Journal Reading

INTRODUCTION
Anal fissure in childhood :
- Rectal bleeding
- Rectal pain
- Crying during defecation
- Stool withholding
- Severe constipation
Conventional therapy for anal fissure :
• Warm sitz bats
• Local application of analgesic ointment
• Stool softener
• Behavioral therapy
 ↑ internal anal
spinchter activity
& High anal resting
Anal fissure
pressure
Anodermal ischemia

Treatment :
- Anal dilatation
- Internal spinchterotomy
- Topical (chemical)
 MATERIALS AND METHODS
• Total sample : 102 patients with anal fissure
• Pediatric surgery department at Gazi University Medical Faculty or Ankara
Diṣkapi Social Security Hospital
• January 1999-May 2000
Lidocaine (L)
• Placebo (P) & 3 treatment groups EMLA
GTN

P  Vaseline
L  10% Lidocaine ointment
EMLA  5% Prilocaine-5% Lidocaine
GTN  0.2% Glyceryl Trinitrate
• Lactulose syrup  given to children with
constipation
• Constipation :
- Defecating < 3 times/week
- Painfull defecating > 3 times/week
• Symptoms & physical sign :
- admission
- 10th day after therapy
- 8th week after therapy
 SYMPTOMS FISSURES
(Expressed by patient or parents) (Based on physical examination)

0 : no relief (unresponsive) 0 : deep, with bleeding

1 : incomplete relief 1 : shallow, without bleeding

2 : complete relief 2 : completely healed

(responsive)
RESULTS
RESULTS
RESULTS
 DISCUSSION
• Cause of anal fissure  obscure
• Recent : increased anal spinchter activity 
high maximal anal resting pressures  anal
fissure
 Treatment : lowering the increased anal
spinchter activity
• Warm sitzs bath & local anesthetic application
 relaxation of the internal anal spinchter
(IAS)
 DISCUSSION
• EMLA
- Topical applicant
- Serious systemic side effect : methemoglobinemia
- Superior than lidocaine
• GTN
- NO donor  relaxes IAS & decreased maximal anal
canal pressure
- Dilates anodermal vessels  increases blood supply
- More effective than EMLA  high cure rate, high
symptomatic relief
 DISCUSSION
Suggestion :
1. GTN Ointment for childhood anal fissures
 fast response rate, comfortable for
children, high fissure healing rates
2. Combination EMLA & GTN  synergistic
effect
The Newcastle Critical Appraisal
Worksheet
A format for examining journal articles*
*(Based on Medical Journal of Australia 1992;157:389-94)
Presented by Dick Heller, Professor of Public Health, The University of
Manchester, UK <Dick.Heller@man.ac.uk>
1. What is the research question?
How is the response rates to fissure treatment
by Lidocaine, EMLA, and GTN?

2. What is the study type?

Randomized, placebo-controlled trial
3. What are the outcome factors?
The outcome factors were relief and symptoms
and fissure healing on 10th day of therapy and
8th week of therapy
4. What are the study factors?
• Gender
• Age
• Fistule localization
• Fistule scores
• Relief of symptoms (0-2)
• Fissure healing (0-2)
5. What important potential confounders are
considered?
No confounders

6. What are the sampling frame and sampling

method?
102 patients with anal fissure admitted to the
Pediatric Surgery Department at Gazi University
Medical Faculty or Ankara Diṣkapi Social Security
Hospital, randomly allocated into 4 groups
7. Are statistical tests considered?
Yes. Using X2 test. P-values less than 0.05 were
considered statistically significant
8. Are the results clinically/socially significant?
Yes clinically significant

9. Are ethical issues considered?

• Yes. Local Medical Ethical Committee was
received for this study
10. What conclusions did the authors reach
about the study question?
- GTN Ointment for childhood anal fissures
shows fast response rate, comfortable for
children, and deliver high fissure healing rate
- Combination EMLA & GTN seem to give
synergistic effect
 CAT
(Critical Appraisal of the Topics)
 Screen for Initial Validity and
Relevance
1. Is the article from a peer-reviewed journal ? Yes, from Journal of
Pediatric Surgery
2. Is the location of the study similar to mine so that the results, if
valid, would apply to my practice ? No, the location was in Turkey
which is a developed country
3. Is the study sponsored by an organization that might influence
the study design or results ? No sponsor
4. Will this information, if true, have a direct impact on the health
of my patients, and is it something they will care about ? No,
because of different situation between the study and mine
5. Is the problem addressed one that is common to my practice,
and is the intervention or test feasible and available to me ? Yes
6. Will this information, if true, require me to change my current
practice ? Yes
 Determine the Intent of the Article
• Why the study was performed?
To determine how is the response rates to fissure
treatment by Lidocaine, EMLA, and GTN

• Four major clinical categories

– Therapy
– Diagnosis
– Causation
– Prognosis
 Clinical Description Preferred Study
category Design

Therapy Tests the effectiveness of a Randomized, double-

treatment, such as a drug, surgical blinded, placebo-
procedure, or other intervention controlled trial

Diagnosis Measures the validity (is it Cross-sectional survey

dependable?) and reliability (will the (comparing the new test
same results be obtained every with a reference
time?) of a diagnostic test, or standard)
evaluates the effectiveness of a test
in detecting disease at a pre
symptomatic stage when applied to
a large population

Causation Assesses whether a substance is

Cohort or case-control
related to the development of an
illness or condition
Prognosis Determines the outcome of a Longitudinal cohort
study
disease
Evaluate the Validity of the Article
Based on Its Intent

• Therapy
• Diagnosis
• Causation
• Prognosis
Level 1 of Evidence
Level 2 of Evidence
Level 3, 4, 5 of Evidence
Grades of Recommendation
THANK YOU