fistula-in-ano, or anal fistula, is a chronic abnormal communication extending from the anorectal lumen (the internal opening) to an external opening on the skin of the perineum or buttock.
Majority are idiopathic.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
2. Objectives
Understanding the :
Pathophysiology and classification of the anal fistulas and anal carcinomas
in brief.
To be familiar with the role of fistulograms , ultrasounds , PET and MRI.
3. ANATOMY
The anal canal is a cylindrical structure
surrounded by two muscular layers, the
internal and external sphincters.
The internal sphincter is composed of
smooth muscle, the fibers of which are
continuous with the circular smooth muscle
of the rectum
The external sphincter is composed of
striated muscle and has posterior
attachments to the anococcygeal ligament
and anterior attachments to the perineal
body and urogenital diaphragm.
The two sphincters are separated by the
intersphincteric space, which contains fat,
areolar tissue, and the longitudinal muscle.
This space forms a natural plane of lower
resistance in which fistulas and pus can
readily spread.
4. ANAL FISTULAS
Basically an anal fistula is a tract
that connects an anal ( or rectal )
internal opening with an external
opening ( perianal skin).
5.
6. Etiology and
Pathogenesis
Primary causes : The most common cause is due to
obstruction of anal gland which leads to stasis and
infection with abscess and fistula formation.
Or they may be secondary to:
Surgery (eg. hemorrhoideal surgery)
Inflammatory bowel diseases ( eg. Crohn's
disease)
diverticulitis
Infections (viral, fungal or TB)
trauma during childbirth
Malignancy
radiation therapy
7. CLINICAL FINDINGS
Chronic draining abscess
Pain with defecation
Pruritis ani
O/E : Erythema , induration and excoriated skin.
10. Fiistulogram of a male patient
showing several high extensions
surrounding the anorectal junction
Limitations:
The pelvis floor ( levator ani muscles )
cannot be visualized directly.
The exact level of the internal opening in
the anal canal is often impossible to
determine with sufficient accuracy
The sphincter muscles themselves are
not directly imaged.
??Supra- or an infralevator location.
Acute tracks may not have a patent
lumen.
Locating these extension is central for
surgical management.
20. Classification of Perianal Fistulas
The most widely used classification is the Parks Classification which
distinguishes four kinds of fistula:
21. PARKS CLASSIFICATION.
A = Intersphincteric (45%)
B = Transsphincteric (30%)
C = Suprasphincteric (20%)
D = Extrasphincteric
The most common fistulas are the intersphincteric and the
transsphincteric.
The extrasphincteric fistula is uncommon and only seen in patients
who had multiple operations. In these cases the connection with
the original fistula tract to the bowel is lost.
A superficial fistula is a fistula that has no relation to the sphincter
or the perianal glands and is not part of the Parks classification.
These are more often due to Crohns disease or anorectal
procedures such as haemorrhoidectomy or sphincterotomy.
22. Reporting
When describing a fistula, it is important to mention the
following characteristics:
-Position of the mucosal opening on axial images (using the
anal clock).
-Distance of the mucosal defect to the perianal skin on coronal
images.
-Secondary fistulas or abscesses.
The drawing illustrates the anal clock, which is the surgeon's
view of the perianal region when the patient is in the supine
lithotomy position.
This scheme corresponds to the orientation of axial MR
images of the perianal region.
24. On the coronal image
the fistula runs caudally
towards the skin.
There is no connection
with the external
sphincter.
25. Transsphincteric fistula
Axial T2WI and T2WI + fatsat of a
transsphincteric fistula.
The defect through the internal and
external sphincter at 6 o'clock is clearly
visible and more apparent on the fat sat
images.
27. An example of a
suprasphincteric fistula.
There are two tracts in the
ischioanal region.
The right sided tract runs
over the puborectal muscle
(asterisk) and the mucosal
opening lies at the level of
the linea dentata (black
arrow).
28. Extrasphincteric fistula
Coronal T2W-images of a
small abscess in the left
ischioanal fossa, the fistula
runs through the levator
ani.
It is therefore above the
sphincter complex and
extrasphincteric.
29. Complex Fistula
Two tracts in the left buttock form a single tract (no. 1-2).
This fistula breaks through the external sphincter (no. 4).
In the intersphincteric space it divides again into two tracts (no. 5).
One ends blindly in the intersphincteric space (no. 6).
The other breaks through the internal sphincter with the mucosal defect at 1 o'clock.complex fistula
30. Crohn's
disease
Patient with a perianal
fistula who has Crohn's
disease
Axial fatsat images
depict the transmural
inflammation with
infiltration of the
mesenteric fat.
Coronal images shows
the thickening of the
bowel wall
31. Fistulography
Fistulography is a traditional radiologic technique used to define the
anatomy of fistulas, yet it is an unreliable technique and is difficult to
interpret.
Ultrasonography
The benefits of ultrasonography over MRI are the former's ubiquity and
lower operating costs
MRI
MRI is the imaging modality of choice.
32. Treatment
Seton fistulotomy
Fistulotomy
Fistulectomy
This patient was already known
to have an interspinchteric
fistula, the mucosal defect is at
1 o'clock.
