Topical nitroglycerin in the management of anal fissure: an explosive outcome!

Anal sphincter spasm is a common finding in patients with anal fissure disease. It is postulated that spasm impedes mucosal blood flow and impairs healing. Topical nitroglycerin (NTG), a nitric oxide donor compound, has been shown to cause relaxation of the anal sphincter and may have treatment efficacy in the management of anal fissure. The purpose of this study was to assess the usefulness of NTG for anal fissure. We performed a retrospective review of patients with anal fissure treated with various concentrations of topical NTG ointments over an 18-month period ending July 1997. Of the 81 patients studied, 44 (54%) were male. There were 42 acute and 39 chronic fissures. NTG preparations included 1 per cent isosorbide (n = 37), 0.2 per cent NTG (n = 38), and 0.5 per cent NTG (n = 6). Healing with NTG therapy occurred in 29 acute (69%) and 21 chronic fissure (54%) patients. There was no difference in the incidence of healing of acute or chronic fissure between the various NTG treatment preparation groups. When acute and chronic fissure therapy was subdivided by time of NTG treatment (immediate versus post-conservative therapy failure (PCF)), 14 (74%) of acute PCF and 5 (42%) of chronic PCF patients healed. We conclude that no single formula was superior. When patients were subdivided into a PCF group, NTG therapy demonstrated a significant salvage rate, thus avoiding surgery.

Exogenous non-crosslinked collagen enhances granulation tissue formation in dermal excision wounds in guinea pigs.

Based on previous observations indicating a role for collagen peptides in eliciting a positive feedback for collagen biosynthesis, this study was initiated to elucidate the effect of non-crosslinked collagen on granulation tissue formation in dermal excision wounds. The wounds were treated with either non-crosslinked or crosslinked native collagen, or left untreated as controls. Granulation tissue was analyzed for collagen type I mRNA, for levels of interstitial collagen and for the number of blood vessels. The results indicated significant increases in procollagen type I mRNA, in interstitial collagen, in the number of blood vessels and in epithelial advance in the non-crosslinked collagen-treated wounds relative to the untreated controls. It is assumed that the presence of non-crosslinked collagen in a healing wound enhances both procollagen type I biosynthesis and the repair process of dermal wounds, due to the more readily released collagen peptides derived from this exogenous collagen dressing.

Lack of influence of cyclosporin A on levels of gingival procollagen types I and III mRNAs in rats of different ages.

Previous studies showed that gingival overgrowth following cyclosporin A (CsA) administration is not associated with an increase in interstitial collagen. It also was shown that CsA causes a significant decrease in collagen content within the gingival stroma. In order to determine whether this decrease is caused by down-regulation of collagen mRNA, the procollagen mRNA level in gingiva of young and old rats was measured correlated with the ratio of interstitial collagen to DNA in these regions. Hybridization of 32P-labelled cDNA probes for procollagen types I and III with total RNA extracted from the molar gingiva showed that administration of Csa did not change the steady-state levels of mRNAs for both procollagens in the gingiva of either young or old rats. The ratio of gingival interstitial collagen to DNA was significantly reduced in the CsA-treated animals (4.2 +/- 0.85) relative to the controls (7.8 +/- 1.6). It is concluded that the reduction in interstitial collagen following CsA treatment is not age-related, and is most probably caused by increased degradation rather by decreased biosynthesis.

Hereditary leukoencephalopathy and palmoplantar keratoderma: a new disorder with increased skin collagen content.

We report a new neurocutaneous syndrome of apparent autosomal recessive inheritance consisting of early-childhood-onset palmoplantar keratoderma followed in adulthood by progressive tetrapyramidal syndrome and cognitive impairment. Of the four affected siblings, two were available for evaluation. Investigation disclosed cerebral white-matter involvement on MRI and arylsulfatase A pseudodeficiency carrier state, which was also identified in clinically unaffected family members. Since skin biopsies showed dermal connective tissue abnormalities, we studied collagens I, III, and VI biosynthesis. Northern blotting of RNA extracted from cultured skin fibroblasts revealed an increased steady-state messenger RNA (mRNA) level of alpha 1(VI) collagen, whereas no differences were detected for pro alpha 1(I), pro alpha 1(III), and tropoelastin mRNAs. The skin content of collagen and total protein was higher in the patients than in controls. We suggest that an extracellular matrix abnormality may be involved in the pathogenesis of this disorder.

