Exploring methods of improving patient understanding and communication in a complex anal fistula clinic: results from a randomized controlled feasibility study.

AIM: Patient understanding of disease can guide decision-making in the management of anal fistula. This prospective feasibility study aimed to assess the acceptability and methods of assessing the impact of viewing realistic models on patients with anal fistula. METHODS: New referrals to a tertiary clinic participated in this single-centre, parallel-group randomized controlled study. Baseline characteristics, Decisional Conflict Scale and understanding of disease were assessed pre-consultation. Participants were randomized to a standard consultation, where disease and treatment options were explained using magnetic resonance images and drawn diagrams, or a similar consultation supplemented with an appropriate generic three-dimensional (3D) printed model. Understanding of disease and proposed surgery, Decisional Conflict Scale and ratings of visual aids were assessed post-consultation, along with 3D model feedback. RESULTS: All 52 patients who were approached agreed to be randomized (25 standard, 27 3D consultation). Understanding of disease increased post-consultation in both groups. Post-consultation decisional conflict (0, no; 100, high decisional conflict) was low (median 27 post-standard vs. 24 post-3D consultation). Patients scored highly on measures assessing understanding of proposed surgery. 3D models were rated highly, with 96% of patients wanting to see them again in future consultations. CONCLUSIONS: Three-dimensional printed fistula models are a welcome addition to outpatient consultations with results suggesting that understanding of surgery is improved. A future trial should be powered to detect whether 3D models result in a significant improvement in understanding beyond traditional methods of explanation and explore the conditions in which models have their maximal utility. GOV REGISTRATION ID: This study was registered on ClinicalTrials.gov (ID: NCT04069728). Registered on 23 August 2019.

The development of a cryptoglandular anal fistula quality of life scale (AF-QoL).

AIM: Quality of life (QoL) is a crucial and core outcome in assessing the effectiveness of treatments for cryptoglandular anal fistula. Despite its extensive impact, there is a lack of patient-centred, disease-specific QoL measurement instruments of adequate quality. The aim of this study is to develop a disease-specific measurement instrument that can accurately measure QoL for patients with cryptoglandular anal fistula. METHOD: Semi-structured qualitative patient interviews and a systematic review of current instruments were used to generate items for the draft instrument. This underwent successive rounds of cognitive interviews to refine its wording and structure. Individual item and overall scale content validity were determined by asking experts to rate the relevance of each item and those deemed irrelevant were removed. The final instrument then underwent psychometric testing and test-retest analysis to determine its sensitivity and stability. RESULTS: A total of 148 patients were involved in item generation, scale development and psychometric testing. A 22-item measurement instrument has been developed; it is scored on a scale of 0-100, where 0 indicates the worst QoL and 100 demonstrates perfect QoL. The scale demonstrates excellent internal consistency (Cronbach-α = 0.927), strong content and construct validity [correlation with Perianal Disease Activity Index = -0.713, Hospital Anxiety and Depression Anxiety (-0.659) and Depression (-0.673) subscales and Short Form-12 physical (0.609) and mental (0.589) component scales] and strong reliability and responsiveness. CONCLUSION: We have developed a cryptoglandular Anal Fistula Quality of Life scale (AF-QoL), a comprehensive, disease-specific patient reported outcome measure assessing QoL in patients with cryptoglandular anal fistula.

European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula.

AIM: The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology. METHODS: Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG. RESULTS: In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations. CONCLUSION: This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.

AFCOS: The Development of a Cryptoglandular Anal Fistula Core Outcome Set.

