Perianal Tuberculosis: Lessons Learned in 57 Patients From 743 Samples of Histopathology and Polymerase Chain Reaction and a Systematic Review of Literature.

BACKGROUND: Few data are published on perianal tuberculosis. OBJECTIVE: This study aimed to determine the best method to diagnose tuberculosis in patients with fistula-in-ano and to conduct a systematic review to determine the incidence and characteristics of tuberculosis fistula-in-ano. DATA SOURCES: The prospective study data and existing literature were derived from PubMed, Google scholar, and Scopus STUDY SELECTION:: Prospective analysis of patients with tuberculous fistula-in-ano treated between 2014 and 2018 was conducted, and a systematic review of studies describing ≥3 patients with tuberculosis fistula-in-ano was completed. INTERVENTION: Testing of tuberculosis was performed by histopathology or polymerase chain reaction of tissue or pus from the fistula tract. MAIN OUTCOME MEASURES: The primary outcomes measured were the detection rate of various tests to detect tuberculosis in fistula-in-ano and the prevalence rate of tuberculosis in simple versus complex fistulas. RESULTS: In 637 samples (410 patients) tested, tuberculosis was detected in 49 samples (43 patients). Additional samples (n = 106) sent in patients with a high index of suspicion tested positive in 14 more patients. Thus, overall, 63 samples tested positive in 57 patients (total: 743 samples in 410 patients were tested). Tuberculosis was detected in 2 of 181 patients (1.1%) in tissue (histopathology), in 28 of 341 patients (8.2%) in tissue (polymerase chain reaction), and in 19 of 115 patients (16.5%) in pus (polymerase chain reaction) samples. To detect tuberculosis, tissue (polymerase chain reaction) was significantly better than tissue (histopathology) (28/341 vs 2/181, p < 0.00001) and pus (polymerase chain reaction) was significantly better than tissue (polymerase chain reaction) (19/115 vs 28/341, p < 0.0009). Tuberculosis was significantly more common in complex fistulas than in simple fistulas (20.3% vs 7.2%, p = 0.0002). The systematic review (n = 199) highlighted that tubercular fistulas are more common in recurrent and complex fistulas and in tuberculosis endemic regions. LIMITATIONS: The true sensitivity and specificity of each testing modality could not be determined because not all patients with tuberculosis fistula-in-ano were tested by every diagnostic modality studied. CONCLUSIONS: The tuberculosis detection rate of polymerase chain reaction was significantly higher than histopathology. Among polymerase chain reaction, pus had higher detection rate than tissue. Tuberculosis was associated with more complex and recurrent fistulas.

High Prevalence of Hypovitaminosis D in Patients Presenting with Proximal Muscle Weakness: A Sub-Himalayan Study.

BACKGROUND: Hypovitaminosis D has emerged as a major public health problem and 25-50% of patients encountered in clinical practice are deficient in vitamin D. This study was conducted to estimate the prevalence of hypovitaminosis D among patients presenting with proximal muscle weakness. STUDY DESIGN: It was a cross-sectional study done on patients ≥18 years presenting in outdoor clinic from May 2008 to April 2013, with difficulty in standing and going up stairs/ diffuse musculoskeletal pains. Proximal muscle weakness due to other causes were excluded through investigations and those taking steroids and/or indigenous drugs were also excluded. Vitamin D levels measured by radioimmunoassay (RIA) in all eligible patients and individuals included in the study were those with hypovitaminosis D (<30ng/dl) and proximal muscle weakness. Patients reassessed after supplementation with vitamin D at 2 and 6 months. RESULTS: 99 patients with hypovitaminosis D associated proximal myopathy included in study. Of these 55 (55.55%) were males and 44 (44.44%) were females. Age ranged from 22 to 82 years with a mean of 52.84 ± 12.6 years. Of 99 patients, 55 (55.55%) were from the rural area and 44 (44.44%) from urban area. Mean duration of symptoms was 22.7 months (range 6-60 months). The level of 25(OH) Vitamin D ranged from 2.0 ng/dl to 35.7 ng/dl with the mean level of 13.18 ± 5.80 ng/dl (males = 12.76± 4.85ng/dl and females = 13.60±6.70ng/dl). Hypovitaminosis D was present in 98.98%. A direct relationship was found between the vitamin D levels (<10 ng/dl) and severity of weakness. Of 83 patients, who reported at the end of two and six months of treatment, 71 (85.54%) patients were able to stand-up from squatting position. CONCLUSION: Muscle weakness is common among vitamin-D deficient individuals. Our study indicates that more focus should be on muscle symptoms in at risk population groups. The vitamin D deficiency related myopathy should not be missed due to its potential reversibility with vitamin D supplementation.

