Perianal disease: Updates and controversies in closing the gaps

Perianal complications are common and morbid in children with Crohn's disease. In this review, we describe the epidemiology, the presentation and diagnosis, evaluation and management. We focus on updates such as the increasing frequency of biologic medications and MRI for evaluation. We also highlight controversies on the timing and approaches to surgical techniques. Finally, perianal disease requires the coordination of multidisciplinary care with nursing, radiology, gastroenterology, and surgery to optimize outcomes - both medical and patient-centered.

Anal pruritus: Don’t look away

Anal pruritus is a common anorectal symptom that can significantly impair a patient’s quality of life, including their mental health. It can be one of the most difficult proctological conditions to treat. Patients often delay seeking medical attention, since it is an embarrassing but non-life-threatening situation. Pruritus ani can be associated with idiopathic and secondary causes, such as anorectal diseases, cancer (anal or colorectal), dermatological and sexually transmitted diseases, fungal infections and systemic diseases. If patients are referred for a colonoscopy, this can sometimes provide the first opportunity to evaluate the perianal area. Classifications of anal pruritus are based on the abnormalities of the perianal skin, one of the most commonly used being the Washington classification. A proper digital anorectal examination is important, as well as an anoscopy to help to exclude anorectal diseases or suspicious masses. Endoscopists should be aware of the common etiologies, and classification of the perianal area abnormalities should be provided in the colonoscopy report. Information on treatment possibilities and follow-up can also be provided. The treatment normally consists of a triple approach: proper hygiene, elimination of irritants, and skin care and protection. Several topical therapies have been described as possible treatments, including steroids, capsaicin, tacrolimus and methylene blue intradermal injections.

Anorectal Emergencies

Anorectal emergencies are rare presentations of common anorectal disorders, and surgeons are often called on to assist in their diagnosis and management. Although most patients presenting with anorectal emergencies can be managed nonoperatively or with a bedside procedure, surgeons must also be able to identify surgical anorectal emergencies, such as gangrenous rectal prolapse. This article provides a review of pertinent anatomy; examination techniques; and workup, diagnosis, and management of common anorectal emergencies including thrombosed hemorrhoids, incarcerated hemorrhoids, anal fissure, anorectal abscess, rectal prolapse, and pilonidal abscess and unique situations including rectal foreign body and anorectal sexually transmitted infections.

Fetal cortical development and neurosonographic findings in obese pregnant women: a case control study from a tertiary hospital

PURPOSE

To investigate the effect of obesity on fetal cortical development.

METHODS

This prospective cross-sectional study was conducted with 91 pregnant women. Fetal neurosonography scans were performed in the third trimester, and according to body mass index (BMI) values, the patients were evaluated in two groups: obese (BMI ≥ 30 kg/m2) and normal weight (BMI < 30 kg/m2). During neurosonography, fetal insular depth and Sylvian fissures, parieo-occipital and cingulate fissure depth, frontal lobe length, and the sizes of the corpus callosum and cavum septum pellucidum were measured using a transvaginal approach. Fetal cortical development and Sylvian fissure operculization were graded.

RESULTS

The number of patients with grade 2 fetal cortical development was significantly higher among the pregnant women in the obese group compared to the normal weight group (n = 17, 41.5% and n = 8, 16.0%, respectively; p = 0.007). In the obese group, the number of pregnant women with grade 4 or below fetal Sylvian fissure operculization was significantly higher (n = 13, 31.7%), and the number of those with grade 9 or above operculization was significantly lower (n = 1, 2.5%) (p = 0.003). The fetal insular depth, frontal lobe anterior-posterior diameter, cingulate fissure depth, and corpus callosum thickness were lower in the obese group, albeit with no significant difference. Parieto-occipital depth significantly decreased in the obese group [6.8 (6) mm)] compared to the control group [10.5 (7.2) mm)] (p = 0.008). The fetal Sylvian fissure ratio and the cavum septum pellucidum ratio were found to be similar between the groups.

CONCLUSION

The data obtained from this study showed that obesity caused fetal cortical changes in pregnant women.

Adjacent lobe invasion of T2 tumor in non-small cell lung cancer has T3 disease-like survival fissure invasion: T2 or T3?

