Transanal Suture Mucopexy for Hemorrhoids.

BACKGROUND: Core factors involved in the treatment of hemorrhoids include the engorgement of hemorrhoids, prolapse, recurrence, and pain. OBJECTIVE: The goal of this study was to assess the safety, pain, and efficacy of the transanal suture mucopexy for the treatment of hemorrhoids. DESIGN: This was a retrospective study over a 13-year period. SETTING: This procedure was performed, and data collected, from medical records at six centers in India. PATIENTS: This study includes 5634 patients who had grade II to IV symptomatic hemorrhoids. Patients suffering from thrombosed hemorrhoids, inflammatory bowel disease, anal strictures, and anorectal carcinoma were excluded. INTERVENTIONS: Hemorrhoidal swelling was reduced by manual massage and a steep Trendelenburg position under saddle block. The reduced hemorrhoids were fixed to the muscles of the rectal wall using sutures. Each suture measured 0.5 to 1.0 cm in length; double-locking continuous sutures were used, along the complete circumference of the rectum, at 2 and 4 cm proximal to the dentate line. MAIN OUTCOME MEASURES: Pain assessed using the visual analog scale and hemorrhoid recurrence served as outcome measures. RESULTS: The transanal suture mucopexy procedure was performed for 5634 patients with symptomatic hemorrhoids. A dull pain compatible with a visual analog score of 2 to 3 was reported in 126 (2.2%) patients; in the remaining 5508 (97.8%) patients, the visual analog score was 1 to 2. Effective treatment without complications occurred for 5541 patients (98.65%). A recurrence rate of 1.3% was recorded in 5634 cases with a mean follow-up of 7 ± 6 years. LIMITATIONS: Utilization of a self-illuminating proctoscope or Brinckerhoff or anal speculum is essential. CONCLUSION: Transanal suture mucopexy, designed with 2 suture rows, is a safe procedure with a short learning curve. It is associated with minimal pain, low recurrence rate, and fewer complications. See Video Abstract at http://links.lww.com/DCR/B841. MUCOPEXIA TRANSANAL CON SUTURA PARA ENFERMEDAD HEMORROIDAL: ANTECEDENTES:Los factores centrales involucrados en el tratamiento de la enfermedad hemorroidal incluyen congestión de hemorroides, prolapso, recurrencia y dolor.OBJETIVO:Evaluar la seguridad, el dolor y la eficacia de la mucopexia transanal con sutura para el tratamiento de la enfermedad hemorroidal.DISEÑO:Estudio retrospectivo durante un período de 13 años.ESCENARIO:Este procedimiento se realizó y se recopilaron datos de expedientes médicos en seis centros en India.PACIENTES:Este estudio incluye 5634 pacientes con enfermedad hemorroidal sintomática grado II a IV. Se excluyeron pacientes que padecían hemorroides trombosadas, enfermedad inflamatoria intestinal, estenosis anales y carcinoma anorrectal.INTERVENCIONES:La inflamación hemorroidal se redujo mediante masaje manual y posición Trendelenburg profundo bajo bloqueo caudal. Las hemorroides reducidas se fijaron a los músculos de la pared rectal mediante suturas. Cada sutura midió 0.5 a 1.0 cm de longitud, se utilizaron suturas en surgete continuo de doble anclado, a lo largo de la circunferencia completa del recto, a dos y cuatro cm proximales a la línea dentada.PRINCIPALES MEDIDAS DE RESULTADO:El dolor se evaluó mediante la escala de puntuación analógica visual y se evaluó la presencia de recurrencia.RESULTADOS:El procedimiento de mucopexia transanal con sutura se realizó en 5634 pacientes con hemorroides sintomáticas. Se informó un dolor sordo compatible con una puntuación analógica visual de 2-3 en 126 (2.2%) pacientes; en los 5508 (97.8%) pacientes restantes, la puntuación analógica visual fue de 1-2. La mayoría (5541 pacientes [98.65%]) tuvo un tratamiento eficaz sin complicaciones. Se registró una tasa de recurrencia del 1.3% en 5634 casos con un seguimiento medio de 7 ± 6 años.LIMITACIONES:La utilización de un proctoscopio autoiluminado o de Brinckerhoff o espéculo anal es esencial.CONCLUSIÓN:La mucopexia transanal con sutura es un procedimiento seguro diseñado con dos filas de suturas asociadas con dolor mínimo y baja tasa de recurrencia con menos complicaciones. Tiene una curva de aprendizaje corta. Consulte Video Resumen en http://links.lww.com/DCR/B841. (Traducción-Dr. Jorge Silva Velazco).

