Efficacy of amoxicillin/clavulanic acid after surgical drainage of perianal abscess in the prevention of the development of anal fistula (PERIQxA study): study protocol for a multicenter randomized, double-blind clinical trial

BACKGROUND

Anorectal fistula, which is a relatively common pathology, is the chronic manifestation of the acute perirectal process that forms an anal abscess. The development of a fistula after incision and drainage of an anal abscess is seen in approximately 26-37%. Its treatment is a relevant topic, and the role of the use of antibiotic therapy in its prevention remains controversial, after the publication of several studies with contradictory results and several methodological limitations. Our hypothesis is that the combination of amoxicillin and clavulanic acid will reduce the incidence of anal fistula.

METHOD

The aim of this study is to evaluate the efficacy of antibiotherapy after surgical drainage of perianal abscess in the development of perianal fistula. The PERIQxA study is a multicenter, randomized, double-blind controlled trial. The study has been designed to include 286 adult patients who will be randomly (1:1) assigned to either the experimental (amoxicillin/clavulanic acid 875/125 mg TDS for 7 days) or the control arm (placebo). The primary outcome measure is the percentage of patients that develop perianal fistula after surgery and during follow-up (6 months).

DISCUSSION

This clinical trial is designed to evaluate the efficacy and safety of amoxicillin/clavulanic in the prevention of perianal fistula. The results of this study are expected to contribute to stablish the potential role of antibiotherapy in the therapeutics for anal abscess.

TRIAL REGISTRATION

EudraCT Number: 2021-003376-14. Registered on November 26, 2021.

Vaccine Effectiveness Against 12-Month Incident and Persistent Anal Human Papillomavirus Infection Among Gay, Bisexual, and Other Men Who Have Sex With Men

BACKGROUND

Real-world evidence of human papillomavirus (HPV) vaccine effectiveness (VE) against longitudinal outcomes is lacking among gay, bisexual, and other men who have sex with men (GBM). We compared 12-month incidence and persistence of anal HPV infection between vaccinated and unvaccinated GBM.

METHODS

We recruited GBM aged 16-30 years in Montreal, Toronto, and Vancouver, Canada, from 2017 to 2019. Participants were followed over a median of 12 months (interquartile range, 12-13 months). Participants self-reported HPV vaccination and self-collected anal specimens for HPV DNA testing. We calculated prevalence ratios (PR) for 12-month cumulative incidence and persistence with ≥1 quadrivalent vaccine type (HPV 6/11/16/18) between vaccinated (≥1 dose at baseline) and unvaccinated participants using a propensity score-weighted, modified Poisson regression.

RESULTS

Among 248 participants, 109 (44.0%) were vaccinated at baseline, of whom 62.6% received 3 doses. PRs for HPV 6/11/16/18 were 0.56 (95% confidence interval [CI], .24-1.31) for cumulative incidence and 0.53 (95% CI, .25-1.14) for persistence. PRs were 0.23 (95% CI, .05-1.03) and 0.08 (95% CI, .01-.59) for incidence and persistence, respectively, among participants who received their first dose at age ≤23 years and 0.15 (95% CI, .03-.68) and 0.12 (95% CI, .03-.54) among participants who were sexually active for ≤5 years before vaccination.

CONCLUSIONS

Findings support national recommendations for HPV vaccination at younger ages or soon after sexual debut.

The clinical and therapeutic approach to anal stenosis

Anal stenosis is a fibrous narrowing of the anal channel. It develops, in most cases, in the aftermath of proctologic surgical procedures with extensive anoderm excision or in the presence of chronic anal inflammation in patients with Crohn Disease. However rare, this condition is thoroughly debilitating for the patients. Symptoms include constipation, pain and bleeding with defecation and a reduction of the caliber of stools. Diagnosis is essentially clinical. Prevention of postsurgical stenosis is based on a scrupulous surgical technique and on an extensive and carefully- planned follow up. Treatment is based on an initially conservative approach with regularization of stool transit through hydration, dietary fibers and bulk-forming laxatives. The role of mechanical dilatation in the treatment of AS is still debated. For severe cases and cases that are not responsive to conservative treatment we must resort to surgery. Surgical approach is tailored on the severity, position and extension. The most severe cases require anoplasty procedures with mucosal or anal flaps. KEY WORDS: Anal stenosis, Anal stricture,Proctology.

