall, the primary patency rate at 1-year was 63.6% ( n  = 49/77) and the secondary patency rate was 67.5% ( n  = 52/77). Independent variables with statistically significant inferior patency rates at 1-year were (1) bypasses with below knee targets (p = 0.0096), (2) chronic limb threatening ischaemia indication (p = 0.038), (3) previous ipsilateral revascularisation (p < 0.001) and (4) absence of hypertension history (p = 0.041). There was also a trend towards significance for American Society of Anesthesiologists (ASA) grade (p = 0.06). Independent variables with log-rank test p values of <0.1 were included in a Cox proportional hazards model. The only variable with a statistically significant impact on primary patency rates was previous open or endovascular ipsilateral revascularisation (HR 2.44 (1.04-5.7), p = 0.04)., Conclusion: At 1-year follow-up, previous ipsilateral revascularisation was the most significant factor in affecting patency rates. Patients in this subgroup should therefore be deemed high-risk, which should be reflected in the informed consent and peri-operative management.

Background: Intermittent claudication (IC) is a common manifestation of peripheral arterial disease. Some patients with IC experience a rise in Urinary N-acetyl-β-D-Glucosaminidase (NAG)/ Creatinine (Cr) ratio, a marker of renal injury, following exercise. In this study, we aim to investigate whether peripheral blood mononuclear cells (PBMC) from patients with IC who exhibit a rise in urinary NAG/ Cr ratio following exercise exhibit differential IL-10/ IL-12 ratio and gene expression compared to those who do not have a rise in NAG/ Cr ratio., Methods: We conducted a single center observational cohort study of patients diagnosed with IC. Blood and urine samples were collected at rest and following a standardised treadmill exercise protocol. For comparative analysis patients were separated into those with any rise in NAG/Cr ratio (Group 1) and those with no rise in NAG/Cr ratio (Group 2) post exercise. Isolated PBMC from pre- and post-exercise blood samples were analysed using flow cytometry. PBMC were also cultured for 20 hours to perform further analysis of IL-10 and IL-12 cytokine levels. RNA-sequencing analysis was performed to identify differentially expressed genes between the groups., Results: 20 patients were recruited (Group 1, n = 8; Group 2, n = 12). We observed a significantly higher IL-10/IL-12 ratio in cell supernatant from participants in Group 1, as compared to Group 2, on exercise at 20 hours incubation; 47.24 (IQR 9.70-65.83) vs 6.13 (4.88-12.24), p = 0.04. 328 genes were significantly differentially expressed between Group 1 and 2. The modulated genes had signatures encompassing hypoxia, metabolic adaptation to starvation, inflammatory activation, renal protection, and oxidative stress., Discussion: Our results suggest that some patients with IC have an altered immune status making them 'vulnerable' to systemic inflammation and renal injury following exercise. We have identified a panel of genes which are differentially expressed in this group of patients., Competing Interests: The authors have declared that no competing interests exist.

Web-based health care content has emerged as a primary source for patients to access health information without direct guidance from health care providers. The benefit of this approach is dependent on the ability of patients to access engaging high-quality information, but significant variability in the quality of web-based information often forces patients to navigate large quantities of inaccurate, incomplete, irrelevant, or inaccessible content. Personalization positions the patient at the center of health care models by considering their needs, preferences, goals, and values. However, the traditional methods used thus far in health care to determine the factors of high-quality content for a particular user are insufficient. Machine learning (ML) uses algorithms to process and uncover patterns within large volumes of data to develop predictive models that automatically improve over time. The health care sector has lagged behind other industries in implementing ML to analyze user and content features, which can automate personalized content recommendations on a mass scale. With the advent of big data in health care, which builds comprehensive patient profiles drawn from several disparate sources, ML can be used to integrate structured and unstructured data from users and content to deliver content that is predicted to be effective and engaging for patients. This enables patients to engage in their health and support education, self-management, and positive behavior change as well as to enhance clinical outcomes., (©Ahmad Guni, Pasha Normahani, Alun Davies, Usman Jaffer. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 19.10.2021.)

Objective: We assessed the association between (1) severity of vessel wall calcification, (2) number of patent vessels at the ankle and (3) arterial spectral waveform features, as assessed on a focused ankle Duplex ultrasound (DUS), and healing at 12-months in a cohort of patients who had their diabetic foot ulcers conservatively managed., Research Design and Methods: Scans performed on 50 limbs in 48 patients were included for analysis. Patient health records were prospectively reviewed for 12-months to assess for the outcome of ulcer healing., Results: We identified that the number of waveform components, peak systolic velocity, systolic rise time and long forward flow as well as the number of vessels patent at the ankle on DUS, may be useful independent predictors of healing, as noted by the trend towards statistical significance., Conclusion: Arterial spectral waveform features may be useful in predicting the chance of diabetic foot ulcer healing.