Utility of Tokyo guidelines and intraoperative safety steps in improving the outcome of laparoscopic cholecystectomy in complex acute calculus cholecystitis: a prospective study.

BACKGROUND: Laparoscopic cholecystectomy (LC) in complicated acute calculus cholecystitis (ACC) poses multiple challenges. This prospective, observational study assessed the utility and safety of a set protocol and intraoperative steps in LC for complex ACC. METHODS: All cases of ACC from 2008 to 2018 were graded as per Tokyo guidelines; moderate and severe ACC were termed as 'complex ACC (CACC).' Patients were subjected to upfront LC or percutaneous drainage (PCD) followed by LC. Seven intraoperative safety steps were used to achieve critical view of safety (CVS). Use of safety steps, duration of surgery, and length of hospital stay were compared between moderate and severe ACC; complications were classified using Clavien-Dindo classification. RESULTS: We analyzed 145 patients with moderate (74.5%) and severe (25.5%) ACC. There were significantly more male (p = 0.0059) and older (p = 0.0006) patients with severe ACC. Upfront LC was performed in 81.4%; PCD required in 6.9%. Timing of LC from symptom onset was < 1 week (53.1%), 2-5 weeks (28.3%), and ≥ 6 weeks (18.6%). CVS was achieved in 97.2%, subtotal cholecystectomy performed in 2.8%, conversion rate was 1.4%, major postoperative complications (Clavien-Dindo Grade IIIa and IIIb) were seen in 4.1%, no bile duct injury, and mortality was 0.7%. The outcomes were similar irrespective of timing of intervention. CONCLUSION: The study concludes that preoperative assessment by Tokyo guidelines, algorithmic plan of treatment and use of intraoperative safety steps results in favorable outcome of LC in ACC.

Optima Nutrition: an allocative efficiency tool to reduce childhood stunting by better targeting of nutrition-related interventions.

BACKGROUND: Child stunting due to chronic malnutrition is a major problem in low- and middle-income countries due, in part, to inadequate nutrition-related practices and insufficient access to services. Limited budgets for nutritional interventions mean that available resources must be targeted in the most cost-effective manner to have the greatest impact. Quantitative tools can help guide budget allocation decisions. METHODS: The Optima approach is an established framework to conduct resource allocation optimization analyses. We applied this approach to develop a new tool, 'Optima Nutrition', for conducting allocative efficiency analyses that address childhood stunting. At the core of the Optima approach is an epidemiological model for assessing the burden of disease; we use an adapted version of the Lives Saved Tool (LiST). Six nutritional interventions have been included in the first release of the tool: antenatal micronutrient supplementation, balanced energy-protein supplementation, exclusive breastfeeding promotion, promotion of improved infant and young child feeding (IYCF) practices, public provision of complementary foods, and vitamin A supplementation. To demonstrate the use of this tool, we applied it to evaluate the optimal allocation of resources in 7 districts in Bangladesh, using both publicly available data (such as through DHS) and data from a complementary costing study. RESULTS: Optima Nutrition can be used to estimate how to target resources to improve nutrition outcomes. Specifically, for the Bangladesh example, despite only limited nutrition-related funding available (an estimated $0.75 per person in need per year), even without any extra resources, better targeting of investments in nutrition programming could increase the cumulative number of children living without stunting by 1.3 million (an extra 5%) by 2030 compared to the current resource allocation. To minimize stunting, priority interventions should include promotion of improved IYCF practices as well as vitamin A supplementation. Once these programs are adequately funded, the public provision of complementary foods should be funded as the next priority. Programmatic efforts should give greatest emphasis to the regions of Dhaka and Chittagong, which have the greatest number of stunted children. CONCLUSIONS: A resource optimization tool can provide important guidance for targeting nutrition investments to achieve greater impact.

