The biggest Achilles heel in perianal fistulae surgery is the risk of recurrence. Since MR imaging identify the internal fistulous opening, classify the fistulae, and delineate the secondary tracts and extensions with a high degree of sensitivity and specificity, a preoperative MRI study can be extremely useful in charting the ball path of surgical management in complex and recurrent perianal fistulae. Forewarned of possible complicating factors, surgeon can plan the surgery well, and achieve a complete eradication of the disease.
Cancer of Oral Cavity Abutting the Mandible; Predictors of Loco-regional Fail...Dr./ Ihab Samy
TAREK K. SABER, M.D.; HESHAM A. HUSSEIN, M.D.; ALI H. MEBEED, M.D.;
HESHAM I. EL SEBAI, M.D.; IHAB SAMI, M.D. and IMAN G. FARAHAT, M.D.*
The Departments of Surgical Oncology and Pathology*, National Cancer Institute, Cairo University.
Journal of the Egyptian Nat. Cancer Inst., Vol. 21, No. 3, September: 219-227, 2009
Cancer of Oral Cavity Abutting the Mandible; Predictors of Loco-regional Fail...Dr./ Ihab Samy
TAREK K. SABER, M.D.; HESHAM A. HUSSEIN, M.D.; ALI H. MEBEED, M.D.;
HESHAM I. EL SEBAI, M.D.; IHAB SAMI, M.D. and IMAN G. FARAHAT, M.D.*
The Departments of Surgical Oncology and Pathology*, National Cancer Institute, Cairo University.
Journal of the Egyptian Nat. Cancer Inst., Vol. 21, No. 3, September: 219-227, 2009
A simplified technique of esophageal self-expandable metallic stent placement...Peachy Essay
The advantages of the simplified technique are as follows: technical ease, cost-effectiveness, no exposure to radiation,
requirement of minimal manpower, and less time-consuming; these advantages make it the technique day-care procedure.
Cervical Sympathetic chain ganglioneuroma : case report and review of literatureiosrphr_editor
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
A simplified technique of esophageal self-expandable metallic stent placement...Peachy Essay
The advantages of the simplified technique are as follows: technical ease, cost-effectiveness, no exposure to radiation,
requirement of minimal manpower, and less time-consuming; these advantages make it the technique day-care procedure.
Cervical Sympathetic chain ganglioneuroma : case report and review of literatureiosrphr_editor
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
Every Drop Matters initiative. Bogachan Benli, UNDP. Kadri Ozen, Coca Cola. Techniques and models to further water cooperation to improve water efficiency and water services in cities. International Annual UN-Water Zaragoza Conference 2012/2013. Preparing for the 2013 International Year. Water Cooperation: Making it Happen! 8-10 January 2013
Session overview. Rudolph Cleveringa, Senior Technical Adviser, IFAD.Furthering water cooperation in rural areas. Making it happen! International Annual UN-Water Zaragoza Conference 2012/2013. Preparing for the 2013 International Year. Water Cooperation: Making it Happen! 8-10 January 2013
Presentation on 'A science based tool for the sistematic integration of geothermal resources into regional energy planning' by Paolo Fulignati, University of Pisa, Italy, at 2014 UN-Water Annual International Zaragoza Conference. Preparing for World Water Day 2014: Partnerships for improving water and energy access, efficiency and sustainability. 13-16 January 2014.
Abstract—3D ultrasound (3-dimensional sonography) when combined with sonosalpingography, it provides detailed information regarding internal and external contours of the uterus, without the need for radiation contrast material or surgical intervention. This study was done because of the need of such diagnostic modality that is highly accurate as well as least invasive. A descriptive study was conducted on 50 infertile females to assess the diagnostic value of 3-dimensional SHG in reference of diagnostic hystero-laproscopy (DHL) assuming as gold standard. It was found that sensitivity of 3-dimensional SHG reasons of tubal patency, ovarian pathology and uterine cavity was found 97.6%, 90.91% and 71.43% respectively. And diagnostic accuracy of 3-dimensional SHG in reference of DHL for tubal patency, ovarian pathology and for uterine cavity was found 96%, 92% and 96% respectively. So it can be concluded from present study that 3-Dimensional sonohysterography is an efficient tool to assess women with infertility. Its sensitivity, specificity, and diagnostic accuracy is comparable to hysterolaproscopy.
