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Am Fam Physician. 2004;69(5):1300-1310

Diagnosis and Treatment of Anal Fissure

The American Gastroenterological Association (AGA) has released a technical review on diagnosis and care of patients with anal fissure. “AGA Technical Review on the Diagnosis and Care of Patients with Anal Fissure” appears in the January 2003 issue of Gastroenterology and is available online at

Anal fissure is a common disorder but often is misdiagnosed as hemorrhoids. Its exact incidence and cause are unknown. Standard treatment traditionally has included fiber supplementation, sitz baths, and topical analgesics. However, this approach recently has been modified to include new treatment options.

Young adults are most frequently affected. The majority of fissures occur in the posterior midline, although anterior midline fissures occur in 25 percent of affected women and 8 percent of affected men. Physical examination confirms the diagnosis. Most fissures are best seen by separating the buttocks with opposing traction. A sentinel skin tag should alert the examiner to the likely presence of a fissure. Digital and endoscopic examinations are not appropriate in patients with marked tenderness, because these methods are traumatic to the patient and rarely yield diagnostic information. When significant anal pain cannot be diagnosed comfortably, examination under anesthesia is warranted.

Anal fissure is associated with elevated resting anal pressure, and therapy is directed at reducing anal tone. About one half of patients who receive standard conservative care will be healed. Preliminary reports of new treatments such as topical sphincter relaxants and locally injected botulinum toxin are promising, although some topical agents are not yet available commercially in the United States. Surgery is a highly successful treatment option; virtually all U.S. experts advocate lateral internal sphincterotomy (LIS) for patients with anal fissure. However, LIS has been associated with minor incontinence in some patients.

Scientific Exhibit Deadline for AAFP Assembly

A call for scientific exhibits has been issued by the American Academy of Family Physicians (AAFP) for presentation at the 2004 Scientific Assembly occurring October 13 to 16 in Orlando, Fla. Applications must be submitted by April 2. Scientific exhibits provide a forum for the presentation of research that is of interest and educational value to family physicians. Membership in the AAFP is not a prerequisite for submission. The exhibits include those presented by residents and medical students.

Travel grants of $1,000 may be awarded to a maximum of 15 resident/student scientific exhibitors whose applications are accepted for presentation at the Assembly. In addition, cash prizes and ribbons for first and second place and ribbons for third place will be awarded to the senior exhibitor of the family medicine resident and medical student poster presentations. Application forms may be obtained from Jeana Higginbottom, Scientific Program Department, AAFP, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211; telephone: 800-274-2237, ext. 6564; or by visiting the AAFP Web site at

Ongoing Care After Cancer Treatment

The number of Americans diagnosed with cancer in 2003 was projected to be nearly 1.3 million, and most were expected to survive for at least five years. The five-year survival rate for all patients with cancer is nearly 62 percent; when lung cancer is excluded, the survival rate is 69 percent. Cancer survivors have unique medical needs that require focused attention. Kattlove and Winn reviewed tumor-specific treatment of patients who have survived cancer. “Ongoing Care of Patients After Primary Treatment for Their Cancer” appeared in the May/June 2003 issue of CA: A Cancer Journal for Clinicians.

Most patients will be more likely than average to have recurrence or to develop a second primary cancer. However, depending on the type of cancer, surveillance to detect recurrence may not be beneficial.

The review focuses on survivors of breast cancer; colorectal cancer; prostate cancer; testicular cancer; Hodgkin's disease; leukemia and non-Hodgkin's lymphoma; lung cancer; gynecologic cancer; and bladder and kidney cancer. Included in the review are discussions about surveillance, assessing genetic susceptibility, diagnosing a second primary cancer, monitoring and treating complications, and dealing with altered physiologic and psychosocial status.

The spectrum of medical and psychologic needs of the cancer survivor is diverse and complex. The authors note that optional management can improve both quality of life and, in some cases, survival.

Online Resources to Combat Obesity, Boost Health

The Centers for Disease Control and Prevention is calling on physicians to take an active role in encouraging obese patients to lose weight. Resources available online include the following:

  • The American Academy of Family Physicians (AAFP) offers patient education handouts online at its consumer Web site, Handouts are available in English and Spanish on topics such as weight control, diets to lose weight, and exercise programs.