Controversy still exists regarding the staging of non-small cell lung cancer (NSCLC) with adjacent lobe invasion (T-ALI) according to the TNM system in terms of T factor and the appropriate surgical resection method. We performed an analysis to compare the prognosis of T-ALI with T2 and T3 disease and to see the effect of our surgical method for these tumors. Two hundred consecutive patients between January 2012 and November 2020, with anatomical lobectomy for T2 or T3 tumor (Group-1) and non-anatomical lobectomy resection (lobectomy plus wedge resection [LWR]) (Group-2) for T-ALI (T2-ALI and T3-ALI) due to primary NSCLC, who did not have lymph node metastases were analyzed retrospectively. All surgeries were performed by two experienced surgeons who adopted the same surgical technique. Those who underwent additional segmentectomy and bilobectomy due to fissure invasion were excluded from the study. Overall survival rates of all patients were determined and factors affecting survival were evaluated by performing univariate and multivariate analyses. Of the patients with a mean age of 62.2 ± 7.8 years, 175 (87.5%) were male and 25 (12.5%) were female. There were 137 (68.5%) patients in Group 1 and 63 (31.5%) patients in Group 2. The mean tumor size in Group 1 (4.4 ± 1.4 cm) was significantly smaller than that in Group 2 (4.9 ± 1.4 cm) (p = 0.014). When T distribution within the groups was considered, the rate of pathological T3 in Group 1 (33.6%) was significantly lower than that in Group 2 (55.6%) (p = 0.005). While the 5-year overall survival rate was 70.1% in Group 1, it was 50.6% in Group 2 (p = 0.022). When tumors were grouped as T2, T2-ALI, T3, and T3-ALI according to T factor, the 5-year overall survival rates were 71.4% and 67.8% in T2 and T3 tumors, respectively, and 49.2% and 51.5% in T2-ALI and T3-ALI tumors, respectively. In the multivariate analysis of these four groups, the overall survival rates for T2-ALI and T3-ALI were significantly lower than those of T2 tumors (p = 0.046 and p = 0.025, respectively). In the analysis made between the T2 tumor group and the new T3 group (T2-ALI, T3, T3-ALI), which was formed by upgrading T2-ALI tumors to the T3 group, T2 tumors were found to have a significantly better survival rate (p = 0.019). The disease-free survival of pT2 patients and new T3 group patients was statistically significant, 63.7% and 45.7%, respectively (p = 0.050). Our results suggest that LWR for T-ALI can be performed with acceptable oncologic outcomes when compared to anatomical lobectomy. T2-ALI has a worse overall survival than T2 tumor and offers a similar prognosis to T3. Given this situation, it is more appropriate to classify T2-ALI as T3. Further studies based on larger series are needed to confirm these preliminary data.

Mathematical tools for recovery of the load on the fissure according to the micro-CT results

In the present paper X-ray microtomographic research of a molar tooth was conducted. The study revealed regions with a reduced mineral density in the vicinity of the fissure tip. The basic assumption investigated is that corrosion induced enamel mineral density decrease is enhanced by high tensile stresses generated by mechanical load on the occlusal surface of the tooth during crushing of food. Magnitude and location of tensile stress concentration occurs at the fissure tip and may be determined by solving the problem of the stress-strain state of the tooth crown enamel with a wedge-shaped notch. The study of stresses in the vicinity of fissure tip make it possible to construct the boundaries of enhanced enamel virtual fracture. Comparison of the sizes and locations of areas with a reduced enamel mineral density with the sizes and locations of areas of virtual enamel fracture made it possible to establish their approximate congruence. This circumstance made it possible to recreate by mathematical means the nature and magnitude of the force load on the lateral surface of the fissure. Degree of influence of the main parameters of the fissure on the geometrical characteristics of the virtual fracture, such as its area and diameters, were determined.

The role of percutaneous tibial nerve stimulation (PTNS) in the treatment of chronic anal fissure: a systematic review

PURPOSE

This study was designed to summarize the current evidence regarding the role of percutaneous tibial nerve stimulation (PTNS) in the treatment of chronic anal fissure (CAF).

METHODS

The present systematic review of the literature was conducted on the basis of the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The primary endpoint of our study was the CAF recurrence rate. Quality assessment was based on the RoB 2 tool and the Case Series Quality Checklist.

RESULTS

Overall, 5 studies and 102 patients were included. A considerably heterogeneity in the neuromodulation technique and setting was identified. The pooled recurrence rate was estimated at the level of 19% (16/84). Post-interventional pain and Wexner scores were considerably reduced. The 2-month healing rate was 72% (18/25), whereas 73.6% of patients were symptom-free at 6 months.

