What is the optimum treatment of chronic anal fissure?

Aim: To compare the efficacy of topical Glyceryl trinitrate 0.2% (GTN) with Lateral internal spincterotomy (LIS) for treating chronic anal fissure (CAF). Methodology: A randomized control trial was carried out in the general surgery department, Lady reading hospital, LRH MTI, Peshawar (January 2018 to July 2018). All consecutive patients 18 to 60 year old presenting to OPD with a clinical diagnosis of chronic anal fissure were enrolled after informed consent. A total of 60 patients were enrolled. The patients were assigned two groups, including treatment group A (lateral internal spinterotomy) or treatment group B (use of Topical GTN ointment 0.2%). Results: Out of the 60 patients, 30 were enrolled into each group. The female had majority of 57% (group A) and 60% (group B). Mean duration regarding symptoms in group A was 1 year with SD ± 3.51 vs 1 year ± 2.98 in group B. Majority of patients in both groups were in the 20 to 40 years age group (74% in group A vs 83% in group B). Complete fissure healing and resolution of symptoms was observed in 27(91%) in group A vs 20(66%) in group B. Conclusion: In conclusion, we derive that lateral internal spincterotomy is more effectual than Topical Glyceryl trinitrate 0.2% for treating chronic anal fissure. Keywords: Chronic anal fissure, lateral internal spincterotomy, Glyceryltrinitrate

Rationalized Approach for The Treatment of Neuropathic Pain

Injury to the nerves causes alteration in normal neurobiological sequences lead to disease of somatosensory nervous system called as neuropathic pain (NP). It affects both central as well as peripheral nervous system. It is a chronic painful condition occurs due to various diseases like HIV, diabetes, lesions, infection, trauma, and metabolic insults. NP affects 7-10% of global population, hence subsequently is a major concern. Pharmacotherapy for NP remains a major clinical challenge due to its complex pathophysiology. Current treatments like Analgesics, anticonvulsants, non-steroidal anti-inflammatory drugs, tri-cyclic antidepressants, sodium channel blocker and opioid agonist administrated individually to patients of NP are providing only meager and partial relief. Furthermore, these drugs have limited efficacy as well as adverse effects. Hence instead of monotherapy, pathophysiology of NP suggests that administering multiple drugs (polypharmacy) show quick and sufficient effect in the treatment of NP. Recent updates indicate that combination of Morphine and gabapentin, Pregabalin and duloxetine, Gabapentin and nortriptyline, Amitriptyline and ketamine (topical), Doxepin and capsaicin (topical), Glyceryl trinitrate (topical) and valproate are also a good choice for the treatment of NP. Several clinical trials also established that combination pharmacotherapy showed greater efficacy than monotherapy in treating NP. Physicians, scientists working in the area of NP are not only looking for its treatment but also in resolving the issues of co-morbidities associated with it. Hence the present review focuses on rationalized approach of combination therapy for the treatment of various aspects of NP.

Pharmacologic Treatment of Idiopathic Chilblains (Pernio): A Systematic Review

Idiopathic chilblains is a cold-induced inflammatory condition that causes significant morbidity. When preventative measures alone are inadequate, oral nifedipine is generally recommended as first-line pharmacologic therapy. Given the natural course of this spontaneously remitting/relapsing condition, controls are needed to critically appraise studies and determine the value of treatments. We report a systematic review of placebo-controlled or comparative therapeutic trials for the treatment of idiopathic chilblains. Our search of PubMed, Embase, and Cochrane databases, identified 11 studies that met our inclusion criteria for a combined study population n = 576. Therapies included nifedipine, pentoxifylline, tadalafil, topical glyceryl trinitrate (GTN), topical minoxidil, diltiazem, corticosteroids, and vitamin D. There was moderate evidence to support the use of nifedipine and pentoxifylline in the treatment of severe or refractory cases of idiopathic chilblains, while other therapies had inadequate evidence or nonsignificant results compared to placebo.

Efficacy of Glyceryl Trinitrate Ointment for Perianal- Intrarectal Local Anesthesia in Transrectal Ultrasound- Guided Prostate Biopsy- Compared to Topical Lignocaine

Objective: Anorectal pain and discomfort during transrectal ultrasound (TRUS)-guided prostate biopsy is an important issue of this procedure. Therefore present study was designed to compare whether the use of topical glyceryl trinitrate (GTN) ointment or lignocaine gel is more effective as an adjunct to periprostatic nerve block (PPNB) in reducing pain associated with transrectal ultrasound (TRUS)-guided prostate biopsy. Methods: In all, 120 consecutive patients having their first TRUS-guided prostate biopsy were randomized to receive either 0.4% GTN ointment or 2% lignocaine gel, 10 minutes or 5 minutes respectively before biopsy. All patients had a biopsy preceded by an injection with 5 ml of 2% lignocaine local anaesthesia. Results: A 100-point visual analogue score was used to record overall pain due to the presence of the probe, the biopsy itself and pain after the procedure. There was no significant difference in age, PSA level and prostate volume between the groups. There was a significantly lower mean pain score due to probe insertion, in the GTN than lignocaine group (18.32 vs 37.48, P < 0.001); pain perception was lower for the whole procedure in the GTN group (16.59 vs 35.17, P < 0.001); and was most pronounced in men aged d”65 years (21.45 vs 40.7, P < 0.001). Five patients (8.3%) in the GTN group complained of headache. Conclusion: So it can be concluded that, topical GTN ointment is safe and effective in reducing the discomfort and pain associated with TRUS-guided prostate biopsy, in particular the insertion of the ultrasound probe. It might be of maximum benefit in the younger patient(d”65years). Bangladesh Journal of Urology, Vol. 21, No. 1, January 2018 p.14-19

Study protocol: a pilot clinical trial of topical glyceryl trinitrate for chronic venous leg ulcer healing

Background: Chronic venous leg ulcers (VLUs) are costly to the healthcare system and a burden to patients, significantly reducing quality of life. Nitric oxide (NO) is important to wound healing, with a small study demonstrating a NO donor, topical glyceryl trinitrate (GTN), was effective for VLU healing. The aim of this study is to examine the application of topical GTN in relation to VLU healing. Methods: A pilot double-blinded randomised controlled clinical trial will be undertaken. Participants in the control group (n=20) will receive a placebo ointment (ointment base) and participants in the treatment group (n=20) will receive a NO donor (base ointment with 2% GTN) weekly for 4 weeks. The inclusion criteria will be adults >18 years of age with a chronic VLU. Rate of healing will be determined by planimetry (ulcer tracing) using the Gillman equation. Significance: This clinical trial aims to provide proof of concept of a novel treatment, topical GTN, which may accelerate wound healing through improvements to vasodilation and antimicrobial properties at the wound bed.