Corticosteroid Injection for Morton's Interdigital Neuroma: A Systematic Review

BackgroudThis review aimed to evaluate the effects of corticosteroid injections on Morton''s neuroma using an algorithmic approach to assess the methodological quality of reported studies using a structured critical framework.MethodsSeveral electronic databases were searched for articles published until April 2020 that evaluated the outcomes of corticosteroid injections in patients diagnosed with Morton''s neuroma. Data search, extraction, analysis, and quality assessments were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). guidelines, and clinical outcomes were evaluated using various outcome measures.ResultsWith 3–12 months of follow-up, corticosteroid injections provided satisfactory outcomes according to Johnson satisfaction scores except in two studies. Visual analog scale scores showed maximal pain reduction between 1 week and 3 months after injection. We found that 140 subjects out of 469 (29.85%) eventually underwent surgery after receiving corticosteroid injections due to persistent pain.ConclusionsCorticosteroid injections showed a satisfactory clinical outcome in patients with Morton''s interdigital neuroma although almost 30% of the included subjects eventually underwent operative treatment. Our recommendation for future research includes using more objective outcome parameters, such as foot and ankle outcome scores or foot and ankle ability measures. Moreover, studies on the safety and effectiveness of multiple injections at the same site are highly necessary.     

ANAL PATHOLOGY IN PATIENTS WITH CROHN'S DISEASE

Background: A distinctive feature of patients suffering from Crohn's disease is a predisposition to develop a variety of anal complications. The aetiology of such conditions is unclear, and the reported incidence of anal involvement in Crohn's disease varies party due to the various criteria used for classification. This study aims to review the management of patients with symptomatic anal pathology associated with Crohn's disease at St Vincent's Hospital, Melbourne. Methods : A database of 306 patients with Crohn's disease referred to the department between January 1978 and October 1994 was reviewed to identify those patients with symptomatic anal disease. The anal pathology was recorded and classified. Demographic data and the clinical and surgical history of the patient were recorded. Results : Of the 306 patients with Crohn's disease, 129 (42.4%) were identified as having symptomatic anal pathology. Patients were likely to present with anal symptoms after they had been diagnosed as having intestinal Crohn's disease (46.1%). The commonest presentations were perianal abscess (29.5%), anal fissure (27.6%), and low anal fistula (26.7%). A minority of patients presented with highkomplex anal fistulae (3.8%), or recto-vaginal fistulae (5.2%). Five per cent of patients had Crohn's disease localized to the anal area. The pattern of intestinal disease in the remaining patients was small bowel 21.1%. small bowel and colon 31.9%, and colon 43.0%. A total of 244 local anal surgical procedures were performed on these patients; the commonest of these were drainage of an abscess (38.5%), examination under anaesthetic (29.1%). and laying open of a low anal fistula (22.5%). Following surgical treatment, the recurrence rate for perianal abscesses was 13%, and for low anal fistulae 6%. Conclusions : The majority of patients with Crohn's disease who develop anal pathology have an excellent prognosis. A minority of patients develop complex anal fistulae and these remain a therapeutic challenge.     

COMPARISON OF VECURONIUM, ATRACURIUM AND TUBOCURARINE IN NORMAL PATIENTS AND IN PATIENTS WITH NO RENAL FUNCTION

Vecuronium (initial dose 0.1 mg kg^–1; incremental doses0.04 mg kg^–1) was given to 21 normal and 21 anephric patients.There were no gross difference between the two groups in theeffect or in the duration of action of either initial or incrementaldoses, except in two anephric patients who were resistant tothe agent. Reversal with neostigmine was satisfactory. In normalpatients the initial dose of vecuronium was slower in onsetof action than was atracurium 0.5 mg kg^–1 (26 patients):the first two incremental doses of vecuronium were administeredsignificantly earlier than the corresponding increments of atracurium(0.2 mg kg^–1), but the duration of action of incrementsover-all was not greatly different. However, in anephric patients,except in the resistant patients, the behaviour of vecuroniumwas similar to that of atracurium (26 patients). A comparisonwith an initial dose of rubocurarine 0.5mg kg^–1 givento 20 anephric patients and tubocurarine 0.6 mg kg^–1 givento 21 normal and 20 anephric patients showed tubocurarine tobe longer acting and considerably less predictable. This wasparticularly so in the anephric group, in which its action sometimespersisted after neostigmine had been given     

A SIX-CENTRE INTERNATIONAL STUDY OF THE OUTCOME OF TREATMENT IN PATIENTS WITH CLEFTS OF THE LIP AND PALATE: THE RESULTS OF A CROSS-LINGUISTIC INVESTIGATION OF CLEFT PALATE SPEECH