Diabetes Drug Prescription Pattern and Awareness Among Health Care Providers in Sub-Himalayan Region of India: A Population Based Study.

BACKGROUND: To determine the pattern of diabetic drug prescription and awareness about diabetes among primary health providers in the rural areas of Himachal Pradesh situated in the western Himalayas at an elevation range from 350 meters (1,148ft) to 6900 meters (22,966ft) above sea level. METHODS AND MATERIAL: Study was conducted in 20 rural areas of Himachal Pradesh, located 50 to 400 Km from state capital, at 2200 to 10,000 feet altitude. Non-pregnant diabetic adults were surveyed through 31 diabetic camps. Detailed history, weight, height, waist circumference, body mass index recorded. Fasting or random blood glucose, glycated hemoglobin, lipid profile measured and blood pressure recorded. RESULTS: 894 diabetic patients were included in the study (59.83% male) with the mean age of 52.94±6.78 years. Two in three patients were on oral hypoglycemic agents (OHAs), and one in three on alternative approaches for diabetes control. Among OHAs, sulphonylureas (SU) were the most commonly prescribed oral agents in 76.09% of patients followed by metformin in 23.87%. Glibenclamide was the most commonly prescribed SU in 44.60%. Amlodipine and atenolol was the commonest anti-hypertensive drug prescribed in 77.85% either in combination or as individual drug. Only 10.59% were on lipid lowering therapy. For primary care providers glycemic target was the mainstay of diabetes treatment with little emphasis on blood pressure control and no emphasis on lipid reduction. CONCLUSIONS: Sulphonylureas were the commonest anti-diabetic drug prescribed by the primary care providers followed by metformin. Insulin was prescribed to 2.23% only. Combination of amlodipine and atenolol was the commonest anti-hypertensive drugs prescribed and only 10% of patients were prescribed statin.

Prevalence of dry eye disease in the patients of allergic conjunctivitis: Hospital-based cross-sectional study.

PURPOSE: Allergic conjunctivitis (AC) is commonly associated with dry eye. This study was conducted to assess the prevalence of dry eye in different subsets of AC patients. METHODS: This observational, cross-sectional study, conducted in the Department of Ophthalmology of a tertiary center in north India, included 132 patients of AC. The diagnosis of dry eye disease (DED) was made on the basis of Ocular Surface Disease Index (OSDI), Schirmer's test, and tear film break-up time (TFBUT). RESULTS: The prevalence of dry eye in AC patients was found to range between 31% and 36%. On OSDI scoring, 20.45% of patients had mild, 18.18% moderate, and 31.81% had a severe grade of DED, respectively. The mean OSDI score was noted to be significantly higher in patients with perennial allergic conjunctivitis (PAC) (29.82 ± 12.41), followed by seasonal allergic conjunctivitis (SAC) (25.35 ± 12.88), and least in the patients of vernal keratoconjunctivitis (VKC) (13.60 ± 8.63) (p < 0.0001), respectively. The TFBUT was found to be less than 10 s in 45.45% of PAC, 30.43% of SAC, and 20% of VKC patients, respectively. The difference between the mean TFBUT among the three groups was statistically insignificant (p = 0.683). Schirmer's test value of <10 mm was observed in 45.45% of PAC, 43.47% of SAC, and 10% of VKC patients, respectively. CONCLUSION: This study revealed a high prevalence of DED in patients with AC. Among the different types of AC patients, PAC had the highest percentage of DED followed by SAC and least in VKC, respectively.

