An evaluation of the validity of the pre-operative oxygen uptake efficiency slope as an indicator of cardiorespiratory fitness in elderly patients scheduled for major colorectal surgery.

This study aimed to investigate the validity of the oxygen uptake efficiency slope as an objective and submaximal indicator of cardiorespiratory fitness in elderly patients scheduled for major colorectal surgery. Patients ≥ 60 years of age, with a metabolic equivalent score using the Veterans Activity Questionnaire ≤ 7 and scheduled for major colorectal surgery participated in a pre-operative cardiopulmonary exercise test. The oxygen uptake efficiency slope was calculated up to different exercise intensities, using 100%, 90% and 80% of the exercise data. Data from 71 patients (47 men, mean (SD) age 75.2 (6.7) years) were analysed. The efficiency slope obtained from all the data was statistically significantly different from the values when 90% (p = 0.027) and 80% (p = 0.023) of the data were used. The 90% and 80% values did not differ significantly from each other (p = 0.152). Correlations between the oxygen uptake efficiency slope and the peak oxygen uptake ranged from 0.816 to 0.825 (all p < 0.001), and correlations between oxygen uptake efficiency slope and the ventilatory anaerobic threshold ranged from 0.793 to 0.805 (all p < 0.001). Receiver operating characteristic curves showed that the oxygen uptake efficiency slope is a sensitive and specific predictor of a peak oxygen uptake ≤ 18.2 ml.kg-1 .min-1 , with an area under the curve (95%CI) of 0.876 (0.780-0.972, p < 0.001) and a ventilatory anaerobic threshold ≤ 11.1 ml.kg-1 .min-1 , with an area under the curve (95%CI) of 0.828 (0.726-0.929, p < 0.001). These correlations suggest that the oxygen uptake efficiency slope provides a valid (sub)maximal measure of cardiorespiratory fitness in these patients, and the predictive ability described indicates that it might help discriminate patients at higher risk of postoperative morbidity. However, future research should investigate the prognostic value of the oxygen uptake efficiency slope for postoperative outcomes.

Hepatocellular carcinoma after danazol treatment for hereditary angio-oedema.

Hereditary angio-oedema is characterised by recurrent episodes of laryngeal, intra-abdominal, facial or peripheral oedema. Danazol can be used as prophylaxis for recurrent attacks. Hepatotoxicity is a recognised adverse effect of danazol. We report an exceptional case of a danazol-induced hepatocellular carcinoma in a 75-year-old patient with hereditary angio-oedema.

Isosorbide dinitrate ointment vs botulinum toxin A (Dysport) as the primary treatment for chronic anal fissure: a randomized multicentre study.

AIM: Nitric oxide donors, such as isosorbide dinitrate ointment (ISDN), are considered as first-choice agents in the treatment of chronic anal fissure. Injection with botulinum toxin A in the internal anal sphincter is often used as a second-line therapy, although it may give better results and fewer side effects than nitric oxide donors. The aim of this randomized clinical trial was to investigate whether botulinum toxin A (Dysport) is more effective than ISDN in the primary treatment of chronic anal fissure. METHOD: From April 2005 until October 2009, 60 patients (32 men) with a median age of 42 (25-82) years were randomized to receive either ISDN 10 mg/ml (1%) (n = 33) or injection with 60 units of Dysport (n = 27). The primary end-point was the percentage of complete fissure healing after 8 weeks. RESULTS: After a median of 9 weeks complete fissure healing was noted in 18 of 27 patients in the Dysport group and in 11 of 33 patients in the ISDN group (P = 0.010). Absolute improvement of pain scores after 9 weeks was similar in both groups (P = 0.733). Patients treated with Dysport had fewer side effects than patients treated with ISDN (P = 0.028). Of the patients with a healed fissure, 28% of the Dysport group and 50% of the ISDN group had a recurrence within 1 year (P = 0.286; hazard ratio 2.08; 95% CI = 0.54-7.97). CONCLUSION: Dysport is more effective than ISDN ointment and has fewer side effects in the primary treatment of chronic anal fissure. The recurrence rate within 1 year in both treatment groups is high.

Brain abscess after transanal hemorrhoidal dearterialization: a case report.

A relatively new therapy in the treatment of hemorrhoids is transanal hemorrhoidal dearterialization (THD). We report a case of brain abscess caused by Streptococcus milleri following THD. Although a brain abscess after drainage of a perianal abscess has been described in the literature, no report exists of a brain abscess following treatment of hemorrhoids. A healthy 51-year-old man with hemorrhoids underwent THD. Two weeks later he presented with a headache, bradyphrenia, flattened behavior and a left hemiplegia. No perianal complaint and/or perianal abscess was present. A contrast CT scan of the cerebrum showed a right temporoparieto-occipital abscess, with edema and compression of the surrounding tissue and lateral ventricles. MRI showed an abscess with leakage in the right lateral ventricle. Treatment with dexamethasone and intravenous antibiotics was started. Because of progression of symptoms, 3 weeks later ventriculoscopy was performed and the abscess was drained. Culture of the punctuate showed S. milleri. Because of developing hydrocephalus 3 days after ventriculoscopy, first an external ventricle drain and later a ventriculoperitoneal drain was placed. Hereafter the hemiplegia and cognitive disorders improved. This case report describes a severe complication following treatment of hemorrhoids with THD which until now, to our knowledge, has never been described in the literature.