Clinical value of pouchogram prior to ileostomy closure after ileal pouch anal anastomosis.

BACKGROUND: In patients who undergo restorative proctocoletomy (RPC) a pouchogram is often used to assess the integrity of the ileal pouch-anal anastomosis (IPAA) before closing the covering ileostomy. There are no good data to support this practice. The aim of the study was to investigate whether contrast pouchography was clinically useful after RPC. METHODS: We conducted a retrospective study of patients who had undergone RPC with a covering ileostomy between September 2013 and September 2015. RESULTS: 61 patients were included. 7 (11%) presented with anastomotic leak and 2 (3%) with pelvic collection, detected on cross-sectional imaging for early postoperative symptoms. In the remaining 52 patients, without immediate postoperative complications, pouchography was performed at a median of 14 weeks (range 7-71 weeks) after RPC. Each patient also underwent examination under anaesthesia (EUA) to assess the integrity of the IPAA on the day of the ileostomy closure. One asymptomatic patient (2%) had an anastomotic leak demonstrated on pouchogram which was subsequently confirmed at EUA. Two patients (3%) with a normal pouchogram, 1 symptomatic and 1 asymptomatic, subsequently had an anastomotic leak demonstrated at EUA. CONCLUSIONS: Pouchogram has a low sensitivity in identifying anastomotic leak before ileostomy reversal in patients after RPC and only rarely changes management. In our series it identified the diagnosis of anastomotic leak in only 1 patient and gave false reassurance in two others. Complications are more frequently detected by clinical history and formal EUA before ileostomy closure.

Haemorrhoids: modern diagnosis and treatment.

Haemorrhoids present often to primary and secondary care, and haemorrhoidal procedures are among the most common carried out. They may co-exist with more serious pathology, and correct evaluation is important. In most cases a one-off colonoscopy in patients aged 50 or above with flexible sigmoidoscopy in younger patients is reasonable. Many people with haemorrhoids do not require treatment. Topical remedies provide no more than symptomatic relief-and even evidence for this is poor. Bulk laxatives alone may improve symptoms of both bleeding and prolapse and seem as effective as injection sclerotherapy. Rubber band ligation is effective in 75% of patients in the short term, but does not treat prolapsed haemorrhoids or those with a significant external component. Conventional haemorrhoidectomy remains the most effective treatment in the long term, the main limitation being post-operative pain. Metronidazole, topical sphincter relaxants and operative technique have all been shown to reduce pain. Stapled haemorrhoidectomy and haemorrhoidal artery ligation techniques are probably less effective but less painful. Long-term data are poor for all procedures, with many studies reporting only 1-3 years of follow-up data. Haemorrhoids are common in pregnancy, occurring in 40% of women. They can usually be treated conservatively during pregnancy, with any treatment delayed until after delivery. Acutely strangulated haemorrhoids may be treated either conservatively or operatively. There is an increased risk of anal stenosis after acute surgery, but the risks of sepsis and sphincter damage are less significant than previously thought. The majority of patients who are treated conservatively will still require definitive treatment at a later date.

Randomized controlled trial of percutaneous versus transcutaneous posterior tibial nerve stimulation in faecal incontinence.

BACKGROUND: Percutaneous, transcutaneous and sham transcutaneous posterior tibial nerve stimulation was compared in a prospective blinded randomized placebo-controlled trial. METHODS: Patients who had failed conservative treatment for faecal incontinence were randomized to one of three groups: group 1, percutaneous; group 2, transcutaneous; group 3, sham transcutaneous. Patients in groups 1 and 2 received 30-min sessions of posterior tibial nerve stimulation twice weekly for 6 weeks. In group 3, transcutaneous electrodes were placed in position but no stimulation was delivered. Symptoms were measured at baseline and after 6 weeks using a bowel habit diary and St Mark's continence score. Response to treatment was defined as a reduction of at least 50 per cent in weekly episodes of faecal incontinence compared with baseline. RESULTS: Thirty patients (28 women) were enrolled. Nine of 11 patients in group 1, five of 11 in group 2 and one of eight in group 3 had a reduction of at least 50 per cent in weekly episodes of faecal incontinence at the end of the 6-week study phase (P = 0·035). Patients undergoing percutaneous nerve stimulation had a greater reduction in the number of incontinence episodes and were able to defer defaecation for a longer interval than those undergoing transcutaneous and sham stimulation. These improvements were maintained over a 6-month follow-up period. CONCLUSION: Posterior tibial nerve stimulation has short-term benefits in treating faecal incontinence. Percutaneous therapy appears to have superior efficacy to stimulation applied by the transcutaneous route. REGISTRATION NUMBER: NCT00530933 (http://www.clinicaltrials.gov).

