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.

A comparison of laparoscopic versus open rectal surgery in 114 consecutive octogenarians.

AIM: The study is a retrospective review of the short-term outcome of all elective rectal resections in 114 consecutive octogenarian patients during the 10-year period January 2000 to December 2009. METHOD: Sixty laparoscopic and 54 open resections were completed. The two groups were evenly matched for age (mean 83 years), American Society of Anesthesiologists score (mean 2.5) and pathology (malignancy 60%). RESULTS: Morbidity and mortality were comparable with no significant differences. Only length of stay in uncomplicated recoveries was significantly different in favour of laparoscopic surgery at 10 vs 14 days, P < 0.003. CONCLUSION: Laparoscopic rectal resection is suitable for octogenarians.

Specific skin lesions occurring in a patient with Hodgkin's lymphoma.

A 47-year-old man presented with a several month history of non-specific acquired ichthyosis, an unknown period of generalized lymphadenopathy and a short history of erythematous papules and nodules affecting the cutaneous drainage area of his right axillary lymph nodes. Histology confirmed these lesions to be specific lesions of Hodgkin's lymphoma; that is, metastatic retrograde lymphatic spread from his axillary lymph nodes of CD30+, CD15+, Reed-Sternberg cells as well as mononuclear Hodgkin's cells. This is the most common site and mode of spread of Hodgkin's disease to the skin. As is typical of advanced Hodgkin's disease, as evidenced by specific cutaneous involvement, this patient died shortly after definitive diagnosis was made.

The health care meanings, values, and practices of Anglo-American males in the rural midwest.

Limited nursing knowledge exists to explain how culture influences men's health care decisions and practices. The purpose of this collaborative research was to explore the health care meanings, values, expressions, lived experiences, and practices of Anglo-American adult males residing in the rural Midwest. Using the ethnonursing research method, data were collected through interviews with 7 key and 12 general informants residing in Iowa. Four culture values and five themes were supported by the findings. Leininger's culture care modes were used to explicate culturally meaningful nursing care actions and decisions that are in harmony with the cultural values and practices of rural men.

Dietary fish oil as a photoprotective agent in hydroa vacciniforme.

Hydroa vacciniforme is a troublesome and scarring photosensitivity disorder for which treatment is unsatisfactory. Dietary fish oil rich in omega-3 polyunsaturated fatty acids reportedly increases the resistance to ultraviolet-induced erythema and rash provocation in polymorphic light eruption. We report for the first time the response of hydroa vacciniforme to dietary fish oil. Three Caucasian boys with the condition were placed on MaxEPA, five capsules daily. Phototesting was performed at baseline and after 3 months supplementation. At baseline, low erythemal thresholds were seen to monochromated UVA at 350 and 370 nm in all three boys, while one also had a low threshold to 320 nm (UVA) and another showed a low threshold to 300 nm (UVB). Broad-band UVA provocation challenge produced typical skin lesions in all the subjects. Following fish oil, all the boys showed reduced erythemal sensitivity to UVA and one also showed reduced sensitivity to UVB. Provocation challenge revealed a reduced response in all three children. Clinically, these changes were accompanied by pronounced improvement in one child, mild improvement in the second child, but no improvement in the third. The third boy subsequently showed good clinical response to azathioprine.

Laparoscopic mesh repair of recurrent inguinal hernia.

BACKGROUND: Pre-peritoneal mesh repair has been a long-standing technique for recurrent hernias. Laparoscopic technique has been applied to this operation with the aim of assessing its results at early follow up of 1 year. METHODS: The outcome in 56 patients was reviewed and all patients contacted 12 months after surgery. RESULTS: There was one immediate failure at 1 week, needing a further operation. There were no other recurrences at 1 year. Ten patients had minor postoperative complications. CONCLUSIONS: At early follow up, this is a satisfactory technique for recurrent hernias.

Re-examining crude coal tar treatment for psoriasis.