OBJECTIVE: To develop a cryptoglandular Anal Fistula Core Outcome Set: a minimum set of outcomes that should be measured in all studies of cryptoglandular anal fistula treatment. BACKGROUND: Variability in the outcomes that are reported in studies of cryptoglandular anal fistula treatment hampers systematic evidence synthesis to identify the best treatment. METHODS: This study followed guidance from the Core Outcome Measures in Effectiveness Trials initiative and consisted of three stages: (1) generation of candidate outcomes through systematic review of the literature and qualitative patient interviews; (2) prioritization of outcomes by key stakeholders, including patients, surgeons, gastroenterologists, and radiologists in an online Delphi consensus process; and (3) determination of the final Core Outcome Set (COS) in a consensus meeting attended by patients and clinicians. RESULTS: Sixty-four outcomes were presented in the first Delphi survey round. A total of 191 participants from over 30 countries ranked these outcomes according to their importance in defining treatment success (57.6% surgeons and gastroenterologists, 8.9% radiologists, and 33.5% patients). After two rounds, 53 outcomes were identified as important and discussed in the consensus meeting attended by 10 patients and 12 clinicians. A final 10 outcomes were voted into the COS: clinical fistula healing, radiological healing, recurrence, development of additional fistulas, fistula symptoms, incontinence, psychological impact of treatment, complications and reinterventions, patient satisfaction, and quality of life. CONCLUSION: The final COS represents an international, multidisciplinary, patient-centered attempt to establish consistency in fistula research, with a substantial focus on patient priorities for treatment.

The development of a minimum dataset for MRI reporting of anorectal fistula: a multi-disciplinary, expert consensus process.

There are a range of sphincter-preserving procedures available to treat anorectal fistula, some of which can be precluded, or rendered more optimal by specific features of fistula anatomy. Magnetic resonance imaging (MRI) is the gold standard modality for assessing anorectal fistula. To maximise clinical utility, the MRI report should accurately describe these clinically relevant features. We aimed to develop a minimum dataset for reporting MRI of anorectal fistula, in order to improve the assessment and management of these patients. A longlist of 70 potential items for the minimum dataset was generated through systematic review of the literature. This longlist was presented to radiologists, surgeons and gastroenterologists in an online survey to understand the features that shape current clinical practice. The longlist and survey results were then presented to an expert consensus panel to generate the final minimum dataset through discussion and anonymous voting. The final minimum dataset details the general characteristics, features of the internal and external openings, path of the fistula through the sphincters and any associated extensions and collections that should be described in all MRI reports for anal fistula. Additional surgical and perianal Crohn's disease subsets were developed to indicate the features that aid decision-making for these patients, in addition to a minimum dataset for the clinical request. This study represents a multi-disciplinary approach to developing a minimum dataset for MRI reporting of anal fistula, highlighting the most important features to report that can assist in clinical decision-making. KEY POINTS: • This paper recommends the minimum features that should be included in all MRI reports for the assessment of anal fistula, including Parks classification, number of tracts, features of the internal and external opening, path of the tract through the sphincters, the presence and features of extensions and collections. • Additional features that aid decision-making for surgery or in the presence of Crohn's disease have been identified. • The items that should be included when requesting an MRI are specified.

Living with cryptoglandular anal fistula: a qualitative investigation of the patient's experience through semi-structured patient interviews.

PURPOSE: Cryptoglandular anal fistula continues to be a subject of extensive surgical research due to the lack of effective and enduring treatments, some of which incur risks to continence and quality of life. However, the patient experience of disease has seldom been reported. The aims of this study are to understand the impact of living with a fistula and the treatment outcomes that are valued by patients. METHODS: Patients with cryptoglandular anal fistula were recruited using purposive sampling from two tertiary referral centres in the UK and the Netherlands. Patients underwent semi-structured interviews that were audio-recorded and transcribed verbatim. Dutch transcripts were translated into English and underwent independent, thematic analysis using open coding by two study team members to identify common themes and sub-themes. RESULTS: Twenty interviews were conducted before saturation was reached (11 male, median age 49, Interquartile range 39-55 years). Four broad themes emerged, covering the physical symptoms of fistula, the patient journey towards understanding the condition, life impact, and treatment. Several inter-related sub-themes were found, reflecting the extensive impact and adjustment that the disease entails. CONCLUSION: The impact of cryptoglandular anal fistula extends beyond the physical symptoms of pain and discharge, requires significant readjustment, and often negatively impacts psycho-social wellbeing. These aspects of disease should receive greater attention in future assessment of treatment and quality of life.