Sacral nerve stimulation: an effective treatment for chronic functional anal pain?

AIM: Chronic idiopathic anal pain is a common condition of unknown aetiology. Patients may have co-existing psychiatric disorders and existing treatments are often ineffective. A small number of published case reports suggest that sacral nerve stimulation (SNS) could treat this condition. This pilot study aimed to investigate the efficacy of SNS for the treatment of chronic anal pain. METHOD: Ten patients with chronic idiopathic anal pain were recruited. All had failed to respond to conservative treatments. Clinical and psychological evaluation was performed in all patients prior to SNS. Temporary stimulation of the S3 foramina was performed for 3 weeks and outcome assessed by comparison of a pain score diary and visual analogue score obtained during stimulation and at baseline. Primary outcome was defined as a > 50% reduction in pain score. RESULTS: Of the 10 patients recruited, five were found to have clinical depression. Four patients withdrew from the study prior to testing and six underwent peripheral nerve evaluation (PNE). Three patients had > 50% reduction in pain score and progressed to permanent SNS. Of these, only one had good pain control at latest follow-up of 5 years; the remaining two patients obtained no benefit and had their devices removed or deactivated. These two patients both had depression that was also not improved by SNS. CONCLUSION: This study would suggest that SNS is not an effective treatment for chronic anal pain in the majority of patients. PNE is not an effective means of identifying which of these patients are likely to respond to permanent SNS.

Sacral nerve stimulation for faecal incontinence: results from a single centre over a 10-year period.

AIM: Sacral nerve stimulation (SNS) is considered a first-line surgical treatment option for faecal incontinence. There is little information on long-term results. The results of SNS for faecal incontinence performed at a single centre over a 10-year period are reported. METHOD: A cohort analysis of consecutive patients treated with SNS for faecal incontinence over a 10-year period was carried out. Data were collected prospectively using bowel habit diaries and St Mark's and Cleveland Clinic incontinence scores. Treatment success was defined as a >50% reduction in episodes of faecal incontinence compared with baseline. RESULTS: Temporary SNS was performed in 118 patients, and 91 (77%) were considered suitable for chronic stimulation. The median period of follow up was 22 (1-138) months. Seventy patients were followed for 1 year with success in 63 (90%). Of 18 patients followed for 5 years, 15 (83%) reported continued success, 11 (61%) maintained full efficacy, 4 (22%) reported some loss, and 3 (17%) reported complete loss. Three patients with a 10-year follow up had no loss in efficacy. Overall, complete loss of efficacy was observed in 14 (16%) patients at a median of 11.5 months following implantation. A further 5 (6%) patients showed deterioration with time. In 9 (47%), no reason for the deterioration in symptoms could be identified. CONCLUSIONS: SNS can be effective for up to 10 years. Some patients experience deterioration in symptoms over time. The reasons for this are often not evident.

Sacral nerve stimulation for faecal incontinence: optimizing outcome and managing complications.

