Modern management of hemorrhoidal disease

Local anaesthetic for pain post rubber band ligation of haemorrhoids: a prospective, single-blinded randomised controlled trial

BACKGROUND

Rubber band ligation (RBL) is a widely accepted intervention for the treatment of haemorrhoids. However, post procedure pain is a common complaint. The aim of this study was to determine whether the addition of local anaesthetic (LA) to the haemorrhoid pedicle base, post RBL, aids in reducing early post-procedure pain. Additionally, to compare perceived perianal numbness, oral analgesia usage and total consumption, and adverse events.

METHODS

This study was a prospective, single-blinded randomised controlled trial. Patients were recruited from colorectal clinics in two Australian hospitals between 2018-2019. Patients randomised to the intervention (LA) group received 2mls bupivacaine 0.5% with adrenaline 1:200,000 to each haemorrhoid base. Patients in the control group were not administered LA. Pain scores were recorded over 48 h using visual analogue scales. Analgesia consumption was documented and other secondary objectives were recorded dichotomously (yes/no).

RESULTS

At 1 h post-procedure, patient reported pain scores were significantly lower in the LA group compared to the control group (p = 0.04). There were no significant differences in pain scores between the groups at 4, 24 or 48 h. Additionally, there were no significant differences between groups with respect to oral analgesia usage, perianal numbness or adverse events.

CONCLUSIONS

LA to the haemorrhoid pedicle post RBL may significantly reduce early post procedure pain without any increased risk of adverse effects.

Pudendal Nerve Block for Posthemorrhoidectomy Pain: A Prospective, Single-Blinded Randomized Control Trial

BACKGROUND

Postoperative pain is common in hemorrhoidectomy patients. Local anesthetic given either as an intraoperative pudendal nerve block or as a local wound infiltration may help alleviate postoperative pain.

OBJECTIVES

This study sought to determine whether the addition of an intraoperative pudendal nerve block to a perianal local wound infiltration and standardized analgesia regimen was superior to a perianal local wound infiltration and standardized analgesia regimen alone in reducing early postoperative pain following hemorrhoidectomy. The secondary objective was to measure differences between treatment groups in perceived perianal numbness, oral opioid requirements, and adverse events.

DESIGN

This study was a prospective, single-blinded randomized controlled trial approved by the Eastern Health Human Research and Ethics Committee in Melbourne, Australia (registration number: E09/2014).

SETTINGS

Patients were recruited across 3 Australian hospitals.

PATIENTS

Eighty patients with symptomatic hemorrhoids requiring hemorrhoidectomy in colorectal surgical outpatient clinics were successfully recruited and enrolled in the study, with 1 patient later dropping out.

INTERVENTION

Patients were randomly assigned to either the pudendal nerve block group or a control group. The pudendal nerve block group received 5 mL bupivacaine 0.5% with adrenaline 1:200,000 to both pudendal nerve trunks bilaterally. Both groups received 10 mL of the same local anesthetic injected into the post-hemorrhoidectomy wound bed.

MAIN OUTCOME MEASURES

Visual analogue scales were used to record patient pain scores. Dichotomous (yes/no) answers were recorded for secondary objectives.

RESULTS

There were no significant differences in postoperative pain between groups at 4 hours, 8 hours, 12 hours, or 24 hours. Additionally, there were no significant differences between groups with respect to perceived perianal numbness, oral opioid usage or adverse events.

LIMITATIONS

The authors recognize that without a nerve stimulator, an argument can be made that the pudendal nerve block was not actually achieved.

CONCLUSION

Pudendal nerve block does not appear to demonstrate additional benefit in post-hemorrhoidectomy pain reduction beyond local anesthetic to the wound. See Video Abstract at http://links.lww.com/DCR/B780.