CONCLUSIONS

PTNS is an effective alternative for the non-operative management of CAF. Due to several limitations further larger and higher quality studies are required.

Lingual primary tuberculosis mimicking malignancy

INTRODUCTION

The constant increase in the incidence of tuberculosis, as long as the emerging global resistance to antituberculous drugs warrants an increased awareness of the possibility of Mycobacterium Tuberculosis in persistent lesions of the oral cavity. Lingual tuberculosis is a rarely described entity of extra pulmonary tuberculosis. It usually presents as a non-healing chronic mucosal lesion that may mimic malignant lingual neoplasms.

CASE REPORT

In the present paper, we report a rare presentation of lingual tuberculosis in a 36 years old woman, which was clinically suspected as an extensive malignant fissure of the tongue. The diagnosis was confirmed by tongue biopsy and the patient responded well to the antitubercular chemotherapy.

DISCUSSION

lingual tuberculosis is a rare clinical and pathological entity of extrapulmonary tuberculosis. Only a few cases have been reported around the world, and in each one of them, a unique clinical form has been described. This variability of clinical presentations can allude to several pathological conditions including malignancy.

CONCLUSION

This case report is a documentation of a unique clinical and radiological presentation of lingual tuberculosis; it also highlights the importance of considering tuberculosis in the differential diagnosis of chronic tongue lesions.

Preoperative delineation of pulmonary fissural anatomy at multi-detector computed tomography in children with congenital pulmonary malformations and impact on surgical complications and postoperative course

BACKGROUND

Delineation of the anatomy and integrity of the pulmonary fissures at CT is important because anomalous or incomplete fissures might increase the risk of surgery and of postoperative complications.

OBJECTIVE

To preoperatively evaluate the integrity of the pleural fissures in children with congenital lung malformations and determine whether anomalous fissural anatomy is a risk factor for a more complicated surgery and postoperative course.

MATERIALS AND METHODS

We reviewed preoperative multi-detector CT scans of consecutive children who underwent open or thoracoscopic resection of a congenital pulmonary malformation from 2008 to 2018, to determine the integrity of the fissural anatomy, and compared these findings with the surgical report. We correlated postoperative factors including operating room time, days in hospital and chest tube with the operating room documented fissural integrity.

RESULTS

We saw a significant association between the radiologically determined fissural integrity at CT and the operative findings independently for the right, left and both lungs combined (P<0.001). The sensitivity of CT to determine fissural integrity was 76.9%, specificity 95.2%, positive predictive value 95.2%, negative predictive value 76.9%, and accuracy 85.1%. There was a statistically significant association between size of the pulmonary malformation and the integrity of the fissure(s) (P=0.024). Larger lesions also resulted in a significantly longer hospitalization (P=0.024).

CONCLUSION

Chest CT showed high accuracy for delineating fissural anatomy in children with congenital pulmonary malformations, with a good interobserver correlation. Incomplete lung fissures were found more often in children with larger congenital pulmonary malformations. In addition, larger lesions were associated with longer hospital stays. Therefore, children with incomplete fissures may have a longer postoperative course. Analysis of the fissural anatomy should be included in the CT report.

Telovelar surgical approach

Surgical access to lesions in the fourth ventricle may be achieved utilizing transvermian or transtelovelar trajectories. We performed a search of the PubMed database for studies describing the microsurgical details and evaluating the clinical utility of the telovelar surgical approach. The telovelar approach has proven to be a safe, effective, and versatile alternative to the transvermian approach. The operative strategy utilizes midline suboccipital craniotomy without or with C1 laminectomy, followed by cerebellar hemispheric and tonsillar retraction, and wide durotomy. Access is generously provided to the fourth ventricle from calamus scriptorius to Sylvian aqueduct and foramen Luschkae bilaterally. Anatomic dissection studies evaluating and comparing the relative benefits of the operative exposure offered by these approaches have demonstrated improved access to the lateral recess gained by the telovelar trajectory and facilitated exposure of rostral reaches of the fourth ventricle by the vermian trajectory. In general, operative exposure may be significantly improved with tonsillar retraction or resection, bilateral telovelar opening, and performing C1 laminectomy in order to improve access to the rostral fourth ventricle, which may be variably combined depending on location of pathology. Cerebellar mutism, a high incidence of which occurs with vermian approaches, is not commonly observed with use of the telovelar trajectory, though injury to the dentate nuclei may precipitate this syndrome. Deficits incurred with the vermian approach may include cerebellar mutism, dysequilibrium, truncal ataxia, posterior fossa syndrome, cranial nucleopathies and nerve palsies, and vascular injury to the posterior inferior cerebellar artery. The telovelar surgical approach has proven a safe and useful alternative to the transvermian trajectory. A significantly lower incidence of cerebellar mutism and cerebellogenic deficits represents the principal advantage of the telovelar approach. Further studies are necessary in order to prospectively evaluate and compare extents of resection, morbidity, and mortality utilizing the telovelar versus vermian approaches for microsurgically resecting fourth ventricular tumors.