Impact of HPV vaccination on anogenital warts and respiratory papillomatosis

Human papillomavirus (HPV), the most common sexually transmitted infection in the US and worldwide, can cause cancers, anogenital warts (AGW), and recurrent respiratory papillomatosis (RRP) in men, women, and children. Global incidence of AGW ranges from 160-289 cases per 100,000 person-years and peaks in young men and women in the third decade of life. RRP has an estimated incidence of 3 per 1 million person-years in children. Pre-licensure trial efficacy, modeling and time-trend ecological studies have shown a significant short-term impact of 4vHPV vaccine. In girls aged 15-19 years, a previously published meta-analysis indicated that genital warts decreased significantly by 31%; stratified analysis revealed more substantial reductions in populations with high (≥50 %) vs. low (<50 % ) vaccination coverage (61% vs. 14%). Longer-term monitoring will reveal whether this impact continues under 9vHPV programs, and whether current declines in AGW are mirrored by declines in RRP.

Clinical Inquiry: Does qHPV vaccine prevent anal intraepithelial neoplasia and condylomata in men?

Yes. Quadrivalent human papillomavirus (qHPV) vaccine reduces rates of anal intraepithelial neoplasia (AIN) by 50% to 54%, and persistent anal infection by 59%, associated with the 4 types of HPV in the vaccine (6, 11, 16, and 18) in young men who have sex with men (MSM); it also reduces external genital lesions by 66%, and persistent HPV infection associated with the same 4 HPV types by 48 to 59% in all young men, heterosexual men, and MSM.

HPV and HPV-associated diseases

Human papillomavirus (HPV) is the most common sexually transmitted infection. HPV is associated with a significant burden of disease and cancer, including anogenital warts and recurrent respiratory papillomatosis, and anogenital and oropharyngeal cancers. Effective prevention is available, including primary prevention of cancers and anogenital warts through HPV vaccination, and secondary prevention of cervical cancer through screening and treatment of precancer. This article focuses on HPV infection and the clinical consequences of infection, with attention to cervical and anogenital squamous intraepithelial neoplasia and anogenital warts.

Prevention of anal condyloma with quadrivalent human papillomavirus vaccination of older men who have sex with men

Background

The quadrivalent human papillomavirus vaccine (qHPV) is FDA-approved for use in males 9 to 26 years old to prevent anogenital condyloma. The objective of this study is to determine if qHPV is effective at preventing anal condyloma among men who have sex with men (MSM) aged 26 years and older.

Methods

This post-hoc analysis of a nonconcurrent cohort study evaluated 210 patients without history of anal condyloma and 103 patients with previously-treated anal condyloma recurrence-free for at least 12 months prior to vaccination/time zero. We determined the rate of anal condyloma development in vaccinated versus unvaccinated patients.

Results

313 patients with mean age 42 years were followed for median 981 days. During 773.6 person-years follow-up, condyloma developed in 10 (8.6%) vaccinated patients (incidence of 3.7 per 100 person-years) and 37 (18.8%) unvaccinated patients (incidence 7.3 per 100 person-years; p = 0.05). Multivariable hazards ratio showed that qHPV was associated with decreased risk of anal condyloma development (HR 0.45; 95% CI 0.22–0.92; p = 0.03). History of anal condyloma was associated with increased risk of anal condyloma development (HR 2.28; 95% CI 1.28–4.05; p = 0.005), as was infection with oncogenic HPV (HR 3.87; 95% CI 1.66–9.03; p = 0.002).

Conclusions

Among MSM 26 years of age and older with and without history of anal condyloma, qHPV reduces the risk of anal condyloma development. A randomized controlled trial is needed to confirm these findings in this age group.

