Gastroesophageal reflux disease in Sri Lanka: An island-wide epidemiological survey assessing the prevalence and associated factors.

Gastroesophageal reflux disease (GERD) is commonly encountered in clinical practice in Sri Lanka. However, its prevalence in Sri Lanka is unknown. Our objective was to study the island-wide prevalence of GERD symptoms in Sri Lanka and its associated factors. A total of 1200 individuals aged 18-70 years (male: female 1: 1.16, mean age 42.7 years [SD 14.4 years]). were recruited from all 25 districts of the country, using stratified random sampling. An interviewer-administered, country-validated questionnaire was used to assess the GERD symptom prevalence and associated factors. Weight, height, waist, and hip circumference were measured. Heartburn and/or regurgitation at least once a week, an internationally used criterion for probable GERD was used to diagnose GERD. In this study, GERD symptom prevalence was 25.3% (male 42.1% and female 57.9%). Factors independently associated with GERD were inadequate sleep, snacking at midnight, sleeping within two hours of consuming a meal, skipping breakfast, increased mental stress, and certain medications used such as statins, and antihypertensive medications (p<0.001, univariate and logistic regression analysis). 38.4% of the study population have been using medication for heartburn and regurgitation in the past 3 months and 19.8% were on proton pump inhibitors. To conclude, the prevalence of GERD symptoms in Sri Lanka (25.3%) is higher than its estimated global prevalence of 13.8%. Several meal-related lifestyle habits, mental stress, and the use of some medications are significantly associated with GERD, indicating the importance of lifestyle modification and stress reduction in its management.

The association between symptoms of gastroesophageal reflux disease and perceived stress: A countrywide study of Sri Lanka.

BACKGROUND/AIMS: Stress is a known associated factor for gastroesophageal reflux disease (GERD). However, the dynamics between stress and GERD are not fully studied, especially in Sri Lanka. Our objective was to assess it. METHODS: For this cross-sectional descriptive study, 1200 individuals (age ranged 18-70 years, mean 42.7 years [SD 14.4 years], 46.1% males), were recruited using stratified random cluster sampling from all 25 districts of Sri Lanka. An interviewer-administered questionnaire, which included a country-validated GERD symptom screening tool, and the Perceived Stress Scale (PSS), was used to assess GERD symptoms and stress. Probable GERD was defined as those having heartburn and/ or regurgitation at least once per week which is on par with globally accepted criteria. Those who did not fulfill these criteria were considered as controls. RESULTS: PSS score was higher in those with probable GERD (mean 13.75 [standard deviation (SD) 6.87]) than in controls (mean 10.93 [SD 6.80]), (p <0.001, Mann-Whitney U test). The adjusted odds ratio for GERD symptoms was 1.96 times higher (95% confidence interval 1.50-2.55) in the moderate to high-stress level compared to the low-stress level participants. PSS score correlated significantly with the GERD screening tool score (R 0.242, p <0.001). Heartburn, regurgitation, chest pain, cough, and burping were significantly frequent in those with moderate to high-stress levels (p <0.001). Those with higher stress scores were more likely to use acid-lowering drugs (p = 0.006). CONCLUSIONS: Individuals exposed to higher levels of stress are more likely to have GERD symptoms. Therefore, stress reduction should be an important part of GERD symptom management.

Prevalence of irritable bowel syndrome and its association with colorectal cancer: a systematic review and meta-analysis.

BACKGROUND: This study evaluates the risk of colorectal cancer (CRC) in patients with Irritable Bowel Syndrome (IBS). METHODS: A literature search was performed on MEDLINE, EMBASE, SCOPUS, and Google Scholar from inception to 31st January 2020 without any limitations on article type or language for studies reporting data on CRC on patients with IBS. A meta-analysis was performed to estimate the prevalence of CRC among patients with IBS. Data extraction was according to the PRISMA guidelines. The quality of the included studies was assessed according to the Newcastle Ottawa Scale. RESULTS: Twenty-one articles were eligible for data extraction and quantitative analysis. Of them, 11 were included in the meta-analysis (IBS n = 284 366, no-IBS n = 8 390 509). The pooled prevalence of CRC in patients with IBS was 0.96% (95% CI-0.184%-2.344%). The prevalence was lowest in the constipation-predominant IBS (pooled prevalence 1.126%. Patients with IBS-D and IBS-U had an equal pooled prevalence of CRC (2.49%). Eleven studies compared the prevalence of CRC in patients with IBS with a control population. The pooled OR was 2.8 (CI 2.305-3.294). CONCLUSIONS: There was an increased risk of CRC among patients diagnosed with IBS, primarily in the first year after IBS diagnosis. REGISTRATION: The review was registered on PROSPERO (CRD42021236707).

Antibody tests for identification of current and past infection with SARS-CoV-2.