  • The Surgeon General's office has launched a new information clearinghouse to help in the battle against childhood obesity. The clearinghouse is available online at More than 1,000 exercise, nutrition, healthy-baby, and other anti-obesity programs are expected to participate in the clearinghouse. The goals are to set up a registry of programs and resources for parents, teachers, physicians, foundations, and government agencies interested in the latest research.

  • The collaborative group, Action for Healthy Kids, has launched its redesigned Web site at The site offers a resource database and fact sheets on nutrition and exercise programs for children and teenagers, and action planning guides. The collaborative, which includes the AAFP as a partner, is working to address the obesity epidemic by promoting sound nutrition and physical activity in U.S. schools.

  • The Children's Aid Society has launched “JumpStart,” an obesity prevention program targeted at preschool-aged children. Information about JumpStart is available online at The program's goal is to establish healthy eating habits and increase physical activity levels in very young children to prevent the later development of obesity and related health problems.

  • The Centers for Disease Control and Prevention has launched “VERB: It's What You Do.” The program aims to promote physical activity through research, media, partnership, and community efforts. VERB partnership efforts address other issues, including the need to ensure access to safe and affordable physical activity opportunities, both free-time and organized. Information about the VERB campaign is available online at

Vaginal Birth After Cesarean Delivery

The risk of uterine rupture from vaginal birth after cesarean delivery is relatively low, according to findings from the Agency for Healthcare Research and Quality (AHRQ). “Vaginal Birth After Cesarean” is available online at

Nearly 23 percent of births in the United States in 2000 occurred by cesarean delivery; this is the highest rate reported since data collection began in 1989. The rate of vaginal deliveries in women with previous cesarean deliveries decreased 27 percent from 1996 to 2000.

A meta-analysis by the AHRQ found that rates of vaginal delivery in women with a previous cesarean delivery who attempt a trial of labor range from 60 to 82 percent. Although data on the effects of labor induction and augmentation are limited, oxytocin use is associated with a 10 percent reduction in the likelihood of vaginal delivery.

A randomized controlled trial showed that radiographic pelvimetry is not able to reliably predict the route of delivery. Imaging studies that combine measurements of the pelvis and fetus show promising results but are limited by their failure to control for confounding factors.

Maternal mortality rates do not differ between women who attempt labor and women who choose to undergo a repeat cesarean delivery, and evidence suggests that hysterectomy rates also do not differ between the groups. Infection rates are higher in women who have cesarean deliveries; evidence is inconsistent about the effects of labor induction on infection rates. The risk of perinatal death in infants of women attempting labor is unclear, and there is insufficient evidence to make conclusions about the effect of route of delivery on Apgar score and respiratory comorbidity.

The rate of asymptomatic uterine rupture is equal in women attempting labor and women who choose a repeat cesarean delivery. However, symptomatic uterine rupture is significantly more common in women attempting labor. Based on severity and frequency of symptomatic uterine rupture, the risk of perinatal death from rupture of a uterine scar is 1.5 per 10,000; the risk of maternal hysterectomy is 4.8 per 10,000.

Call for Papers of Family Medicine Research Presentations

A call for papers has been issued by the American Academy of Family Physicians (AAFP) for presentation at the 2004 Scientific Assembly occurring October 13 to 17 in Orlando, Fla. Applications must be submitted by April 2. Membership in the AAFP is not a prerequisite for submission.

Applications may be submitted in two different categories. Category I is for original research relevant to family medicine; Category II includes case studies and literature reviews. Each category has six author classifications: family physicians and fellows primarily in academic medicine, family physicians primarily in clinical practice, family medicine residents, medical students, international attendees, and others. The international attendee classification is open to anyone outside the United States who conducted clinical or educational research relevant to family medicine.

Up to six first place winners in Category I and one first-place winner in Category II will each receive a cash award of $1,000. Up to six runners-up in Category I and one runner-up in Category II will receive $250 cash awards. All awards are given at the discretion of the Subcommittee on Family Medicine Research Presentations. Application forms may be obtained by visiting the AAFP Web site at or from Carrie Vickers, Scientific Program Department, AAFP, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211; telephone: 800-274-2237, ext. 6568 or

Trends in Breast Cancer by Race and Ethnicity

Although breast cancer rates have increased among women of all races since the early 1980s, mortality rates from breast cancer have decreased in the past decade, according to data from the American Cancer Society. “Trends in Breast Cancer by Race and Ethnicity” appears in the November/December 2003 issue of CA: A Cancer Journal for Clinicians.