Improvement of cooking quality of germinated brown rice attributed to the fissures caused by microwave drying

Germinated brown rice (GBR) contains rich bio-active components, but has poor edible quality. To improve the cooking quality of GBR, fissure generation in kernels caused by microwave drying were investigated considering cooking properties, microstructure and textural attributes. The microwave intensity had significant effects on the fissure percentage of GBR, and microwave intensity of 3-4 W/g may be suitable for the microwave drying of GBR based on the distribution of fissure percentage for the GBR. The fissures of GBR caused by microwave drying provided the suitable penetration routes of water into GBR kernel. Appropriate fissure amount in range of 3-4 in GBR kernels were conducive to increase its cooking quality and rice taste due to the moderate water absorption and starch gelatinization. The results present a new viewpoint from the perspective of fissures inside grain kernels to evaluate the drying quality of cereal materials such as GBR.

Improving Head Rice Yield and Milling Quality: State-of-the-Art and Future Prospects

Increasing paddy yield in rice does not directly translate to enhancing food security because significant decrease in grain yield can happen during postharvest processing of the rice paddy. In parallel with enhancing paddy yield, improving the milling quality of rice is essential in ensuring food security by mitigating the impact of significant losses during the postharvest processing of rice grains. From an industrial standpoint, maximizing the milling recovery of whole grain polished rice is crucial in fetching higher revenues to rice farmers. Significant advances in rice postharvest processing technology have been achieved which are geared toward reducing the incidence of fissures and chalkiness to increase head rice yield (HRY) in rice. The genetic bases of kernel development and grain dimension are also characterized. In addition to these advancements, an integrated phenotyping suite to simultaneously characterize phenotypes related to milling quality will help in screening for breeding lines with high HRY. Toward this goal, modern imaging tools and computer algorithms are currently being developed for high-throughput characterization of rice milling quality. With the availability of more sophisticated, affordable, automated, and nondestructive phenotyping methods of milling quality, it is envisioned that significant improvement in HRY will be made possible to ensure rice food security in the future.

Promising effects of purslane cream on the breast fissure in lactating women: A clinical trial

OBJECTIVES

The traditional uses of Portulaca oleracea L. (purslane) with anti-inflammatory and anti-cancer activity as well as anti-oxidants properties were expressed previously. This is a double-blind randomized clinical trial to evaluate the protective effects of purslane cream on the nipple fissure.

METHODS

After expressing the goals and methods of the study and obtaining written consent from 86 lactating women with nipple fissure, they were randomly divided into two groups: 43 in purslane cream group and 43 in lanolin ointment group. The score of nipple fissure before the intervention and on the third and eighth day after the study was measured using the Stour scale.

RESULTS

The mean score of left and right breast fissures in the group of treatment with lanolin group similar to the group of treatment with purslane cream showed a significant decrease at the third day and eighth day (P=0.001). Mann-Whitney test comparing mean score of the fissure between two groups showed that two groups were homogeneous before the intervention, but there was a significant difference between two groups on the third and eighth days (p < 0.001). The recovery process occurred faster in the group of treatment with purslane cream.

CONCLUSION

We showed that the use of purslane cream without any complications could accelerate the repairing of nipple fissure. Based on this clinical trial, purslane cream (2% w/w) can be used as an accelerator for improving the nipple fissure in lactating women.