BLOQUEO DEL NERVIO PUDENDO PARA EL DOLOR POSHEMORROIDECTOMA ESTUDIO PROSPECTIVO, ALEATORIO, CONTROLADO, CIEGO

ANTECEDENTES:El dolor posoperatorio es común en pacientes luego de una hemorroidectomía. La administración de anestésico local como bloqueo del nervio pudendo intraoperatorio o infiltración local de la herida puede ayudar a aliviar el dolor posoperatorio.OBJETIVOS:Determinar si agregar un bloqueo intraoperatorio del nervio pudendo a una infiltración local perianal de la herida y un régimen de analgesia estandarizado fue superior a una infiltración local perianal de la herida más un régimen de analgesia estandarizado para reducir el dolor posoperatorio precoz después de una hemorroidectomía. Los objetivos secundarios incluyeron sensación de adormecimiento perianal, requerimientos de opioides orales y eventos adversos informados.DISEÑO:Este estudio fue un ensayo controlado aleatorio, prospectivo, ciego, aprobado por el Comité de Ética e Investigación en Humanos de Eastern Health en Melbourne, Australia (número de registro: E09 / 2014).ESCENARIO:Los pacientes fueron reclutados en tres hospitales australianos.PACIENTES:Ochenta pacientes se inscribieron con éxito en el estudio, y más tarde un paciente abandonó.INTERVENCIÓN:Los pacientes fueron asignados al azar al grupo de bloqueo del nervio pudendo o al grupo control. El grupo de bloqueo del nervio pudendo recibió 5 ml de bupivacaína al 0,5% con adrenalina 1: 200.000 en ambos troncos del nervio pudendo bilateralmente. Ambos grupos recibieron 10 ml del mismo anestésico local inyectado en el lecho de la herida posterior a la hemorroidectomía.PRINCIPALES VARIABLES ANALIZADAS:Se utilizaron escalas analógicas visuales para registrar las puntuaciones de dolor del paciente. Se registraron respuestas dicotómicas (sí / no) para los objetivos secundarios.RESULTADOS:No hubo diferencias significativas en el dolor posoperatorio entre los grupos a las 4, 8, 12 o 24 horas. Además, no hubo diferencias significativas entre los grupos con respecto al adromecimiento perianal percibido, el uso de opioides orales o los eventos adversos.LIMITACIONES:Sin el uso de un estimulador nervioso, se puede argumentar que el bloqueo del nervio pudendo no se logró realmente.CONCLUSIÓNES:El bloqueo del nervio pudendo no parece demostrar un beneficio adicional en la reducción del dolor posterior a la hemorroidectomía más allá del anestésico local en la herida. Consulte Video Resumen en http://links.lww.com/DCR/B780.

Intravitreal Ranibizumab Alone or in Combination with Calcium Dobesilate for the Treatment of Diabetic Macular Edema in Nonproliferative Diabetic Retinopathy Patients: 12-Month Outcomes of a Retrospective Study

OBJECTIVE

This study investigates the efficacy of CaD combined with intravitreal ranibizumab for the treatment of diabetic macular edema (DME) in patients with nonproliferative DR.

METHODS

This retrospective, observational, case-control study enrolled consecutive patients newly diagnosed with DME. The patients were treated with 3-monthly loading dose injections of intravitreal ranibizumab (IVR) followed by pro re nata injections (3 + PRN), with or without daily oral CaD. The patients were treated and followed up for 12 months. We reviewed their medical records to determine the optical coherence tomography (OCT) findings, number of injections, best-corrected visual acuity (BCVA), and central macular thickness (CMT) at 3, 6, and 12 months after the first injection.

RESULTS

We reviewed 102 eyes of 102 patients; 54 patients received IVR combined with oral CaD (IVR + CaD group) and 48 received only IVR (IVR group). In both groups, BCVA was higher, and CMT was lower, at 3, 6, and 12 months after the injection compared to those at the baseline (p < 0.05 for all), while there were no significant differences in BCVA improvement or CMT reduction between the two groups (p > 0.05). The mean number of IVR injections was significantly lower in the IVR + CaD group than the IVR group (5.4 ± 1.1 vs. 6.7 ± 1.6 injections, p < 0.05) during 1 year of treatment. No adverse events were noted in either group.

