Comparative Evaluation of the Efficacy of Hydrocortisone Suppository and Durvadi gudavarti in Raktarsha: A Management Protocol

The most common diagnosis for any anorectal complaint particularly of rectal bleeding in adults is haemorrhoidal disease. Regardless of grading conservative treatment is used primarily in symptomatic haemorrhoids. In Ayurveda, Sthanik Chikitsa (Local application) in the management of Arsha (Hemorrhoids) includes pralepa/pratisaran (Paste application). Instead of applying the lepa in the clinics by the clinician/proctologist, those formulations could be developed into Gudavarti (traditional suppository) & used in the management of Raktarsha (bleeding piles) for better compliance. Hence, development of ‘Durvadi Gudavarti’ using the indigenous medicinal herbs mentioned in Charaka Sanhita (Classical Ayurveda text) for pratisaran/pralepa in Raktarsha & its efficacy will be evaluated. Objectives: To study & compare the efficacy in patient treated with standard- Hydrocortisone suppository group & interventional- Durvadi Gudavarti group in the management of Raktarsha (Bleeding piles). Methodology: 130 patients of 2nd grade hemorrhoids will be selected and will be allocated into two equal groups by computer randomization. Experimental group will be treated with Durvadi Gudavarti & control group with Hydrocortisone based suppository for 2 weeks. Following Symptoms- PR Bleeding, Anal Pain, Prolapse of Pile mass/Lump, Anal pruritus, Mucous discharge & Constipation will be assessed subjectively and Size/ (Volume in cubic millimeter) of pile mass will be the objective parameter for study. Clinical evaluation will be done at Baseline and 3rd, 5th, 10th, 15th day after treatment onset. Proportion of patients that would respond clinically on 10th day will be the main end point, determined via disappearance of the clinical symptoms & more than or equal to 50 % reduction in the initial size of pile mass/lump. Time to response & need for any oral/ parenteral medication for pain, bleeding and constipation would be the secondary variables. Side effects (type, duration & severity) will be registered carefully. Expected Results: Durvadi Gudavarti contains indigenous herbs having anti-inflammatory, analgesic, haemostatic, wound healing, astringent, & laxative properties. Hence, it is expected to be as efficacious as Hydrocortisone suppository with lesser side effect in the management of Raktarsha. Results will be assessed on the basis of clinical assessment criteria using proper statistical values and tools. Changes will be observed in objective outcomes. Conclusion: Durvadi Gudavarti will be efficacious in the management of Raktarsha.

Combined Rothia dentocariosa and Streptococcus viridans Corneal Ulcer in an Immunocompromised Patient

Keratitis is a very common condition seen by ophthalmologists. However, many factors can complicate the treatment of this depending on the causative organism and other patient comorbid conditions. The objective of this clinical case report is to highlight the treatment of keratitis caused by Rothia dentocariosa. It also looks at the unique considerations in keratitis presentations for patients immunocompromised by chemotherapy agents. Our patient is a 58 yo female undergoing chemotherapy with folinic acid, fluorouracil, irinotecan, and panitumumab who presented with several days of a red, painful right eye with mucous discharge. Cultures were positive for Rothia dentocariosa and Streptococcus viridans. The patient ultimately underwent a conjunctival flap procedure as medical therapy with proper oral and topical antibiotics failed to resolve keratitis. This case is unique as previously, only a couple of cases of keratitis caused by Rothia dentocariosa have been reported and none of those patients were immunocompromised nor failed antibiotic therapy.

EFFECT OF CITRAKADI KSARA LĒPA IN THE MANAGEMENT OF SECOND-DEGREE INTERNAL HAEMORRHOIDS

Background and Objectives: Haemorrhoids are dilated veins within the anal canal in the sub-epithelial region formed by radicles of superior, middle, and inferior rectal veins. It hampers the routine life of an affected person. In India about 50% of the population would have haemorrhoids at some point in their life. Achārya Vāgbhata defines Arsas (haemorrhoids) as an abnormal growth which obstructs the anal canal and troubles continuously like an enemy The objective of the study is to assess the efficacy of citrakādi kṣāra lēpa in the management of second- degree internal haemorrhoids. The study also aims to find out an easy, effective and less complicated procedure for second-degree haemorrhoids. The 15 participants with second degree internal haemorrhoids were selected as per inclusion criteria. After doing all the preoperative procedures, the citrakādi kṣāra lēpa was done in a single sitting. The duration of the study was 30 days. The assessment of reduction of size of haemorrhoids, mucosal changes after the procedure and frequency of bleeding were done before the treatment, on 1st, 3rd, 5th, 7th, 15th, and 30th day using the required assessment tools. The symptoms, constipation and mucous discharge were assessed on the 0th and 30th days. The follow up was done on the 60th day. The statistical analysis of the results was done using non- parametric tests. On analysing, it was found that the Citrakādi kṣāra shows 86.11% of the efficacy in the reduction of both subjective and objective parameters. Key words: Haemorrhoids, Arsas, Citrakādi kṣāra

