Complex stories can be entwined in children's rhymes, like ‘Pop goes the Weasel’, which has many versions. One stanza included above has the monkey, representing cockney rhyming slang for ₤500, going round and round the Mulberry pub, which also acts as a pawn shop, where you can hock your ‘weasel and stoat’, meaning cockney rhyming slang for your coat, which can also mean your suit or your Sunday best [1]. The vicissitudes of 1800s London for some, pawning your suit on a Monday and getting it back for church by Sunday, may not appeal to us from a distance of 200 years. Still, the origins of cause and effect in a vicious cycle are likely to interest us if we have a stake in one side of the equation.

So it is that Sarofim et al.'s [2] paper published online in January 2024 in Colorectal Disease provides food for thought regarding the relationship of irritable bowel syndrome (IBS) and faecal incontinence (FI) following primary repair of major obstetric anal sphincter injuries (OASIS). Just like finding out that ‘Pop goes the Weasel’ is a tune from 1854 that was a favourite of Queen Victoria and that the tune came first, and then the stanzas, unless you accept the possibility that the words may be 400 years old and then the whole thing got transferred and altered by word of mouth across the Atlantic, takes time, patience, clarity and continually checking your bearings [3]. What the words now mean and what they were meant to mean can be lost in time, translation and cognisance. So it is with research and appropriately connecting association which does not equal causation. My comments are from the point of view of being asked to review the second revision of this paper, and therefore are encouraging and not disparaging.

The authors surveyed a series of 82 women post-OASIS, with an 89% response rate at a mean of 26 months. They compared these patients with 55 primigravid women who completed surveys during the first trimester of pregnancy when first being reviewed by a provider, and 83 patients were primigravid women who underwent an elective C-section. The authors state that the first control group allows for IBS comparison with uninjured sphincters, and the second for comparison of full-term effect on the pelvic floor.

In the abstract conclusion, one concern I had was the importance of adding a time clause indicating that at medium follow-up, that is, at 26 months, OASIS has a limited negative effect. This is important because the study does not have long-term follow-up at 10, 20, 30, 40 years when many of these women show up again. We also do not want OASIS to be perceived as not necessary to repair either.

While IBS may be associated with Cleveland Clinic faecal incontinence (CCI) scores, the IBS tool was used post-OASIS and cannot exclude the possibility that the OASIS is the cause of the IBS. Likewise, since the IBS criteria were used post-delivery, I fail to see how the authors can recommend use of the IBS tool as a screening tool when they used it as a post-partum tool; they did not do that study except a priori with a group they assume is their valid control. Why are the IBS-reported symptoms not a confounder for the pelvic floor damage and subsequent functional problems associated with OASIS?

The paper's conclusion commences with the obvious conclusion which is ‘After primary repair of major OASIS, patients are less likely to retain perfect continence compared to control groups’. Yet the abstract conclusion does not commence with this most obvious and provable result of this study.

The authors present the CCI scores according to the three groups in Table 5, and also the IBS present or absent status in Table 3, but they do not present the incidence of IBS across the CCI stratifications of the three groups. If that had been added to Table 5, the reader could have viewed the distribution of CCI and IBS across the three groups A, B, C. It is also usual to see a univariate and multivariate table with the data to see the outcome and variables more clearly. This does not require an extra table, but enhancing one already there. I had envisioned Tables 5–7 being combined and including the multivariate data. The point, as stated, is to better understand the data, and allow self-interpretation in this most important subset of patients [4].

复杂的故事可以与儿歌交织在一起，比如《黄鼠狼流行》就有很多版本。上面的一节中有一只猴子，代表伦敦押韵俚语，价格为 500 英镑，在 Mulberry 酒吧里转了一圈又一圈，这里也是一家当铺，你可以在那里使用“黄鼠狼和白鼬”，意思是你的外套的伦敦押韵俚语。 ，这也可以表示您的西装或周日最好的衣服 [ 1 ]。对于一些人来说，1800 年代伦敦的沧桑，周一当掉你的西装，周日把它带回教堂，可能对我们相距 200 年没有吸引力。尽管如此，如果我们在等式的一侧有利害关系，那么恶性循环中因果关系的起源可能会让我们感兴趣。

因此，Sarofim 等人于 2024 年 1 月在《结直肠疾病》在线发表的 [ 2 ] 论文提供了有关产科肛门括约肌初次修复后肠易激综合征 (IBS) 和大便失禁 (FI) 之间关系的思考伤害（绿洲）。就像发现“Pop go the Weasel”是一首 1854 年的曲子，维多利亚女王最喜欢的曲子，先是曲子，然后是诗节，除非你接受这样的可能性：这些词可能有 400 年的历史，然后是诗节。整个事情通过大西洋彼岸的口口相传而转移和改变，需要时间、耐心、清晰度和不断检查你的方位[ 3 ]。这些词现在的含义以及它们原本的含义可能会随着时间、翻译和认知而消失。研究和适当地联系关联并不等于因果关系也是如此。我的评论是从被要求审查本文第二次修订的角度出发的，因此是鼓励而不是贬低。

作者对 OASIS 后的 82 名女性进行了一系列调查，平均 26 个月的回复率为 89%。他们将这些患者与 55 名初产妇进行了比较，这些妇女在怀孕前三个月接受服务提供者的首次审查时完成了调查，其中 83 名患者是接受选择性剖腹产的初产妇。作者指出，第一个对照组允许与未受伤的括约肌进行 IBS 比较，第二个对照组用于比较对盆底的足月影响。

在抽象结论中，我担心的一个问题是添加一个时间条款的重要性，表明在中期随访（即 26 个月）时，OASIS 的负面影响有限。这一点很重要，因为该研究没有对 10、20、30、40 年这些女性中的许多人再次出现的情况进行长期随访。我们也不希望 OASIS 被认为不需要修复。

虽然 IBS 可能与克利夫兰诊所大便失禁 (CCI) 评分相关，但 IBS 工具是在 OASIS 之后使用的，不能排除 OASIS 是 IBS 原因的可能性。同样，由于 IBS 标准是在产后使用的，因此我不明白作者在将 IBS 工具用作产后工具时如何建议使用 IBS 工具作为筛查工具；他们没有进行这项研究，除非先验地与他们认为是有效对照的一组进行了研究。为什么 IBS 报告的症状不会与 OASIS 相关的盆底损伤和随后的功能问题混杂在一起？

论文的结论从一个明显的结论开始，即“在主要 OASIS 初次修复后，与对照组相比，患者不太可能保持完美的自制能力”。然而，抽象结论并不是从这项研究最明显、最可证明的结果开始的。

作者根据表 5 中的三组提供了 CCI 评分，并在表 3 中提供了 IBS 存在或不存在状态，但他们没有提供三组 CCI 分层中 IBS 的发生率。如果将其添加到表 5 中，读者可以查看 A、B、C 三组中的 CCI 和 IBS 分布。通常还可以查看包含数据的单变量和多变量表，以查看结果和变量更清楚。这不需要额外的表，而是增强已有的表。我曾设想将表 5-7 合并并包含多变量数据。如前所述，重点是更好地理解数据，并允许对这一最重要的患者子集进行自我解释 [ 4 ]。