CONCLUSIONS

Compared to IVR alone, the addition of oral CaD to IVR in DME patients was safe and effective for improving visual function and restoring the retinal anatomy and was associated with the need for fewer injections.

A new method for anti-negative interference of calcium dobesilate in serum creatinine enzymatic analysis

Background

Serum creatinine is a widely used biomarker for evaluating renal function. Sarcosine oxidase enzymatic (SOE) analysis is currently the most widely used method for the detection of creatinine. This method was negatively interfered with by calcium dobesilate, causing pseudo‐reduced results. The aim of this study was to explore a new method to alleviate the negative interference of this drug on creatinine detection.

Method

We formulated eight drug concentrations and 12 creatinine concentrations from serum. The SOE method, the new method, and the Jaffe method were used for detection in five systems. Creatinine biases were analyzed under the conditions with or without the interference of calcium dobesilate, at consistent or inconsistent creatinine concentrations. Creatinine concentrations were also analyzed at three medical decision levels (MDLs).

Results

Calcium dobesilate had negative interference in creatinine SOE analysis. With the increase in calcium dobesilate concentrations, the negative bias increases. The new BG method showed an anti‐negative interference effect. In the Roche system, the BG method reduced the negative bias from −71.11% to −16.7%. In the Abbott system, bias was reduced from −45.15% to −2.74%. In the Beckman system, the bias was reduced from −65.36% to −7.58%. In the Siemens system, the bias was reduced from −58.62% to −7.58%. In the Mindray system, the bias was reduced from −36.29% to −6.84%.

Conclusion

The new method alleviated the negative interference of calcium dobesilate in creatinine SOE detection. The negative bias could be reduced from −60% or −70% to less than −20%.

Safety and effectiveness of hemorrhoidal artery ligation using the HAL-RAR technique for hemorrhoidal disease

PURPOSE

A wide variety of methods has been proposed for treating hemorrhoidal disease. The aim of the study is to assess the safety and effectiveness of hemorrhoidal artery ligation with rectoanal repair (HAL-RAR).

METHODS

Retrospective study from January 2010 to November 2019 of patients who underwent HAL-RAR for grade II, resistant to conservative treatment, and grades III and IV hemorrhoidal disease. Demographics, degree of disease, hospital stay, postoperative pain, complications, and recurrence were recorded. Patients were followed up at postoperative days 1 and 8 and at 1, 6, and 12 months.

RESULTS

A total of 105 patients (60 men, 45 women) underwent HAL-RAR. Median age was 49 (range, 20-86) years. Two patients with hemorrhoidal thrombosis underwent emergent excision of the hemorrhoid. Median length of hospital stay was 2 (range, 1-13) days. Patients reported median visual analog scale pain score 3 (range, 1-5) on the 1st postoperative day. At 1 month, no patient reported pain, 84.76% of patients confirmed complete resolution of symptoms, while complication rate was 7.61%: 2 patients presented urinary retention, 3 dyschezia, 2 bleeding, and 1 hemorrhoidal necrosis. At 6 months, 2 patients presented mild symptoms and 7 recurrence. At 12 months, 92.4% of patients experienced complete resolution of symptoms, 2 patients intermittent bleeding, and 2 recurrence. Overall recurrence and re-intervention rate were 8.57% rate and 10.5%, respectively.

CONCLUSION

HAL-RAR is a safe and effective minimal invasive operative technique related to a high percentage of success, low complication, and recurrence rates. Long-term follow-up is lacking and would better establish the results of this technique.

TRIAL REGISTRATION

Trial registration number NCT04778124 Date of registration 26/02/2021 "retrospectively registered".