The Essential Role of a Multidisciplinary Approach in Inflammatory Bowel Diseases: Combined Medical-Surgical Treatment in Complex Perianal Fistulas in CD.

Perianal fistulizing Crohn's disease (PFCD) represents a challenging and complex disease phenotype. Patients typically suffer a more severe disease course than those without perianal complications and are often managing debilitating symptoms. Etiology is understood to be multifactorial, with genetic predisposition, microbiological insult, aberrant immunity, and mechanical factors all implicated. As a result, multimodal treatment strategies must be employed to achieve disease control and fistula closure. This requires the complimentary involvement of medical and surgical disciplines in order to ensure thorough assessment and treatment tailored to the individual scenario and patient goals. The aim of this article is to describe an overview of the various treatment strategies available for PFCD, focusing on how a synergistic approach is required to ensure maximal chances of success.

Is fistulotomy with immediate sphincter reconstruction (FISR) a sphincter preserving procedure for high anal fistula? A systematic review and meta-analysis.

AIM: This systematic review aimed to assess the outcomes of fistulotomy or fistulectomy and immediate sphincter repair (FISR) in relation to healing, incontinence and sphincter dehiscence both overall and in patients with high anal fistulae. METHODS: Medline, Embase and The Cochrane library were searched for studies of patients undergoing FISR for anal fistula. Data regarding healing, continence and sphincter dehiscence were extracted overall and for high anal fistulae. The DerSimonian-Laird random-effects method was used for pooled analysis, heterogeneity between studies was assessed based on the significance of between-study heterogeneity, and on the size of the I2  value. Risk of bias was assessed using the Cochrane risk of bias tool and the Newcastle-Ottawa scale. RESULTS: We identified 21 studies evaluating 1700 patients. Pooled analysis of healing reached 93% (95% CI: 91%-95%, I2  = 51% p-value for heterogeneity = 0.004), with continence disturbance and worsening continence reaching 11% (95% CI: 6%-18%, I2  = 87% p < 0.001) and 8% (95% CI: 4%-13%, I2  = 74% p < 0.001), respectively. Subgroup analysis according to fistula height could only be conducted on limited data. Pooled healing in high anal fistulae was 89% (95% CI: 84%-94%, I2  = 76% p < 0.001), 16% suffered disturbance of continence (95% CI: 7%-27%, I2  = 89% p < 0.001), 8% worsening continence from baseline (95% CI: 2%-16%, I2  = 80% p < 0.001) and 2% suffered sphincter dehiscence (95% CI: 0%-10%, I2  = 89% p < 0.001). CONCLUSION: The evidence suggests FISR is a safe, effective procedure. However, data are limited by inconsistencies in reporting of continence and definition of fistula height, particularly high anal fistulae. Significant heterogeneity means that outcomes in high fistulae remain uncertain.

Encapsulation of water soluble pesticides for extended delivery of pesticides without contaminating water bodies.

The main objective of this study is to develop polymeric encapsulated formulation for the water soluble broad-spectrum pesticides. Pesticides contaminate the environment in different ways but foremost hazards are linked with the contamination of water bodies. Water soluble pesticides are the major deleterious agents and go off into ground water and different water bodies through leaching or surface runoff from the applied places. Besides this some of the water soluble pesticides are broad-spectrum, but proper methods and techniques are not available for their effective and safe usage, all broad-spectrum pesticide are disappearing from the pesticide lists every year. Hence, the present study is based on development of encapsulated formulation for water soluble broad-spectrum pesticide i.e. Monocrotophos. In this study, water soluble pesticide was encapsulated in polyvinyl alcohol (PVA) polymer along with surfactants and cross linker. The developed microspheres were analyzed in HPLC for calculating loading capacity and encapsulation efficacy, these were calculated 0.75 and 90% respectively. The FT-IR data results confirmed that the monocrotophos successfully encapsulated in the PVA polymer with respective bands. The degradation studies show that in encapsulated formulation monocrotophos degradation was found only 10% after 94 hrs. Optical micrographs in aqeous solution indicate spherical shapes with size in the rage of 7-8 µm of encapsulated formulation. XRD data further crystalline nature of polymeric encapsulated formulation. The study may provide a new corridor to save the broad-spectrum water soluble pesticides which are on the verge to be banned.