During the period 1964–73, 286 patients were treated for mandibular fractures. 229 patients (80%) attended the follow-up examination. The length of observation was from 1 to 9 years. The treatment and the follow-up evaluations in the 229 patients are described. Early fracture treatment has been the objective, also in patients who have undergone severe cerebral traumas. Antibiotic prophylaxis was implemented in cases of compound fractures. Preservation of teeth and tooth buds in the line of fracture was attempted. Clinical infection occurred in 0.4% of the patients. At the follow-up examination 1 patient presented with a fracture displacement outside the condylar process. Neither malocclusion nor pseudarthrosis following fracture or after treatment were seen. Permanent sensory disturbances in the innervation area of the mental nerve following fracture occurred in 8%. Radiological examination of the teeth in the line of fracture revealed unnoticed apical bone lesions in 17% of 118 patients. In a further 23% there was a negative response to the vitality test. Follow-up control of mandibular fractures is advised at 12 to 18 months after treatment.     

A COMPARISON OF PENTAZOCINE AND PETHIDINE IN PATIENTS WITH PAIN FOLLOWING CHOLECYSTECTOMY

Forty-nine patients who had undergone cholecystectomy were investigatedin a double-blind, between-patient single-dose comparison ofpentazocine and pethidine. Patients were matched for age, sex,weight and pre-operative blood pressure, and received pentazocine0.3 mg/kg body weight or pethidine 0.5 mg/kg by intravenousinjection. All measurements were made by the same observersin the first 3 hours after the operation. Systolic and diastolicpressures remained unchanged in the pentazocine group, but therewas a significant fall of about 10 per cent in both systolicand diastolic pressures 90 minutes after the injection of pethidine.Although pethidine gave slightly better analgesia, the degreeof sedation was significantly greater, and side effects occurredmore frequently. It is concluded that pentazocine may have advantagesover pethidine especially in the immediate postoperative periodwhen the cardiovascular system is unstable.     

A COMPARISON OF PROSTATE CANCER PATIENTS IN JAPAN AND THE USA

Clinical characteristics of prostate cancer patients were anatyzed to compare the rates of progression of prostate cancer between patients in Japan (Gunma Urological Oncology Study Group: GUOSG) and the USA (Roswell Park Cancer Institute: RPCI), between 1980 and 1989. The stage of disease was more advanced and the age was greater in GUOSG patients compared with RPCI patients. However, the prostate cancer death rate of stage D patients at RPCI was significantly higher than that of the GUOSG. Moreover, the survival rate of stage A patients in the GUOSG was better than that of RPCI patients. The possibility of biases which may affect both the clinical characteristics and survival rates in the 2 populations studied is discussed. To determine whether there is a real difference in the rate of prostate cancer growth between the 2 countries will require a prospective study, ideally conducted in large population groups.     

COMPARISON OF HAEMODYNAMIC EFFECTS OF METOCURINE AND PANCURONIUM IN PATIENTS WITH CORONARY ARTERY DISEASE

The haemodynamic effects of large bolus doses of metocurine0.45 mg kg^–1 and pancuronium 0.1 mg kg^–1 were comparedin patients with coronary artery disease anaesthetized withdiazepam, anileridine and nitrous oxide. Hypotension occurredmore frequently after metocurine and was a result of a decreasein systemic vascular resistance. After pancuronium there wasno increase in arterial pressure or heart rate, but a smallincrease in cardiac index. The decrease in heart rate aftermetocurine was the principal cause of the statistically significantdifference in cardiac index between the two groups. Contraryto previous findings, metocurine did not attenuate circulatoryresponses to tracheal intubation. During surgical stimulation,two of the 10 patients of the pancuronium group developed significantST segment depression and three patients had a rate-pressureproduct greater than 12000mm Hg beat min^–1. However, thedifference in rate-pressure product between the groups was notstatistically significant.     

COMPARISON OF THORACIC ELECTRICAL BIOIMPEDANCE AND THERMODILUTION FOR THE MEASUREMENT OF CARDIAC INDEX IN PATIENTS WITH SEVERE SEPSIS

Cardiac index was measured using thoracic bioimpedance (Clbi)and thermodilution (Cltd) in 19 patients with proven sepsis,undergoing artificial ventilation of the lungs. There was apoor correlation between the techniques (r = 0.36, 242 datasets, regression line Clbi = 0.16 Cltd + 2.56 litre min^–1m^–2). The overall bias (Cltd-Clbi) was 1.69 litre min^–1m^–2 with limits of agreement (precision) of +4.17 to –0.79litremin^–1 m^–2. In individual patients the bias was from0.46 to 4.56 litre min¹ m^–2 with the limits of agreementfrom ±0.29 to ±2.55 litre min^–1 m^–2around the bias values. The two techniques cannot be used interchangeablyin this group of patients. (Br. J. Anaesth. 1993; 70: 58–62) ^*Present address, for correspondence: Nuffield Department ofAnaesthetics, Radcliffe Infirmary, Woodstock Road, Oxford OX26HE     