Clinical Efficacy of Medicinal Leech Therapy in Treating Third- and Fourth-Degree Hemorrhoids

Objectives Hemorrhoids are characterized by bleeding, mucous discharge, itching, pain, and prolapse. This condition is known as bawaseer in Unani medicine, and Hirudinaria granulosa has been used for its treatment in Irsal-e Alaq, or medicinal leech therapy (MLT), for centuries. Hirudinaria granulosa with antithrombotic and antiinflammatory action is used in the treatment of chronic venous disease and hemorrhoids. The present study was aimed to investigate the efficacy of MLT in third and fourth-degree hemorrhoids. Methods A single-centre prospective, clinical trial with a pre and postanalysis design was conducted at the hospital of the National Institute of Unani Medicine. Twenty male and female patients, with a mean age of 38 years, presenting moderate symptoms assessed with the colorectal evaluation of clinical therapeutics scale (CORECTS) questionnaire were included in the study. Hirudinaria granulosa were applied around the pile mass for 15 minutes weekly, for 4 weeks. The efficacy of the treatment was measured by an objective and subjective assessment using the CORECTS. Results When analyzed by the clinician, MLT reduced the symptoms' severity score in the following domains: pain (55% improvement; p < 0.001); anorectal itching (30% improvement; p < 0.10); and bleeding (10% improvement; p < 0.7963). Significant improvement (p < 0.001) was reported in the CORECTS score in relation to pain (44.09% improvement; p < 0.001), itching (38.55% improvement; p < 0.001), swelling (44% improvement; p < 0.001), bleeding (17.28% improvement; p < 0.007), discomfort (34.01% improvement; p < 0.001), and wellbeing (32.35 %improvement; p < 0.001), giving an average overall opinion on the therapy of 4/10. Conclusion The results of the study albeit smaller in sample size show that MLT is an effective and safe therapeutic option in reducing the symptoms of 3rd and 4th degree haemorrhoids.

Method of surgical treatment of chronic dacryocystitis and its effectiveness in monitoring patients in the early postoperative period

The aim. To develop a method for endonasal endoscopic dacryocystorhinostomy (EEDCR) and evaluate its effectiveness in monitoring patients in the early postoperative period. Materials and methods. The study group (1st group) consisted of 45 patients with chronic dacryocystitis (CD), who underwent EEDCR according to the developed method, the comparison group (2nd group) included 36 patients who, after performing the developed EEDCR, an implant was installed in the dacryorhinostoma zone. The control group (3rd group) included 28 patients who underwent EEDCR according to the generally accepted method. Patients of groups 1 and 2 were divided into 2 subgroups: 1A and 2A included patients who underwent computed tomography of the lacrimal ducts in the preoperative period according to the developed method, and patients of subgroups 1B and 2B – according to the traditional algorithm. Reliably the best results of restoring lacrimation function were in subgroups 1A and 1B already from the 3rd day of observation after surgery, as well as in the subsequent periods of observation. The worst values of lacrimation function were recorded in the control clinical group with a statistically significant difference from other groups (p<0.05). When comparing the results of treatment of subgroups 1A with 1B and 2A with 2B, the best indicators were observed in subgroups 1A and 2A, but due to the small sample of patients, statistical significance in the differences could not be achieved (p>0.05). Results. A method of EEDCR has been developed, a comparative analysis of groups of patients according to the above indicators has been performed when observing patients in the early postoperative period. On the first day after surgery, the mean score of the severity of lacrimation according to the Munk scale significantly decreased in all groups and gradually decreased on the 7th day and after 2 weeks (p<0.05). Significantly better indicators were in subgroups 1A and 1B in the entire early postoperative period (p<0.05). The degree of edema of the mucosa of the dacryorhinostoma zone and the middle nasal meatus at all periods of observation was the lowest in subgroup 1A from 3rd day and in each subsequent period of observation with a statistically significant difference from other groups (p<0.05). On the 7th day, significantly more patients with mucous discharge in the area of dacryorhinostoma and middle nasal meatus were observed in subgroup 2B and in 3rd group (p<0.05), and significantly better results were noted in subgroup 1A, where more than 2/3 patients had no mucous discharge. Reliably the best results of restoring lacrimation function were in subgroups 1A and 1B already from the 3rd day of observation after surgery, as well as in the subsequent periods of observation. The worst values of lacrimation function were recorded in the control clinical group with a statistically significant difference from other groups (p<0.05). When comparing the results of treatment of subgroups 1A with 1B and 2A with 2B, the best indicators were observed in subgroups 1A and 2A, but due to the small sample of patients, statistical significance in the differences could not be achieved (p>0.05). Conclusions. The developed EEDCR method complies with the principles of sparing surgery, is effective in the treatment of patients with CD, while there is a faster rate of recovery of the lacrimal function and mucosa, improves the quality of life of patients

