Ambulatory treatment of anal fissure

Not a long time ago, the standard treatment for anal fissure was surgical, inpatient care; this concept failed in the last years, ambulatory treatment becoming the rule and the inpatient care the exception. We wish to present here our results in 125 ambulatory patients, who were referred to our proctologic office with anal fissure. We used two methods: a conservative one, by applying topical 0.2% nitroglycerine, similar to other proctology practitioners, and one method of our own which is a minimal surgical procedure consisting of sphincterotomy. The average follow-up period was 6 months. Symptom-free and anatomic-free states were obtained in 61.2% for conservative treated patients and in 91.4% for operated patients, respectively. We had no postoperative complications, rebounds or sequelae. We consider the results at least equal in effectiveness to those of standard surgical treatment. This is why we underline that ambulatory treatment for anal fissure reaches the goal to be of a first line option.     

Neonatal Volkmann's compartment syndrome. A report of two cases

Neonatal Volkmann's compartment syndrome is a rare entity. This diagnosis may be suspected when a case presents cutaneous damage associated with poor hand and wrist function after delivery. We present two such cases of neonatal Volkmann compartment syndrome with long term clinical and x-ray follow-up. In our patients, a hand surgeon was not consulted in the perinatal period and early fasciotomy was not performed. No particular aetiology or associated cerebrovascular accident was found. A series of operations was necessary in order to improve function of the hand. Neonatal Volkmann compartment syndrome must be recognised early in order to enable further investigation of any underlying condition and to perform early surgical decompression. Long term clinical and x-ray follow-up is necessary to prevent and treat wrist deformation and finger contractures.     

Calcimimetics, mechanisms of action and therapeutic applications

The extracellular calcium-sensing receptor (CaR) on the parathyroid cell surface negatively regulates secretion of parathyroid hormone (PTH). Its activation by small changes in the extracellular concentration of ionized calcium (ec[Ca2+]) decreases PTH secretion and secondarily bone turnover. CaR is an ideal target for compounds that may be developed to modulate its activity - activating calcimimetics and inhibiting calcilytics. Calcimimetics can amplify the sensitivity of the CaR to ec(Ca2+), thereby suppressing PTH levels and in turn reducing blood Ca++. They dose-dependently reduce the secretion of PTH in cultured parathyroid cells, in animal models and in humans. In uremic animals, these compounds prevent parathyroid cell hyperplasia when given at the onset of the disease and stop cell proliferation if they are administered afterwards, when the hyperplasia already exists. They normalize plasma PTH levels and bone remodeling. In uremic patients undergoing hemodialysis, calcimimetics reduce plasma PTH concentrations in the short (12 weeks) and long (2 years) terms. They also reduce serum levels of calcium-phosphorus product. Calcimimetics are therefore an alternative for the treatment of secondary hyperparathyroidism, particularly in dialysis patients, when increased serum levels of calcium-phosphorus product, the attendant risk of cardiovascular calcification, and its lack of efficacy limit use of the standard treatment.     

Criss-cross heart: anesthetic considerations for total cavopulmonary shunt (Fontan procedure)

We report the anesthetic technique used for interatrial septal defect a 2-year-old girl weighing 11 Kg who presented with crossed atrioventricular connection (criss-cross heart), transposition of the great vessels, interatrial and interventricular septal defects, and subpulmonary and pulmonary valve stenoses. The patient was proposed for total cavopulmonary anastomosis with basal arterial oxygen saturation (SapO2) at 65%. Anesthesia was induced with inhaled agents and after intubation, hyperventilation was induced to achieve an end-tidal carbon dioxide pressure around 27 mm Hg. General anesthesia was provided in combination with spinal infusion of morphine chloride (100 microg Kg(-1)) for pain control. A Fontan procedure was carried out uneventfully with cardiopulmonary bypass. Milrinone was used at the extracorporeal circuit pump outlet. The patient was transferred to the pediatric intensive care unit where she was extubated without complications 90 minutes after admission. Anesthetic management is based on maintaining adequate preloading doses by administering volume, inhaled and/or intravenous agents, or use of vasoconstrictors and adjustment of ventilator parameters to modify pulmonary or systemic vascular resistance. We were able to maintain normal arterial pressure in our patient and provide adequate preloading through hyperventilation to reduce pulmonary vascular resistance.