Two separate, double-blind, randomized, half-and-half body comparisons, each involving 20 in-patients with psoriasis, were conducted to compare the effect of different concentrations of crude coal tar in yellow soft paraffin. The therapeutic effect of 1% crude coal tar used twice daily for 10 days was significantly less than that achieved with an incremental regimen starting at 5% and increasing by 5% every second day to a maximum of 25%. No such difference was seen when a steady concentration of 5% was compared with the same incremental regimen. We conclude that there appears to be no benefit from exceeding a concentration of 5% crude coal tar in yellow soft paraffin in the treatment of patients with psoriasis and that the plateau in the dose-response curve for the action of crude coal tar in psoriasis begins at a point between 1 and 5%.

Low-dose exposure to antigen induces sub-clinical sensitization.

We examined the effects of a small initial sensitizing dose of antigen (dinitrochlorobenzene, DNCB) on the subsequent response to a second, defined sensitizing stimulus. The second stimulus was actually the regimen of four doses of DNCB (3.125, 6.25, 12.5, and 25 micrograms) normally used as the elicitation challenge. In two separate experiments 13 and 18 control subjects received an initial 'challenge' with the four doses to induce sensitivity, and 4 weeks later their responses were determined with a second, elicitation challenge. Two groups of 12 and 15 experimental subjects received an initial dose predicted to induce clinically detectable sensitivity in 50% or 25%, respectively. Four weeks later, their responsiveness was determined with quantitative challenge and the subjects who gave no response received a further challenge 4 weeks later. Their responses, compared with those from the control subjects, were augmented, indicating that sub-clinical priming of the immune system had indeed occurred.

Localization of elevated transforming growth factor-alpha in psoriatic epidermis.

Biopsies of involved and uninvolved skin from five patients with plaque psoriasis and normal skin from four healthy volunteers were investigated for steady-state quantities of TGF-alpha RNA and protein by in situ hybridization and immunohistochemistry. Increased levels of TGF-alpha RNA were found only in the high-level keratinocytes of involved psoriatic skin (p less than 0.001). Elevated levels of TGF-alpha protein were seen in both the high-level and basal layers of involved psoriatic skin compared to uninvolved psoriatic and normal control skin. Elevated TGF-alpha gene expression is thus implicated in the hyperproliferation of keratinocytes and possibly the altered maturation pattern seen in psoriasis.

Novel variants of human papillomavirus type 2 in warts from immunocompromised individuals.

Twenty cutaneous warts from I8 renal transplant recipients (RTR) and a single wart sample from a patient suffering from Hodgkin's disease were screened for the presence of human papillomavirus (HPV) sequences by Southern blot analysis. Thirteen samples were shown to contain HPV DNA sequences, one was identified as HPV-3, two as HPV-4, six as HPV-2 and four were unidentifiable by restriction digest analysis. HPV-3 was identified in the wart sample from the patient suffering from Hodgkin's disease. In the six samples in which HPV-2 was found, the viral genome showed polymorphism for the PvuII and PstI sites. Two PvuII patterns and one PstI pattern are novel.

The inanimate environment of an intensive care unit as a potential source of nosocomial bacteria: evidence for long survival of Acinetobacter calcoaceticus.

Environmental surface and personnel hand impression cultures were obtained during 13 sampling periods in the University of Virginia Pediatric Intensive Care Unit to document potential reservoirs of nosocomial pathogens. In 78 environmental cultures Staphylococcus aureus was found eight times and gram-negative bacilli ten times. The patient chart cover was the most commonly contaminated surface. Acinetobacter calcoaceticus was found in five of ten cultures positive for gram-negative bacilli. Thirty of 59 hand cultures were positive for S aureus and gram-negative bacilli; nurses and residents had both, respiratory therapists only gram-negative bacilli, and A calcoaceticus was the most commonly isolated bacterium of potentially nosocomial significance (14/30). Laboratory investigation of bacterial survival revealed that gram-negative bacilli survived on a dry formica surface from a few hours up to three days but Acinetobacter survived up to 13 days. Since A calcoaceticus has been implicated in many nosocomial infections, its long survival on a dry surface may be an additional factor in its transmission in hospitals and suggests that more attention be paid to environmental surfaces as a source of significant nosocomial pathogens.