External hemorrhoidal disease in child and teenage: Clinical presentations and risk factors

Objective

Hemorrhoidal disease (HD), though mostly seen in adults, has recently emerged as a common problem among children. However, the diagnosis and treatment of HD in children is mostly based on the data obtained in adult studies. In this study, we aimed to evaluate risk factors, diagnostic and treatment modalities in the children diagnosed with external HD.

Methods

The study was conducted at Sakarya University Medical School Pediatric Surgery Department between January 2012 and July 2018. We reviewed children who were diagnosed as having HD at Pediatric Surgery clinic. Age, gender, presenting symptoms, physical examination findings, risk factors, and treatment outcomes were evaluated for each patient.

Results

The study included 56 patients with a mean age of 140.8±45.2 months. The patients comprised 48 (85.7%) boys and 8 (14.3%) girls. Constipation and a positive family history were the most common risk factor (n=33; 58.9%, n=29; 51.8%, respectively). Conservative treatment was performed in 53 (94.6%) patients. Recurrence was observed in 5 (8.9%) and skin tag was detected in 6 (10.7%) patients.

Conclusions

External HD mostly occurs in boys in their second decade of life. Positive family history and constipation were the most common risk factors in our patients. Conservative treatment is sufficient for the management of external HD in children because of its low recurrence rates.

Pathophysiology of internal hemorrhoids

Hemorrhoidal disease is a fairly common and debilitating clinical entity. Despite centuries’ of attempts to shed light on its pathophysiology, to cure those affected and to improve sufferers’ quality of life, many aspects of the disease remain elusive. Individual beliefs and historical legends, accompanied by undocumented theories, have established and perpetuated the confusion regarding the mechanisms leading to the development of the disease and the rules governing its treatment. Hemorrhoids are classified as internal or external and are viewed as a disease when they become symptomatic. Returning to basic medical sciences, this mini-review focuses on internal hemorrhoids and aims to define the histology and anatomy of the normal and abnormal internal hemorrhoidal plexus and to encourage clinicians to comprehend the pathophysiology of the disease. If doctors can understand the pathophysiology of hemorrhoidal disease, they will be able to clarify the nature of the associated symptoms and complications and to make the correct therapeutic decision.

Negative interferences by calcium dobesilate in the detection of five serum analytes involving Trinder reaction-based assays

Previously, we reported the strong negative interference of calcium dobesilate, a vasoprotective agent, in creatinine assays involving the Trinder reaction. It is hypothesized that a similar effect occurs in the detection of uric acid (UA), total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C). The interferences of calcium dobesilate during the detection of the five serum analytes were investigated on automated systems/analysers, and the effects were compared among eight different assay systems for each analyte. A calcium dobesilate standard was added into two sets of the blank serum pools of each analyte at final concentrations of 0, 2, 4, 8, 16, 32, and 64 μg/mL. The percentage deviation of each analyte value was calculated between each drug concentration and the drug-free samples. The clinically acceptable error levels for UA, TC, TG, HDL-C, and LDL-C were defined as ±4.87%, ±4.1%, ±9.57%, ±5.61%, and ±5.46%, respectively. The observed interference was concentration dependent for each analyte. In the presence of 16 μg/mL calcium dobesilate, which was within the therapeutic range, all seven Trinder reaction-based UA assay systems, two TG assay systems, two HDL-C assay systems and one TC assay system exhibited negative drug interferences. Calcium dobesilate negatively interferes with the detection of UA, TG, TC, and HDL-C in assay systems based on the Trinder reaction. The effect was most significant in UA and TG detection.

