External haemorrhoidal thrombosis: evidence for current management.

BACKGROUND: External haemorrhoidal thrombosis (EHT) may be managed surgically or conservatively. The optimal treatment is, however, unclear, as is the long-term outcome following treatment. METHODS: A literature search was undertaken to review and grade the evidence available for EHT management, determine the optimal management modality and assess long-term outcome after each treatment. RESULTS: Among 800 articles on haemorrhoids, only two prospective studies encompassing 248 patients and two retrospective studies of 571 patients were found. Excision significantly relieves presenting symptoms by postoperative day 4 compared with incision or topical GTN (Level IB evidence). Symptoms last over 3 weeks with conservative treatment (Level III evidence) and this period may be reduced by combining topical nifedipine and lignocaine rather than using lignocaine alone (Level IB evidence). There is no evidence regarding the optimal time for non-surgical options. CONCLUSIONS: There is a remarkable paucity of studies on EHT and few of those available provide high levels of evidence. Surgery may be superior to conservative treatment but there is no evidence regarding the optimal period of initiation of conservative management. Prospective comparative studies are needed.

A pilot comparative study of fissurectomy/diltiazem and fissurectomy/botulinum toxin in the treatment of chronic anal fissure.

BACKGROUND: Treatment of chronic anal fissure (CAF) by fissurectomy with botulinum toxin A (BTA) injection results in a healing rate of greater than 90%. BTA injection, however, can cause incontinence and perianal sepsis. The decrease in sphincter pressure following topical treatment with 2% diltiazem cream (DTC) is comparable to that following BTA injection but with potentially fewer complications and at less cost. We report the shortterm results of a pilot study comparing fissurectomy with BTA and fissurectomy followed by DTC for the treatment of CAF. METHODS: The recorded outcomes of CAF following treatment with the two methods were analysed retrospectively. Patients underwent either fissurectomy followed by injection of 40 U BTA into the internal sphincter (group A) or fissurectomy followed by the perianal application of DTC twice daily for 8 weeks (group B). Symptom resolution and treatment side effects at the initial follow-up were compared. RESULTS: Demographics, fissure characteristics and the number of multiparous women between the two groups were comparable. At a median follow-up of 12 weeks (range 8-20 weeks), the two groups had similar rates of complete symptom resolution (group A, 25/28, 89.3%; group B, 19/23, 82.6%; p=0.7739), with minor side effects. CONCLUSIONS: In this small pilot study fissurectomy combined with chemical sphincterotomy resulted in high short-term fissure healing rates. The study also suggested that fissurectomy followed by 8 weeks of topical DTC may be as good as fissurectomy with BTA injection in the treatment of CAF. A prospective study, adequately powered to determine the significance of differences is needed.

Management of gallstone disease in the elderly.

AIM: To determine the outcome of management of symptomatic gallstone disease (GSD) in patients aged 80 years or more. PATIENTS AND METHODS: A retrospective review of the outcome of 79 patients admitted to 2 district general hospitals with symptomatic GSD over a 1-year period was undertaken. Patients were grouped according to method of management: non-operative, ERCP, and cholecystectomy. POSSUM scores for the ERCP and cholecystectomy groups were calculated and observed, and predicted outcome compared. RESULTS: Obstructive jaundice and biliary colic were the most common presenting symptoms. Each patient had been admitted at least once before the study period (median, 2; range, 1-3). Outcomes are detailed in Table 1. Non-operative management failed in 18 of 23 patients, with 17.4% mortality. ERCP was successful in 40 of 47 patients with 3 complications (0.24 of predicted) and no mortality. In all, 11 laparoscopic and 12 open cholecystectomies were performed with 6 complications and 1 mortality (0.95 and 0.83 of predicted, respectively): 4 complications and the only death occurring after emergency cholecystectomy. Table 1 Outcomes Management Number Mortality Morbidity Outcome Non-operative 23 4 9 5 OK, 13 re-admitted, 4 still symptomatic ERCP 47 0 3 1 PTC, 6 operated Operative 23 1 6 CONCLUSIONS: This study suggests that recurrent GSD in elderly patients managed non-operatively may have fatal outcome. Elective cholecystectomy has acceptable morbidity and mortality in this age group and there is often ample opportunity to avoid emergency surgery, but a prospective randomised study is required to improve clinical algorithms.

Immunologic responses to vaccinia vaccines administered by different parenteral routes.

To develop a less reactogenic but equally immunogenic vaccine, this study of 91 human volunteers compared the safety and immunogenic potency of a new, cell culture-derived vaccinia virus vaccine administered intradermally and intramuscularly with the licensed vaccinia vaccine administered by scarification. Cutaneous pox lesions developed in a higher proportion of scarification vaccinees. Scarification and intradermal vaccine recipients who developed cutaneous pox lesions had more local reactions but also achieved significantly higher cell-mediated and neutralizing antibody responses than those who did not develop pox lesions. Although less reactogenic, intradermal or intramuscular administration of vaccinia vaccine without the concomitant development of a cutaneous pox lesion induced lower immune responses.

Epidemic of diarrhea caused by Vibrio cholerae non-O1 that produced heat-stable toxin among Khmers in a camp in Thailand.