BACKGROUND: The diagnostic challenges associated with the COVID-19 pandemic resulted in rapid development of diagnostic test methods for detecting SARS-CoV-2 infection. Serology tests to detect the presence of antibodies to SARS-CoV-2 enable detection of past infection and may detect cases of SARS-CoV-2 infection that were missed by earlier diagnostic tests. Understanding the diagnostic accuracy of serology tests for SARS-CoV-2 infection may enable development of effective diagnostic and management pathways, inform public health management decisions and understanding of SARS-CoV-2 epidemiology. OBJECTIVES: To assess the accuracy of antibody tests, firstly, to determine if a person presenting in the community, or in primary or secondary care has current SARS-CoV-2 infection according to time after onset of infection and, secondly, to determine if a person has previously been infected with SARS-CoV-2. Sources of heterogeneity investigated included: timing of test, test method, SARS-CoV-2 antigen used, test brand, and reference standard for non-SARS-CoV-2 cases. SEARCH METHODS: The COVID-19 Open Access Project living evidence database from the University of Bern (which includes daily updates from PubMed and Embase and preprints from medRxiv and bioRxiv) was searched on 30 September 2020. We included additional publications from the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) 'COVID-19: Living map of the evidence' and the Norwegian Institute of Public Health 'NIPH systematic and living map on COVID-19 evidence'. We did not apply language restrictions. SELECTION CRITERIA: We included test accuracy studies of any design that evaluated commercially produced serology tests, targeting IgG, IgM, IgA alone, or in combination. Studies must have provided data for sensitivity, that could be allocated to a predefined time period after onset of symptoms, or after a positive RT-PCR test. Small studies with fewer than 25 SARS-CoV-2 infection cases were excluded. We included any reference standard to define the presence or absence of SARS-CoV-2 (including reverse transcription polymerase chain reaction tests (RT-PCR), clinical diagnostic criteria, and pre-pandemic samples). DATA COLLECTION AND ANALYSIS: We use standard screening procedures with three reviewers. Quality assessment (using the QUADAS-2 tool) and numeric study results were extracted independently by two people. Other study characteristics were extracted by one reviewer and checked by a second. We present sensitivity and specificity with 95% confidence intervals (CIs) for each test and, for meta-analysis, we fitted univariate random-effects logistic regression models for sensitivity by eligible time period and for specificity by reference standard group. Heterogeneity was investigated by including indicator variables in the random-effects logistic regression models. We tabulated results by test manufacturer and summarised results for tests that were evaluated in 200 or more samples and that met a modification of UK Medicines and Healthcare products Regulatory Agency (MHRA) target performance criteria. MAIN RESULTS: We included 178 separate studies (described in 177 study reports, with 45 as pre-prints) providing 527 test evaluations. The studies included 64,688 samples including 25,724 from people with confirmed SARS-CoV-2; most compared the accuracy of two or more assays (102/178, 57%). Participants with confirmed SARS-CoV-2 infection were most commonly hospital inpatients (78/178, 44%), and pre-pandemic samples were used by 45% (81/178) to estimate specificity. Over two-thirds of studies recruited participants based on known SARS-CoV-2 infection status (123/178, 69%). All studies were conducted prior to the introduction of SARS-CoV-2 vaccines and present data for naturally acquired antibody responses. Seventy-nine percent (141/178) of studies reported sensitivity by week after symptom onset and 66% (117/178) for convalescent phase infection. Studies evaluated enzyme-linked immunosorbent assays (ELISA) (165/527; 31%), chemiluminescent assays (CLIA) (167/527; 32%) or lateral flow assays (LFA) (188/527; 36%). Risk of bias was high because of participant selection (172, 97%); application and interpretation of the index test (35, 20%); weaknesses in the reference standard (38, 21%); and issues related to participant flow and timing (148, 82%). We judged that there were high concerns about the applicability of the evidence related to participants in 170 (96%) studies, and about the applicability of the reference standard in 162 (91%) studies. Average sensitivities for current SARS-CoV-2 infection increased by week after onset for all target antibodies. Average sensitivity for the combination of either IgG or IgM was 41.1% in week one (95% CI 38.1 to 44.2; 103 evaluations; 3881 samples, 1593 cases), 74.9% in week two (95% CI 72.4 to 77.3; 96 evaluations, 3948 samples, 2904 cases) and 88.0% by week three after onset of symptoms (95% CI 86.3 to 89.5; 103 evaluations, 2929 samples, 2571 cases). Average sensitivity during the convalescent phase of infection (up to a maximum of 100 days since onset of symptoms, where reported) was 89.8% for IgG (95% CI 88.5 to 90.9; 253 evaluations, 16,846 samples, 14,183 cases), 92.9% for IgG or IgM combined (95% CI 91.0 to 94.4; 108 evaluations, 3571 samples, 3206 cases) and 94.3% for total antibodies (95% CI 92.8 to 95.5; 58 evaluations, 7063 samples, 6652 cases). Average sensitivities for IgM alone followed a similar pattern but were of a lower test accuracy in every time slot. Average specificities were consistently high and precise, particularly for pre-pandemic samples which provide the least biased estimates of specificity (ranging from 98.6% for IgM to 99.8% for total antibodies). Subgroup analyses suggested small differences in sensitivity and specificity by test technology however heterogeneity in study results, timing of sample collection, and smaller sample numbers in some groups made comparisons difficult. For IgG, CLIAs were the most sensitive (convalescent-phase infection) and specific (pre-pandemic samples) compared to both ELISAs and LFAs (P < 0.001 for differences across test methods). The antigen(s) used (whether from the Spike-protein or nucleocapsid) appeared to have some effect on average sensitivity in the first weeks after onset but there was no clear evidence of an effect during convalescent-phase infection. Investigations of test performance by brand showed considerable variation in sensitivity between tests, and in results between studies evaluating the same test. For tests that were evaluated in 200 or more samples, the lower bound of the 95% CI for sensitivity was 90% or more for only a small number of tests (IgG, n = 5; IgG or IgM, n = 1; total antibodies, n = 4). More test brands met the MHRA minimum criteria for specificity of 98% or above (IgG, n = 16; IgG or IgM, n = 5; total antibodies, n = 7). Seven assays met the specified criteria for both sensitivity and specificity. In a low-prevalence (2%) setting, where antibody testing is used to diagnose COVID-19 in people with symptoms but who have had a negative PCR test, we would anticipate that 1 (1 to 2) case would be missed and 8 (5 to 15) would be falsely positive in 1000 people undergoing IgG or IgM testing in week three after onset of SARS-CoV-2 infection. In a seroprevalence survey, where prevalence of prior infection is 50%, we would anticipate that 51 (46 to 58) cases would be missed and 6 (5 to 7) would be falsely positive in 1000 people having IgG tests during the convalescent phase (21 to 100 days post-symptom onset or post-positive PCR) of SARS-CoV-2 infection. AUTHORS' CONCLUSIONS: Some antibody tests could be a useful diagnostic tool for those in whom molecular- or antigen-based tests have failed to detect the SARS-CoV-2 virus, including in those with ongoing symptoms of acute infection (from week three onwards) or those presenting with post-acute sequelae of COVID-19. However, antibody tests have an increasing likelihood of detecting an immune response to infection as time since onset of infection progresses and have demonstrated adequate performance for detection of prior infection for sero-epidemiological purposes. The applicability of results for detection of vaccination-induced antibodies is uncertain.