Synthesis and surface engineering of magnetic nanoparticles for environmental cleanup and pesticide residue analysis: a review.

In recent years, water pollution and pesticide accumulation in the food chain have become a serious environmental and health hazard problem. Direct determination of these contaminants is a difficult task due to their low concentration level and the matrix interferences. Therefore, an efficient separation and preconcentration procedure is often required prior to the analysis. With the advancement in nanotechnology, various types of magnetic core-shell nanoparticles have successfully been synthesized and received considerable attention as sorbents for decontamination of diverse matrices. Magnetic core-shell nanoparticles with surface modifications have the advantages of large surface-area-to-volume ratio, high number of surface active sites, no secondary pollutant, and high magnetic properties. Due to their physicochemical properties, surface-modified magnetic core-shell nanoparticles exhibit high adsorption efficiency, high rate of removal of contaminants, and easy as well as rapid separation of adsorbent from solution via external magnetic field. Such facile separation is essential to improve the operation efficiency. In addition, reuse of nanoparticles would substantially reduce the treatment cost. In this review article, we have attempted to summarize recent studies that address the preconcentration methods of pesticide residue analysis and removal of toxic contaminants from aquatic systems using magnetic core-shell nanoparticles as adsorbents.

ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment.

This article is the second in a series of two publications on the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of prior ECCO guidelines.

Where Are We and Where to Next?-The Future of Perianal Crohn's Disease Management.

Perianal fistulizing Crohn's Disease (pCD) affects about 25% of patients with Crohn's Disease (CD). It remains a difficult entity to manage with a therapeutic ceiling of treatment success despite improving medical and surgical management. The refractory nature of the disease calls for an imminent need to better understand its immunopathogenesis and classification to better streamline our treatment options. In this article, we overview the current state of pCD management and discuss where the future of its management may lie.

Eco-Oriented Formulation and Stabilization of Oil-Colloidal Biodelivery Systems Based on GC-MS/MS-Profiled Phytochemicals from Wild Tomato for Long-Term Retention and Penetration on Applied Surfaces for Effective Crop Protection.

Vegetable oils as hydrophobic reserves in oil dispersions (OD) provide a practical approach to halt bioactive degradation for user and environment-efficient pest management. Using biodegradable soybean oil (57%), castor oil ethoxylate (5%), calcium dodecyl benzenesulfonates as nonionic and an-ionic surfactants, bentonite (2%), and fumed silica as rheology modifiers, we created an oil-colloidal biodelivery sytem (30%) of tomato extract with homogenization. The quality-influencing parameters, such as particle size (4.5 µm), dispersibility (97%), viscosity (61 cps), and thermal stability (2 years), have been optimized in accordance with specifications. Vegetable oil was chosen for its improved bioactive stability, high smoke point (257 °C), coformulant compatibility, and as a green build-in-adjuvant by improving spreadability (20-30%), retention and penetration (20-40%). In in vitro testing, it efficiently controlled aphids with 90.5% mortalities and 68.7-71.2% under field-conditions without producing phytotoxicity. Wild tomato-derived phytochemicals can be a safe and efficient alternative to chemical pesticides when combined wisely with vegetable oils.

Do Patient-Reported Quality-of-Life (QoL) Scales Provide an Adequate Assessment of Patients with Cryptoglandular Anal Fistulae? A Systematic Review of Measurement Instruments and Their Content Validity.