Overlapping MAF is a modification of the original MAF technique used in the management of high anal fistulas. This simple modification showed to improve the success rate in 10% more than the original technique.
Comparative Study Of Pterygium Excision With Conjunctival Autograft,Wet Amnio...Dr. Jagannath Boramani
Presenter: Dr. Pavitra K. Patel, Co-authors: Dr. Sachin Daigavane,Dr. Mala Kamble, Department of Ophthalmology, Jawarharlal Nehru Medical College & Acharya Vinoba Bhave Rural Hospital, Sawangi, Wardha.
HCC is the most common primary liver malignancy and cause of cancer-related death worldwide including Bangladesh. It occurs more often in males than females. The incidence of HCC continues to escalate due to HBV, HCV infection, non-alcoholic fatty liver disease (NAFLD). HBV and HCV are also important etiological factors for developing chronic liver disease (CLD) and HCC.
Study of the sensitivity of Hydrocolonic Sonography (HS) in the detection of colonic lesions and how hydrocolonic sonography with echographic contrast agent (HSEC) can improve this technique.
Hydrocolonic Sonography. A Forgotten TechniqueJohnJulie1
Exploration of the splenic angle and upper portion of the descending colon using contrast. On the left, in contrast mode. In the left half, the enhanced lesion has a central area where the saline solution does not show contrast. This behaviour gives it the characteristic “inverted apple core” appearance of an adenocarcinoma, which can be seen in the first 20 seconds and after the 50 seconds mark until the end of the video. However, in the second period the enhancement is lower. In the right half, the hypoechoic lesion can be seen without enhancement. Note how linear the wall is without lesions in both halves. Faecal remains appear as hyperechoic images which move with the serum.
Similar to Significance of MR imaging in setting the ball path of surgical management in perianal fistulae (20)
Malignant Mixed Mullerian Tumor – Case Reports and Review ArticleApollo Hospitals
Malignant mixed mullerian tumors are very rare genital tumors. They are biphasic neoplasms composed of an admixture of malignant epithelial and mesenchymal elements. In descending order of frequency they originate in the uterus, ovaries, fallopian tubes, cervix and vagina. Also they arise denovo from peritoneum. They are highly aggressive and tend to occur in postmenopausal low parity women. Because of rarity, there is as such no treatment guidelines available. Multimodality treatment in the form of radical surgery followed by adjuvant chemotherapy or radiotherapy or combined chemoradiation gives a better prognosis & outcome. Two case reports of such tumors, one from ovary and other from penitoneum are presented along with the review of literature.
Intra-Fetal Laser Ablation of Umbilical Vessels in Acardiac Twin with Success...Apollo Hospitals
To interrupt blood supply to the acardiac twin in a case of TRAP sequence of monochorionic diamniotic multiple pregnancy to allow for continuation of the normal twin.
Breast Cancer in Young Women and its Impact on Reproductive FunctionApollo Hospitals
Breast cancer is the most common cancer in women in developed countries. Chemotherapy for breast cancer is likely to negatively impact on reproductive function. We review current treatment; effects on reproductive function; breastfeeding and management of menopausal symptoms following breast cancer.
Turner syndrome (gonadal dysgenesis) is one of the most common chromosomal abnormalities occuring 1 in 2500 to 1 in 3000 live-born girls. It is an important cause of short stature in girls and primary amenorrhea in young women that is usually caused by loss of part or all of an X chromosome. This review briefly summarises the current knowledge about the syndrome and the management strategies.