Calcium dobesilate may alleviate diabetes‑induced endothelial dysfunction and inflammation

Diabetic kidney disease (DKD) is a leading cause of end‑stage renal disease. However, the pathogenesis of DKD remains unclear, and no effective treatments for the disease are available. Thus, there is an urgent need to elucidate the pathogenic mechanisms of DKD and to develop more effective therapies for this disease. Human umbilical vein endothelial cells (HUVECs) were cultured using different D‑glucose concentrations to determine the effect of high glucose (HG) on the cells. Alternatively, HUVECs were incubated with 100 µmol/l calcium dobesilate (CaD) to detect its effects. The authors subsequently measured HUVEC proliferation via cell counting kit‑8 assays. In addition, HUVEC angiogenesis was investigated via migration assays and fluorescein isothiocyanate (FITC)‑labelled bovine serum albumin (BSA) permeability assays. The content or distribution of markers of endothelial dysfunction [vascular endothelial growth factor (VEGF), VEGF receptor (R) and endocan) or inflammation [intercellular adhesion molecule (ICAM)‑1, monocyte chemotactic protein (MCP)‑1 and pentraxin‑related protein (PTX3)] was evaluated via reverse transcription‑quantitative polymerase chain reaction and western blotting. HG treatment induced increased in VEGF, VEGFR, endocan, ICAM‑1, MCP‑1 and PTX3 mRNA and protein expression in HUVECs. HG treatment for 24 to 48 h increased cell proliferation in a time‑dependent manner, but the cell proliferation rate was decreased at 72 h of HG treatment. Conversely, CaD inhibited abnormal cell proliferation. HG treatment also significantly enhanced HVUEC migration compared to the control treatment. In contrast, CaD treatment partially inhibited HUVEC migration compared to HG exposure. HG‑treated HUVECs exhibited increased FITC‑BSA permeability compared to control cells cultured in medium alone; however, CaD application prevented the HG‑induced increase in FITC‑BSA permeability and suppressed HG‑induced overexpression of endothelial markers (VEGF, VEGFR‑2, endocan) and inflammation markers (ICAM‑1, MCP‑1, PTX3) in HUVECs. CaD has angioprotective properties and protects endothelial cells partly by ameliorating HG‑induced inflammation. The current results demonstrated the potential applicability of CaD to the treatment of diabetic nephropathy, particularly during the early stages of this disease.

Treatment of hemorrhoids with individualized homeopathy: An open observational pilot study

Aim:

Controversies and disagreement exist on conventional treatment strategies of hemorrhoids due to relapse, inefficacy, and complications. We intend to evaluate the role of individualized homeopathic treatment in hemorrhoids.

Materials and Methods:

In this prospective, open, observational trial, hemorrhoids patients were treated using five standardized scales measuring complaints severity and anoscopic score. It was conducted at two homeopathic hospitals in India, during from mid-July 2014 to mid-July 2015. Patients were intervened as per individualized homeopathic principles and followed up every month up to 6 months.

Results:

Total 73 were screened, 52 enrolled, 38 completed, 14 dropped out. Intention to treat population (n: = 52) was analyzed in the end. Statistically significant reductions of mean bleeding (month 3: −21.8, 95% confidence interval [CI]: −30.3, −13.3, P: < 0.00001, d = 0.787; month 6: −25.5, 95% CI −35.4, −15.6, P: < 0.00001, d = 0.775), pain (month 3: −21.3, 95% CI −28.6, −14.0, P: < 0.00001, d = 0.851; month 6: −27.6, 95% CI −35.6, −19.6, P: < 0.00001, d = 1.003), heaviness visual analog scales (VASs) (month 3: −8.1, 95% CI −13.9, −2.3, P: = 0.008, d = 0.609; month 6: −12.1, 95% CI −19.1, −5.1, P: = 0.001, d = 0.693), and anoscopic score (month 3: −0.4, 95% CI −0.6, −0.2, P: < 0.0001, d = 0.760; month 6: −0.5, 95% CI −0.7, −0.3, P: < 0.0001, d = 0.703) were achieved. Itching VASs reduced significantly only after 6 months (−8.1, 95% CI −14.6, −1.6, P: = 0.017, d = 0.586). No significant lowering of discharge VASs was achieved after 3 and 6 months.

Conclusion:

Under classical homeopathic treatment, hemorrhoids patients improved considerably in symptoms severity and anoscopic scores. However, being observational trial, our study cannot provide efficacy data. Controlled studies are required. Trial Reg. CTRI/2015/07/005958.