BACKGROUND: Cryptoglandular anal fistulae can significantly affect patient quality of life (QoL), making it essential to ensure that any study of fistula treatment assesses the impact on QoL. The aim of this systematic review was to evaluate the content validity of Patient-Reported Outcome Measures (PROMs) that assess QoL in patients with a fistula. METHODS: MEDLINE, EMBASE, PsycINFO, and Scopus were searched and studies assessing the content validity of patient-reported QoL measurement instruments, or PROM development studies in patients with cryptoglandular anal fistulae, were included. Data were extracted from eligible studies to determine the instruments' relevance, comprehensiveness, and comprehensibility, and their quality was assessed according to COnsensus-based Standards for the Selection of health Measurement Instruments (COSMIN). RESULTS: Two PROM development studies were identified, both of which described the development of a disease-specific QoL measurement instrument for patients with cryptoglandular anal fistulae. The overall content validity of these instruments was inconsistent and supported by very low-quality evidence. There were no studies assessing the content validity of established QoL measurement instruments in patients with fistulae. CONCLUSIONS: This systematic review could not establish the content validity of the available QoL PROMs for patients with anal fistulae, due either to the absence of designated content validity studies or a lack of comprehensiveness of the available PROMs. This highlights an important gap in the literature that needs to be addressed to ensure high-quality outcome assessment in patients with fistulae.

Bioengineering of neem nano-formulation with adjuvant for better adhesion over applied surface to give long term insect control.

Although safe and eco-friendly botanical pesticides have been intensively promoted to combat pest attacks in agriculture, but their stability and efficacies remain an issue for their wide acceptability as sustained and effective approaches. The purpose of this work was to develop stable neem oil based nano-emulsion (NE) formulation with enhanced activity employing suitable bio-inspired adjuvant. So, Neem NEs (with and without) natural adjuvants (Cymbopogon citratus and Prosopis juliflora) in different concentrations were prepared and quality parameters dictating kinetic stability, acidity/alkalinity, viscosity, droplet size, zeta potential, surface tension, stability and compatibility were monitored using Viscometer, Zetasizer, Surface Tensiometer, High Performance Liquid Chromatography (HPLC) and Fourier Transform Infrared Spectroscopy (FTIR). Nano-emulsion biosynthesis optimization studies suggested that slightly acidic (5.9-6.5) NE is kinetically stable with no phase separation; creaming or crystallization may be due to botanical adjuvant (lemongrass oil). Findings proved that Prosopis juliflora, acted as bio-polymeric adjuvant to stabilize NE by increasing Brownian motion and weakening the attractive forces with smaller droplets (25-50 nm), low zeta potential (-30 mV) and poly-dispersive index (<0.3). Botanical adjuvant (30%) based NE with optimum viscosity (98.8cPs) can give long term storage stability and improved adhesiveness and wetting with reduced surface tension and contact angle. FT-IR analysis assured azadirachtin's stability and compatibility with adjuvant. With negligible degradation (1.42%) and higher half-life (t1/2) of 492.95 days, natural adjuvant based NE is substantially stable formulation, may be due to presence of glycosidic and phenolics compounds. Neem 20NE (with 30% adjuvant) exhibited remarkable insecticidal activity (91.24%) against whitefly (Bemisia tabaci G.) in brinjal (Solanum melongena) as evidenced by in-vivo assay. Results thus obtained suggest, bio-pesticide formulation may be used as safer alternative to chemical pesticides to minimize pesticide residues and presence of natural adjuvant may improves the stability and efficacy of biopesticides for safe crop protection in organic agriculture and Integrated Pest Management.

Classifying perianal fistulising Crohn's disease: an expert consensus to guide decision-making in daily practice and clinical trials.

Perianal fistulising Crohn's disease is an aggressive disease phenotype that can have a substantial detrimental impact on patients' quality of life. Current biological understanding of perianal fistulising Crohn's disease remains inadequate and previous classification systems have not provided clear guidance on therapy in clinical practice nor on defining patient cohorts within clinical trials. We propose a new classification system for perianal fistulising Crohn's disease that was developed through a modified nominal group technique expert consensus process. The classification identifies four groups of patients. Key elements include stratification according to disease severity as well as disease outcome; synchronisation of patient and clinician goals in decision making, with a proactive, combined medical and surgical approach, on a treat to patient goal basis; and identification of indications for curative fistula treatment, diverting ostomy, and proctectomy. The new classification retains an element of flexibility, in which patients can cycle through different classes over time. Furthermore, with each specific class comes a paired treatment strategy suggestion and description of clinical trial suitability. The proposed classification system is the first of its kind and is an important step towards tailored standardisation of clinical practice and research in patients with perianal fistulising Crohn's disease.