In the tract there is a linear
structure with a low signal
intensity. This is the Seton
which was inserted to treat the
fistula.
34. EPIDEMILOGY
Anal cancer is a relatively uncommon malignancy & accounts for only 1 – 2 % of all large
bowel malignancy.
Ratio of 1:2 for men to women.
Median age is 60 yrs.
RISK FACTOR
HIV infection
Immunosuppression
The number of lifetime sexual partners, and receptive anal intercourse
Smoking
In females: previous in situ or invasive cervical, vulval or vaginal cancer.
35. Clinical Presentation
Approximately 45% of patients may present with bleeding per rectum.
Around 30% of patients may have pain and/or a sensation of a mass.
36. Pathology
Anal carcinoma typically originates
between the anorectal junction above
and the anal verge below.
The vast majority of anal canal
cancers are squamous cell cancers.
39. Early T1 anal tumor
MR image shows that normal low
signal of anal canal muscle has
been replaced by intermediate-
signal tumor (arrow) that is less than
2 cm.
40. T2 Anterior Anal canal carcinoma.
-MR image shows that lesion
measures >2 cm and < 5cms.
-There is invasion of external
sphincter (arrow).
41. T3 Anal Carcinoma
- Size more than 5 cm.
- No evidence of adjacent organ
invasion, as evidenced by complete
low-signal rim (arrowheads)
separating tumor from prostate
anteriorly.
42. T4 anal cancer
MR image shows lobulated
tumor with invasion into
posterior vagina (arrow).
43. T4 Anal Carcinoma + nodal & organ
metastasis
- Size More than 5cms and invasion into
adjacent organs.
- Inguinal nodal metastases.
- Bilateral enhancing perirectal
adenopathy (arrows)
45. Conclusion…
• MR imaging has emerged as the imaging technique of choice for
preoperative evaluation of perianal fistulas and anal carcinomas providing a
highly accurate, rapid, and noninvasive means of performing pre-surgical
and post treatment assessment.
• FDG PET/CT alters staging of anal carcinoma in approximately 20% of
cases and treatment intent in approximately 3–5% of cases.
This is what the surgeon sees . The external openings…. What is actually important is the internal opening and their extensions…
Extensions from the primary tract may fail to fill with contrast material if they are plugged with debris, are very remote, or there is excessive contrast material reflux from either the internal or external opening
• the sphincter muscles themselves are not directly imaged, which means that the relationship between any tract and the sphincter must be guessed
• difficult to decide whether an extension has a supra- or an infralevator location
• the exact level of the internal opening in the anal canal is often impossible to
determine with sufficient accuracy
• Acute tracks may not have a patent lumen
• Difficult to relate the track to the sphincter and levator ani
• Shown to be accurate in only 16 %
• cannot distinguish between the different types of fistula and its exact course
through/in between anal sphincters and also fails to know the integrity of
sphincters
Water soluble iodine dye is used.
This can be used intraoperatively.
Intersphincteric fistulas accounted for 45% of cases. These fistulas ramify only in the inter-sphincteric space and do not traverse the external sphincter, which forms a relative barrier to the spread of infection. The track runs along the longitudinal muscle layer between the internal and external sphincters and may reach the perianal skin through or medial to the subcutaneous external sphincter.
In transsphincteric fistulas (30% of cases in the study), the track passes from the intersphincteric space through the external sphincter into the ischiorectal fossa.
In suprasphincteric fistulas (20% of cases in the study), the track progresses upward into the intersphincteric space, passes over the top of the puborectalis muscle, then descends through the levator plate to the ischiorectal fossa and finally to the skin.
In extrasphincteric fistulas, the track passes from the perineal skin through the ischiorectal fossa and levator muscles then into the rectum.
Thus, this fistula lies completely outside the external sphincter complex.
Anal fistulas are classified according to their progression relative to the anal sphincter and pelvic floor structures.
To locate the point of origin and describe the direction of the fistulous track, we use an “anal clock” scheme, which is the same as that used by surgeons to describe injuries around the anal region
When you see fistulas track passes from the perineal skin through the ischiorectal fossa and levator muscles then into the rectum…
Think of Crohns disease
References can be provided
Seton fistulotomy is a technique where a rubber ligature or vessel loop is pulled through the fistula, it then is tightened every 2 weeks or so in order to obtain pressure necrosis so that the Seton is slowly pulled through the muscle. This has the advantage that the muscle is slowly cut and fibroses at the same time in order to cause as little damage as possible to the sphincter complex.
MRI has become the imaging modality of choice for locoregional staging and assessment of tumor response after chemoradiotherapy.
MRI provides high-resolution multiplanar information about the location, size, circumferential and craniocaudal extent of the primary tumor and information regarding the involvement of adjacent structures.
FDG PET/CT has an increasing role in staging and treatment planning of anal carcinoma, particularly because up to 98% of anal tumors are FDG-avid.
At diagnosis, FDG PET/CT is used to evaluate primary tumor size, lymph node status, and whether distant metastases are present.
FDG PET/CT can also be useful for planning radiation therapy by clearly defining sites of metabolically active tumor. .
Increased FDG uptake (arrow) and metabolically active right inguinal node, pelvic side wall lymph node and distant liver metastasis…