Due to pregnancy thyroid economy is affected with changes in iodine metabolism, TBG and development of maternal goiter. The incidence of hypothyroidism in pregnancy is quite common with autoimmune hypothyroidism being the most important cause. Overt as well as subclinical hypothyroidism has a varied impact on maternal and neonatal outcome. After multiple studies also, routine screening in pregnancy for hypothyroidism can still not be recommended. Management mainly comprises of dosage adjustments as soon as pregnancy is diagnosed based on results of thyroid function tests. The aim should be to keep FT4 at the upper end of normal range.
Growth Hormone Deficiency (GHD) can persist from childhood or be newly acquired. Confirmation through stimulation testing is usually required unless there is a proven genetic/structural lesion persistent from childhood. Growth harmone (GH) therapy offers benefits in body composition, exercise capacity, skeletal integrity, and quality of life measures and is most likely to benefit those patients who have more severe GHD. The risks of GH treatment are low. GH dosing regimens should be individualized. The final decision to treat adults with GHD requires thoughtful clinical judgment with a careful evaluation of the benefits and risks specific to the individual.
Advances in the management of thalassemia have led to marked improvements in the life span and quality of life of children and young adults. This poses new challenges for the treating physicians. There is now increasing recognition that thalassemics have impaired bone health which is multifactorial in etiology. This paper aims to highlight the factors that predispose these patients to osteoporosis and suggests measures to minimise the impact on bone health.
Laparoscopic Excision of Foregut Duplication Cyst of StomachApollo Hospitals
Retroperitoneal gastric duplication cysts lined by ciliated columnar epithelium are extremely rare lesions and its presentation during adulthood is a diagnostic challenge for treating clinicians. This entity often resembles cystic pancreatic neoplasm, retroperitoneal cystic lesions and sometimes as an adrenal cystic neoplasm. Correct diagnosis on the basis of radiological investigation is difficult and histopathologic analysis. We report a case of gastric duplication cyst in a 16year old girl that mimicked as a retroperitoneal /pancreatic /adrenal cystic lesion and was successfully managed by laparoscopy.
Occupational Blood Borne Infections: Prevention is Better than CureApollo Hospitals
Viral infections like HIV, hepatitis Band C virus pose a big risk to the contacts of individuals with high risk behaviour as well as to the attending health care workers. Blood, semen, vaginal and other potentially infectious materials can transmit the infection to the susceptible contacts. Universal precautions should be strictly implemented during clinical examination, laboratory work and surgical procedures to prevent transmission to the health care providers. Health care workers should receive vaccination for hepatitis B infection. An inadvertent exposure should be managed with proper first aid and infectivity of the source and severity of exposure should be assessed. Severity of exposure is based on the nature and area of exposed surface, mode of injury and volume of infective material. Post-exposure prophylaxis (PEP) should be started as soon as possible after a proper counseling about the effectiveness of post-exposure prophylaxis, side effects and risk of carrying the infection to his familial contacts and its prevention.
Evaluation of Red Cell Hemolysis in Packed Red Cells During Processing and St...Apollo Hospitals
Storage of red cells causes a progressive increase in hemolysis. Inspite of the use of additive solutions for storage and filters for leucoreduction some amount of hemolysis is still inevitable. The extent of hemolysis however should not exceed the permissible threshold for hemolysis even on the 42nd day of storage.
Efficacy and safety of dexamethasone cyclophosphamide pulse therapy in the tr...Apollo Hospitals
Various drugs used to treat pemphigus can cause remission, but none can provide permanent remission as relapses are common. With the introduction of DCP in pemphigus in 1984, patients started being in prolonged/permanent remission. This study was done to compare the efficacy of DCP to oral corticosteroids and cyclophosphamide in combination.
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)Apollo Hospitals
Severe skin adverse drug reactions can result in death. Toxic epidermal necrolysis (TEN) has the highest mortality (30–35%); Stevens-Johnson syndrome and transitional forms correspond to the same syndrome, but with less extensive skin detachment and a lower mortality (5–15%). Hypersensitivity syndrome, sometimes called Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), has a mortality rate evaluated at about 10%. It is characterised by fever, rash and internal organ involvement. Prompt diagnosis is vital, along with identification and early withdrawal of suspect medicines and avoidance of re-exposure to the responsible agent is essential. Cross-reactivity to structurally-related syndrome caused by Carbamazepine medicines is common, thus first-degree relatives may be predisposed to developing this syndrome. We report a case of DRESS secondary to use of Carbamazepine.
Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?Apollo Hospitals
Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications for laparoscopic removal of gall bladder few years back.
We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May'08 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when we found -dense fibrotic adhesions in and around Callot's triangle, gangrenous gall bladder, empyma, large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi's syndrome, h/o biliary pancreatitis, CBD stones, acute cholecystitis of <72 hrs duration.
Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases were converted to open.
With growing experience and technical advancement surgery can be completed in most of the difficult cases. This is important because recently it is shown in literature that laparoscopic cholecystectomy is associated with less morbidity than open method irrespective of duration of the surgery.
Deep vein thrombosis prophylaxis in a tertiary care center: An observational ...Apollo Hospitals
Deep vein thrombosis (DVT) is a major health problem with substantial mortality and morbidity in medically ill patients. Prevention of DVT by risk factor stratification and subsequent antithrombotic prophylaxis in moderate- to severe-risk category patients is the most rational means of reducing morbidity and mortality.
The spread of dengue and dengue haemorrhagic fever is increasing, atypical manifestations are also on the rise, although they may be under reported because of lack of awareness. We report two such cases of dengue hemorrhagic fever with hepatitis, intraocular hemorrhage, ARDS and myocarditis.
A 71-year-old male presented in ENT department with dysphagia for last three weeks, more to solids than liquids. He had a hard bony bulge in the posterior pharyngeal wall on palpation and hence was referred for an Orthopaedic opinion. Lateral radiograph of the cervical spine revealed diffuse ossification of the anterior longitudinal ligament. This ossification was extending almost half the width of the cervical body from its anterior body at C1 and C2 vertebra level.
Pediatric Liver Transplant (LT) is now an established procedure for End Stage Liver Disease (ESLD) with biliary atresia being the commonest indication. Intensive pre-transplant evaluation, nutritional buildup and immunization are the fundamental pre-requisites of a successful LT. With improvement in surgical micro-anastomotic techniques and superior immunosuppressive regimens the success rate of pediatric LT is in excess of 90%. Most of the transplants in our country however are Living related, due to which a fairly large number of children expire awaiting a donor liver. There should be a concerted effort to evolve the cadaveric donation program, so that majority of the children are benefitted.
Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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
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.
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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3. 2 a p o l l o me d i c i n e x x x ( 2 0 1 4 ) 1e5
1. Introduction
Perianal fistula is an abnormal communication between the
anorectum and the perianal skin. Such a communication may
be associated with one or more secondary ramifications and/or
abscesses. A high internal opening and/or transsphincteric
location can exaggerate thecomplexity of a fistula. The surgical
challenge lies in finding success in eradication of fistula in toto,
including all its branches. The persistence of residual disease
complicates and upstages the complexity of remnant fistula.
The situation may be compounded if the anal sphincter com-plex
suffers any damage. This can lead to incontinence. A mild
to moderate incontinence may occur in up to 50% cases.1e3
If the level and site of internal opening, anatomy of pri-mary
tract and presence of secondary ramifications and/or
abscesses can be accurately identified before the surgeon
embarks upon the surgery, such complicating factors can be
nullified, and a complete eradication of the disease can be
achieved. A preoperative pelvic MRI can help achieve these
primary goals.4
2. Materials and methods
This prospective study comprises of 30 consecutive patients
with complex or recurrent perianal fistulae. Each was suitably
counseled, a written informed consent was obtained, and the
findings on digital rectal examination (DRE) were recorded.
This was followed by a pelvic MRI examination.
A high FOV (field of view) localiser sequence was used to
plan out the T1 and T2 weighted sequences followed by pre
and post contrast T1 weighted fat-saturation sequence in axial
and coronal oblique plane. The characteristics of perianal
fistulae were recorded with regard to the site of internal fis-tulous
opening, class of fistula,5 presence of secondary rami-fications
and/or abscess and horseshoeing.