Factors associated with stoma formation in ileocolic resection for Crohn's disease and the development of a predictive scoring system.

PURPOSE: The likelihood of a stoma following ileocolic resection (ICR) for Crohn's disease (CD) is an important consideration. This study aims to identify the factors associated with an increased likelihood of a stoma and develop a predictive scoring system (SS). METHODS: Patient data were collected from St. Marks Hospital, London, UK and Humanitas Clinical and Research Center, Milan, Italy, on all patients who underwent an ICR for CD from 2005 to 2017. A logistic regression analysis was used for multivariate analysis. The SS was developed from the logistic regression model. The performance of the SS was evaluated using receiver operating characteristics area under the curve (AUROC). RESULTS: A total of 628 surgeries were included in the analysis. Sixty-nine surgeries were excluded due to missing data. The remaining 559 were divided into two cohorts for the scoring system's development (n = 434) and validation (n = 125). The regression model was statistically significant (p < 0.0001). The statistically significant independent variables included sex, preoperative albumin and haemoglobin levels, surgical access and simultaneous colonic resection. The AUROC for the development and validation cohorts were 0.803 and 0.905, respectively (p < 0.0001). Youden's index suggested the cut-off score of - 95.9, with a sensitivity of 87.6% and a specificity of 62.9%. CONCLUSIONS: Male sex, low preoperative albumin, anaemia, laparoscopic conversion and simultaneous colonic resection were associated with an increased likelihood of requiring a stoma and were used to develop an SS. The calculator is available online at https://rebrand.ly/CrohnsStoma .

Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID-19.