AIM: A knowledge of the principles of neurostimulation is essential to achieve optimal efficacy and minimize adverse effects. The aim of this article was to review the current evidence regarding device programming in the management of patients having sacral nerve stimulation (SNS) for faecal incontinence. METHOD: A Medline search was performed including the keywords and/or MeSH headings of sacral nerve stimulation, neuromodulation, artificial pacemaker, faecal incontinence, programming, adverse effects and complications. Further studies were identified by cross-referencing from relevant articles and by appraisal of recent peer-reviewed conference abstracts and proceedings. RESULTS: Neurostimulator programming is an important component of SNS. Efficacy can be improved or restored with reprogramming. Adverse stimulation is often reversible, and nonstimulation-related complications are correctable. A total loss of efficacy can be explained in over one-half of patients. CONCLUSION: An improved outcome of SNS can be achieved by selecting the best possible stimulation parameters individualized to each patient. Further research into the optimal settings is needed.

Sacral nerve stimulation for faecal incontinence: patient selection, service provision and operative technique.

AIM: Faecal incontinence is estimated to affect between 2 and 3% of Western adult populations. In recent years sacral nerve stimulation has become an important treatment modality, often as the first-line surgical therapy. The aim of this article was to review the current evidence regarding patient selection and surgical technique and to evaluate the logistics of providing a neurostimulation service. METHOD: A Medline search was performed including the keywords and/or MeSH headings of sacral nerve stimulation, neuromodulation, artificial pacemaker, faecal incontinence, patient selection, predictive factors and anal canal. Further studies were identified by cross-referencing from relevant articles and by appraisal of recent peer-reviewed conference abstracts and proceedings. RESULTS: Despite the success of sacral nerve stimulation for several pathophysiological causes of incontinence, case selection is of paramount importance. Sacral nerve stimulation should not be offered outside a multidisciplinary pelvic floor unit. Temporary evaluation using diary cards can lead to false positive and negative results. Adherence to a meticulous surgical technique, using low amplitude stimulation to guide lead placement, provides optimal clinical outcome. CONCLUSION: The short-term outcome of sacral nerve stimulation is dependent on patient factors and operative technique. Despite this, specific preoperative predictive factors of treatment success have yet to be identified.

Long-term outcome of the use of botulinum toxin injection for functional anal pain.

AIM: Anal pain may occur in the absence of demonstrable anal pathology. Spasm of the sphincter muscles has been suggested as a cause in some patients. We aimed to assess the effectiveness of injection of botulinum toxin in treating this condition. METHOD: Patients who had injection of botulinum toxin over a 3-year period were identified retrospectively. Patients were excluded if anal fissure or other organic pathology was found to account for their symptoms on examination under anaesthetic. Long-term outcome was assessed at a minimum 3-year post-procedure telephone follow up. RESULTS: Fourteen (eight male) patients were identified, of median age 50 years. Botulinum toxin (20-200 u) was injected into the internal sphincter. Seven of the 14 patients reported significant improvement in symptoms at 3 months. Seven were available for a structured telephone review at a median of 59 (42-68) months. The four patients who had benefited from the injection had remained asymptomatic. CONCLUSION: Injection of botulinum toxin into the internal anal sphincter has a role in alleviating symptoms in a small proportion of patients with functional anal pain.

Outcomes following repair of traumatic cloacal deformities.

BACKGROUND: Severe obstetric injury can result in a defect similar to a congenital cloacal deformity, with associated faecal incontinence and sexual dysfunction. The aim of this study was to assess the efficacy of surgical repair of such injuries. METHODS: Patients were identified retrospectively from hospital records. Long-term follow-up data were collected by telephone interview. RESULTS: Outcomes in 31 consecutive patients seen over a 14-year period were reviewed. An overlapping external sphincter repair, with repair of the anorectum and vagina, was performed in 29 patients. Detailed long-term follow-up data were available for 20 patients at a median of 5 years after surgery. Three patients had a stoma at presentation. Surgical repair reduced incontinence to solid stool from seven of 17 to none of 20 patients, to liquid stool from 14 of 17 to ten of 20, and to flatus from 17 of 17 to 12 of 20. Nine patients reported improvement in sexual function. CONCLUSION: Surgical repair of a cloacal injury is associated with significant improvements in faecal incontinence and sexual function. Outcomes are similar to those seen with repair of less severe injuries, and may be maintained in the long term.