During the course of surgical exploration, intraoperative
findingswere recorded.These observations were correlatedwith
pelvic MRI data. With intraoperative findings as gold standard,
sensitivity, specificity, positive predictive value and negative
predictive value both for DRE and MR imaging were calculated.
3. Results
This study includes 19 first-time patients with complex peri-anal
fistulae and 11 with recurrent disease. DRE could identify
the external opening in all 30 patients. The internal opening
was felt in 10 (33.33%); induration of the tract with a possibility
of supralevator disease in 13; while in 7 the disease was
thought to be extrasphincteric with a high internal opening in
the rectum. DRE could also detect secondary extensions and
abscesses in 8, and horseshoeing in 7 patients.
On MR examination, the internal opening was visualized in
29 (96.67%) patients; while 1 was classified as perianal sinus.
Abscess were found in 9, horseshoeing in 11 and secondary
tracts in 18 patients.
The study cohorts were classified in accordance with St.
James University Classification5 (Table 1). Nine (30.0%)
Table 1 e Classification of perianal fistulaea in the study
cohort (n ¼ 30).
Fistula classification Number Percentage
Grade 1 (Intersphincteric with
4 13.33
no extensions)
Grade 2 (Intersphincteric with
secondary extensions)
4 13.33
Grade 3 (Transsphincteric with
no extensions)
7 23.34
Grade 4 (Transsphincteric with
secondary extensions)
9 30.00
Grade 5 (Extrasphincteric/
Suprasphincteric)
6 20
Total 30 100
a St. James University MRI Classification.5
patients had grade 4 (transsphincteric fistula with secondary
extensions/abscesses) perianal fistulae; 7 (23.34%) had grade 3
(transsphincteric with no extensions) perianal fistulae; 6 (20%)
had grade 5 (extrasphincteric/suprasphincteric) perianal
fistulae; and 4 (13.33%) patients each had grade 1 (inter-sphincteric
with no extensions) and grade 2 (intersphincteric
with secondary extensions) perianal fistulae.
While DRE could correctly grade the disease in 10/30 pa-tients,
MRI succeeded in doing so in 26/30 patients. The
comparative sensitivity, therefore, was 33.33% for DRE, and
86.67% for MRI (Table 2).
DRE could identify 8/9 associated abscesses with a sensi-tivity
of 88.89%, while MRI could pick all, with a sensitivity of
100%. DRE identified horseshoeing in 7/11 patients, with a
sensitivity of 63.63% and NPV of 82.60%. MRI identified all 11,
with a sensitivity, specificity, PPV and NPV of 100%.The sec-ondary
tracts were felt in 8/19 patients on DRE with a detec-tion
rate of 42.11%, while MRI detected secondary tracts in 18
cases with a sensitivity of 94.74% (Table 3).
4. Discussion
This study probes into the clinical usefulness of MRI in oper-ative
management of complex and recurrent perianal fistulae.
This usefulness hinges on accurate localization of site and
level of internal opening, delineating the primary tract and
identifying its secondary ramifications. In this study, MRI
demonstrated a high degree of accuracy in identifying each of
the three characteristics.
The external opening was localized on DRE in all 30 sub-jects.
Of them, 17 (56.67%) were situated in posterior and
posterolateral position. The high precedence of this location is
Table 2 e Comparative accuracy of clinical vs. MRI
findings in classification of perianal fistulae.
Disease
Clinical
MR imaging
characteristic
classification
classification
Surgical
validation
Fistulae correctly
classified
10(33.33%) 26(86.67%) 30(100%)
Fistulae falsely
classified
20(66.67%) 4(13.33%) 0
Total 30 30 30
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perianal fistulae, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.08.005
4. a p o l l o m e d i c i n e xxx ( 2 0 1 4 ) 1e5 3
related to anatomy of anal glands, which open posteriorly into
the anal crypts most commonly. Similar results were found in
400 subjects, with the external opening in 44.7% subjects being
posterior and lateral in location.6 This evaluation of external
opening on DRE is critical from the perspective of triage
making use of the Goodsall's rule in pre-empting the
complexity of fistula.