BACKGROUND: COVID-19 illness is highly variable, ranging from infection with no symptoms through to pneumonia and life-threatening consequences. Symptoms such as fever, cough, or loss of sense of smell (anosmia) or taste (ageusia), can help flag early on if the disease is present. Such information could be used either to rule out COVID-19 disease, or to identify people who need to go for COVID-19 diagnostic tests. This is the second update of this review, which was first published in 2020. OBJECTIVES: To assess the diagnostic accuracy of signs and symptoms to determine if a person presenting in primary care or to hospital outpatient settings, such as the emergency department or dedicated COVID-19 clinics, has COVID-19. SEARCH METHODS: We undertook electronic searches up to 10 June 2021 in the University of Bern living search database. In addition, we checked repositories of COVID-19 publications. We used artificial intelligence text analysis to conduct an initial classification of documents. We did not apply any language restrictions. SELECTION CRITERIA: Studies were eligible if they included people with clinically suspected COVID-19, or recruited known cases with COVID-19 and also controls without COVID-19 from a single-gate cohort. Studies were eligible when they recruited people presenting to primary care or hospital outpatient settings. Studies that included people who contracted SARS-CoV-2 infection while admitted to hospital were not eligible. The minimum eligible sample size of studies was 10 participants. All signs and symptoms were eligible for this review, including individual signs and symptoms or combinations. We accepted a range of reference standards. DATA COLLECTION AND ANALYSIS: Pairs of review authors independently selected all studies, at both title and abstract, and full-text stage. They resolved any disagreements by discussion with a third review author. Two review authors independently extracted data and assessed risk of bias using the QUADAS-2 checklist, and resolved disagreements by discussion with a third review author. Analyses were restricted to prospective studies only. We presented sensitivity and specificity in paired forest plots, in receiver operating characteristic (ROC) space and in dumbbell plots. We estimated summary parameters using a bivariate random-effects meta-analysis whenever five or more primary prospective studies were available, and whenever heterogeneity across studies was deemed acceptable. MAIN RESULTS: We identified 90 studies; for this update we focused on the results of 42 prospective studies with 52,608 participants. Prevalence of COVID-19 disease varied from 3.7% to 60.6% with a median of 27.4%. Thirty-five studies were set in emergency departments or outpatient test centres (46,878 participants), three in primary care settings (1230 participants), two in a mixed population of in- and outpatients in a paediatric hospital setting (493 participants), and two overlapping studies in nursing homes (4007 participants). The studies did not clearly distinguish mild COVID-19 disease from COVID-19 pneumonia, so we present the results for both conditions together. Twelve studies had a high risk of bias for selection of participants because they used a high level of preselection to decide whether reverse transcription polymerase chain reaction (RT-PCR) testing was needed, or because they enrolled a non-consecutive sample, or because they excluded individuals while they were part of the study base. We rated 36 of the 42 studies as high risk of bias for the index tests because there was little or no detail on how, by whom and when, the symptoms were measured. For most studies, eligibility for testing was dependent on the local case definition and testing criteria that were in effect at the time of the study, meaning most people who were included in studies had already been referred to health services based on the symptoms that we are evaluating in this review. The applicability of the results of this review iteration improved in comparison with the previous reviews. This version has more studies of people presenting to ambulatory settings, which is where the majority of assessments for COVID-19 take place. Only three studies presented any data on children separately, and only one focused specifically on older adults. We found data on 96 symptoms or combinations of signs and symptoms. Evidence on individual signs as diagnostic tests was rarely reported, so this review reports mainly on the diagnostic value of symptoms. Results were highly variable across studies. Most had very low sensitivity and high specificity. RT-PCR was the most often used reference standard (40/42 studies). Only cough (11 studies) had a summary sensitivity above 50% (62.4%, 95% CI 50.6% to 72.9%)); its specificity was low (45.4%, 95% CI 33.5% to 57.9%)). Presence of fever had a sensitivity of 37.6% (95% CI 23.4% to 54.3%) and a specificity of 75.2% (95% CI 56.3% to 87.8%). The summary positive likelihood ratio of cough was 1.14 (95% CI 1.04 to 1.25) and that of fever 1.52 (95% CI 1.10 to 2.10). Sore throat had a summary positive likelihood ratio of 0.814 (95% CI 0.714 to 0.929), which means that its presence increases the probability of having an infectious disease other than COVID-19. Dyspnoea (12 studies) and fatigue (8 studies) had a sensitivity of 23.3% (95% CI 16.4% to 31.9%) and 40.2% (95% CI 19.4% to 65.1%) respectively. Their specificity was 75.7% (95% CI 65.2% to 83.9%) and 73.6% (95% CI 48.4% to 89.3%). The summary positive likelihood ratio of dyspnoea was 0.96 (95% CI 0.83 to 1.11) and that of fatigue 1.52 (95% CI 1.21 to 1.91), which means that the presence of fatigue slightly increases the probability of having COVID-19. Anosmia alone (7 studies), ageusia alone (5 studies), and anosmia or ageusia (6 studies) had summary sensitivities below 50% but summary specificities over 90%. Anosmia had a summary sensitivity of 26.4% (95% CI 13.8% to 44.6%) and a specificity of 94.2% (95% CI 90.6% to 96.5%). Ageusia had a summary sensitivity of 23.2% (95% CI 10.6% to 43.3%) and a specificity of 92.6% (95% CI 83.1% to 97.0%). Anosmia or ageusia had a summary sensitivity of 39.2% (95% CI 26.5% to 53.6%) and a specificity of 92.1% (95% CI 84.5% to 96.2%). The summary positive likelihood ratios of anosmia alone and anosmia or ageusia were 4.55 (95% CI 3.46 to 5.97) and 4.99 (95% CI 3.22 to 7.75) respectively, which is just below our arbitrary definition of a 'red flag', that is, a positive likelihood ratio of at least 5. The summary positive likelihood ratio of ageusia alone was 3.14 (95% CI 1.79 to 5.51). Twenty-four studies assessed combinations of different signs and symptoms, mostly combining olfactory symptoms. By combining symptoms with other information such as contact or travel history, age, gender, and a local recent case detection rate, some multivariable prediction scores reached a sensitivity as high as 90%. AUTHORS' CONCLUSIONS: Most individual symptoms included in this review have poor diagnostic accuracy. Neither absence nor presence of symptoms are accurate enough to rule in or rule out the disease. The presence of anosmia or ageusia may be useful as a red flag for the presence of COVID-19. The presence of cough also supports further testing. There is currently no evidence to support further testing with PCR in any individuals presenting only with upper respiratory symptoms such as sore throat, coryza or rhinorrhoea. Combinations of symptoms with other readily available information such as contact or travel history, or the local recent case detection rate may prove more useful and should be further investigated in an unselected population presenting to primary care or hospital outpatient settings. The diagnostic accuracy of symptoms for COVID-19 is moderate to low and any testing strategy using symptoms as selection mechanism will result in both large numbers of missed cases and large numbers of people requiring testing. Which one of these is minimised, is determined by the goal of COVID-19 testing strategies, that is, controlling the epidemic by isolating every possible case versus identifying those with clinically important disease so that they can be monitored or treated to optimise their prognosis. The former will require a testing strategy that uses very few symptoms as entry criterion for testing, the latter could focus on more specific symptoms such as fever and anosmia.

