High-dose versus low-dose botulinum toxin in anal fissure disease.

BACKGROUND: There is no consensus on the optimal dosage of botulinum toxin (BT) as a sphincter sparing alternative to lateral internal sphincterotomy for chronic anal fissure. The aim of this study was to assess the long-term efficacy of high-dose BT as well as the presence of incontinence following the treatment of chronic anal fissure at a single institution. METHODS: A retrospective case-control study was performed at a single institution over a 6-year period (2009-2014). Patients given high-dose (80-100 IU) BT were compared to low-dose (20-40 IU) case controls. Clinical notes were reviewed, and follow-up was carried out via a telephone questionnaire. RESULTS: One hundred and fifty-eight patients were treated with BT injections within the study period (103 high dose; 55 low dose). The mean length of follow-up was 25 months (range 4-52 months). Classic posterior fissures with high anal tone were more prevalent in the low-dose group (40 vs 47%, p = 0.3). Patient satisfaction was higher in the high-dose group (90 vs 78%, p = 0.05). Long-term recurrence (6 months after the last treatment) was also lower (23 vs 53%, p = 0.0001) on multivariate analysis. No long-term incontinence was observed. CONCLUSIONS: In this series, the recurrence rate post-BT injection was significantly lower in the high-dose group. There was no long-term incontinence. Further studies are needed to confirm our results.

Is retinal assessment useful in epileptic patients with hyperhomocysteinemia?

PURPOSE: The arteriole-to-venule ratio (AVR) is widely used for investigating subclinical cerebral microangiopathy. The possible occurrence of retinal vascular caliber changes was investigated in a population of hyperhomocysteinaemic (plasma total homocysteine (tHcy) >13 micromol/l) adult epileptic patients. METHODS: Retinal photographs of cases and controls were evaluated for generalized narrowing of the retinal arterioles, measured as AVR, by graders masked to case-control status using standardized protocols. Plasma total homocysteine (tHcy) levels were assayed by HPLC. RESULTS: Sixty-seven patients (36M/31F, 36.4+/-7.5 years of age; mean level of tHcy 22.8+/-11.4 micromol/l), and 75 control subjects (42M/33F, 35.4+/-8.5 years of age; mean level of tHcy 7.8+/-2.3 micromol/l) were enroled. No retinal caliber changes were detected in any patient and healthy subject. The analysis of retinal photographs failed to identify any difference in the venular diameters, arteriolar diameters, and AVR measurements between the two groups (P=0.98). CONCLUSIONS: We showed that adult hyperhomocysteinaemic epileptic patients do not show any changes in retinal vascular caliber assessed by the measurement of AVR.

An open-label trial of levetiracetam in severe myoclonic epilepsy of infancy.

OBJECTIVE: To conduct an open-label, add-on trial on safety and efficacy of levetiracetam in severe myoclonic epilepsy of infancy (SMEI). PATIENTS AND METHODS: SMEI patients were recruited from different centers according to the following criteria: age > or =3 years; at least four tonic-clonic seizures/month during the last 8 weeks; previous use of at least two drugs. Levetiracetam was orally administrated at starting dose of approximately 10 mg/kg/day up to 50 to 60 mg/kg/day in two doses. Treatment period included a 5- to 6-week up-titration phase and a 12-week evaluation phase. Efficacy variables were responder rate by seizure type and reduction of the mean number per week of each seizure type. Analysis was performed using Fisher exact and Wilcoxon tests. RESULTS: Twenty-eight patients (mean age: 9.4 +/- 5.6 years) entered the study. Sixteen (57.1%) showed SCN1A mutations. Mean number of concomitant drugs was 2.5. Mean levetiracetam dose achieved was 2,016 mg/day. Twenty-three (82.1%) completed the trial. Responders were 64.2% for tonic-clonic, 60% for myoclonic, 60% for focal, and 44.4% for absence seizures. Number per week of tonic-clonic (median: 3 vs 1; p = 0.0001), myoclonic (median: 21 vs 3; p = 0.002), and focal seizures (median: 7.5 vs 3; p = 0.031) was significantly decreased compared to baseline. Levetiracetam effect was not related to age at onset and duration of epilepsy, genetic status, and concomitant therapy. Levetiracetam was well tolerated by subjects who completed the study. To date, follow-up ranges 6 to 36 months (mean, 16.2 +/- 13.4). CONCLUSION: Levetiracetam add-on is effective and well tolerated in severe myoclonic epilepsy of infancy. Placebo-controlled studies should confirm these findings.

Tobacco education in low-literacy individuals.

Approximately 20% of the adult population in the United States have low-literacy skills. The subpopulations with the highest incidence of low literacy are nearly identical to those with the highest prevalence of tobacco use. Low-literacy smokers are more likely to underestimate the risks related to tobacco use, have less social pressure and support to quit smoking, may experience more life stress and consequently rely more heavily on nicotine use for stress reduction and require more assistance in developing a sense of self-efficacy. This indicates a need to modify smoking cessation methods of counselling, content and selection of educational materials for the marginally literate. Currently available low-literacy materials are listed, and suggestions for adjusting or developing materials are made.