Tramadol for neuropathic pain.

BACKGROUND: Peripheral neuropathic pains often include symptoms such as burning or shooting sensations, abnormal sensitivity to normally painless stimuli, or an increased sensitivity to normally painful stimuli. Neuropathic pain is a common symptom in many diseases of the peripheral nervous system. OBJECTIVES: We aimed to review systematically the evidence from randomised controlled trials for the efficacy of tramadol in treating neuropathic pain. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Register (June 2005), MEDLINE (January 1966 to June 2005), EMBASE (January 1980 to June 2005), and LILACS (January 1982 to June 2005) for randomised and quasi-randomised controlled trials. We also searched bibliographies of published trials. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials comparing tramadol with placebo, other pain relieving treatment, or no treatment in people of both sexes and all ages with neuropathic pain of all degrees of severity. DATA COLLECTION AND ANALYSIS: Two authors extracted data and scored trial quality. We calculated relative risks and numbers needed to treat for effectiveness and adverse effects. MAIN RESULTS: We identified six eligible trials, four comparing tramadol with placebo, one comparing tramadol with clomipramine, and one comparing tramadol with morphine. All four trials comparing tramadol with placebo showed a significant reduction in neuropathic pain with tramadol. Three of the trials which compared tramadol to placebo (total 269 participants) were combined in a meta-analysis. The number needed to treat with tramadol compared to placebo to reach at least 50% pain relief was 3.8 (95% confidence interval 2.8 to 6.3). There were insufficient data to draw conclusions about the effectiveness of tramadol compared to either clomipramine or morphine.Only one trial considered subcategories of neuropathic pain. It found a significant therapeutic effect of tramadol on paraesthesiae, allodynia, and touch evoked pain. Numbers needed to harm were calculated for side effects resulting in withdrawal from the placebo controlled trials. Three trials provided these data, and the combined number needed to harm was 8.3 (95% confidence interval 5.6 to 17). AUTHORS' CONCLUSIONS: Tramadol is an effective treatment for neuropathic pain.

Clinical evaluation of a side entry access port: a novel dual-lumen venous access device.

The initial clinical experience with a low-profile side entry access (SEA) dual-lumen implantable venous access port for cancer chemotherapy administration is summarized in this report. The catheter material is polyurethane. The overall experience in 35 patients in this study was a total of 6,224 patient days, with a mean of 178 days per patient. A variety of chemotherapeutic agents, biologic response modifiers, and antibiotics were administered. In 26% of the patients, the device chambers were in simultaneous use during the treatment period. A 6% incidence of clinical subclavian vein thrombosis was noted. There was no infectious complications. Inconsistencies in blood withdrawal and temporary catheter dysfunction were comparable to other access ports in clinical use. The novel design of this side entry port and the catheter material of low thrombogenicity make this device a good option in patients requiring a low-profile system and dual access. Nursing staff should be made aware of the side entry design and that in-service training for accessing the septum is required in centers where such devices are not routinely used.

Incentives vs outreach workers for latent tuberculosis treatment in drug users.

BACKGROUND: Drug users are at increased risk for latent tuberculosis infection (LTBI) and also at increased risk for noncompletion of medication regimens for treatment of LTBI or tuberculosis disease. Directly observed therapy (DOT) provided by outreach workers, the use of incentives, or both have been suggested as a means to increase adherence. OBJECTIVE: To compare the independent and combined effects of monetary incentives and outreach worker provision of DOT for LTBI treatment in a sample of active drug users. METHODS: The research design was a randomized controlled trial in a community outreach program setting. Participants consisted of a volunteer sample of 163 active injection drug and crack cocaine users placed on twice weekly DOT. Condition 1 of the interventions consisted of provision of DOT by an outreach worker at a location chosen by the participant (active outreach) and a $5 per visit incentive. Condition 2 was comprised of active outreach with no monetary incentive, and Condition 3, provision of DOT at the study community site and a $5 per visit incentive. The main outcome measures were percentage of medication taken as prescribed and completion of medication regimen. RESULTS: The percentage of prescribed medication taken was higher for those who received incentives, either with (71%) or without (68%) active outreach, compared to those who received active outreach alone (13%). Only 4% of participants assigned to Condition 2 completed treatment, compared to 53% of Condition 1 participants, and 60% of Condition 3 participants. CONCLUSIONS: Monetary incentives were clearly superior to active outreach. Active outreach in combination with monetary incentives did not increase adherence over incentives alone.