Anal sphincter fatigability in assessing anal incontinence: A systematic review.

BACKGROUND: Diagnosing anal incontinence (AI) based on manometry results is challenging due to the variation of the normal values and overlap between patients with and without AI. This study aimed to perform a systematic review on the difference in sphincter fatigability between patients with and without AI. METHODS: MEDLINE, EMBASE, SCOPUS, and Google Scholar were searched. Studies were included if they included adult patients and assessed anal sphincter fatigability between using manometry. The effect size was estimated as the standardized mean difference (SMD) with 95% confidence intervals. A random-effects model was used. RESULTS: The database searches identified 125 unique articles, and five additional articles were identified from the reference list of articles. One hundred thirteen were excluded through title and abstract review. Nine articles were included in the final analysis. There was no statistically significant difference in the resting pressure between the two groups. Patients with AI had significantly lower squeeze pressure. There was no statistically significant difference between the groups in the fatigue rate. The FRI was significantly lower in patients with AI (SMD 1.636, p = 0.001). Approximately a third of the patients in one study were able to maintain a contraction for 20s without reducing pressure. There was significant heterogeneity in the studies. The data available were inadequate for more robust calculations. CONCLUSIONS: Sphincter fatigability, measured by the Fatigability Rate Index, has good discriminating power for anal incontinence. A standardized protocol needs to be followed by future researchers. Graphical Abstract The analysis used six studies with 413 patients to compare Fatigue Rate Index between patients with AI and controls. All studies reported a lower FRI in patients with incontinence and the FRI was significantly lower in patients with AI (standardized mean difference [SMD] 1.636, p= 0.001). Conflicting results were reported on the correlation between FRI and AI symptom scores.

The Worldwide Epidemiology of Acute Appendicitis: An Analysis of the Global Health Data Exchange Dataset.

BACKGROUND: This study aims to describe the worldwide epidemiology and changing disease trends of acute appendicitis (AA). METHODS: Epidemiological data on the incidence of AA and deaths were collected from the Global Health Data Exchange repository from 1990 to 2019. Data were stratified by age, sex and Socio-Demographic Index (SDI). RESULTS: In 2019, there were an estimated 17.7 million cases (incidence 228/100,000) with over 33,400 deaths (0.43/100,000). Both the absolute number and the incidence had increased from 1990 to 2019 (+ 38.8% and + 11.4%, respectively). The number of deaths and deaths per 100,000 declined during this period (- 21.8% and - 46.2%, respectively). These trends were largely similar in all 5 SDI groups. There was a significant difference in the incidence of AA between the SDI groups, with low SDI group having the lowest and high SDI group having the highest. The high SDI group had the lowest mortality rate (Kruskall-Wallis test, p < 0.001). The peak incidence was in the 15-19-year age group. The mortality rate increased exponentially from the third decade of life. CONCLUSIONS: The mortality rate of AA is declining worldwide, while the incidence is increasing. The peak incidence is in the 15-19-year group.

A scoring system to predict a prolonged length of stay after surgery for Crohn's disease.