Magnetic Solid-Phase Extraction (MSPE) Using Magnetite-Based Core-Shell Nanoparticles with Silica Network (SiO2) Coupled with GC-MS/MS Analysis for Determination of Multiclass Pesticides in Water.

BACKGROUND: For the analysis of pesticide residues in water samples, various extraction techniques are available. However, liquid-liquid extraction (LLE) and solid-phase extraction (SPE) are most commonly used. LLE and SPE extraction techniques each have their own disadvantages. OBJECTIVE: The aim of the study was to develop an environment-friendly multi-residue method for determination of multiclass pesticides in environmental water samples (ground water, agricultural field/irrigation run-off water, etc.). METHODS: The magnetic solid-phase extraction (MSPE) technique using surface-fabricated magnetic nano-particles was used for extraction of water samples, followed by quantification by gas chromatography tandem mass spectrometry. The developed multi-residue method was validated in terms of linearity, LOD, LOQ, recovery, and repeatability. RESULTS: Recovery data were obtained at the spiking concentration level of 1, 5, and 10 µg/L, yielding recoveries in the range of 70-120%. Overall, non-polar pesticides from all the groups, i.e., synthetic pyrethroid, organophosphorus, organochlorine, herbicides, and fungicides, show acceptable recovery percentages. Good linearity (r2 value ≥ 0.99) was observed at the concentration range of 0.5-100 µg/L. RSD values were found ≤ 18.8. CONCLUSIONS: The study shows that the method is specific, rapid, and low cost, as well as having a good linearity and recovery; thus, this method is applied in routine purposes for the analysis of pesticide residue in real water samples. HIGHLIGHTS: Due to better adsorption ability, permeability, and magnetic separability, the functionalized nano-particles were found effective in the enrichment of 22 multiclass pesticides including organo-phosphorus, organo-chlorine, synthetic pyrethroid, herbicides, and fungicides.

Current review of the management of fistulising perianal Crohn's disease.

Perianal manifestations of Crohn's disease constitute a distinct disease phenotype commonly affecting patients and conferring an increased risk of disability and disease burden. Much research has gone into management of fistulising manifestations, with biological therapy changing the landscape of treatment. In this article, we discuss the up-to-date surgical and medical management of perianal fistulas, highlighting current consensus management guidelines and the evidence behind them, as well as future directions in management.

Role of high shear mixing in improving stability and bio-efficacy of botanical oil in water formulation for early stage mosquito eradication.

Neem based formulations conventionally being used as dustable powders, wettable powders, emulsifiable concentrates etc for controlling insects and mosquitoes. These formulations are prepared by mechanical mixing or low shear mixing processes. Among these formulations solvent based EC formulation is more common in use, though it have many drawbacks like phyto-toxicity, flammability, environmental contamination and dermal toxicity. Along with these drawbacks stability of the active ingredient is the most concerned problem, as the active ingredients are unstable in solvent based formulations. Neem oil based oil in water emulsion formulation (EW) formulation may be a safer alternative to EC formulation. In the present study, composition and process technology involved in Neem EW formulations were optimized. Different types of the EW formulation has already been formulated, but no investigations were made to prove the influence of high shear mixing, turbulence flow, time duration on the stability of formulation and its bio-efficacy. The main objective of the study is to determine the effect of turbulence stirring duration on droplet size and emulsion stability. The 60 min turbulence flow mixing at 3600 rpm decreased the particle size from 6.7 to 1.2µm. The prepared formulation stability was further confirmed by different analytical techniques like HPLC and FTIR. The 60 min high shear turbulence stirring enhanced the bio-efficacy in terms of 99 % mortality after 24 h at concentration of 500 ppm of 10 EW.