A COMPARISON OF THE EFFECTS OF SUXAMETHONIUM AND TUBOCURARINE IN PATIENTS IN LONDON AND NEW YORK

The effects of suxamethonium and tubocurarine were studied inLondon and New York patients anaesthetized with thiopentone,nitrous oxide and halothane. The action of tha muscle relaxantswere assessed by measurement of the twitch respone of the adductorpollicis muscle to supramaximal stimulation of the ulnar nerve.The duration of action of suxamethonium (1 mg/kg) was less inLondon patients than in a comparable group of New York patients.With tubocurarine (0.1 mg/kg) the magnitude and duration ofaction was less in London than in New York patients. In a groupof Amercian patients at a United States Air Force (USAF) hospitalthe magnitude and duration of action of tubocurarine (0.1 mg/kg)was similar to that seen in New York patients. It was also observedthat the response to tubocurarine (0.1 mg/kg) was affected bythe prior administration of suxamethonium (1 mg/kg). Both themagnitude and duartion of action of tuborcurarine were greaterin patients who had previously received suxamethonium than inthose who had not.     

COMPARISON OF THE MAGILL AND LACK ANAESTHETIC BREATHING SYSTEMS IN ANAESTHETIZED PATIENTS

The Magill and Lack anaesthetic breathing systems were comparedby measuring inspired and expired carbon dioxide concentrationsand expired minute volumes in lightly anaesthetized, unstimulatedsubjects. There were no significant differences between thetwo breathing systems at fresh gas flow rates of approximately50 and 70 ml kg^–1 min^–1. Inspired carbon dioxideconcentrations increased in one of six subjects at the higherfresh gas flow rate using the Magill system and in two usingthe Lack system. Inspired carbon dioxide concentration did notincrease in only one of six subjects at the lower fresh gasflow rate with both systems. Expired carbon dioxide concentrationsand expired minute volume increased in the majority of subjectsat both fresh gas flow rates using each system. We concludethat a fresh gas flow rate greater than 70 ml kg^–1 min^–1(which approximated to alveolar minute volume in our subjects)should be supplied to the Magill and Lack breathing systems. ^*Present address: Burton General Hospital, New Street, Burtonupon Trent, Staffordshire DE14 3QH.     

MORBIDITY AND MORTALITY AFTER SINGLE- AND DOUBLE-STAPLED COLORECTAL ANASTOMOSES IN PATIENTS WITH CARCINOMA OF THE RECTUM

Background : The optimal method of restoring intestinal continuity after rectal resection has been controversial. This study aims to compare the morbidity, mortality and survival of patients having either single-stapled (SS) or double-stapled (DS) colorectal anastomoses following resection of the rectum for cancer. Methods : Peri-operative and long-term follow-up data were prospectively documented in all patients undergoing rectal resection for carcinoma with a stapled anastomosis at our institution over a 14-year period. Patients were stratified by anastomotic technique (SS or DS). Peri-operative mortality, complications potentially related to anastomotic technique and cancer-related outcome were compared. Results : Two hundred and thirty-five patients had SS and 65 patients had DS anastomoses. The groups were well matched for age, sex, and tumour stage. Double-stapled anastomoses were used more frequently in the distal third of the rectum (P < 0.001). The distal margin of resection was not influenced by anastomotic technique. Major anastomotic leakage in 2.9% of SS cases was not significantly different from 6.1% of DS cases, and leakage was not influenced by anastomotic technique at any given level of the rectum. Two-year local recurrence rates were not significantly different between groups (SS 3.5%: DS 5.9%). Conclusions : These results suggest that the double-stapling technique is as safe as the single-stapling technique for constructing an anastomosis after excision of the rectum for cancer, in terms of the risk of leakage, the development of an anastomotic stricture. or local recurrence.     

COMPARISON OF THE HAEMODYNAMIC EFFECTS OF ENOXIMONE AND PIROXIMONE IN PATIENTS AFTER CARDIAC SURGERY

We have compared the haemodynamic effects of the imidazole derivativephosphodiesterase inhibitors enoximone and piroximone in patientswith low cardiac output after cardiac surgery. Ten patients(group E) received enoximone and 10 patients (group P) receivedpiroximone, both at a loading dose of 0.5 mg kg^–1 followedby an infusion of 5 µg kg^–1 min^–1. In bothgroups the main changes with time were increases in cardiacindex (maximum 24.5% in group E, 25.8% in group P) and decreasesin systemic vascular resistance (maxi mum 26.8% in group E and24.8% in group P). There were moderate increases in heart rate(maximum 11.3% in group E and 13% in group P) but a greaterpercentage decrease in mean arterial pressure in group E (maximum11.9% vs 7.9%) with time. One patient in group E developed hypertensionduring the loading dose. Two patients in group E and two ingroup P developed hypotension during the loading dose. One patientin group E developed ventricular extras ystoles which may havebeen related to the drug being studied. (Br. J. Anaesth. 1993;71: 869–872)     