AIM: Many factors influence the postoperative length of stay (LOS) in Crohn's disease (CD). This study aims to identify the factors associated with a prolonged LOS after ileocolic resection (ICR) for CD and to develop a scoring system to predict the postoperative LOS in CD. METHOD: Patient data were collected from St Marks Hospital, London, UK, and the Humanitas Clinical and Research Center Milan, Italy, for all patients who underwent an ICR for CD from 2005 to 2017. Logistic regression was used for multivariate analysis. The scoring system was developed from the logistic regression model. The performance of the scoring system was evaluated using the area under the receiver operating characteristic curve (AUROC). RESULTS: A total of 628 surgeries were included in the analysis. Eighty eight surgeries were excluded due to missing data. The remaining 543 were divided into two cohorts for the development (n = 418) and validation (n = 125) of the scoring system. The regression model was statistically significant (p < 0.0001). The statistically significant independent variables included the time since diagnosis, American Society of Anesthesiologists (ASA) grade, perioperative use of steroids, surgical access, strictureplasty and platelet count. The AUROCs for the development and validation cohorts were 0.732 and 0.7, respectively (p < 0.0001). The cut-off score suggested by Youden's index was 50, with a sensitivity of 65.6% and a specificity of 73.3%. CONCLUSION: The time since diagnosis, ASA grade, steroid use, surgical access, strictureplasty and platelet count were associated with a prolonged LOS and were used to develop a scoring system. The calculator is available online at https://rebrand.ly/Crohnscal.

Correlation between immunity from BCG and the morbidity and mortality of COVID-19.

BACKGROUND: To investigate the association between parameters indicating immunity from BCG at country level (presence of BCG vaccination policy, BCG coverage, age-specific incidence of tuberculosis (TB)) and the morbidity and mortality of COVID-19. METHODS: Country-specific data for COVID-19 cases and deaths, demographic details, BCG coverage and policy, age-specific TB incidence and income level were obtained. The crude COVID-19 cases and deaths per 100,000 population were calculated and assessed against the parameters indicating immunity from BCG using linear regression analysis. RESULTS: Univariate analysis identified higher income level of a country to be significantly associated with COVID-19 cases (p < 0.0001) and deaths (p < 0.0001) but not with its case fatality rate. The association between COVID-19 and TB was strongest for TB incidence in patients > 65-years (Cases (rs = - 0.785,p = 0.0001)) and deaths (rs = - 0.647,p = 0.0001).Multivariate analysis identified the higher income level of a country and not having a universal BCG vaccination policy to affect the COVID-19 cases. The deaths were inversely affected by the presence of BCG vaccination policy and coverage; and positively by the TB incidence in patients > 65-years. CONCLUSION: Significant inverse correlations observed between cases and deaths of COVID-19 and BCG related parameters highlights immunity from BCG as a likely explanation for the variation in COVID-19 across countries.

Translation and Validation of the Sinhala Version of the EORTC-QLQ-CR29 Questionnaire.

PURPOSE: To validate the Sinhalese version of the EORTC QLQ-CR29 quality of life questionnaire for colorectal cancer. METHOD: We translated and pilot-tested (n=10) the questionnaire in Sri Lanka. We then assessed the reliability, factor structure and construct validity according to the EORTC guidelines. The testing was done in two tertiary care hospitals in Sri Lanka. RESULTS: Of 110 participants, 103 (93%) returned the questionnaire, and 15 out of 20 (75%) returned the repeat-test questionnaire within a period of two weeks. Out of the original four scales three had better reliability than the original scales: urinary frequency (Cronbach α - 0.82), blood and mucus in stools (α-0.85), defaecation problems (α-0.76). The body image scale showed low reliability (α - 0.33).  However, when one of the 3 items in the scale was omitted, it showed sufficient reliability (α - 0.74). Factor analysis showed good reliability for overall assessment of the two item scale for stool frequency (α - 0.82) and six item scale for defaecation problems (α - 0.76). Correlations between the subscales of CR29 and C30 questionnaires were below 0.40, except for body image, which correlated moderately (r-0.44) with emotional functioning. This confirmed satisfactory overall construct validity  Conclusion: The scales for urinary frequency, blood and mucus in stools and defaecation problems which were reliable and had good validity. Body image scale failed to show sufficient reliability with the three-item scale and we suggest omitting one of the items to improve the overall reliability of the questionnaire. Construct validity was comparable to published data.

Value of three-dimensional endoanal ultrasound scan (3D-EAUS) in preoperative assessment of fistula-in-ano.

OBJECTIVE: The aim of this study was to determine the accuracy of three-dimensional endoanal ultrasound scan (3D-EAUS) in the pre-operative assessment of fistula-in-ano in identifying the fistula tract and comparing with findings at surgery in a South Asian cohort. A retrospective analysis of 87 patients with suspected fistula-in-ano who underwent pre-operative 3D-EAUS between January 2009 and January 2016 was carried out. All patients subsequently had surgical exploration under anaesthesia (EUA), irrespective of 3D-EAUS findings. The 3D-EAUS results were compared with the surgical findings to determine the accuracy of 3D-EAUS. RESULTS: A total of 86 (98.9%) patients (male = 75) were subsequently shown to have a fistula at surgical exploration and of them, 3D-EAUS detected a fistula in 79 (92%) patients. In this cohort, 3D-EAUS correctly predicted the surgical findings in (n = 61, 70.9%) patients with the highest accuracy being for transphincteric fistulae (87.1%). However, the overall concordance in our study was low with a kappa coefficient of 0.318. Additional findings such as sphincter defects were detected by the 3D-EAUS in 37 patients (internal sphincter defects-21, external sphincter defects-7, both-9) which were not evident at EUA. Therefore, 3D-EAUS had a good accuracy in selected types of fistulae and particularly useful in identifying sphincter defects before surgery.