Approximately 211,300 new cases of breast cancer were expected to be diagnosed in 2003, mainly in white women. The annual age-adjusted incidence rate from 1996 to 2000 was 140.8 cases per 100,000 persons in white women, 121.7 per 100,000 in blacks, 97.2 per 100,000 in Asian Americans and Pacific Islanders, 89.8 per 100,000 in Hispanics, and 58 per 100,000 in American Indians and Alaska Natives. The increasing rate in white women predominantly involves small (i.e., 2 cm or smaller) and localized-stage tumors. Black women are more likely to be diagnosed with large tumors and distant-stage disease; the proportion of disease diagnosed at an advanced stage and with larger tumors is greater in all minorities than in white women.

The prevalence of several established risk factors differs across racial and ethnic subpopulations and may contribute to the higher incidence rates in whites compared with other racial and ethnic groups. These include differences in underlying reproductive risk factors (older age at first birth), use of hormone therapy, and access to and use of screening. White women tend to have delayed child bearing and more commonly use hormone therapy. Mammography use also has been historically higher in white women, although rates have become comparable in the most recent survey years.

Mortality rates have decreased by 2.5 percent per year in white women since 1990 and by 1 percent per year in black women since 1991. The disparity in mortality rates between white and black women increased progressively since 1980; by 2000, the age-standardized mortality rate was 32 percent higher in black women.

AHA Policy on Medical Emergencies in Schools

The Emergency Cardiovascular Care Committee of the American Heart Association (AHA) has published a policy statement on medical emergencies in schools. “Response to Cardiac Arrest and Selected Life-Threatening Medical Emergencies: the Medical Emergency Response Plan for Schools” appears in the January 6, 2004 issue of Circulation. The policy statement introduces a public health initiative to help schools prepare to handle life-threatening medical emergencies.

Life-threatening emergencies can occur in any school, at any time. They can be caused by preexisting health problems, violence, injuries, and other unexpected events. They can affect students or the adults who teach and supervise them. At the same time, schools now employ fewer nurses than before, leaving teachers, coaches, and other staff in charge of first aid before the arrival of emergency medical services (EMS) personnel. Yet, in one recent Midwestern survey, one third of teachers had no training in first aid, and almost one half had never completed a course in cardiopulmonary resuscitation (CPR).

The following five key elements are recommended by the AHA for medical emergency response plans in schools:

  1. Effective and Efficient Communication Throughout the School Campus. The statement recommends establishing a rapid communication system that links all parts of a school campus, including outdoor facilities and practice fields, to the local EMS system.

  2. Coordinated and Practiced Response Plan. Schools are encouraged to develop a response plan applicable to a variety of common medical emergencies. Potential resources for developing a plan include the school nurse, athletic team physicians and trainers, and the local EMS agency. The emergency response plan should be practiced at the beginning of each school year and periodically throughout the year.

  3. Risk Reduction. The statement emphasizes injury prevention with appropriate precautions in classrooms and on playgrounds. It suggests identifying students, faculty, and staff members who have medical conditions that might increase their risk of life-threatening emergencies. School personnel should be trained and equipped to respond to the emergency conditions.

  4. Training and Equipment for First Aid and CPR. The statement encourages schools to train as many teachers and school personnel as possible in first aid and CPR, and to provide the equipment necessary to respond appropriately to emergencies. It also encourages schools to train all high school students in CPR.

  5. Implementation of a Lay-Rescuer Automated External Defibrillator (AED) Program in Schools with an Established Need. AED programs have been shown to improve survival in adults who have cardiac arrest outside of a hospital.

The statement was written to address both the need for school medical emergency planning and questions raised by recent publicity and unfunded legislation requiring schools to acquire an AED. The statement makes the point that schools should not focus on a piece of equipment such as an AED, which only may have the potential to help in a small percentage of occurrences. Rather, schools should focus on more important and more common events through comprehensive school medical emergency planning as outlined in the statement.

Organizations endorsing the AHA statement include the American Academy of Pediatrics, the American College of Emergency Physicians, the American National Red Cross, the National Association of School Nurses, the National Association of State EMS Directors, the National Association of EMS Physicians, and the National Association of Emergency Medical Technicians.