PERFACT procedure: a new concept to treat highly complex anal fistula.

AIM: To check the efficacy of the PERFACT procedure in highly complex fistula-in-ano. METHODS: The PERFACT procedure (proximal superficial cauterization, emptying regularly fistula tracts and curettage of tracts) entails two steps: superficial cauterization of mucosa at and around the internal opening and keeping all the tracts clean. The principle is to permanently close the internal opening by granulation tissue. This is achieved by superficial electrocauterization at and around the internal opening and subsequently allowing the wound to heal by secondary intention. Along with this, all the tracts are curetted and it is ensured that they remain empty and clean in the postoperative period until they heal completely. The latter step also facilitates the closure of the internal opening by preventing collected fluid in the tracts from entering the internal opening and thus not letting it close. Objective incontinence scoring was done preoperatively and 3 mo after the operation. RESULTS: Fifty-one patients with complex fistula-in-ano were prospectively enrolled. The median follow-up was 9 mo (5-14 mo). The mean age was 42.7 ± 11.3 years. Male:female ratio was 43:8. Fistula was recurrent in 76.5% (39/51), horseshoe in 50.1% (26/51), had multiple tracts in 52.9% (27/51), had an associated abscess in 41.2% (21/51), was anterior in 33.3% (17/51), the internal opening was not found in 15.7% (8/51) and 9.8% (5/51) of fistulas had a supralevator extension. Seven patients were excluded (5 lost to follow up, 2 with tuberculosis leading to/associated with fistula-in-ano). The success rate was 79.5% (35/44) and the recurrence rate was 20.5% (9/44). Out of these recurrences, three underwent reoperation (2 PERFACT procedure, 1 fistulotomy) and all three were successful. Thus, the overall success rate was 86.4%. The only complication was a non-healing tract in 9.1% (4/44) of patients. There was no significant change in objective incontinence scores three months after the operation. The pain was minimal, with all patients resuming their normal activities within 72 h of the operation. CONCLUSION: The PERFACT procedure is a new effective method for complex fistula-in-ano, effective even in fistula associated with abscess, supralevator fistula-in-ano and where the internal opening is non-localizable.

Laying open (deroofing) and curettage under local anesthesia for pilonidal disease: An outpatient procedure.

AIM: To test the efficacy of lay open (deroofing, not excision) with curettage under local anesthesia (LOCULA) for pilonidal sinus as an outpatient procedure. METHODS: LOCULA procedure was done for all types of pilonidal disease. The primary outcome measure was cure rate. The secondary outcome measures were hospital stay, operating time, return to work, healing time and complication rate. RESULTS: Thirty-three (M/F-30/3, mean age-23.4 ± 5.8 years) consecutive patients were operated and followed for 24 mo (6-46 mo). Eleven were pilonidal abscess and 22 were chronic pilonidal disease. Six had recurrent disease. Operating time and the hospital stay was 22.3 ± 5.6 min and 63.8 ± 22.3 min respectively. The patients could resume normal work in 4.3 ± 3.2 d and the healing time was 42.9 ± 8.1 d. Thirty (93.8%) patients had complete resolution of the disease and two (6.2%) had a recurrence. Both the recurrences happened in patients who had complete healing but ignored the prescribed recommendations. One out of these got cured after getting operated again with the same procedure. Thus the overall success rate of this procedure was 96.9%. CONCLUSION: Lay open (deroofing) with curettage procedure under local anesthesia is an effective procedure to treat both simple and complicated pilonidal sinus and abscess. It is a simple procedure, has a high cure rate (up to 97%), doesn't require admission and is associated with minimal morbidity and scarring. Considering the distinct advantages, this procedure has the potential to become the first line procedure for treating pilonidal disease.

Single-incision laparoscopic cholecystectomy vs. conventional laparoscopic cholecystectomy: a meta-analysis of randomized controlled trials.