Treatment of fistula in-ano with fistula plug: experience of a tertiary care centre in South Asia and comparison of results with the West.

OBJECTIVES: Surgery for fistula in ano is associated with anal incontinence. The biologic anal fistula plug (AFP) can minimize this. This is a retrospective analysis of patients with cryptoglandular anorectal fistulae, who underwent a surgical procedure using AFP. Patient's demographics and characteristics of the fistulae were obtained from a prospective database. Each primary opening was occluded by using an AFP. Success was defined by the closure of the external opening and absent drainage. RESULTS: Fifty-one patients were treated with AFP (male:female: 37:14), mean age 42 years (SD ± 14.86, range 26-70). Ten patients defaulted follow-up. Forty-seven procedures were analysed. Twenty-three (56.1%) patients had complete healing while 18 (43.9%) patients failed the fistula plug procedure during the follow up period of 12 months. Logistical regression failed to identify any statistical significant association with demographic or disease factors and healing. Healing was 1.5 times less likely for every failed procedure prior to AFP insertion. Contrary to other published studies, placement of fistula plug was associated with much lower overall rates of fistula healing. Highest success rates were seen in simple fistulae when compared to the complex type. Repeat plug placement may be successful in selected patients.

Duration taken for the anal sphincter pressures to stabilize prior to anorectal manometry.

OBJECTIVES: Anorectal manometry (ARM) is an integral part of evaluating the anal sphincter function. The current recommendation of waiting for 5 min (lead-in-time) prior to beginning the recording has no evidence. A prolonged procedure may reduce patient compliance. RESULTS: We analyzed data from 100 consecutive patients who underwent 3-dimensional ARM at a single center. Their pressure studies were analyzed in consecutive 10-s segments, beginning from the time of insertion of the probe into the anal canal. We defined stabilization of the pressure as the absence of a pressure difference among two consecutive 10-s segments. The study population had 31 males. Their mean age was 33.0 years (SD-14.4). The mean time for the pressure to stabilize was 84.2 s (SD-29.5), range 17.2-203.7 s, 95th percentile 136.2 s. Eleven and one participant(s) took longer than 120 and 150 s for the pressure to stabilize, respectively. There was no correlation of sex (Mann-Whitney U test, p = 0.89) and the time to pressure stabilization. Age and the time to stabilize (Spearman rho - 0.246, p = 0.017) showed a weak negative correlation. A lead-in-time of 5 min, as recommended by present guidelines may be unnecessary. Waiting for 150 s/2½ min may be sufficient and will minimize the procedure duration.

Three-Dimensional Endoanal Ultrasound Features of the Anal Sphincter in Asian Primigravidae.

OBJECTIVES: The normal parameters of 3-dimensional endoanal ultrasound (3DEAUS) of the anal sphincter have not been reported for primigravidae or pregnant women at present. 3DEAUS parameters in Asian primigravidae were assessed in this study. METHODS: We analyzed 3DEAUS data of 101 consecutives Asian primigravidae, assessed in the early third trimester. The assessment was performed with a rigid ultrasonic probe (Olympus® RU 12M-R1 probe and EU-ME1 ultrasound system (Olympus Corp., Shinjuku, Japan). The Wilcoxon signed-rank test was used to detect the differences in pressure in different quadrants. RESULTS: The participants had a mean age of 24.7 (standard deviation [SD], 5.1) years. The Cleveland Clinic Incontinence Score was normal in all participants. The anal sphincter complex had 3 characteristic segments that were identifiable: upper, middle and lower. The puborectalis muscle was identified as a striated "V"-shaped sling, and its mean thickness was 7.44 (SD, 1.41) mm. The mean thickness of internal (IAS) and external (EAS) sphincters at the mid-sphincter level were 1.78 (SD, 0.59) and 5.49 (SD, 1.21) mm, respectively. The EAS measured 6.02 (SD, 1.07) mm at the lower sphincter level. The statistically significant differences seen in the in quadrants were: the IAS was thicker anteriorly (Z = -2.642; P = .008), the EAS at both midsphincter level (Z = -3.70; P < .001) and lower sphincter level (Z = -7.712; P < .001) was thicker posteriorly, and the IAS was thicker at the 9 o'clock position (Z = -2.081; P = .037). Good symmetry at all 3 levels was seen in the EAS (including the puborectalis muscle). CONCLUSIONS: Normal values of 3DEAUS for primigravidae have been identified and may serve as reference values for other laboratories.

Anal incontinence and quality of life following operative treatment of simple cryptoglandular fistula-in-ano: a prospective study.