Monetary versus nonmonetary incentives for TB skin test reading among drug users.

BACKGROUND: In a prior study, we reported that monetary incentives were effective in increasing return for tuberculosis (TB) skin test reading. The purpose of this study was to compare the effects of monetary versus nonmonetary incentives and a theory-based educational intervention on return for TB skin test reading in a sample of newly recruited active injection and crack cocaine users, and to determine the prevalence of TB infection in this sample. METHODS: Active injection drug and/or crack cocaine users (n = 1,078), recruited using street outreach techniques, were skin tested for TB. They were randomly assigned to 1 of 5 experimental treatment conditions: $10 cash, grocery store coupons, bus tokens/fast-food coupons, motivational education, or usual encouragement to return. Nonmonetary incentives had a $10 value, and all incentives were provided at return for skin test reading. RESULTS: Ninety-five percent of those who received $10 returned for skin test reading compared to 86% of those who received grocery store coupons and 83% of those who received either bus tokens or fast-food coupons. In contrast, only 47% of those who received the educational session and only 49% of those who received usual encouragement returned for skin test reading. The prevalence of a positive tuberculin test was 21%, and was similar for crack cocaine and injection drug users. CONCLUSIONS: Nonmonetary and monetary incentives dramatically increased the return rate for TB skin test reading among drug users who are at high risk of TB infection. Nonmonetary incentives were somewhat less effective than monetary incentives.

Optimism in children's judgments of health and environmental risks.

Although optimistic bias has been well documented for adults, little is known about how children view their own risks vis-à-vis those of their peers. Two studies of 6th graders examined optimism and the degree of differentiation in perceived risks across diverse health, lifestyle, and environmental problems. The findings revealed perceptions of relative invulnerability and highly differentiated risk assessments. The strongest levels of optimism emerged for controllable and stigmatizing events such as illicit drugs, smoking, and AIDS. The effects of gender, assessment context, and methodological variations were minimal. Discussion focused on the implications for health-promoting interventions with school-age children, the need for developmental information about risk perception processes, and the difficulty of distinguishing realistic from biased optimism.

Impact of gastric restrictive surgery on hypertension in the morbidly obese.

Hypertension is a major health risk factor in patients who are morbidly obese. Two hundred eighty-nine morbidly obese patients undergoing gastric restrictive surgery were evaluated for the presence of hypertension (blood pressure greater than or equal to 160/90 mm Hg or currently undergoing antihypertensive therapy) pre- and postoperatively. Of 74 (26%) preoperatively hypertensive patients, 67 (91%) were available for follow-up. Preoperative hypertension resolved in 66% (44 of 67) of patients following gastric restrictive surgery. Superobese and morbidly obese patients had similar reductions in hypertension after surgery (69% versus 63%). Patients not receiving antihypertensives preoperatively had a greater reduction of hypertension than those medically treated preoperatively (78% versus 58%). The amount of weight loss significantly predicted the reduction of hypertension, whereas follow-up weight achieved did not. The amounts of weight loss for patients with resolved and persistent hypertension were 89.3 +/- 5.6 lbs (mean +/- standard error of the mean +ADSEM+BD) and 66.0 +/- 8.3 lbs, respectively (p less than 0.02). For patients with resolved hypertension, follow-up weights for the morbidly obese and superobese were 162.0 +/- 10.8 lbs (133% +/- 4% ideal body weight +ADIBW+BD) and 220.4 +/- 9.5 lbs (170% +/- 7% IBW). Gastric restrictive surgery is effective therapy for hypertension in morbidly obese patients. Patients need not achieve weights approaching IBW to enjoy the benefits of gastric restrictive surgery on hypertension.