Correction to: Optima nutrition: an allocative efficiency tool to reduce childhood stunting by better targeting of nutrition-related interventions.

It has been highlighted that the original manuscript [1] contains a typesetting error in the name of Meera Shekar. This had been incorrectly captured as Meera Shekhar in the original article which has since been updated.

Maximizing the impact of malaria funding through allocative efficiency: using the right interventions in the right locations.

BACKGROUND: The high burden of malaria and limited funding means there is a necessity to maximize the allocative efficiency of malaria control programmes. Quantitative tools are urgently needed to guide budget allocation decisions. METHODS: A geospatial epidemic model was coupled with costing data and an optimization algorithm to estimate the optimal allocation of budgeted and projected funds across all malaria intervention approaches. Interventions included long-lasting insecticide-treated nets (LLINs), indoor residual spraying (IRS), intermittent presumptive treatment during pregnancy (IPTp), seasonal mass chemoprevention in children (SMC), larval source management (LSM), mass drug administration (MDA), and behavioural change communication (BCC). The model was applied to six geopolitical regions of Nigeria in isolation and also the nation as a whole to minimize incidence and malaria-attributable mortality. RESULTS: Allocative efficiency gains could avert approximately 84,000 deaths or 15.7 million cases of malaria in Nigeria over 5 years. With an additional US$300 million available, approximately 134,000 deaths or 37.3 million cases of malaria could be prevented over 5 years. Priority funding should go to LLINs, IPTp and BCC programmes, and SMC should be expanded in seasonal areas. To minimize mortality, treatment expansion is critical and prioritized over some LLIN funding, while to minimize incidence, LLIN funding remained a priority. For areas with lower rainfall, LSM is prioritized over IRS but MDA is not recommended unless all other programmes are established. CONCLUSIONS: Substantial reductions in malaria morbidity and mortality can be made by optimal targeting of investments to the right malaria interventions in the right areas.

Clinical Stage Transitions in Persons Aged 12 to 25 Years Presenting to Early Intervention Mental Health Services With Anxiety, Mood, and Psychotic Disorders.