Inhaled Corticosteroid Therapy for Asthma

Inhaled corticosteroid therapy remains the gold standard of asthma treatment, according to a new report released by the American College of Chest Physicians, the American Academy of Allergy, Asthma, and Immunology, and the American College of Allergy, Asthma, and Immunology. “Systematic Review of the Evidence Regarding Potential Complications of Inhaled Corticosteroid Use in Asthma” appears in the December 2003 issue of Chest and is available online at

A panel of experts and representatives from the three professional associations identified critical questions that impact decisions regarding the use of inhaled corticosteroid therapy in relation to the five adult and pediatric risk areas of bone mineral density (BMD), cataracts, glaucoma, growth retardation, and skin thinning. Overall, the panel concluded that the benefits associated with inhaled corticosteroid therapy greatly exceed the risks.

In regard to the effect of inhaled corticosteroid therapy on BMD, the panel strongly supported the conclusion that inhaled corticosteroid therapy is not associated with a reduction in BMD in children with asthma. The panel also supported the conclusion that inhaled corticosteroid therapy is associated with skin thinning and easy bruising in adults and children, but that dosage, duration of use, and patient gender are important variables affecting overall risk.

In addition, the panel fully supported the conclusion that inhaled corticosteroid therapy is associated with a decrease in short-term growth rates in children, but that the overall effect is small and may not be sustained with long-term therapy. Conclusions regarding the effect of inhaled corticosteroid therapy on BMD in adults and the effect of inhaled corticosteroid therapy on the development of cataracts and glaucoma were insubstantial because they were supported only by conflicting or insufficient data.

AHRQ Report on Total Knee Replacement

The Agency for Healthcare Research and Quality (AHRQ) has released a report on total knee replacement. “Evidence Report/Technology Assessment: No. 86, Total Knee Replacement” is available online at

Total knee arthroplasty is one of the most common orthopedic procedures performed; 171,335 primary knee replacements and 16,895 revisions occurred in 2001. Because these procedures are elective and expensive (Medicare paid approximately $3.2 billion in 2000 for hip and knee joint replacements) and because the prevalence of arthritis is expected to grow substantially as the population ages, these procedures are likely to come under increasing scrutiny.

Previous reports suggest that total knee arthroplasty improves functional status, relieves pain, and results in relatively low perioperative morbidity. However, based on conclusions from consensus panels or surveys of health care professionals, there is considerable disagreement about the indications for the procedure; that is, which patients are most likely to benefit from total knee arthroplasty and, conversely, in which patients is the procedure contraindicated or of low value.

Observations in the evidence report include the following:

  • Total knee arthroplasty and total knee arthroplasty revisions are associated with improved function. The strongest evidence exists over a follow-up period of up to two years, but the studies that extend to five and even 10 years of follow-up show positive results as well.

  • The average age of patients undergoing total knee arthroplasty was 70 years, with few over age 85. Two thirds were female, one third were considered obese, and nearly 90 percent had osteoarthritis. No studies provided data on racial/ethnic status.

  • There is no evidence that age, gender, or obesity is a strong predictor of functional outcomes.

  • Patients with rheumatoid arthritis show more improvement than those with osteoarthritis, but this difference may be related to their poorer functional scores at the time of treatment and thus their potential for more improvement.

  • The revision rate through five or more years is 2.0 percent of knees and 2.1 percent of patients.

  • Perioperative complications as defined by the investigator occurred in 5.4 percent of patients and 7.6 percent of knees. Most of these complications were “knee related” or deep venous thrombosis. There were only eight cardiovascular or pulmonary complications reported among nearly 6,000 patients, suggesting that these adverse effects were not fully addressed in the literature.

  • There is reason to suspect selection effects in both the type of patients referred for total knee arthroplasty and the cases being reported in the literature, as well as the attrition on follow-up. Therefore, these findings must be interpreted with caution as the basis for clinical practice.

  • Total knee arthroplasty revisions show a similarly positive functional effect (with the same design limitations).

These conclusions are tempered by the limitations of the designs of many studies included in the analysis. Although osteoarthritis does not seem to be a predictor of outcomes, the results seem to be somewhat better in patients who have rheumatoid arthritis, but few of these studies simultaneously controlled for other patient aspects.

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