Use of hyperbaric oxygen chamber in the management of radiation-related complications of the anorectal region: report of two cases and review of the literature.

PURPOSE: This article was undertaken to present two cases of nonhealing ulcers that occurred after primary radiation therapy and local excision of suspected residual or recurrent anal carcinomas. Both patients responded favorably to hyperbaric chamber treatment. Review of the literature is discussed, including cause, clinical presentation, diagnosis, and options for management of radiation-related complications in the anorectal region and use of hyperbaric oxygen treatment in colorectal surgery. METHODS: The cases of two patients with recurrent or residual anal carcinomas were reviewed. Objective clinical, laboratory test, and intraoperative findings were implemented to define this pathologic entity precisely, results of its treatment, and management of radiation-related complications. RESULTS: The study shows clinical effectiveness of hyperbaric chamber treatment for nonhealing wounds in the previously radiated anorectal region. The refractory wounds of both our patients healed. The patients were rendered free of symptoms. CONCLUSIONS: Substantial pathologic changes in the irradiated tissues leading occasionally to nonhealing radiation proctitis are relatively infrequent consequences of radiation therapy for pelvic malignancies. Excisional and incisional biopsies of the radiation-injured tissues result in chronic ulcers accompanied by debilitating symptoms. Hyperbaric chamber treatment seemed to be a very effective means of therapy of radiation proctitis and nonhealing wounds in the involved anorectal region after conventional therapy had failed.

[Malignant polyps of the colon and rectum]. / Problematika maligního polypu tlustého streva a rekta.

It is important for the general surgeon to have a clear idea of what is a malignant polyp and factors determining its clinical management. A malignant polyp is either sessile or pedunculated and harbors an invasive carcinoma which means that malignant cells have penetrated into or through the muscularis mucosae. Carcinoma in situ, intramucosal carcinoma, superficial carcinoma, carcinoma within the the mucosa or lamina propria are terms commonly used that must be distinguished from true invasive malignancy. These polyps should be treated by complete polypectomy and followed up as in a benign polyp. A polyp with invasive carcinoma requires careful evaluation to make a decision if simple polypectomy is sufficient treatment or whether surgical treatment is indicated. This decision is based on the risk factors such as a residual/recurrent tumour and the risk of lymph node metastases. We present a current review of the literature on the subject.

Desmoid tumour: a pleomorphic lesion.

BACKGROUND: Desmoid tumour (DT) is an uncommon locally invasive non-metastasizing neoplastic lesion. The aetiology of this tumour is unknown and its treatment is controversial. Twelve cases of DT are presented and the literature is reviewed. METHODS: Twelve cases of DT treated at our institution during a 3.5-year period are analysed and the literature reviewed. Ten patients were referred with a primary tumour, one with local recurrence and one patient with a second primary desmoid tumour. One patient had multiple mesenteric DT (familial adenomatous polyposis coli-FAP), and in the remaining 11 patients the tumour was located in the abdominal wall in four, at an extremity in three, in the upper back in two patients, in the pelvis in one and retroperitoneally in one. RESULTS: The largest mesenteric DT was marginally excised en bloc with total jejunectomy. In the remaining 11 DT, complete excision to microscopically tumour-free margins was possible in nine cases and to microscopically involved margins in two cases. At a mean follow-up of 22 months (range 7-38 months), one patient was alive with stable disease (Gardner's syndrome), 10 patients were alive and free of recurrence and one patient (9%) developed local recurrence which was re-excised-she is disease-free 10 months later. CONCLUSIONS: Complete excision is the main modality of treatment for primary and recurrent DT. This is feasible in most cases except for tumours involving the base of the bowel mesentery. Surgical resection alone achieved local control of the tumour in most of the patients in this series (92%).

Subcutaneous manifestations of severe acute pancreatitis.

Subcutaneous manifestations of severe acute pancreatitis (Grey Turner's sign, Cullen's sign, and disseminated fat necrosis) are often discussed but seldom observed. Grey Turner's sign and Cullen's sign develop in <3% of patients with acute pancreatitis; subcutaneous fat necrosis occurs even less frequently. Few younger physicians have ever seen representative cases. Only recently have studies begun to clarify the development of these clinical signs. Grey Turner's sign is produced by the spread of hemorrhagic fluid from the posterior pararenal space to the lateral edge of the quadratus lumborum muscle and, subsequently, to the subcutaneous tissues via a defect in the fascia of the flank. Cullen's sign arises from the diffusion of retroperitoneal blood into the falciform ligament and, subsequently, to the subcutaneous umbilical tissues via the connective tissue covering of the round ligament complex. In contrast to the ecchymotic signs, our review of the existing literature concerning the development of subcutaneous fat necrosis in patients with acute pancreatitis did not reveal a definitive pathogenesis. Multiple factors seem to be involved in the production of subcutaneous fat necrosis, and a simple cause-and-effect relationship of circulating lipolytic enzymes seems unlikely.