HAEMODYNAMIC EFFECTS OF THE PHOSPHODIESTERASE INHIBITOR ENOXIMONE IN COMPARISON WITH DOBUTAMINE IN ESMOLOL-TREATED CARDIAC SURGERY PATIENTS

In a randomized study, the haemodynamic effects of the new phosphodiesterase-III-inhibitor,enoximone, were compared with dobutamine in acutely ß-adrenoceptorblocked patients. Twenty patients scheduled for aorto-coronarybypass grafting suffering from tachycardia (heart rate (HR)> 100 beat min^–1) were treated by infusion of esmolol,an ultra-short acting, selective ß₁-blocker. Twentyminutes after the start of esmolo, either enoximone 0.5 mg kg^–1as a bolus (n = 10) or dobutamine 5 µg kg^–1 min^–1was administered. Haemodynamic effects were monitored for 40min, including measurement of left ventricular haemodynamics.Esmolol reduced HR (–27%) and dP/dt_max (–38%) significantlyin both groups. Cardiac index (Cl) was decreased also. Enoximoneincreased Cl (+35%) and dP/dt_max (+39%) significantly, whileno change in dobutamine-treated patients was observed. Systemicvascular resistance increased only in the dobutamine group (+44%).     

DIURNAL RHYTHM OF SERUM gM-SEMINOPROTEIN IN PATIENTS WITH UNTREATED PROSTATE CANCER: COMPARISON OF THE ORIGINAL AND REVISED ASSAY KITS

To compare levels of y-seminoprotein (gM-Sm) assayed by original and revised assay systems, blood was obtained every 4 h over a 32-h period from 8 untreated prostate cancer patients. Serum levels of prostate specific antigen (PSA) were also examined. In 6 patients, the coefficient of variation (CV) of the serum levels assayed by the revised assay was significantly different from that of the intra-assay samples. In contrast, the CV of the gM-Sm serum levels assayed by the original assay differed significantly from that of the intra-assay samples in only 2 patients. The fluctuations in gM-Sm assayed by the revised assay were, at least in part, similar to those of the PSA serum levels in all patients. The mean CV of the gM-Sm serum levels assayed by the revised assay was significantly larger than that for levels measured by the original assay. After treatment, the rate of decrease in gM-Sm serum levels determined by the original assay differed from that in the serum levels of PSA and prostatic acid phosphatase. These results indicate that the original assay for gM-Sm do not detect diurnal differences in serum gM-Sm levels, even at levels below 20 ng/ml. These observations indicate that the analysis of data obtained using the original gM-Sm kit should be interpreted with caution.     

A CROSSOVER RANDOMIZED TRIAL OF TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION AND OXYBUTYNIN IN PATIENTS WITH DETRUSOR INSTABILITY

PURPOSE: Management of idiopathic detrusor instability is difficult in most patients mainly due to the lack of a complete understanding of the pathophysiology. Oxybutynin and transcutaneous electrical nerve stimulation have been used but to our knowledge no direct comparisons have been made. MATERIALS AND METHODS: Patients with frequency, urgency, urge incontinence and proved detrusor instability were studied with urodynamics, quality of life instruments, and frequency and volume charts. Patients were randomized to transcutaneous electrical nerve stimulation or oxybutynin. After 6 weeks of treatment, they were reassessed and after a washout of 2 weeks, they were started on the second arm of treatment and reassessed 6 weeks later. RESULTS: A total of 13 male and 30 female patients were studied. Functional capacity had increased and number of voids daily had decreased significantly compared with before treatment in both arms (p <0.005). There were significant improvements in symptom specific quality of life measures but no changes were found on the global Short Form 36 (SF-36) quality of life questionnaire. The volume to first desire to void and first unstable contraction had increased significantly with oxybutynin but not with transcutaneous electrical nerve stimulation. Of 23 patients 7 were stabilized with treatment, including 2 with oxybutynin only, 2 with either nerve stimulation or oxybutynin and the remaining 3 with only nerve stimulation. Total bladder capacity did not change significantly with either treatment but patients noticed side effects more commonly with oxybutynin. CONCLUSIONS: Both treatments clearly improved subjective parameters. However, only oxybutynin showed significant improvements in objective urodynamic parameters. Transcutaneous electrical nerve stimulation can be used in patients who cannot take oxybutynin. Further studies are needed to show the long-term efficacy and cost analyses of nerve stimulation.