INTRODUCTION: We analyzed different morbidity parameters between single-incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC). METHODS: Pubmed, Ovid, Embase, SCI database, Cochrane, and Google Scholar were searched. The primary endpoints analyzed were cosmetic result and the postoperative pain (at 6 and 24 h) and the secondary endpoints were operating time, hospital stay, incidence of overall postoperative complications, wound-related complications, and port-site hernia. RESULTS: Six hundred fifty-nine patients (SILC-349, CLC-310) were analyzed from nine randomized controlled trials. The objective postoperative pain scores at 6 and 24 h and the hospital stay were similar in both groups. The total postoperative complications, wound-related problems, and port-site hernia formation, though higher in SILC, were also comparable in both groups. SILC had significantly favorable cosmetic scoring compared to CLC [weighted mean difference = 1.0, p = 0.0001]. The operating time was significantly longer in SILC [weighted mean difference = 15.63, p = 0.0001]. CONCLUSIONS: Single-incision laparoscopic cholecystectomy does not confer any benefit in postoperative pain (6 and 24 h) and hospital stay as compared to conventional laparoscopic cholecystectomy while having significantly better cosmetic results at the same time. Postoperative complications, though higher in SILC, were statistically similar in both the groups.

Comparison of cosmetic outcome between single-incision laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy: an objective study.

BACKGROUND: Single-incision laparoscopic cholecystectomy (SILC) has been projected to have better cosmetic outcome compared with conventional laparoscopic cholecystectomy (CLC). However, there are scarce data that have objectively compared the patient's perception of cosmetic outcome after SILSC and CLC. METHODS: The SILC and CLC patients, who were operated in the last 2 years, were personally interviewed and assessed using the Patient Scar Assessment Questionnaire. A lower score indicated a better patient outcome. The satisfaction with the appearance and the symptoms due to the scars was assessed in all the patients. RESULTS: Fifty-two patients were included in the study (25 SILC, 27 CLC). The age and sex distributions and body mass indexes were similar in both groups. The scores of different parameters assessed as per Patient Scar Assessment Questionnaire-appearance (SILC, 1.08 ± 0.4; CLC, 1.14 ± 0.5: P=.57), symptoms (SILC, 1.16 ± 0.5; CLC, 1.18 ± 0.4; P=.83), scar consciousness (SILC, 1.04 ± 0.2; CLC, 1.07 ± 0.3; P=.6), satisfaction with symptoms (SILC, 1.12 ± 0.3; CLC, 1.18 ± 0.4; P=.52), and satisfaction with appearance (SILC, 1.04 ± 0.2; CLC, 1.11 ± 0.3; P=.34)-were similar in both groups. The overall satisfaction scores were also statistically similar in both groups (SILC, 5.44 ± 1.4; CLC, 5.70 ± 1.7; P=.54). Overall, a majority of patients (>80%) in both groups gave the lowest score (1), indicating maximum satisfaction, in all the categories. CONCLUSIONS: Patient perception regarding cosmetic outcome after SILC and CLC was similar in both groups. SILC does not seem to offer any significant cosmetic advantage over CLC. This point needs to be assessed in detail by larger studies, as cosmetic benefit is projected as one of the major advantages of single-incision surgery.

Impact of closed-suction drain in preperitoneal space on the incidence of seroma formation after laparoscopic total extraperitoneal inguinal hernia repair.

PURPOSE: To study the effect of closed suction drain in preperitoneal space on seroma formation after laparoscopic total extraperitoneal repair (TEP). METHODS: A closed suction drain-12G was put through the midline 5 mm port incision and removed with in 24 hours of operation in TEP repair. The results were compared with a group with TEP without any drain. RESULTS: In 929 patients (1753 hernias), drain was put in 849 patients (1607 hernias) and no drain was put in 80 patients (146 hernias). Follow-up ranged from 9 to 45 months. Seroma formation was significantly lower in the drain group (12/1607; 0.75%) compared with the nondrain group (22/146; 15.1%) (P<0.0001). Both the groups were comparable in pain scores, conversion to open, hospital stay, and days taken to return to normal activity and recurrence rates. There was no infection in either group. CONCLUSIONS: Drain after TEP significantly reduces the incidence of seroma formation without increasing the risk of infection or recurrence.