Mefloquine prophylaxis: an overview of spontaneous reports of severe psychiatric reactions and convulsions.

Since the time of its introduction in 1985, mefloquine (Lariam) has been used extensively for malaria prophylaxis. The international Drug Safety Department of the manufacturer gathered all spontaneous adverse drug reactions reported in association with this drug from all available sources and monitored the literature on a world-wide basis. The serious neurologic and psychiatric adverse events reported in association with Lariam prophylaxis from the time of introduction until May 1991 were reviewed. During this time, 59 serious neurologic and psychiatric adverse reactions were reported as follows: 26 convulsions, 12 depressions, 20 psychotic episodes, and one toxic encephalopathy; none were fatal. While spontaneous reporting systems are biased by under-reporting, they provide useful instruments for analysis of clinical risks factors. The neurologic and psychiatric adverse events reported in association with mefloquine prophylaxis were of the same types as those reported with other quinine derivative antimalarials. The precise mechanism of serious neurologic and psychiatric reactions is unknown. The only patient population identified at this time as having an increased risk of developing these serious reactions to mefloquine are persons with a history of seizures or manic-depressive illness. Mefloquine prophylaxis should not be prescribed to such patients.

Dextromethorphan. An overview of safety issues.

Dextromethorphan is a highly effective and widely used nonopioid antitussive drug. As it has been in use for more than 30 years, a large body of clinical experience has been used to formulate a safety profile. An anthology of adverse drug events has been analysed, drawn both from published case records and a data base recording dextromethorphan-related adverse events spontaneously reported by physicians or pharmacists. The resulting safety profile indicates that adverse drug reactions are infrequent and usually not severe. The predominant symptoms are usually dose related and include neurological, cardiovascular and gastrointestinal disturbances. Particular safety concerns arise when monoamine oxidase inhibiting (MAOI) drugs and dextromethorphan are coadministered. In addition to adverse drug reactions, the safety profile of dextromethorphan is affected by episodic and sporadic abuse. In fact, abuse appeared to be the most significant hazard identified by analysis of spontaneous adverse event reporting. No evidence could be found that the well documented pharmacokinetic polymorphism observed with dextromethorphan is correlated with any clinically significant safety risk if it is used for short term treatment. In summary, the safety profile of dextromethorphan is reassuring, particularly relating to overdose in adults and children.

Review of yellow cards (1986): report to the Committee on the Safety of Medicines.

1. In 1986 the CSM received 15,527 yellow cards. This was the highest number received in any one year since the scheme started in 1964. Much of the increase was due to the use by doctors of the yellow cards now included in the British National Formulary and NHS prescription pads. 2. The overall profile of reports of serious reaction, in 1986, was broadly similar to that of the previous years. The most commonly reported serious suspected adverse reactions involved the gastro-intestinal tract (801 reports), the skin (539 reports), the central nervous system (535 reports), and the blood (505 reports). 3. Of the drugs introduced between 1984 and 1986 appreciable numbers of reports of serious reactions were received in association with the use of diltiazem (33 reports), mitozantrone (30 reports), enalapril (173 reports) and etodolac (27 reports).

An animal model for chronic ulceration.

Few techniques are available for the study of persistent ulceration. In this report we describe a suitable animal model. Intracutaneous injection of sodium tetradecyl sulphate (STD) in guinea-pig flank skin caused a reproducibly sized and shaped superficial ulcer that healed approximately three times more slowly than punch biopsies of comparable size. Histological, immunofluorescent and autoradiographic studies showed that it possesses many of the morphological and kinetic features of human stasis ulceration. STD ulcers treated with a streptokinase/streptodornase solution healed with less slough and tended to re-epithelialize more rapidly than controls, but ulcers treated with dextran polymer beads or a stabilized hydrogen peroxide cream healed at the same rate as their control.

An examination of joint laxity in haemophilia.

An adolescent haemophiliac group (all less than 1 per cent Factor VIII) and a normal, similarly aged, 'control group' of boys were examined to measure joint laxity in an effort to identify a causative factor for bleeding. Definitive laxity was found in the thumb joints and in finger extension of haemophiliacs compared with normal boys. The haemophiliacs who were more lax-jointed showed no tendency towards an increased number of bleeds when they were followed for 100 days. Possible explanations for these phenomena are discussed.

The frequency of bleeding and height of adolescent haemophiliacs.

The relation between the height of adolescent haemophiliacs and their bleeding frequency has been studied. 45 haemophiliacs aged 10--19 years were divided into 3 groups: small, medium and tall, using a Height Standard Deviation Score. The average bleeding frequency per 100 days in the group of small haemophiliacs was 8.71 +/- SD 4.47, in the medium height group 10.18 +/- SD 6.71, while the tall individuals bled in average 15.97 +/- SD 3.15 every 100 days. There was no relationship between age and bleeding frequency.