1% hydrocortisone ointment is an effective treatment of pruritus ani: a pilot randomized controlled crossover trial

BACKGROUND

Pruritus ani (PA) is a common condition which is difficult to treat in the absence of obvious predisposing factors. There is paucity of evidence-based guidelines on the treatment of this condition. We examined whether 1% hydrocortisone ointment is an effective treatment for PA.

MATERIALS AND METHODS

A pilot randomized, double-blind, placebo-controlled, crossover trial was carried out. Eleven patients consented to take part in the trial and ten completed the study. After a 2-week run-in period, patients with primary PA were randomly allocated to receive 1% hydrocortisone ointment or placebo for 2 weeks followed by the opposite treatment for a further 2-week period. There was a washout period of 2 weeks between treatments. The primary outcome measure was reduction in itch using a visual analogue score (VAS). The secondary outcome measures were improvement in quality of life measured using a validated questionnaire (Dermatology Life Quality Index, DLQI) and improvement in clinical appearance of the perianal skin using the Eczema Area and Severity Index (EASI) score.

RESULTS

Treatment with 1% hydrocortisone ointment resulted in a 68% reduction in VAS compared with placebo (P=0.019), a 75% reduction in DLQI score (P=0.067), and 81% reduction in EASI score (P=0.01).

CONCLUSION

A short course of mild steroid ointment is an effective treatment for PA.

Increased presence of serotonin-producing cells in colons with diverticular disease may indicate involvement in the pathophysiology of the condition

INTRODUCTION

Serotonin is an important neuroendocrine transmitter participating in the control of colonic motor activity through neural and biochemical mechanisms in the Enteric Nervous System (ENS). A possible pathophysiological factor for diverticular disease (DD) is altered colonic motility. The study compared the distribution of serotonin cells (SC) in the colonic mucosa of patients with diverticular disease to controls.

METHODS

Sixteen paraffin specimens with sigmoid diverticular disease were selected and sections of bowel without diverticula from the same specimen were used as its own control. The resection margins from sixteen colonic specimens excised for sigmoid cancer were additional controls. Immunocytochemical staining for serotonin cells was performed on 4-mum tissue sections with polyclonal antibody (NCL-SEROTp). The number of serotonin-positive cells per ten microscopic fields (x200) was assessed in all groups and the staining distribution was defined as low (0-33%), moderate (>33-66%) and high (>66%) according to the percentage of the entire cell containing contrast material. The control specimens were blinded before analysis. Student's t test was used for statistical analysis and significance level was set as P < 0.05.

RESULTS

The mean number of serotonin-positive cells per ten fields in the colonic mucosa of specimens with diverticular disease was significantly higher [252.44 (SD 90.64)] than the specimen's own control [147.31 (SD 50.16)] and at normal resection margins of cancer specimens [228.38 (SD 120.10)]. The paired analysis between diverticular disease specimens and its own control (paired t test) showed significant differences for moderate (P = 0.008), high (P = 0.001) and total (P = 0.002) number of serotonin cells. There was no evidence of significance between mean DD and cancer values.

DISCUSSION

Increased presence of SCs and the higher proportion of high and moderate staining cells (indicating increased hormone content) indicate the possible role of serotonin in DD. This may be contributing to the pathogenesis of the condition by altered colonic motility in the affected segments in a similar way as in irritable bowel syndrome.

Endoscopic sympathectomy in the treatment of facial blushing

INTRODUCTION

Bilateral endoscopic thoracic sympathectomy (BETS) has been shown to be an effective, permanent, and safe treatment for severe upper limb hyperhydrosis. More recently, the possibility of using BETS to treat facial blushing, a redness of the face bought on by emotional or social stress, has been raised. This followed incidental reports from patients of relief from their blushing following this procedure for hyperhydrosis. At King's College Hospital, 120 patients underwent BETS over a 3-year period for both upper limb hyperhydrosis and facial blushing. In this study we report our results in relation to facial blushing.