Use of human papillomavirus vaccine in HIV-infected men for the prevention of anal dysplasia and cancer

There are two commercially available vaccines licensed worldwide for the prevention of cervical cancer and other human papillomavirus-associated cancers such as anal cancer. However, only two countries have implemented healthcare programs that include human papillomavirus vaccination for boys and men. Although most of the human papillomavirus-related cancers in the world are attributable to cervical cancer, in developed countries anal cancer accounts for a larger proportion of human papillomavirus-related cancers. Most cases of anal cancer occur in HIV-infected men who have sex with men. In this review, we discuss the burden of human papillomavirus-related cancers in men, the most plausible immune mechanism associated with the high efficacy of the human papillomavirus vaccine, and address key issues of vaccination for HIV-infected men. Finally, we review cost-effectiveness considerations for the use of the vaccine in boys and recent guidelines for vaccination in boys, with attention to HIV-infected men.

HPV vaccine against anal HPV infection and anal intraepithelial neoplasia

BACKGROUND

The rate of anal cancer is increasing among both women and men, particularly men who have sex with men. Caused by infection with human papillomavirus (HPV), primarily HPV type 16 or 18, anal cancer is preceded by high-grade anal intraepithelial neoplasia (grade 2 or 3). We studied the safety and efficacy of quadrivalent HPV vaccine (qHPV) against anal intraepithelial neoplasia associated with HPV-6, 11, 16, or 18 infection in men who have sex with men.

METHODS

In a substudy of a larger double-blind study, we randomly assigned 602 healthy men who have sex with men, 16 to 26 years of age, to receive either qHPV or placebo. The primary efficacy objective was prevention of anal intraepithelial neoplasia or anal cancer related to infection with HPV-6, 11, 16, or 18. Efficacy analyses were performed in intention-to-treat and per-protocol efficacy populations. The rates of adverse events were documented.

RESULTS

Efficacy of the qHPV vaccine against anal intraepithelial neoplasia associated with HPV-6, 11, 16, or 18 was 50.3% (95% confidence interval [CI], 25.7 to 67.2) in the intention-to-treat population and 77.5% (95% CI, 39.6 to 93.3) in the per-protocol efficacy population; the corresponding efficacies against anal intraepithelial neoplasia associated with HPV of any type were 25.7% (95% CI, -1.1 to 45.6) and 54.9% (95% CI, 8.4 to 79.1), respectively. Rates of anal intraepithelial neoplasia per 100 person-years were 17.5 in the placebo group and 13.0 in the vaccine group in the intention-to-treat population and 8.9 in the placebo group and 4.0 in the vaccine group in the per-protocol efficacy population. The rate of grade 2 or 3 anal intraepithelial neoplasia related to infection with HPV-6, 11, 16, or 18 was reduced by 54.2% (95% CI, 18.0 to 75.3) in the intention-to-treat population and by 74.9% (95% CI, 8.8 to 95.4) in the per-protocol efficacy population. The corresponding risks of persistent anal infection with HPV-6, 11, 16, or 18 were reduced by 59.4% (95% CI, 43.0 to 71.4) and 94.9% (95% CI, 80.4 to 99.4), respectively. No vaccine-related serious adverse events were reported.

CONCLUSIONS

Use of the qHPV vaccine reduced the rates of anal intraepithelial neoplasia, including of grade 2 or 3, among men who have sex with men. The vaccine had a favorable safety profile and may help to reduce the risk of anal cancer. (Funded by Merck and the National Institutes of Health; ClinicalTrials.gov number, NCT00090285.).

Incision and drainage of perianal abscess with or without treatment of anal fistula

BACKGROUND

The perianal abscess is a common surgical problem. A third of perianal abscesses may manifest a fistula-in-ano which increases the risk of abscess recurrence requiring repeat surgical drainage. Treating the fistula at the same time as incision and drainage of the abscess may reduce the likelihood of recurrent abscess and the need for repeat surgery. However, this could affect sphincter function in some patients who may not have later developed a fistula-in-ano.

OBJECTIVES

We aimed to review the available randomised controlled trial evidence comparing incision and drainage of perianal abscess with or without fistula treatment.

SEARCH STRATEGY

Randomised trials were identified from MEDLINE, EMBASE, the Cochrane Library, and reference lists of published papers and reviews.

SELECTION CRITERIA

Trials comparing outcome after fistula surgery with drainage of perianal abscess compared with drainage alone were included in the review.

DATA COLLECTION AND ANALYSIS

The primary outcomes were recurrent or persistent abscess/fistula which may require repeat surgery and short-term and long-term incontinence. Secondary outcomes were duration of hospitalisation, duration of wound healing, postoperative pain, quality of life scores. For dichotomous variables, relative risks and their confidence intervals were calculated.

