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Notes: Objective To assess the value of hormone replacement therapy (HRT) in postmenopausal women with faecal incontinence.Design Prospective observational study using a bowel function questionnaire and anorectal physiological testing before and after six months of standard oestrogen hormone replacement therapy.Setting Menopause and colorectal clinics of two university teaching hospitals.Participants Twenty postmenopausal women (mean age 61 years) with demonstrable faecal incontinence (mean duration 6.1 years) previously untreated with HRT.Main outcome measures Improvement in symptoms and objective alteration in anorectal physiology tests.Results All women had significant symptoms of anorectal dysfunction before treatment, whereas 5/20 (25%) were asymptomatic after six months of HRT, and a further 13/20 (65%) were symptomatically improved in terms of flatus control, urgency, and faecal staining. There was no change in bowel frequency or stool consistency following HRT, but social activity was considerably improved. Anal resting pressures and voluntary squeeze increments were significantly increased following oestrogen therapy, although no differences in anal canal vector symmetry index were observed. Insignificant changes occurred in threshold volume of rectal sensation and volume of defaecatory urge, but there was a significant change in maximum tolerated rectal volume after six months. Neither anal canal electrosensitivity nor pudendal nerve terminal motor latency was altered following HRT. Seven of the 20 women (35%) had an identifiable anal sphincter defect on anal endosonography. Statistical analysis, however, showed no significant difference in outcome in this group compared with those with an intact anal sphincter. A larger population sample may demonstrate this.Conclusion This observational study has shown a possible benefit of oestrogen replacement in postmenopausal women with symptoms of impaired faecal continence. A prospective randomised controlled trial is now advisable to test this hypothesis.

Notes: Objective To assess the effects of delayed vs immediate pushing in second stage of labour with epidural analgesia on delivery outcome, postpartum faecal continence and postpartum anal sphincter and pudendal nerve function.Design Prospective, randomised, controlled trial.Setting Tertiary referral maternity teaching hospital.Population One hundred and seventy nulliparous women randomised at full dilatation to immediate or delayed pushing.Methods A total of 178 nulliparous women, all with continuous epidural analgesia, were randomised at full cervical dilatation, but before the fetal head had reached the pelvic floor, to either immediate pushing or 1 hour delayed pushing. Labour outcome was analysed and all women underwent postpartum assessment of anal sphincter function, including anal manometry. Those women who had a normal delivery underwent neurophysiology studies, while those women who had an instrumental delivery underwent endoanal ultrasound.Main outcome measures Mode of delivery; altered faecal continence.Results Ninety women were randomised to immediate pushing and 88 to delayed pushing. The spontaneous delivery rate was 56% (50/90) in the immediate pushing group and 52% (46/88) in the delayed pushing group. Mean duration of labour for the immediate pushing group was 427 minutes compared with 480 minutes for the delayed pushing group (P= 0.005). Eighty-four percent (76/90) of women in the immediate pushing group received oxytocin to augment labour, 21/76 (28%) in the second stage only. Eighty-one percent (71/88) of women in the delayed pushing group received oxytocin to augment labour, 22/71 (31%) in the second stage only. Fetal outcome did not differ between the two groups. Episiotomy rates were 73% and 69% in the immediate pushing and delayed pushing groups, respectively. 26% (23/90) of the immediate pushing group and 38% (33/88) of the delayed pushing group complained of altered faecal continence after delivery (NS). Manometry, ultrasound and neurophysiology studies did not differ significantly between the two groups. Overall, 55% of women after instrumental delivery had endosonographic evidence of damage to the external anal sphincter, while 36% of women after spontaneous delivery had abnormal neurophysiology studies.Conclusions Rates of instrumental delivery were similar following immediate and delayed pushing, in association with epidural analgesia. Delayed pushing prolonged labour by 1 hour but did not result in significantly higher rates of altered continence or anal sphincter injury, when compared with immediate pushing.

Notes: Objective To compare, in a prospective, randomised controlled trial, differences in anal sphincter function following forceps or vacuum assisted vaginal delivery in an institution practising standardised management of labour.Design Prospective, randomised controlled trial.Setting Tertiary-referral maternity teaching hospital.Population One hundred and thirty women.Methods Primiparous women were recruited antenatally and if an instrumental delivery was indicated, were randomised to either a vacuum or low-cavity, non-rotational forceps assisted delivery. Follow up consisted of a symptom questionnaire, anal manometry and endoanal ultrasound at three months postpartum.Main outcome measures Faecal continence scores, anal manometry, endoanal ultrasound.Results Sixty-one women delivered with forceps assistance (40 for failure to progress in the second stage) and 69 with vacuum assistance (33 for failure to progress); 16/69 vacuum deliveries proceeded to a forceps assisted delivery (23%). There were no statistical differences in the antecedent antenatal factors between the two groups. A third degree perineal tear followed 10 (16%) forceps and 5 (7%) vacuum deliveries. Based on intention-to-treat analysis, 36 (59%) women complained of altered faecal continence after forceps delivery compared with 23 (33%) following vacuum delivery three months postpartum (RR 2.88, 95% CI 1.41–5.88). Endoanal ultrasound was reported as abnormal following 34 (56%) forceps deliveries and 34 (49%) vacuum deliveries (RR 1.3, 95% CI 0.65–258). After exclusion of ‘failed vacuum’, median anal canal resting pressure was significantly lower following forceps delivery compared with vacuum delivery alone (P= 0.004). There were no significant differences in degree of ultrasound abnormality between the two groups.Conclusions Symptoms of altered faecal continence are significantly more common following forceps assisted vaginal delivery. Based on continence outcome, when circumstances allow, vacuum should be the instrument of first choice in assisted delivery.

Notes: A 52-year-old apparently healthy, normotensive woman who presented for elective cholecystectomy experienced intra-operative hypertension and tachycardia, which were controlled by propranolol. Oesophageal temperature increased, there was a metabolic and respiratory acidosis with hypoxaemia, and malignant hyperthermia was diagnosed. Severe cardiogenic pulmonary oedema ensued, and was treated with intravenous glyceryl trinitrate. Ventricular fibrillation caused cardiac arrest, and this was treated successfully. Postoperatively a phaeochromocytoma was discovered, and removed at a subsequent operation. The case illustrates the similarities in presentation of malignant hyperthermia and phaeochromocytoma, and the possibility that misdiagnosis may exacerbate the crisis.

Notes: The incidence of cardiac dysrhythmia during inpatient dental anaesthesia with enflurane was studied following either hyoscine or droperidol as a supplement to papaveretum premedication. None of the subgroup given droperidol exhibited dysrhythmias, compared to 4.4% of those patients given hyoscine. This difference was not significant at the 5% level (0.2 〉 p 〉 0.1).

Notes: The incidence of cardiac dysrhythmias during inpatient dental anaesthesia under halothane was studied following either hyoscine or droperidol as a supplement to papaveretum for premedication. Forty-three percent of patients given hyoscine exhibited cardiac dysrhythmias compared to 23 percent of the group given droperidol (p = 0.03). The incidence of dysrhythmias bore no relationship to the age. sex or weight of the patient. nor to the end tidal carbon dioxide tension.

Notes: A 55-year-old male cardiac transplant recipient presented with cutaneous nodules on the limbs caused by Alternaria alternata. Oral fluconazole 200 mg daily for 3 weeks was ineffective. Itraconazole 100 mg oral daily was ceased when hyperglycaemia developed. Individual lesions were successfully treated with either curettage and cautery or double freeze-thaw cryotherapy. Alternaria spp. are ubiquitous fungal saprophytes which may cause cutaneous infections particularly in immunocompromised patients.