PATIENTS AND METHODS

The outcome was evaluated by questionnaire and symptoms assessed using the visual analogue scale. Questions on postoperative complications and overall quality of life were included.

RESULTS

A total of 80 patients responded to our questionnaire of whom 59 (74%) experienced facial blushing. In 12 patients, this was their only symptom. Severity of facial blushing was reduced from a mean score of 78 before operation to 26 after BETS (P < 0.001); 29% reported complete resolution of their facial blushing. There was no mortality or conversion to open surgery. Quality of life was reported to be much better in 63% of facial blushers following the procedure.

CONCLUSIONS

This study demonstrates both a statistically significant reduction in severity of facial blushing as well as a clear improvement in quality of life following a safe procedure with few complication rates. Facial blushing can, therefore, be considered as an indication for BETS on its own merit when not associated with hyperhydrosis.

Feasibility and morbidity of reversal of Hartmann's

OBJECTIVE

Reversal of Hartmann's is a major surgical procedure and associated with substantial morbidity and mortality.

METHOD

This study retrospectively analysed the data at a single centre over an eight-year period to assess the clinical results and morbidity of reversal of Hartmann's.

RESULTS

One hundred and ten Hartmann's procedures were performed during the period. Only 66 (61%) of patients had a reversal. Advanced age and comorbidity were the primary reasons for not reversing. Complications among the 66 patients (36 males and 30 females) who underwent reversal occurred in 26 (41%). There were no deaths. Patients who underwent reversal were ASA 2 (60%), ASA 3 (25%) and ASA 4 (4.6%). Univariate analysis demonstrated a significant association between complications following reversal and ASA grade (P =0.01), and hypertension (P = 0.03) There was no correlation between the patient variables and anastomotic leakage. Multiple logistic regression analysis showed a significant influence of hypertension, smoking and ASA grade on complications.

CONCLUSIONS

About 40% of patients who undergo Hartmann's procedure will not have a reversal. Reversal is a feasible operation for selected patients, but there is a high complication rate.

Influence of folate status on genomic DNA methylation in colonic mucosa of subjects without colorectal adenoma or cancer

DNA hypomethylation may increase the risk of colorectal cancer. The main aim of this study was to assess the influence of folate status (serum and erythrocyte folate and plasma homocysteine concentrations) on DNA methylation. Methylenetetrahydrofolate reductase (MTHFR 677C --> T and 1298A --> C), methionine synthase (MS 2756A --> G) and cystathionine synthase (CBS 844ins68) polymorphisms were measured to account for potential confounding effects on folate status and DNA methylation. A total of 68 subjects (33 men and 35 women, 36-78 years) free from colorectal polyps or cancer were recruited in a cross-sectional study. Tissue biopsies were obtained at colonoscopy for the determination of DNA methylation in colonic mucosa using an in vitro radiolabelled methyl acceptance assay. Serum and erythrocyte folate were inversely correlated with plasma homocysteine (r=-0.573, P<0.001 and r=-0.307, P=0.01 respectively) and DNA hypomethylation in colonic mucosa (r=-0.311, P=0.01 and r=-0.356, P=0.03). After adjusting for gender, age, body mass index, smoking and genotype, there were weak negative associations between serum and erythrocyte folate and colonic DNA hypomethylation (P=0.07 and P=0.08, respectively).

The technique of endoscopic thoracic sympathectomy: resection, clipping and cautery

Three authors describe their individual technique for performing ETS. These are 1) a two-port approach under singlelung ventilation using a double-lumen tube and cutting the chain, 2) a two-port approach under endotracheal or mask anesthesia and clipping of the chain, and 3) a single-port approach under endotracheal or mask anesthesia and cautery of the chain. The sections are purely didactic and no attempt is made to compare or contrast the methods.