Features of course of year-round allergic rhinitis against the background of respiratory intracellular infection

As it is known, allergic rhinitis is one of the most pressing issues of modern rhinology. At present, special attention is directed to the study of the problem of year-round allergic rhinitis, since in recent years its incidence in economically developed countries has been steadily growing. Often the only complaint of patients is the constant stuffy nose with mucous discharge, so both patients and doctors often underestimate the importance of timely diagnosis and treatment of the disease. According to research, year-round allergic rhinitis can contribute to the development of pathology of the nasopharynx, middle ear and auditory tube, nasal cavity and paranasal sinuses, which often take on a chronic or recurrent form. The treatment proposed in the clinical recommendations, carried out in three main areas, does not always lead to persistent remission of the atopic process. This article covers the course of ENT diseases against the background of respiratory chlamydia and mycoplasmic intracellular infection. The problem of year-round allergic rhinitis associated with respiratory intracellular infection has not been elucidated to date, but the chronization of the process, long uncontrolled course, and the tendency to complications of this pathology of the upper respiratory tract may be related to it.

Temporal Changes in Physical Signs of Estrus and Validation of Fetal Parameters for Estimation of Gestational Stage through B-mode Ultrasonography in Beetal goats

The current study evaluates changes in the physical signs of estrus (vulvar hyperemia, edema and mucous discharge) from their onset until ovulation, and validates fetal parameters for the estimation of gestational stage in Beetal goats. In experiment 1, temporal changes in estrus signs were monitored subjectively after the administration of two injections of PGF2α at 10-days interval and a cumulative behavioural index (BI) was calculated in goats that showed estrus response (n=7). Ovulation occurred after 18.8±2.3 h relative to peak vulvar hyperemia and edema; ovulation coincided with maximum mucous discharge (0±2.4 h). Maximum BI was observed between 7 to 31 h after the onset of estrus and was highly correlated with vulvar hyperemia (r=0.94), followed by vulvar edema (r=0.90) and mucous discharge (r=0.85). In experiment 2, fetal parameters were monitored in pregnant goats (n=7) via ultrasonography for estimation of gestational stage, and for validation in a separate set of goats (n=20; experiment 3). Gestational stage correlated significantly (P<0.05) with the uterine diameter (UD), crown-rump length (CRL), trunk diameter (TD), intercostal space (ICS); diameter of amniotic vesicle (AV), biparietal diameter (BPD), placentome diameter (PD) and umbilical cord (UC) diameter. Validation revealed the difference between the actual and estimated day of gestation was less for TD than BPD (4.1±0.6 vs 6.8±1.0 days; P<0.05). In conclusion, vulvar hyperemia, edema, and mucous discharge are highly correlated with BI. Fetal parameters are strongly associated with the gestational stage, and the estimation of the actual gestational stage is less variable through TD than BPD in Beetal goats

Sore eyes as the most significant ocular symptom experienced by people with COVID-19: a comparison between pre-COVID-19 and during COVID-19 states