MR imaging was far superior to DRE in defining the internal
opening of perianal fistulae. The sensitivity of DRE in detec-tion
of internal opening was 33.33% and on MRI 96.67% and
both had a PPV of 100%. This failure of DRE in its inability to
detect the internal opening may relate to several reasons: in
some patients, the internal opening was flush with the rectal
mucosa, and in others, the induration and inflammation from
preceding surgery made the differentiation between the
granulation tissue at the internal opening and the healed scar
of previous surgery difficult. Even on MR imaging, the detec-tion
of internal opening of perianal fistulae is not always easy.
The opening must be inferred by following the course of fis-tulous
tract in the intersphincteric space and the area of
maximum intersphincteric sepsis. In the solitary case, where
MRI failed us, the failure occurred due to confusion between
possible postoperative signal alteration and active inter-sphincteric
sepsis. Since this was a patient with recurrent
disease, we mistook the intersphincteric sepsis as a post-operative
tissue change.
On MR imaging, the largest number (16/30; 53.34%) were
transsphincteric fistulas, i.e., St. James University Hospital
Classification Grade 3 and 4. These results are divergent from
other studies,5,7 which report intersphincteric fistulas to be
the commonest. This difference in the type of fistulae possibly
relates to inclusion of far more complex recurrent perianal
fistulas in the present series.
The MR imaging is able to delineate the pelvic anatomy
well and with high resolution (Fig. 1a and b). Due to these
virtues, it is capable of demonstrating the relationship of the
perianal fistula with sphincter complex and helps in accurate
categorization of perianal fistula (Fig. 2). In this series, we
could classify the fistulae accurately with MR imaging in 26
(86.67%) patients. Of the 4 patients where we failed, 3 were
transsphincteric fistulae. We mistook them as intersphinc-teric.
Each of them had recurrent disease, with gross distor-tion
of perianal anatomy which interfered with the
visualization of outer interface of external sphincter muscle.
When we retrospectively analyzed the MR images in these
patients, we found the primary fistulous tract was criss-crossing
the external sphincter muscle randomly, and this
could have contributed to the blemish.
The results of this study show a linear increasing trend
between clinical and MR imaging for their accuracy in
classifying the disease as the sensitivity for correctly classi-fying
the disease was 33.33% on DRE as against 86.67% on MRI.
This trend is similar to that recorded by Steve Halligan et al.
who reported a significant linear trend (p ¼ 0.001) in the pro-portion
of fistula tracks (n ¼ 108) correctly classified with each
modality, as follows: clinical examination, 66 (61%) patients;
endosonography, 87 (81%) patients; MR imaging, 97 (90%)
patients.8
A study from the St Mark's Hospital Intestinal Imaging
Centre has also recently concluded that MR imaging is an
optimal technique for discriminating complex from simple
perianal fistula. While the sensitivity of MRI in this study
was found to be 95%, that of clinical assessment was restricted
to 75%.9
Table 3 e Correlation of preoperative clinical evaluation,
MRI and intraoperative findings.
Disease
Clinical
MR
characteristics
evaluation
imaging
Surgical
data
Internal opening 10 (33.33%) 29 (96.67%) 30 (100%)
Abscesses 8 (88.89%) 9 (100%) 9 (100%)
Horse shoeing 7 (63.64%) 11 (100%) 11 (100%)
Secondary extensions 8 (42.11%) 18 (94.74%) 19 (100%)
Fig. 1 e (a and b): Normal MR Anatomy of sphincter
complex. Axial T1 weighted image (a) of perianal region
shows the intermediate signal intensity internal (short
arrow) and external sphincter (long arrow) muscles. The
high signal intensity ischioanal fat bounds them on either
side. Coronal T1 weighted image (b) shows puborectalis
muscle (short arrow) which continues as external
sphincter (long arrow).