A robust method for evaluation of NANC transmission in human sigmoid colon muscle in vitro

INTRODUCTION

Human tissues are notoriously difficult to work with, giving results that are quantitatively variable within and between studies. Hence, previous investigations of nonadrenergic, noncholinergic (NANC) relaxation in human colon muscle report both partial and complete inhibitions of the NANC response by specific competitive inhibitors of nitric oxide (NO) production. We have established a robust and reproducible model to examine the contribution of NO during NANC relaxation assay in human sigmoid colon muscle strips.

METHODS

Complete control curves to long-train, stepwise, frequency-dependent, continuous electrical field stimulation (EFS) relaxation using vertical platinum electrodes connected to a biphasic pulse train stimulator generated NANC responses in fresh human sigmoid colon circular muscle strips set up in Bennett baths. A second complete curve was generated on the same strip in the presence of specific drugs to determine the contribution of NO to NANC relaxation. Responses to NO were also generated in muscle strips. Results were fitted to the Hill equation.

RESULTS

The first and second frequency-response curves without test drugs could be fitted to the Hill equation, resulting in similar midpoint locations ([f](50)), maximal asymptotes (alpha), and midpoint slope (n) parameters. L-N(G)-nitro-arginine (L-NOARG), TTX, and haemoglobin produced a tonic contraction in the muscle strips. NANC relaxations to EFS were inhibited by L-NOARG (30-37%), TTX (56-62%), and haemoglobin (48-90%). NO relaxations were concentration dependently inhibited by haemoglobin. Haemoglobin was equipotent in mediating tonic contraction and inhibiting NO relaxation.

DISCUSSION

We established reproducible assays for human colon muscle strips by the generation of two complete dose-response curves to long-train EFS, thus enabling a "within-preparations" study. The results suggest that NO contributes but is not the sole mediator of relaxations to long-train EFS in human sigmoid colon muscle. Moreover, a basal production of NO may serve to regulate tone of human colonic muscle.

Survey of methods of treatment of haemorrhoids and complications of injection sclerotherapy

INTRODUCTION

This study was conducted to survey current practices in the treatment of haemorrhoids (Hs), prevalence of complications associated with injection sclerotherapy (IS) and attitudes to its use to treat anterior Hs.

METHODS

Postal questionnaires were sent to 92 consultant surgeons in the South East Thames Region. They were returned anonymously.

RESULTS

Seventy questionnaires were returned (76% response rate) and 61 questionnaires were used in the data analysis; 18 from coloproctologists and 43 from non-coloproctologists who treated Hs. First degree Hs were mostly treated with IS alone (76%). Second degree Hs were treated with rubber band ligation (RBL) alone (36%) or a combination of IS and RBL (36%). Third degree Hs were mostly treated with haemorrhoidectomy (76%). Nineteen surgeons (31%) reported complications using IS; 82% of these were urological. Nine surgeons (15%) did not use IS to treat anterior Hs and 10 (16%) advised their trainees not to inject anteriorly.

CONCLUSIONS

IS is a common treatment of Hs. Nearly one-third of consultants reported complications, the majority of which were urological and likely to be secondary to IS of anterior Hs. It may be safer to avoid IS of anterior haemorrhoids.

Consistency of teaching in parallel surgical firms: an audit of student experience at one medical school

BACKGROUND

Traditional clinical clerkships have been based on the apprenticeship model of learning, with opportunistic teaching by doctors on presenting patients. Students at King's College School of Medicine, London had expressed concern that they were receiving inequitable experiences in different clerkships. This had become more apparent since the introduction of a school-wide end-of-year skills assessment. We decided to assess the consistency of delivery of the surgical syllabus.

METHOD

A multistage questionnaire survey was undertaken with third-year (first clinical year) undergraduate medical students on surgical clerkships. The questionnaire required students to record topics about which they had been taught, and practical skills on which they had been supervised, from the surgical syllabus pertaining at the time.