MAIN RESULTS

We identified six trials, involving 479 subjects, comparing incision and drainage of perianal abscess alone versus incision and drainage with fistula treatment. Metaanalysis showed a significant reduction in recurrence, persistent abscess/fistula or repeat surgery in favour of fistula surgery at the time of abscess incision and drainage (RR=0.13, 95% Confidence Interval of RR = 0.07-0.24). Transient manometric reduction in anal sphincter pressures, without clinical incontinence, may occur after treatment of low fistulae with abscess drainage. Incontinence at one year following drainage with fistula surgery was not statistically significant (pooled RR 3.06, 95% Confidence Interval 0.7-13.45) with heterogeneity demonstrable between the trials (Chi(2) =5.39,df=3, p=0.14, I(2) =44.4%).

AUTHORS' CONCLUSIONS

The published evidence shows fistula surgery with abscess drainage significantly reduces recurrence or persistence of abscess/fistula, or the need for repeat surgery. There was no statistically significant evidence of incontinence following fistula surgery with abscess drainage. This intervention may be recommended in carefully selected patients.

Necessity of preventive colostomy for Fournier's gangrene of the anorectal region

BACKGROUND

The aim of this study was to evaluate the necessity of preventive colostomy for Fournier's gangrene of the anorectal region.

METHODS

The medical records of 37 patients with perianal Fournier's gangrene were evaluated retrospectively. Debridement(s) alone was performed in 18 patients (Group D), while debridement(s) plus Hartmann colostomy was performed in 19 patients (Group D&HC).

RESULTS

There were no statistically significant differences between the D and D&HC groups with respect to mean age (p=0.73), sex ratio (p=1.00), diabetes mellitus (p=0.88), concomitant diseases (p=0.57), and number of debridements (p=0.75). The medical and surgical complication and mortality rates and duration of hospital and intensive care unit stays were also not significantly different between the D and D&HC groups (p>0.05). Fecal diversion was done at the initial operation in 11 patients, at second operation in 6 patients, and at third operation in 2 patients. When compared, morbidity rates were similar, but mortality rates were statistically different (p=0.031).

CONCLUSION

Fournier's gangrene remains a difficult surgical problem. Despite aggressive multidisciplinary treatment, it still has a high mortality rate. Fecal diversion in the treatment of Fournier's gangrene is controversial. If necessary, preventive colostomy should be performed during the initial debridement.

Pain level and anal discomfort during transrectal ultrasound for guided prostate biopsy. Does intrarectal administration of local anesthetic before periprostatic anesthesia makes any difference?

AIM

The aim of this study was to evaluate the anal discomfort and pain level, during transrectal ultrasound probe insertion and before the periprostatic anesthesia in young patients (<65 years of age).

METHODS

This study enrolled 147 patients, who underwent prostate biopsy and were divided in two groups: 74 patients received perianal local anesthesia with lidocaine cream 2% (first group), while 73 received only lubricant gel as perianal local anesthesia (second group) prior the insertion of ultrasound probe. Patients in both groups received periprostatic anesthesia. Pain and discomfort due to the probe and due to the biopsy were estimated with visual analogue scale. Patients' characteristics, complications, and surgical data were analyzed for both groups.

RESULTS

No serious intraoperative and postoperative complications were noted in both groups. The mean pain score for pain and anal discomfort was 1.7 and 5.7 for the first and second group, respectively. During biopsy, patients in the first group reported also less pain but there was no significant difference.

CONCLUSIONS

The intrarectal introduction of lidocaine cream 2% can significantly reduce anal discomfort and pain before the probe insertion for ultrasound guided biopsies in young patients. Considering that these patients could undergo repeated biopsies, a higher level of local anesthesia is desired.

Anogenital Warts Knowledge and Counseling Practices of US Clinicians: Results From a National Survey

OBJECTIVES

To examine messages US clinicians use when counseling patients diagnosed with anogenital warts.