ObjectiveConjunctivitis has been reported in people suffering from COVID-19. However, many ocular symptoms are associated with the term ‘conjunctivitis’ which may be misleading. It is also unknown whether ocular symptoms were different in chronic sufferers of anterior eye diseases, when they were experienced or how long they lasted for compared with other COVID-19 symptoms.MethodsAn online structured questionnaire obtained self-report data from people who had a confirmed diagnosis of COVID-19. Data for the type, frequency and duration of different COVID-19 symptoms were ascertained. Anterior eye symptoms experienced by participants in the pre-COVID-19 state were compared with during the COVID-19 state.ResultsData from 83 participants showed that the most reported COVID-19 symptoms were dry cough (66%), fever (76%), fatigue (90%) and loss of smell/taste (70%). The three most common ocular symptoms experienced by participants were photophobia (18%), sore eyes (16%) and itchy eyes (17%). The frequency of sore eyes was significantly higher (p=0.002) during COVID-19 state (16%) compared with pre-COVID-19 state (5%). There were no differences between males and females (p>0.05). 81% of participants reported to have experienced ocular symptoms within 2 weeks of other COVID-19 symptoms, and 80% reported they lasted for less than 2 weeks.ConclusionThe most significant ocular symptom experienced by people suffering from COVID-19 was sore eyes. Other symptoms associated with other types of conjunctivitis, such as mucous discharge and gritty eyes linked to bacterial infection, did not reach significance. The term ‘conjunctivitis’ is too broad and should be used with caution.

716. A Case of Symptomatic Intestinal Spirochetosis

Background Intestinal spirochetosis (IS) is a condition caused by Brachyspira aalborgi and Brachyspira Pilosicoli. Its clinical significance has long been a point of contention with some debating that these spirochetes are simply colonic commensals. It is a condition that is more prevalent in developing nations as well as patients with HIV and the homosexual population. The epidemiology and prevalence of IS has not been studied in the local context. Methods We reviewed a case of a 37-year-old man who presented with a two month history of persistent lower abdominal pain, hematochezia, and increase in mucous discharge per rectum. He is sexually active with multiple male partners, and was previously treated for gonorrhea, chlamydia, and syphilis. His basic laboratory investigations were unremarkable, Venereal Disease Research Laboratory (VDRL) antibody and human immunodeficiency virus (HIV) screen were both non-reactive. Computed tomography of the abdomen was unremarkable. Endoscopic evaluation revealed multiple discrete ulcers measuring 1-2mm seen only in the rectum. Random biopsies of the cecum, ascending colon, transverse colon and descending colon showed mild acute colitis with IS. There was also mild to moderate acute proctitis in the rectum with spirochetes seen. 16s RNA gene sequencing of the biopsy specimen were confirmatory for Brachyspira aalborgi. Investigation findings. A: Discrete Ulcers found in rectum, B: Hemotoxylin and Eosin stained specimen showing proctitis, C: False brush Border appearance D: Spirochetes on Warthin Starry stain Results The patient received a 10 day course of metronidazole with complete resolution of his symptoms. Conclusion This case demonstrates the existence of a treatable condition that can be diagnosed with current available investigations for patients with similar symptoms. Recognising at risk populations can also raise clinical suspicion for this condition. Some studies have found associations between IS with development of colonic polyps and also certain colorectal cancers. Further studies on this treatable condition and its disease burden in the local context should be further explored. Disclosures All Authors: No reported disclosures

A CLINICALANALYSIS OF THE OUTCOME OF CHIVATE'S PROCEDURE AND MILLIGAN-MORGAN PROCEDURE FOR HAEMORRHOIDS

Aim: To study the outcome of the Chivate’s transanal suture rectopexy with milligan morgan procedure in patients of haemorrhoids from clinical perspective. Methods: From April 2018 to September 2019,30 patients of haemorrhoids(grade III/ IV) were randomly assigned to undergo either the transanal suture rectopexy (n= 15) or Milligan Morgan procedure (n=15). Outcome assessment was performed at 12 hours,24 hours,3days,weekly once for 1 month,monthly once for 5months. Variables included Post-operative complications, resolution of symptoms. Results: Both the groups were comparable in terms of demographic data. Of the 15 patients who underwent Chivate’s procedure, none of the patients complained of Pain. 1pt had minimal bleeding intra-operatively. 3 pts had urinary retention and another 2 pts had transient anal incontinence to flatus. Mild mucous discharge per rectum noted in 1 patient. All the patients were discharged in 24hrs. Of the 15 patients who underwent Milligan-Morgan procedure, 10 patients complained of severe pain in the post-operative periods. Bleeding was seen intra operatively in 3 pts and urinary retention seen in 1 pt. Mild mucus discharge per rectum was seen in the early post-operative period in 1 pt. Most of the patients stayed under admission for 3-4days. There was difficulty in passing stools postop in 3patients, thus, requiring increased use of laxatives in these patients. None of the patients had residual pile masses or recurrence in this study after long term follow up. Conclusion: Transanal suture rectopexy certainly offers lower incidence of post-op morbidities and better patient compliance than milligan morgan open hemorrhoidectomy.