RESULTS

194 (46.4%) questionnaires were returned. A low level of consistency was reported in the teaching of theoretical topics and practical skills across surgical clerkships in eight different locations. There were substantial differences, both in overall coverage of the syllabus and in the priority given to different topics. There were no overall differences between teaching hospital- and district general hospital-based clerkships.

DISCUSSION

Students in so called 'parallel' clerkships did not receive comparable teaching. The traditional opportunistic nature of clinical teaching led, in effect, to individual curricula within each clerkship. The General Medical Council has called for a core curriculum to be delivered across different clinical sites within each medical school. To achieve this, medical schools may need to introduce guidelines to direct teaching in the same way that clinical protocols have been developed to achieve greater standardization in clinical practice.

Smoking may be associated with complications in diverticular disease

BACKGROUND

The vast majority of people with diverticula remain asymptomatic or develop minor symptoms while a small group develop serious complications that are associated with significant morbidity and mortality rates. The aim was to identify any risk factors predisposing to complications.

METHODS

Eighty patients with diverticular disease were studied. Patients in group 1 (n = 45) with complications requiring hospitalization or surgery were compared with those in group 2 (n = 35) with asymptomatic diverticula or minor symptoms. Logistic regression analysis was performed.

RESULTS

No differences in epidemiological factors, concurrent and past medical and surgical conditions or chronic medication were detected between the two groups. Generalized disease was not associated with more complications than sigmoid disease. However, smoking seemed to be an independent factor predisposing to complications; the proportion of smokers in group 1 was significantly greater (24 of 45) than that in group 2 (ten of 35) (odds ratio 2.9, P = 0.028).

CONCLUSION

In patients with diverticular disease, smoking is associated with an increased risk of complications.

Lymphogranuloma venereum as a cause of rectal strictures

Rectal strictures are uncommon in young patients without a history of malignancy, inflammatory bowel disease or previous surgery. Lymphogranuloma venereum of the rectum has been described as a rare cause of rectal strictures in the western world, mainly in homosexual men and in blacks. It presents with nonspecific symptoms, rectal ulcer, proctitis, anal fissures, abscesses and rectal strictures. Clinical and endoscopic findings as well as histology resemble Crohn's disease, which may be misdiagnosed. Serology is often positive for Chlamydia trachomatis but negative serology is not uncommon. We present two young black women who suffered from chronic diarrhoea, abdominal pain and weight loss. There was no previous history and investigations showed in both cases a long rectal stricture. Serology was positive in one patient. They were treated with erythromycin and azithromycin and they both underwent an anterior resection of the rectum. Postoperative histology confirmed the presence of lymphogranuloma venereum of the rectum. We conclude that rectal lymphogranuloma venereum is a rare cause of rectal strictures but surgeons should be aware of its existence and include it in the differential diagnosis of unexplained strictures in high-risk patients.

Predicting changes in the distribution of sweating following thoracoscopic sympathectomy

BACKGROUND

Compensatory sweating is a common symptom following thoracic sympathectomy; however, the reported incidence of this complication varies greatly, and its severity has not been quantified.

METHODS

In this study changes in the distribution of sweating following bilateral T2-3 thoracoscopic sympathectomy for hyperhidrosis were assessed in 42 patients. Sweat production in the palms, axillae, face, trunk and feet was assessed using a linear analogue scale.

RESULTS

The operation was most successful in reducing sweat production in the palms, axillae and face (in descending order). The operation also reduced pedal sweat production in 12 of the 29 patients who suffered concomitant pedal hyperhidrosis. Compensatory truncal sweating occurred in 36 of the 42 patients; it was severe in ten, moderate in 16 and minimal in ten.

CONCLUSION

Patients should be warned about compensatory sweating before thoracic sympathectomy.

Emergency surgery in Ethiopia

The surgical needs of Ethiopia are not met by traditionally trained surgeons. Ten recently registered doctors were trained for a two-month period in 20 selected lifesaving procedures. Evaluation of their skills one year after their course suggested that they were able to save lives and to use their skills either under supervision or alone. The training of physicians before their appointment to rural areas is a possible solution to the unacceptably high morbidity and mortality from surgical causes in rural Ethiopia.