STUDY DESIGN

In mid-2004, we conducted a confidential mail survey of nationally representative samples of physicians practicing internal and adolescent medicine, family/general practice, obstetrics/gynecology, urology, or dermatology; nurse midwives; physician assistants; and nurse practitioners. The survey assessed knowledge and counseling practices of clinicians who had diagnosed anogenital warts.

RESULTS

After adjusting for survey eligibility, 81% responded. Most (89%) were aware that human papillomavirus (HPV) causes anogenital warts, but only 48% were aware that oncogenic and wart-related HPV genotypes usually differ. Most (>95%) clinicians reported telling patients with warts that warts are an STD, are caused by a virus, or that their sex partners may have or may acquire warts. Many clinicians (>/=85%) also reported discussing STD prevention or assessing STD risk with such patients. Most reported addressing ways to prevent HPV (89%), including using condoms; limiting sex partners or practicing monogamy; or abstinence. Many also reported recommending prompt (82%) or more frequent (52%) Pap testing to female patients with anogenital warts. Potential barriers to counseling included providing definitive answers on how HPV infection was acquired, dealing with patients' psychosocial issues, and inadequate reimbursement.

CONCLUSIONS

Most surveyed clinicians appropriately counseled patients about the cause and prevention of anogenital warts. However, many clinicians were unaware that oncogenic and wart-related HPV types usually differ, and this may explain why many reported recommending more aggressive cervical cancer screening for female patients with warts.

Risk factors for genital and anal warts in a prospective cohort of HIV-negative homosexual men: the HIM study

OBJECTIVE

The objective of this study was to determine the prevalence, incidence, and risk factors for genital and anal warts in HIV-negative homosexual men in Sydney.

STUDY DESIGN

The authors conducted a prospective cohort study. Participants were asked whether they had had genital and anal warts at each interview. Details of lifetime sexual contacts and sexual behaviors in the last 6 months were collected.

RESULTS

Among 1,427 men recruited, 8.9% and 19.6% reported a history of genital and anal warts at baseline, respectively. Incidence rates for genital and anal warts were 0.94 and 1.92 per 100 person-years, respectively. In multivariate analysis, both incident genital and anal warts were associated with younger age. In addition, incident genital warts was associated with insertive fingering (P trend = 0.018), whereas incident anal warts was associated with insertive fingering (P trend = 0.007) and insertive fisting (P trend = 0.039).

CONCLUSIONS

Anal warts were twice as common as genital warts. Fingering and other manual sexual practices may be an important transmission route for both.

Vaccines for preventing HPV-related anogenital infection and neoplasia

Human papillomavirus (HPV) is a common sexually transmitted pathogen. Although most anogenital HPV infections resolve within several years, persistent infection may lead to neoplasia of the cervix, vagina, vulva, anus, and penis, and also genital warts. High-risk HPV types 16 and 18 are known to cause approximately 70% of all cervical cancers, and low-risk HPV types 6 and 11 are the main causes of genital warts. Prophylactic HPV vaccines have the potential to block the acquisition of HPV and hence subsequent development of anogenital neoplasia. Results from several clinical trials have demonstrated that the HPV L1 virus-like-particle vaccines are safe and highly immunogenic. These trials have documented a 100% vaccine efficacy in prevention of persistent HPV infection and, more important, of HPV-associated anogenital neoplasia in per-protocol analyses. Widespread vaccination of sexually naïve preadolescent children could substantially reduce the morbidity and mortality associated with anogenital malignancies. Furthermore, such a primary prevention program would also reduce healthcare costs.

Application of imiquimod by suppositories (anal tampons) efficiently prevents recurrences after ablation of anal canal condyloma

BACKGROUND

After surgical removal, anal canal condyloma (ACC) has a higher risk of recurrence compared with extragenital warts.

OBJECTIVES

To reduce local recurrences of ACC using follow-up treatment with imiquimod-containing suppositories (anal tampons).

METHODS

After ablation of ACC, 10 male patients received treatment with imiquimod suppositories three times weekly for 3-4 months.

RESULTS

Treatment with imiquimod anal tampons was well tolerated. Early initial recurrences in some patients cleared after treatment with the imiquimod suppositories. Within a mean follow-up of 9 months no patient demonstrated recurrence of ACC.

CONCLUSIONS

These data suggest that imiquimod anal tampons may represent a new therapeutic option to prevent recurrences of ACC following ablative surgery.