An epidemic of a cholera-like disease occurred among Khmers in a camp in Aranyaprathet, Thailand, in May 1990. Of 215 patients with diarrhea, Vibrio cholerae O1 was isolated from 25 (12%) and V. cholerae non-O1 was isolated from 15 (7%). Five of 15 (33%) non-O1 V. cholerae isolates hybridized with two different oligonucleotide probes previously used to detect V. cholerae non-O1 that produces a heat-stable toxin. This is the first description of an epidemic of diarrhea caused by V. cholerae non-O1 that produces heat-stable toxin.

Scrub typhus in Korea: importance of early clinical diagnosis in this newly recognized endemic area.

Scrub typhus became a well recognized infectious disease threat to military operations in the Pacific Theater during World War II. Early diagnosis and treatment with tetracycline or chloramphenicol dramatically reduces the mortality and morbidity of this disease. Korea is a newly recognized scrub typhus endemic country. We report our experience with 189 scrub typhus patients seen at a civilian outpatient clinic in Chinhae, Republic of Korea, from 1985 through 1990, and verify the accuracy of clinical diagnosis by serologic tests.

Diarrheal disease in Cambodian children at a camp in Thailand.

The etiology of acute diarrhea (less than or equal to 3 days duration) and persistent diarrhea (greater than or equal to 14 days duration) was determined in Cambodian children under age 5 years in a refugee camp on the Thai-Cambodian border between May and October 1989; potential risk factors associated with persistent diarrhea were examined in an age-matched case-control study. Specimens collected from children and environmental sources were examined by standard microbiologic methods; Escherichia coli isolates were examined for hybridization with specific DNA probes and in tissue culture adherence assays. The same bacterial, viral, or parasitic agents were identified in 79 children with persistent diarrhea and in 408 children with acute diarrhea. Only one of nine children with persistent diarrhea excreted the same organism, Cryptosporidium, for that extended period. The most important risk factors identified for developing persistent diarrhea were living with other young children (odds ratio (OR) = 2.0, 95% confidence interval (Cl) 1.2-3.4) and being undernourished (OR = 2.6, 95% Cl 1.2-5.7). Persistent diarrhea in children in this camp was associated with several different agents rather than persistent infections with a single organism.

PIP: Researchers conducted a age matched case control study from May-October 1989 of 5 year old Cambodian refugees with diarrhea examined at Greenhill hospital at Site B UN resettlement camp near Surin, Thailand on the Thai-Cambodian border to determine the etiology of the diarrhea and to identify potential risk factors. The age specific diarrheal disease rate stood at 63 episodes/1000 5 year old children and 123/1000 for 1 year old infants. Incidence was 9.5/1000 5 year old children and 17/1000 for 1 year old infants. Rotavirus was responsible for 24% of the 487 children with diarrhea. Campylobacter species and enterotoxigenic Escherichia coli caused the most frequent bacterial infections. The same enteric pathogens infected children with persistent diarrhea as well as those with acute diarrhea. Children with persistent diarrhea tended to not shed the same pathogen the entire time. 1 patient did excrete Cryptosporidium for an extended period, however. 37% of the children with persistent diarrhea received antibiotics after a positive culture, but they did not stop diarrhea. Besides 98% of the Shigella strains in children with acute diarrhea and all 4 strains in those with persistent diarrhea were resistant to sulfamethoxazole-trimethoprim. All Shigella strains were resistant to nalidixic acid. Further all aggregative adherent E. coli were resistant to colistin. Oral rehydration solution use and readily available medical care limited the number of deaths from diarrhea to 1. Living with other young children and malnutrition (3rd percentile weight/height standard) were the most significant risk factors for diarrhea (odds ration=2 and 2.6 respectively). In fact, with each percentile increment in weight for height, the risk for persistent diarrhea fell 1%. The hands of both mothers and children harbored enteric pathogens. Enteric pathogens were also isolated from water and animals, especially cats. Thus preventive measures should include hand washing, reduce overcrowding, and supplemental feeding.

A comparative study of gastrointestinal infections in United States soldiers receiving doxycycline or mefloquine for malaria prophylaxis.

A double blind study of daily doxycycline (100 mg) vs. weekly mefloquine (250 mg) was performed on United States soldiers training in Thailand to assess the effect of doxycycline malaria prophylaxis on the incidence of gastrointestinal infections. During a 5 week period, 49% (58/119) of soldiers receiving doxycycline and 48% (64/134) of soldiers receiving mefloquine reported an episode of diarrhea. Infection with bacterial enteric pathogens was identified in 39% (47/119) of soldiers taking doxycycline and 46% (62/134) of soldiers taking mefloquine. Forty-four percent (59/134) of soldiers receiving mefloquine and 36% (43/119) of soldiers receiving doxycycline were infected with enterotoxigenic Escherichia coli (ETEC), while 9% (12/134) of soldiers receiving mefloquine and 4% of soldiers receiving doxycycline were infected with Campylobacter. Side effects from either medication were minimal. After 5 weeks in Thailand, the percent of non-ETEC strains resistant to greater than or equal to 2 antibiotics increased from 65% (77/119) to 86% (95/111) in soldiers on mefloquine and from 79% (84/106) to 93% (88/95) in soldiers on doxycycline. Doxycycline prophylaxis did not prevent or increase diarrheal disease in soldiers deployed to Thailand where ETEC and other bacterial pathogens are often resistant to tetracyclines.