One lung ventilation in endoscopic transthoracic sympathectomy

Endoscopic transthoracic sympathectomy currently requires one lung anaesthesia to facilitate access to the thoracic sympathetic chain. This may cause reduced perioperative arterial oxygen saturation. We describe a series of patients in which the collapsed lung is kept partially inflated using continuous positive airway pressure (CPAP) with 100% oxygen. This modification of anaesthetic technique enabled a normal arterial oxygen saturation to be maintained thus preventing operative delays whilst the lung was reinflated to restore adequate oxygen saturation.

A novel means of securing a laparoscopic port in the obese patient

Advanced interventional laparoscopy has necessitated the development of a vast array of new equipment, but inevitably some of this equipment has had to be adapted to specific patient needs. Standard laparoscopic ports may be too short for use in obese patients. We describe a technique using a Portex endotracheal tube as an over-tube, which will overcome this problem.

Pyoderma faciale in a patient with Crohn's disease

We wish to report the progress of a patient with pyoderma faciale and Crohn's disease. The patient is interesting in that on two occasions the relapse in her skin condition coincided with the introduction of non-steroidal anti-inflammatory drugs. Therapy with isotretinoin was effective and well tolerated.

Endoscopic transthoracic sympathectomy for idiopathic upper limb hyperhidrosis

A 5-year experience of 51 endoscopic transthoracic dorsal sympathectomies for idiopathic palmar hyperhidrosis in 26 patients is presented. Fifty-two percent complained of excessive sweating over their hands, 28% of axillary sweating and 20% over both areas, with a mean duration of 10 years. The second, third and fourth thoracic ganglia and their interconnecting fibres on the affected side were ablated using diathermy cautery. Over a mean follow up time of 26 months, this procedure was successful in curing or improving intractable sweating in 92%. However, axillary sweating was less well controlled than in the palms with 20% of patients describing residual wetness in the axilla. Compensatory sweating (75%) and gustatory sweating (48%) were the commonest side effects; despite this, most patients were satisfied with the functional and cosmetic outcome. Other complications included a temporary Horner's syndrome in one patient, a pneumothorax in the immediate post-operative period in another and a unilateral non-infective reactionary pleural effusion in a third. Two patients developed recurrence of palmar hyperhidrosis within 6 months of surgery. One has been successfully treated by re-operation on the affected side. All patients complained of mild to moderate interscapular chest pain which was easily controlled by non-steroidal anti-inflammatory agents, and resolved within 7-10 days post-operatively. The technique of endoscope transthoracic sympathectomy is effective, relatively simple to perform and usually requires only an overnight stay. It is recommended as the surgical treatment of choice for upper limb hyperhidrosis unresponsive to conservative measures.

Pseudosepsis in rheumatoid arthritis due to cellular and lipid abnormalities in synovial fluid

In acute septic arthritis, the synovial fluid is usually frankly purulent. However, the presence of pus does not always imply the presence of infection, and some synovial fluids are easily mistaken for pus. An exaggeration of the normal leucocyte response in inflammatory joint fluids may alone simulate sepsis; marked increases in certain lipid fractions of the fluid may produce similar appearances. We describe a patient who presented with two examples of such 'pseudoseptic arthritis'.

Endoscopic transthoracic sympathectomy in the treatment of hyperhidrosis

A 5-year experience of 50 endoscopic transaxillary dorsal sympathectomies is presented. The procedure was successful in either curing or improving the symptoms of hyperhidrosis in the great majority of patients. The commonest side effects were compensatory sweating (75%) and gustatory sweating (48%); despite this, there was an extremely high level of patient satisfaction. Permanent Horner's syndrome did not occur. The procedure is effective, simple, cheap, and requires only an overnight stay; and is recommended as the method of choice for the surgical treatment of upper limb hyperhidrosis.