Application of 'tying, binding and fixing operation' in surgical treatment of severe mixed hemorrhoids

The aim of the present study was to examine the clinical value of ‘tying, binding and fixing operation’ in treating severe mixed hemorrhoids. A total of 160 patients with severe mixed hemorrhoids were selected and randomly divided into the experimental (n=80) and control (n=80) groups. The groups were treated using ‘tying, binding and fixing operation’ and Doppler ultrasound-guided hemorrhoidal artery ligation (DG-HAL), respectively. The results showed that the average operative time of the experimental group (35.57±6.17) was significantly higher than that of the control group (12.73±4.92). There was no significant difference of blood loss during the operation between the two groups (P>0.05). There was also no significant difference in improving the hemorrhage symptom between the two groups (P>0.05). In addition, concerning improvement of prolapse symptoms and reduction of the volume of hemorrhoids, the experimental group were significantly improved as compared to the control group. No anal function damage in the two groups was identified, and the length of stay in hospital for the two groups was not significantly different (P>0.05). However, the hospitalization cost in the experimental group (5,334.77±875.54) was significantly lower than that of the control group (8,551.81±1,806.54) and satisfaction degree was significantly higher than that of the control group. The incidences of perianal pain, anal edema and dysuria between two groups were not significantly different (P>0.05). There were 10 cases of secondary hemorrhage and 18 cases of infection in the experimental group, and 12 cases of secondary hemorrhage and 14 cases of infection in the control group, although the differences between the two groups were not statistically significant (P>0.05). The incidence rate of local hematoma in the experimental group (1.2%) was significantly lower than that in the control group (15.0%). The recurrence rate of the control group (22.5%) was also significantly higher than that of the experimental group (2.5%). In conclusion, tying, binding and fixing operation is a promising method that may be employed for the treatment of sever mixed hemorrhoids, and it is better than DG-HAL in improving the prolapse and reducing the volume of hemorrhoids.

A prospective, randomized, three arm, open label study comparing the safety and efficacy of PP110, a novel treatment for hemorrhoids to preparation-H® maximum strength cream in the treatment of grade 2-3 hemorrhoids

BACKGROUND

Hemorrhoids are a common disorder that affects the quality of life of millions of people worldwide. The effectiveness of OTC medication is limited and they mainly provide symptomatic relief. In order to treat this ailment, we formulated PP110 Gel and Wipes, as a novel treatment for hemorrhoids. PP110 is based on known active ingredients with a topical film-forming agent designed to provide physical protection and prolonged tissue contact with the active ingredients.

METHODS

PP110 Gel, PP110 Wipes and the comparator Preparation-H® were used on three patient cohorts. Treatment was administered once daily for PP110, and three-four times daily for Preparation-H®, for 14 days. Six different clinical parameters relating to common symptoms of hemorrhoids were monitored.

RESULTS

PP110 Gel was significantly better than Preparation-H® in reducing bleeding (Δ = 6 %), providing pain relief (Δ = 10 %) and controlling itching (Δ = 11 %). These three parameters are considered as the most common distressing symptoms for hemorrhoids patients, demonstrating that PP110 is superior to conventional treatment.

CONCLUSION

This study demonstrated the efficacy of the PP110 Gel in treating hemorrhoids and its superiority to conventional treatments. The PP110 film-based formulation provides a slow-release mechanism and as a consequence, a prolonged therapeutic window. PP110 was both more effective in reducing hemorrhoids symptoms and more convenient to use, in that it only required application once per day.

A prospective, randomized, three arm, open label study comparing the safety and efficacy of PP110, a novel treatment for hemorrhoids to preparation-H® maximum strength cream in the treatment of grade 2-3 hemorrhoids

Background

Hemorrhoids are a common disorder that affects the quality of life of millions of people worldwide. The effectiveness of OTC medication is limited and they mainly provide symptomatic relief. In order to treat this ailment, we formulated PP110 Gel and Wipes, as a novel treatment for hemorrhoids. PP110 is based on known active ingredients with a topical film-forming agent designed to provide physical protection and prolonged tissue contact with the active ingredients.