Background: Web-based content is rapidly becoming the primary source of health care information. There is a pressing need for web-based health care content to not only be accurate but also be engaging. Improved engagement of people with web-based health care content has the potential to inform as well as influence behavioral change to enable people to make better health care choices. The factors associated with better engagement with web-based health care content have previously not been considered., Objective: The aims of this study are to identify the factors that affect engagement with web-based health care content and develop a framework to be considered when creating such content., Methods: A comprehensive search of the PubMed and MEDLINE database was performed from January 1, 1946, to January 5, 2020. The reference lists of all included studies were also searched. The Medical Subject Headings database was used to derive the following keywords: "patient information," "online," "internet," "web," and "content." All studies in English pertaining to the factors affecting engagement in web-based health care patient information were included. No restrictions were set on the study type. Analysis of the themes arising from the results was performed using inductive content analysis., Results: The search yielded 814 articles, of which 56 (6.9%) met our inclusion criteria. The studies ranged from observational and noncontrolled studies to quasi-experimental studies. Overall, there was significant heterogeneity in the types of interventions and outcome assessments, which made quantitative assessment difficult. Consensus among all authors of this study resulted in six categories that formed the basis of a framework to assess the factors affecting engagement in web-based health care content: easy to understand, support, adaptability, accessibility, visuals and content, and credibility and completeness., Conclusions: There is a paucity of high-quality data relating to the factors that improve the quality of engagement with web-based health care content. Our framework summarizes the reported studies, which may be useful to health care content creators. An evaluation of the utility of web-based content to engage users is of significant importance and may be accessible through tools such as the Net Promoter score. Web 3.0 technology and development of the field of psychographics for health care offer further potential for development. Future work may also involve improvement of the framework through a co-design process., (©Liam Alperen Oktay, Eyad Abuelgasim, Aida Abdelwahed, Nour Houbby, Smaragda Lampridou, Pasha Normahani, Nicholas Peters, Usman Jaffer. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 23.09.2021.)

Background and Aims: Patients with obesity are at high risk of suffering from arterial and venous peripheral vascular disease (PVD). Bariatric surgery is an effective strategy to achieve weight reduction for patients with obesity. The long-term impact of bariatric surgery on obesity-related morbidity is subject to increasing research interest. This study aimed to ascertain the impact of bariatric surgery on the long-term occurrence of PVD in patients with obesity., Methods: The study population was extracted from the Clinical Practice Research Datalink, a nation-wide database containing primary and secondary care records of consenting patients. The intervention cohort was 2959 patients who had undergone bariatric surgery during follow-up; their controls were 2959 propensity-score-matched counterparts. The primary endpoint was development of any PVD: arterial or venous. Secondary endpoints were incident peripheral arterial disease alone, incident peripheral venous disease alone., Results: Three hundred forty-six patients suffered a primary endpoint during follow-up. Bariatric surgery did not improve peripheral vascular disease rates as a whole, but it was associated with significantly lower event rates of arterial disease (HR = 0.560, 95%CI 0.327-0.959, p = 0.035) but higher event rates of venous disease (HR = 1.685, 95%CI 1.256-2.262, p < 0.001)., Conclusions: Bariatric surgery was associated with significantly reduced long-term occurrence of arterial disease but increased occurrence of venous disease in patients with obesity.

Objective: No agreement has been reached regarding which bedside test is the most useful for the diagnosis of peripheral arterial disease (PAD) in patients with diabetes. The aim of the present systematic review and meta-analysis was to evaluate the performance of bedside tests for the detection of PAD in individuals with diabetes., Methods: MEDLINE and EMBASE databases were systematically searched for studies providing data on the diagnostic performance of bedside tests used for the detection of PAD in those with diabetes. A meta-analysis was performed to obtain pooled estimates of sensitivity and specificity for the diagnosis of PAD., Results: A total of 18 studies, reporting on a total of 3016 limbs of diabetic patients, were included in our qualitative review. Of these, 11 studies (1543 limbs) were included in the meta-analysis of diagnostic accuracy: ankle-brachial pressure index (9 studies and 1368 limbs; sensitivity, 63.5% [95% confidence interval (CI), 51.7%-73.9%]; specificity, 89.3% [95% CI, 81.1%-94.2%]); toe-brachial pressure index (3 studies and 221 limbs; sensitivity, 83.0% [95% CI, 59.1-94.3%]; specificity, 66.3% [95% CI, 41.3%-84.6%]); and tibial waveform assessment (4 studies and 397 limbs; sensitivity, 82.8% [95% CI, 73.3%-89.4%], specificity, 86.8% [95% CI, 75.5%-93.3%]). Overall, we found a high risk of bias across the studies, most frequently relating to patient selection and the lack of blinding., Conclusions: The toe-brachial pressure index, pulse oximetry, and tibial arterial waveform assessment demonstrated some promise, warranting further investigation., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)