Rheumatological manifestations of the leukaemias and graft versus host disease

Bone and joint involvement in the leukaemias is discussed. Particular emphasis is placed upon osteoarticular presentations which may predate the haematological changes or divert attention from the primary pathology. A description of acute and chronic graft versus host disease is presented with particular emphasis on the rheumatological manifestations.

British surgeons training abroad--an evaluation

The experience and practice of a surgeon training in Africa is reviewed. Clinical, practical and management skills are invaluable. The value of an elective period in a British training system is suggested.

Prevention of haematogenous infection in prosthetic joints

A survey was conducted to identify the attitude of consultant orthopaedic surgeons and rheumatologists in Scotland, North East England and Ireland, to the prevention of blood-borne infection in prosthetic joints. Of the 61% who completed the questionnaire, 65% gave advice about intercurrent infection, a similar number gave advice about the use of prophylactic antibiotics before certain surgical procedures, with less than half of the patients receiving any written instructions about inter-current infection, and less than a quarter of the patients receiving any written instructions about antibiotic prophylaxis. 36% of the respondents were confused as to what to advise or ignored the problem. The reality of late infection is discussed and a policy to minimise the risk of late infection in prosthetic joints is presented for consideration.

Insulin as an amyloid-fibril protein at sites of repeated insulin injections in a diabetic patient

A patient with Type 1 (insulin-dependent) diabetes mellitus developed localised amyloidosis at the sites of his injections of porcine insulin. A major amyloid fibril protein was extracted and, by means of its amino acid composition and amino acid sequence, it was shown to contain intact insulin molecules. Porcine insulin is the tenth protein and the first foreign protein to be chemically identified in human amyloid fibrils.

Eicosanoid formation by mammalian intestine. Effects of some intestinal secretagogues

Intestinal tissues of man, rat, mouse, guinea-pig and rabbit were preincubated with laxatives, homogenised, and incubated with [14C]arachidonic acid. After extraction into chloroform, the eicosanoids were separated by thin layer chromatography. Metabolism of [14C]arachidonic acid into prostaglandins (PGs), and the lipoxygenase products LTB4 and 5-HETE, was stimulated by ricinoleic acid (100 micrograms/ml) or phenolphthalein (100 micrograms/ml), and to a lesser extent by picosulphate (125 micrograms/ml) and sulfosuccinate (200 micrograms/ml). Mannitol (500 micrograms/ml) had no effect. Indomethacin (1 microgram/ml) inhibited the stimulation of PG formation. The dual pathway inhibitor BW755C (1 microgram/ml) reduced the formation of prostaglandins, LTB4 and 5-HETE. In some experiments on rat colon, prostanoids were separated from lipoxygenase products, characterised by their chromatographic mobility and quantitated (relative amounts PGE2 greater than PGF2 alpha greater than TXB2 greater than PGD2). Their formation was enhanced by ricinoleic acid (100 micrograms/ml) and inhibited by either indomethacin or BW 755C (1 microgram/ml). The present results indicate that mammalian isolated gut tissue can convert [14C]arachidonic acid into both cyclo-oxygenase and lipoxygenase products, and support the suggestion that eicosanoids may participate in the laxative effect of some secretagogues.

The surgical treatment of upper limb hyperhidrosis

Primary hyperhidrosis is a common and poorly understood condition. Surgical thoracic sympathectomy, either by the cervical or transaxillary route, entails major surgery, so there is a tendency to offer this only to those most severely affected. Endoscopic thoracic sympathectomy is a simple, safe and effective procedure. The technique and results are described and it is recommended as the appropriate procedure for treating upper limb hyperhidrosis, including localized axillary sweating.

Endoscopic thoracic sympathectomy in the treatment of upper limb hyperhidrosis

The technique of endoscopic sympathectomy is described and its value in the treatment of upper limb hyperhidrosis is reported in an initial series of 7 patients (13 sympathectomies). It is recommended as the treatment of choice for this condition.