Please cite this article in press as: Kumar N, et al., Significance of MR imaging in setting the ball path of surgical management in
perianal fistulae, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.08.005
5. 4 a p o l l o me d i c i n e x x x ( 2 0 1 4 ) 1e5
The identification of the secondary tracts also poses great
difficulty in patients with complex recurrent fistulae. Such
patients tend to have secondary extensions several centime-ters
away from the anal canal and, to make things worse,
these tracts traverse virtually in any direction (Fig. 3). In the
present study, 19 patients were found to have secondary ex-tensions
at the time of surgery. Of them, 18 (95%) could be
picked on MR imaging. This failure could be due to spuriously
high signal in scarred (healed) tract or faulting secondary tract
for adjacent vessel.
The sensitivity of DRE was 42%, while that of MRI was a
robust 94.74%, with 100%specificity and 91.67% NPV. Similar
results have been reported by others. Spencer et al., in a study
of 42 patients with perianal fistulae, found DRE failed to pick
abscesses in 8 of the 22 patients, and was unable to detect
complex secondary tracts in 3/6 (50%) patients with complex
perianal fistula.5
Horseshoe extensions can be identified by their unique
configuration when the extension occurs in horizontal plane
on either side of midline (Fig. 4). In the present study, DRE
identified the associated abscesses and horseshoeing well,
with a detection rate of 89% (8/9) and 64% (7/11) respectively.
This finding however is in contrast to findings of Halligan
et al.; they could identify only 23/68 (36%) horseshoe exten-sions.
8 In the present study, MRI identified the abscess and
horseshoeing in all cases and enjoyed 100% sensitivity, spec-ificity,
PPV and NPV.
The information gleaned from MR imaging in the present
study had a palpable effect on the patient's surgical manage-ment.
Besides the 10 (33%) internal openings identified on
clinical assessment, MR imaging could pick the internal
Fig. 2 e Relationship of the fistula tract with sphincter
complex. Coronal T1 weighted MR image of perianal region
shows slightly hyperintense fistula tract (white long arrow)
in the right perianal region traversing the external (short
colored arrow) and internal anal sphincter muscle (long
colored arrow) with uninvolved levator ani muscles
bilaterally (vertical arrow) consistent with right sided
trans-sphincteric fistula (Grade 3).
Fig. 3 e Axial T1 weighted MRI of perianal region. Multiple
secondary tracts (arrows) are seen on either side of anal
canal in a complex trans-sphincteric fistula (Grade 4).
Fig. 4 e Axial post contrast T1 weighted MR image of
perianal region. There is evidence of a complex trans-sphincteric
fistula (Grade 4) with horseshoeing across the
midline posteriorly and widening of fistula tract (vertical
arrow) with low signal air foci within the abscess.
Please cite this article in press as: Kumar N, et al., Significance of MR imaging in setting the ball path of surgical management in
perianal fistulae, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.08.005
6. a p o l l o m e d i c i n e xxx ( 2 0 1 4 ) 1e5 5
opening in another 19 (63%) patients. If clinical evaluation
could correctly classify the disease in 10 (33.33%) patients, MR
imaging could do so in 16 (53.33%) more. Likewise, besides the
8 secondary tracts detected on DRE, MRI could identify 10
(52.63%) more.
MR imaging is therefore an optimal modality for the eval-uation
of complex and recurrent perianal fistulae. It can
identify the internal opening, classify the disease, and delin-eate
the secondary tracts and extensions well. This provides
an excellent roadmap to the operating surgeon, who can
achieve a complete eradication of disease by excising the fis-tula
in toto.
5. Conclusion
A precise preoperative anatomic detailing of the fistula is
essential from the standpoint of its complete eradication. This
can be best achieved with MR imaging of the perianal region,
particularly in such cases, where a perianal fistula is thought
to be complex or the disease is recurrent.
Conflicts of interest
All authors have none to declare.
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Please cite this article in press as: Kumar N, et al., Significance of MR imaging in setting the ball path of surgical management in
perianal fistulae, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.08.005