Crohn's disease: bowel resection to protect the proctium in severe perianal disease?

Patients with anal Crohn's disease generally have a bad prognosis. Up to 50% end up with an anus praeter or proctectomy. Many of these young people develop psychological and social problems causing them to become invalids. Local surgery and conservative therapy in such aggressive cases of Crohn's disease presenting with recurring perianal fistulae and abscesses are often unsuccessful; the destruction of the proctium continues. The purpose of our study was to look at the outcome of our patients with regard to these aspects. We included all 56 patients suffering from Crohn's disease treated at our clinic from 1984 until 1991 in a retrospective study and focused on the 13 patients with anal manifestation. The mean follow-up was 15.8 years (3-28 years). Often there was no improvement of perianal disease without resection of the involved bowel, especially in cases where both the colon and the rectum were affected. Anal destruction went on. Seven of the 13 patients suffering from anal complications finally received an anus praeter. An previous bowel-resection or the construction of a temporary anus praeter seem to be necessary to protect the proctium irrespective of abdominal symptoms in patients with recurrent severe perianal Crohn's disease.

Complications of Milligan-Morgan hemorrhoidectomy

Based on a retrospective review of a personal experience with 500 modified Milligan-Morgan hemorrhoidectomies, technical suggestions for avoiding early and late complications are presented. The problems of early and delayed bleeding, anal verge and mucosal stenosis, pain and prolonged healing due to persistent anal ulcer are discussed

The role of early colposcopy in the management of females with first episode anogenital warts

212 females attending a genitourinary medicine (GUM) clinic with first episode anogenital warts were screened by cervical cytology and colposcopy/histology for the presence of cervical epithelial abnormalities in keeping with infection by the human papillomavirus (HPV infection) and/or cervical intraepithelial neoplasia (CIN). The prevalence of cervical epithelial abnormalities detected by cervical cytology alone was 32%, rising to 56% after colposcopic examination. However, the majority of cervical lesions detected by colposcopy alone were of low grade (HPV infection and/or CIN I). Histologically-confirmed high grade cervical lesions (CIN II or CIN III) were detected more frequently in those females in whom cervical cytological examination indicated dyskaryosis in keeping with any grade of CIN, compared to females without dyskaryotic changes on cervical smear (P < 0.05, chi-squared test with Yates' correction). Early colposcopy is indicated for females with anogenital warts in the presence of a cervical smear showing dyskaryosis in keeping with any grade of CIN, because of the statistically significant increased risk of detecting a potentially progressive high grade cervical lesion. In females without dyskaryotic changes on cervical smear, the value of early colposcopy is uncertain and warrants larger more long-term trials.

Problems after ileo-pouch anal anastomosis for ulcerative colitis. How can we prevent it? What can we do?

During the last 10 years (1982-1992) 370 patients have had a pelvic pouch constructed in the Colorectal Unit at the Department of Surgery II, Sahlgrenska Hospital. The complications and the eventual outcome in 307 patients (median follow-up 5.5 years ranging from 1.5 to 11 years) have been analysed. The overall complication rate was 22%. Anastomotic leaks, anal ulcerations or fissures and strictures (13%) and small bowel obstruction (5%) were the most common followed by ileostomy-related complications (2%). Re-laparatomy was required in 10%. Most anastomosis-related complications were successfully managed by prolonged ileostomy diversion combined with local procedures. The anastomotic leaks all proved to be radiologically healed at the time of ileostomy closure. Three of 16 patients who had had radiological leaks developed complications subsequently, but all could be successfully managed. In contrast, 6 of 15 patients in whom clinical leaks healed initially developed complications that eventually resulted in failure. The overall late complication rate was 22%. The most common complications were anastomotic stricturing (4%), small bowel obstruction (5%) and poor pouch function (pelvic pain, high evacuation frequency and other functional imperfections) (6%). Anal abscess, fistula or pouch-vaginal fistula were uncommon, however. While laying open of simple anal fistula and dilation of stenosis during anaesthesia were sometimes successful, re-laparotomy with redo of the pouch-anal anastomosis was needed for successful treatment of grossly fibrotic strictures, complex pouch-vaginal fistulae and poorly functioning pouches.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy and safety of 0.5% podofilox solution in the treatment and suppression of anogenital warts

PURPOSE

For the patient-administered treatment of anogenital warts, 0.5% podofilox (podophyllotoxin), one of the active compounds of podophyllin, has been shown to be more effective than the vehicle alone. This study was designed to evaluate the safety and efficacy of 0.5% podofilox treatment followed by prophylaxis.