An assessment of the value of Ag NOR staining in the identification of dysplastic and other borderline melanocytic naevi.

One hundred and six melanocytic lesions were studied to determine the value of the so called Ag NOR technique in differentiating dysplastic naevi, Spitz naevi and spindle cell naevi of Reed from malignant melanoma and from 'banal' compound or intradermal naevi. In 79 cases Ag NOR counts were possible. The banal naevi (36) had a mean count of 1.54, (SD 0.3), and the unequivocally malignant superficial spreading melanomas (13), lentigo maligna melanomas (4) and secondary melanomas (4) had a mean count overall of 3.9 (SD 1.59). For dysplastic naevi (16) the mean Ag NOR count was 1.63 (SD 0.36) and for Spitz and spindle cell naevi (in toto 6) the figure was 1.72 (SD 0.55). The difference in Ag NOR counts between all types of naevi and all types of melanoma was highly statistically significant, but there was no difference between banal naevi and dysplastic, Spitz, and spindle cell naevi. Correlation of Ag NOR counts between three independent observers was good. This technique may, therefore, be a useful adjunct in separating true melanoma from borderline melanocytic naevi.

Antigenic stimulation during ultraviolet therapy in man does not result in immunological tolerance.

People receiving therapy with either 8-methoxypsoralen plus long wavelength ultraviolet radiation (PUVA) or medium wavelength ultraviolet radiation (UVB) have been studied to see whether their unresponsiveness to the contact sensitizer dinitrochlorobenzene (DNCB) is a form of immunological tolerance. It was confirmed that both PUVA and UVB therapy impair sensitization by DNCB:4/13 PUVA-treated and 9/29 UVB-treated psoriatic subjects became sensitized by a dose of DNCB which sensitizes 100% of untreated patients. Subjects unsuccessfully sensitized during PUVA therapy could subsequently be sensitized perfectly normally. Subjects unsuccessfully sensitized during UVB therapy showed slight impairment of subsequent sensitization which was not statistically significant, and which was probably a persistent effect of UVB exposure. In conclusion, the temporary unresponsiveness seen in human subjects exposed to antigens during PUVA or UVB therapy is not due to immunological tolerance.

Evaluation of ultraviolet light for disinfection of hospital water contaminated with Legionella.

An epidemic of nosocomial Legionella micdadei pneumonia occurred among renal transplant patients in the University of Virginia hospital between 1978 and 1982. Although no further cases were diagnosed after 1982, filters and ultraviolet light (UVL) fittings were installed in 1985 as an attempt to disinfect water piped to rooms of transplant patients, because of concern about persistence of L micdadei in hospital water. Water samples were obtained from eight UVL-treated rooms and eight control rooms. 26 of 95 control samples were culture positive for L micdadei compared with 0 of 71 samples of filtered, UVL-treated water (p less than 0.0001, Fisher's exact test). After the UVL fitting and filter had been bypassed because of a leak, 9 of 33 samples from the UVL rooms were positive (p less than 0.0001). These data suggest that UVL treatment may be useful in continuous disinfection of water in the hospital rooms of high-risk patients.

Recovery of cutaneous immune responsiveness after PUVA therapy.

We studied sensitization to dinitrochlorobenzene (DNCB) in psoriatic patients before, during and 2, 4, and 6 weeks after a course of photochemotherapy (PUVA). The inhibition of sensitivity observed during PUVA was completely reversed after 6 weeks. Thus the PUVA-mediated inhibition of cutaneous immune responsiveness is of short duration. However, whether there are long-term sequelae remains to be established.