BACKGROUND: Anal incontinence is a known complication following operative treatment of fistula-in-ano which can significantly impact the quality of life. This study was aimed to objectively assess the impact of operative treatment of simple fistula-in-ano on quality of life related to anal incontinence. Therefore, a prospective study was conducted in 34 patients who underwent surgery for fistula-in-ano over a period of 24 months. Quality of life and incontinence were assessed using fecal incontinence quality of life (FIQL) scale and Cleveland clinic incontinence score (CCIS) preoperatively and after a minimum of 12 months follow up (mean-27 months, range 12-40 months). The difference in FIQL and CCIS was analysed using Wilcoxon Rank test and Mann-Whitney U test. RESULTS: The median age of the participants was 42.5 years (range 22-63, males = 30). The majority had a trans-sphincteric tract (n = 22, 65%). Superficial tracts and inter-sphincteric tracts were found in 8 (24%) and 4 patients (12%). The overall preoperative and postoperative rates of incontinence were 18 and 38% respectively, but the severity was low. The mean overall FIQL was 16.0 (SD ± 0.4) preoperatively and 16.1 (SD ± 0.4) postoperatively. Considerable difference was seen in the scale measuring "depression/self-perception" (p = 0.012). Only 1 patient (3%) had reduction in scale "lifestyle" which measures the impact of incontinence on day-to-day activities. CONCLUSIONS: Analysis of a cohort of simple cryptoglandular fistula-in-ano with low pre-operative incontinence showed no worsening in the FIQL following successful treatment despite minor worsening of incontinence. Since greater improvement was noted in scale measuring depression/self-perception, psychological interventions may be helpful before surgery to improve quality of life.

Incidence of esophageal cancer in Sri Lanka: Analysis of cancer registry data and comparison with other South Asian populations.

INTRODUCTION: The objectives of this study were to report the incidence of Carcinoma of Esophagus (CaE) in Sri Lanka and to compare these values with other cancer registry data of the region and with migrant populations. MATERIALS AND METHODS: We compared the data published by the National Cancer Control Program over the last two decades with data from the National Cancer Registry Programme of the Indian Council of Medical Research and Karachi Cancer Registry. SEERstat was used to analyze the surveillance, epidemiology and end results database to analyze data on Indian migrant population. RESULTS: CaE was the fourth most common cancer overall and among females and third most common cancer among males. The incidence of CaE rises with age in both sexes, with a peak in the 70-74 year age group. There was a disproportionately higher number of CaE in the Tamil population (chi-square test, P < 0.00001). The commonest type of CaE in Sri Lanka was squamous cell carcinoma, Not otherwise specified (NOS) (n = 750, 70.5%), followed by adenocarcinoma, NOS (n = 83, 7.8%). India, Pakistan and Sri Lanka have comparable age-adjusted incidence and age distribution of CaE. All migrant populations had lower incidence of CaE than original population or population in their present country. Both cigarette smoking and alcohol consumption are more prevalent in Sri Lankan males than females. DISCUSSION AND CONCLUSIONS: The incidence of CaE and its distribution among age groups in Sri Lanka was comparable to other countries of the region. Persons of Tamil ethnicity have a higher risk of developing CaE.

Effect of vaginal delivery on anal sphincter function in Asian primigravida: a prospective study.

INTRODUCTION AND HYPOTHESIS: The true incidence of obstetric anal sphincter injuries (OASI) among Asian primigravida is not known. This study aimed to evaluate OASI in Sri Lankan primigravida. METHODS: One hundred and one consecutive primigravida in their last trimester were recruited from antenatal clinics at a tertiary care centre in Sri Lanka and followed up 6 weeks and 6 months after delivery. They were assessed using anorectal manometry (3D-ARM) and endoanal ultrasound (3D-EAUS) on both occasions. RESULTS: Seventy-three (75.3 %) had vaginal delivery without instrumentation, whereas 3 (3.1 %) each delivered using forceps or vacuum. Twelve (12.4 %) had emergency caesarean sections and 6 (6.2 %) had elective caesarean sections. None had clinically identified anal sphincter injuries. EAUS identified IAS defects in 3 (5.1 %) and EAS defects in 28 (47.5 %). Both resting (p = 0.3) and squeeze (p = 0.001) pressures had decreased following childbirth. Multivariate analysis identified antepartum RP and postpartum EAS defects to be associated with RP reduction (χ(2)(4)=17.825, p < 0.0005) and antepartum SP and postpartum EAS defects to be associated with SP reduction (χ(2)(5)=31.517, p < 0.0005). Episiotomy was protective, whereas delivering after 40 weeks' gestation and delivering a baby with a longer length increased the risk of SP reduction. EAS defects (χ(2) (6)=23.502, p = .001) were more common in mothers who had labour augmented by oxytocin and in those who delivered a baby with a larger head circumference. Labour induction and delivering a longer baby were protective for EAS defects. CONCLUSIONS: Several risk and protective factors for the structural and functional damage of sphincters were identified. These findings will help to formulate a policy to minimize future obstetric anal sphincter injuries.