Importance: The large contribution of psychiatric disorders to premature death and persistent disability among young people means that earlier identification and enhanced long-term care for those who are most at risk of developing life-threatening or chronic disorders is critical. Clinical staging as an adjunct to diagnosis to address emerging psychiatric disorders has been proposed for young people presenting for care; however, the longer-term utility of this system has not been established. Objectives: To determine the rates of transition from earlier to later stages of anxiety, mood, psychotic, or comorbid disorders and to identify the demographic and clinical characteristics that are associated with the time course of these transitions. Design, Setting, and Participants: A longitudinal, observational study of 2254 persons aged 12 to 25 years who obtained mental health care at 2 early intervention mental health services in Sydney, Australia, and were recruited to a research register between June 18, 2008, and July 24, 2018 (the Brain and Mind Centre Optymise Cohort). Main Outcomes and Measures: The primary outcome of this study was transition from earlier to later clinical stages. A multistate Markov model was used to examine demographic (ie, age, sex, engagement in education, employment, or both) and clinical (ie, social and occupational function, clinical presentation, personal history of mental illness, physical health comorbidities, treatment use, self-harm, suicidal thoughts and behaviors) factors associated with these transitions. Results: Of the 2254 individuals included in the study, mean (SD) age at baseline was 18.18 (3.33) years and 1330 (59.0%) were female. Data on race/ethnicity were not available. Median (interquartile range) follow-up was 14 (5-33) months. Of 685 participants at stage 1a (nonspecific symptoms), 253 (36.9%) transitioned to stage 1b (attenuated syndromes). Transition was associated with lower social functioning (hazard ratio [HR], 0.77; 95% CI, 0.66-0.90), engagement with education, employment, or both (HR, 0.47; 95% CI, 0.25-0.91), manic-like experiences (HR, 2.12; 95% CI, 1.19-3.78), psychotic-like experiences (HR, 2.13; 95% CI, 1.38-3.28), self-harm (HR, 1.42; 95% CI, 1.01-1.99), and older age (HR, 1.27; 95% CI, 1.11-1.45). Of 1370 stage 1b participants, 176 (12.8%) transitioned to stage 2 (full-threshold) disorders. Transition was associated with psychotic-like experiences (HR, 2.31; 95% CI, 1.65-3.23), circadian disturbance (HR, 1.66; 95% CI, 1.17-2.35), psychiatric medication (HR, 1.43; 95% CI, 1.03-1.99), childhood psychiatric disorder (HR, 1.62; 95% CI, 1.03-2.54), and older age (HR, 1.24; 95% CI, 1.05-1.45). Conclusions and Relevance: Differential rates of progression from earlier to later stages of anxiety, mood, psychotic, or comorbid disorders were observed in young persons who presented for care at various stages. Understanding the rate and factors associated with transition assists planning of stage-specific clinical interventions and secondary prevention trials.

Idiopathic Scrotal Calcinosis.

Idiopathic scrotal calcinosis (ISC) is a rare benign condition which presents with multiple, asymptomatic, and painless nodules on the scrotal skin wall. The lesions have been attributed as sebaceous cysts, calcified steatocystoma, fibroma, atheroma, and xanthoma. Shapiro et al. reviewed the histologic data and found no evidence of an epithelial lining, residual cysts, and lipid or organisms, and concluded that the calcification was idiopathic introducing the term "idiopathic scrotal calcinosis." We have studied four cases of idiopathic scrotal calcinosis, one of which had scrotal calcinosis involving the whole of the scrotum. He presented with painless multiple nodules over the scrotum. He was subjected for surgery with SOS skin grafting, but as the scrotal skin is so lax, primary closure is easily possible. In all our four cases, primary closure was easily possible.

Retroperitoneal Mass-lymphangiomyoma.

We report a case of retroperitoneal mass, in a postmenopausal lady,about a size 10-8 cm in left side of abdomen. This turned out pathologically lymphangio-myoma. Retrospectively when we searched in literature we found that, commonly lymphangiomyoma seen in premenopausal women and is associated with ascites or renal angiomyolipoma or plural effusion. But in our case CxR -PA was normal and abdominal USG was not showing renal or ovarian involvement. It was a rare case and presentation was rare than the literature.

Hereditary angioedema-presenting as recurrent abdominal pain.

We report a very rare case of HEREDITARY ANGIOEDEMA, presenting as recurrent acute abdomen. A 22 yr old Maharastrian male, law college student, got admitted for about fifteen times in previous three years for severe, acute onset, upper abdominal pain, vomiting, distention and acute exudative inflammatory ascites .The whole episode used to subside spontaneously within 2-3 days with or without conservative general management .He underwent various investigations from far basic type, to advanced and invasive type with each recurrence but without definitive diagnosis. He also underwent unnecessary appendectomy. The authors did a review of his previous records, but didn't find any definite surgical or medical cause for his acute abdomen. Obviously it was something rare. Authors did search for it in various surgical and medical literature and searched extensively on internet for rare causes of abdominal pain which guided them for further appropriate investigations and diagnose him as a case of HEREDITARY ANGIOEDEMA ,as his clinical features and C1-INH,C3-C4 levels were strongly in favour of it . It goes without saying that the internet has become a standard accessory to conventional literature for cases with diagnostic dilemmas and for treatment options as well.