Topological differences in the expression of collagen type I and collagen type III mRNAs in the rat gingiva.

Collagen mRNA levels in the gingival cells of molars and incisors in rats were measured and correlated with the ratio of interstitial collagen to DNA in these regions. Hybridization of 32P-labeled specific cDNA probes for collagen types I and III with total RNA isolated from gingival tissue of rat molars and incisors showed that the steady-state levels of mRNAs of type I was significantly higher in the molars than in the incisors (molars/incisors = 2.12 +/- 0.12, P < 0.004). However, the ratio of interstitial collagen to DNA in the gingiva of the molars was significantly lower than that found in the incisors (collagen/DNA = 4.13 +/- 0.90 and 12.89 +/- 1.24 respectively, P < 0.001). It is suggested that the difference between the mRNA levels and those of interstitial collagen may reflect an intrinsic characteristic presumably associated with the different modes of mastication between molars and incisors of the rat.

Type I and type III collagen mRNA levels in kidney regions of old and young rats.

Interstitial fibrosis is a common feature of renal aging. The steady-state levels of type I and type III collagen mRNAs as well as DNA, protein and collagen deposition were investigated in the cortex, inner and outer medulla of aged (22 months old) rats in comparison to young (5 months old) controls. Our data show that the cortex and outer medulla of old rats expressed significantly higher percentage of type I collagen mRNA compared to the respective regions in the young rat kidneys. Moreover, within the group of the old rats, the cortex expressed significantly higher percentage of type I collagen mRNA compared to the inner medulla whereas in the group of the young rats the expression was similar in all kidney regions. The ratio of extracellular collagen to DNA was significantly higher in the cortex, inner and outer medulla of old compared to young rats. The ratio of collagen to total protein, although showing a similar age-related difference, attained statistical significance in the cortex only. Thus, the present study indicates a close relationship between the expression of the mRNA for type I collagen, the major structural constituent of fibrotic tissues, and the deposition of collagen in both the cortex and outer medulla of the kidney. Moreover, the clear differences found between old and young rat kidneys can serve as markers for renal aging and might explain at least some of the kidney impairments caused by fibrosis during senescence.

Organic tooth wear--overlooked in anatomy texts.

Most anatomy texts depict gear-like apposition of adult upper and lower teeth. But this apposition generally does not occur in civilized man. On the contrary the widespread tooth attrition which occurs in primitive man, is well established. This attrition, which is not depicted in anatomy texts or correctly evaluated in medical and dental education, is a natural protective mechanism that functions to preserve, oral, pharyngeal, and respiratory physiology throughout life. As man removed grit, sand and other abrasive food from his diet, he deprived himself of a natural aid, i.e. attritional wear of teeth that protects the physiology of his mouth and the swallowing and respiratory apparatus (4). In contrast to this the unworn teeth, characteristic of present-day man, prevent anatomic and physiologic changes that normalize oral pathways. For these reasons, 'textbook' tooth occlusion should be re-evaluated.

The use of a curved uterine vulsellum for removal of rectal foreign bodies: report of a case.

Removal of retained foreign bodies can be a tedious process, requireing considerable skill and ingenuity on the part of the surgeon. Employment of a curved, double-pronged, uterine vulsellum can be useful in simplifying removal of certain of these objects. A method which can be employed on an outpatient basis is described. When this method fails, suitable cooperation by the patient is lacking, or there is evidence of serious rectal injury or perforation, hospitalization for appropriate treatment under general or regional anesthesia is indicated.