Methods

PP110 Gel, PP110 Wipes and the comparator Preparation-H® were used on three patient cohorts. Treatment was administered once daily for PP110, and three-four times daily for Preparation-H®, for 14 days. Six different clinical parameters relating to common symptoms of hemorrhoids were monitored.

Results

PP110 Gel was significantly better than Preparation-H® in reducing bleeding (Δ = 6 %), providing pain relief (Δ = 10 %) and controlling itching (Δ = 11 %). These three parameters are considered as the most common distressing symptoms for hemorrhoids patients, demonstrating that PP110 is superior to conventional treatment.

Conclusion

This study demonstrated the efficacy of the PP110 Gel in treating hemorrhoids and its superiority to conventional treatments. The PP110 film-based formulation provides a slow-release mechanism and as a consequence, a prolonged therapeutic window. PP110 was both more effective in reducing hemorrhoids symptoms and more convenient to use, in that it only required application once per day.

Strong Negative Interference by Calcium Dobesilate in Sarcosine Oxidase Assays for Serum Creatinine Involving the Trinder Reaction

The vasoprotective drug calcium dobesilate is known to interfere with creatinine (Cr) quantifications in sarcosine oxidase enzymatic (SOE) assays. The aim of this study was to investigate this interference in 8 different commercially available assays and to determine its clinical significance. In in vitro experiments, interference was evaluated at 3 Cr levels. For this, Cr was quantified by SOE assays in pooled serum supplemented with calcium dobesilate at final concentrations of 0, 2, 4, 8, 16, 32, and 64 μg/mL. Percent bias was calculated relative to the drug-free specimen. For in vivo analyses, changes in serum concentrations of Cr, cystatin C (CysC; a renal function marker), and calcium dobesilate were monitored in healthy participants of group I before and after oral calcium dobesilate administration. In addition, variations in interference were also examined among different SOE assays using serum obtained from healthy participants of group II. Lastly, Cr levels from the 10 patients treated with calcium dobesilate were measured using 4 SOE assays and liquid chromatography-isotope dilution tandem mass spectrometry (LC-IDMS/MS) for comparison. Our in vitro analyses indicated that the presence of 8 μg/mL calcium dobesilate resulted in a -4.4% to -36.3% reduction in Cr serum concentration compared to drug-free serum for 8 SOE assays examined. In vivo, Cr values decreased relative to the baseline level with increasing drug concentration, with the lowest Cr levels obtained at 2 or 3 hours after drug administration in participants of group I. The observed Cr concentrations for participants in group II were reduced by -28.5% to -3.1% and -60.5% to -11.6% at 0 and 2 hours after administration related to baseline levels. The Cr values of 10 patients measured by Roche, Beckman, Maker, and Merit Choice SOE assays showed an average deviation of -20.0%, -22.4%, -14.2%, and -29.6%, respectively, compared to values obtained by LC-IDMS/MS. These results revealed a clinically significant negative interference with calcium dobesilate in all sarcosine oxidase-based Cr assays, but the degree of interference varied greatly among the assays examined. Thus, extra care should be taken in evaluating Cr quantification obtained by SOE assays in patients undergoing calcium dobesilate therapy.

Common anorectal conditions: evaluation and treatment

Anorectal conditions are frequently encountered clinical entities but are often misunderstood and misdiagnosed. Although the most common anorectal disorders are not considered life threatening, they can negatively impact patients' activities of daily living and quality of life. Comprehensive anorectal examination, including the use of anoscopy, has become a "lost art," and graduate medical education programs should utilize more formal training in this area. This review discusses the comprehensive anorectal exam and the diagnosis and management of three common anorectal disorders: hemorrhoids, anal fissure, and pruritus ani.