PATIENTS AND METHODS

A total of 103 patients were entered in stage 1 of the study. Stage 1 was an open label study, and patients self-administered 0.5% podofilox twice daily for 3 consecutive days per week for 4 weeks. A total of 100 patients remained available for efficacy and safety analyses. At the end of stage 1, patients who had a complete response proceeded to stage 2 of the study. Patients who had a 50% to 99% reduction in measured total wart area were offered cryotherapy every 10 days, up to 5 times. If cleared of warts, they were also entered into stage 2. A total of 57 patients were enrolled into stage 2, a double-blind, randomized, placebo-controlled prophylactic study of 0.5% podofilox self-administered once daily for 3 days per week for 8 weeks, on the sites of healed warts. A total of 45 patients in stage 2 were available for efficacy analysis.

RESULTS

By the end of stage 1, 68% of the warts had disappeared, and 29 of 100 patients (29%) had a complete response. A total of 49 patients had a 50% or greater improvement in wart area and underwent cryotherapy. Rates of local side effects after 1 week of treatment were 57% for inflammation, 39% for erosion, 47% for pain, 48% for burning, and 44% for itching. However, these symptoms and signs were mostly mild to moderate in intensity and diminished over time. Therefore, overall treatment was well tolerated. In stage 2, only 4 of 21 patients (19%) in the podofilox group experienced a recurrence as opposed to 12 of 24 (50%) in the placebo group (P = 0.031). As in stage 1, the side effects were modest, and the drug was well tolerated.

CONCLUSION

This study confirms the efficacy and good tolerance of 0.5% podofilox in the treatment of anogenital warts. It also establishes the safety and superior efficacy of patient-administered podofilox over the vehicle alone as prophylaxis against recurrence of lesions. Although long-term efficacy and tolerance remain to be established, podofilox appears to be a useful agent in the control of this disease.

[Anatomical measurements of the internal anal sphincter--the relative site of the dentate line in the internal anal sphincter]

Not only the length and the width of the internal anal sphincter but also the relative site of the dentate line in the internal anal sphincter were investigated in 62 resected specimens obtained by abdominoperineal resection of the rectum for malignancy. Mean length and width of the internal sphincter were 25.8 +/- 4.1mm (mean +/- standard deviation) and 4.0 +/- 1.1mm, respectively. The length of the internal sphincter from its distal end to the level of the dentate line was 11.3 +/- 3.1mm, which corresponded to 44% of the total length of the internal sphincter. The individual difference in the site of the dentate line in the internal sphincter was objectively demonstrated. It seems to be therefore important to modulate the extent of sphincterotomy in order to minimize postoperative anal dysfunction on the surgery for fissure or fistula-in-ano, in which sphincterotomy is widely practiced up to the level of the dentate line.

Glycogen storage disease type Ib: infectious complications and measures for prevention

A patient with glycogen storage disease (GSD) type Ib, neutrophenia, chronic inflammatory bowel disease and recurrent abscesses was treated with recombinant human granulocyte-macrophage colony stimulating factor (GM-CSF). GM-CSF (and also granulocyte colony stimulating factor) therapy markedly increased the neutrophil counts and reduced the frequency of infections and inflammation. We conclude that myeloid growth factors are effective for the treatment and prevention of acute infections and chronic inflammatory complications in patients with GSD Ib.

[Results of inadequate aftercare following surgical correction of proctatresia (author's transl)]

For deep proctatresia, postoperative aftercare consisting of adequate, long-term bougienage is important. On the basis of 10 cases, it was shown that inadequate postoperative bougienage for proctatresia leads to formation of a megacolon and to overflow incontinence. The incontinence can then only be controlled by carrying out a proctectomy and a sigmoidectomy together with surgical formation of the gracilis. This proved to be satisfactory for all 10 cases presented.