Gastric restrictive operations for morbid obesity.

Gastric restrictive surgery has evolved over the past decade as the treatment of choice for morbid obesity. We reviewed our experience with 289 patients who underwent gastric surgery for morbid obesity. Comorbid diseases included respiratory insufficiency in 19 percent of the patients, hypertension in 36 percent, diabetes in 15 percent, arthritis in 30 percent, and heart disease in 6 percent. Operative mortality was 0. The follow-up rate was 93 percent. Overall mortality was 1 percent, with no death directly attributed to the operative procedure. Weight loss was studied over the 6-year study period. Four to 6 years postoperatively, overall weight loss was 50 to 64 percent of excess weight. The treatment failure rate 12 to 18 months postoperatively was 5 percent. The experience with gastric restrictive surgery in 12 centers involving 5,178 patients was reviewed and compared with our results. Overall operative and late mortality rates were quite similar to observed death rates for nonobese men and women between 25 and 64 years of age. These data suggest that gastric surgery for morbid obesity results in a significant reduction in health risk.

Tramadol for neuropathic pain.

BACKGROUND: Neuropathic pain syndrome consists of a group of symptoms, including burning or shooting sensations, abnormal sensitivity to normally painless stimuli, or a greatly raised sensitivity to painful stimuli. A wide range of disorders can cause neuropathic pain, nerve damage being the only common factor. OBJECTIVES: We aimed to review systematically the evidence from randomised controlled trials for the efficacy of tramadol in treating neuropathic pain. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group trials register (July 2002), MEDLINE (January 1966 to July 2002), EMBASE (January 1980 to July 2002), and LILACS (January 1982 to July 2002) for randomised and quasi-randomised controlled trials. We also searched bibliographies of published trials. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials comparing tramadol with placebo, other pain relieving treatment, or no treatment in people of both sexes and all ages with neuropathic pain of all degrees of severity. DATA COLLECTION AND ANALYSIS: Two reviewers extracted data and scored trial quality. We calculated relative risks and numbers needed to treat for effectiveness and adverse effects. MAIN RESULTS: We identified five eligible trials, three comparing tramadol with placebo, one comparing tramadol with clomipramine, and one comparing tramadol with morphine. All three trials comparing tramadol with placebo showed a significant reduction in neuropathic pain with tramadol. Two of the trials that compared tramadol to placebo (total 161 participants) were combined in a meta-analysis. The number needed to treat with tramadol compared to placebo to reach at least 50% pain relief was 3.5 (95% confidence interval 2.4 to 5.9). There were insufficient data to draw conclusions about the effectiveness of tramadol compared to either clomipramine or morphine. Only one trial considered subcategories of neuropathic pain. It found a significant therapeutic effect of tramadol on paraesthesiae, allodynia, and touch-evoked pain. Numbers needed to harm were calculated for side effects resulting in withdrawal from the placebo-controlled trials. Two trials provided these data, and the combined number needed to harm was 7.7 (95% confidence interval 4.6 to 20). REVIEWERS' CONCLUSIONS: Tramadol is an effective treatment for neuropathic pain.

Medicine compliance in paediatric outpatients.

In a study of children attending the outpatient department of the Red Cross War Memorial Children's Hospital it was found that less than one-quarter of the medicines dispensed were correctly taken. Antibacterials, the most frequently ordered medications, had the poorest compliance rates. Furthermore, in this group the parent least understood the purpose of the prescribed preparation. The best compliance was obtained when the purpose was well understood.

In the absence of breast, which milk is best?

The prices of liquid formula and evaporated milk at retail outlets have increased markedly over a period of 4 years. At local authority clinics the prices are almost 50% less, and communities in which the health of children is at risk should have increased access to these facilities.