Fecal evacuation disorders in anal fissure, hemorrhoids, and solitary rectal ulcer syndrome

The causative factors for hemorrhoids, anal fissure, and solitary rectal ulcer syndrome (SRUS) are poorly understood. The study was done to identify the prevalence of fecal evacuation disorders in patients with anal fissure, hemorrhoids, and SRUS using anorectal manometry (ARM). Retrospective analysis of ARM data from three centers across India was done. Baseline demographic details and symptoms pertaining to bowel movements were noted. Limited colonoscopy details pertaining to hemorrhoids, fissure-in-ano, and SRUS were noted. The patients were divided into two groups-group I (those with fissure, hemorrhoids, or solitary rectal ulcer) and group II (normal study). ARM parameters of resting anal pressure, squeeze pressure, dyssynergic defecation, and abnormal balloon expulsion were compared between the two groups. Sub-analysis was done for ARM metric differences between those with hemorrhoids, chronic fissure, and SRUS. Appropriate statistical tests were used. A p-value of < 0.05 was considered significant. There were more men in group I (87%; p-value 0.01) with a higher resting anal pressure (80 vs. 69 mmHg, p-value 0.03). Functional evacuation disorders (p < 0.0001), dyssynergic defecation (77.2% vs. 46.8%, p < 0.0001) and abnormal balloon expulsion (66.7% vs. 20.3%, p < 0.0001) were significantly higher in group I. These were significantly more common in patients with anal fissure and SRUS compared to those with hemorrhoids (p-value 0.028). Functional evacuation disorders are frequently noted in patients with hemorrhoids, anal fissure, and SRUS.

The Burden and Management of Dental Caries in Older Children

Dental caries is endemic in children and adolescents and has significant morbidity. This complex and chronic disease has both genetic and environmental etiologic factors. In children the preponderance of caries affects tooth surfaces with pits and fissures despite these representing only a small portion of the tooth surfaces that are at risk. Pit and fissure sealants are effective in preventing and managing noncavitated caries lesions in these surfaces. A variety of materials are clinically effective, and health care guidelines recommend the use of pit and fissure sealants as part of a comprehensive dental caries prevention program.

Anal ulcerations in Crohn's disease: Natural history in the era of biological therapy

BACKGROUND

The natural history of anal ulcerations in Crohn's disease remains unknown.

AIMS

To assess the long-term outcomes of anorectal ulcerations.

METHODS

Data from consecutive patients with perineal Crohn's disease were prospectively recorded. The data of patients with anal ulceration were extracted.

RESULTS

Anal ulcerations were observed in 154 of 282 patients (54.6%), and 77 cases involved cavitating ulcerations. The cumulative healing rates were 47%, 70% and 82% at 1, 2 and 3 years, respectively. Patients with a primary fistula phenotype had a shorter median time to healing of their anal ulceration (28 [13-83] weeks) than those with a stricture (81 [28-135] weeks) or those with isolated ulceration (74 [31-181] weeks) (p=0.004). Among patients with ulcerations but no fistula at referral (n=67), only 4 (6%) developed de novo abscesses and/or fistula during follow-up. There was no benefit associated with introducing or optimising biologics, nor with combining immunosuppressants and biologics.

CONCLUSION

Anal ulceration in Crohn's disease usually requires a long time to achieve sustained healing. Determining the impact of biologics on healing rates will require dedicated randomised trials although it does not show a significant healing benefit in the present study.

Anorectal emergencies

Anorectal emergencies refer to anorectal disorders presenting with some alarming symptoms such as acute anal pain and bleeding which might require an immediate management. This article deals with the diagnosis and management of common anorectal emergencies such as acutely thrombosed external hemorrhoid, thrombosed or strangulated internal hemorrhoid, bleeding hemorrhoid, bleeding anorectal varices, anal fissure, irreducible or strangulated rectal prolapse, anorectal abscess, perineal necrotizing fasciitis (Fournier gangrene), retained anorectal foreign bodies and obstructing rectal cancer. Sexually transmitted diseases as anorectal non-surgical emergencies and some anorectal emergencies in neonates are also discussed. The last part of this review dedicates to the management of early complications following common anorectal procedures that may present as an emergency including acute urinary retention, bleeding, fecal impaction and anorectal sepsis. Although many of anorectal disorders presenting in an emergency setting are not life-threatening and may be successfully treated in an outpatient clinic, an accurate diagnosis and proper management remains a challenging problem for clinicians. A detailed history taking and a careful physical examination, including digital rectal examination and anoscopy, is essential for correct diagnosis and plan of treatment. In some cases, some imaging examinations, such as endoanal ultrasonography and computerized tomography scan of whole abdomen, are required. If in doubt, the attending physicians should not hesitate to consult an expert e.g., colorectal surgeon about the diagnosis, proper management and appropriate follow-up.

Spontaneous colonic perforation: a rare complication of collagenous colitis

Collagenous colitis is a clinicopathologic syndrome characterized by chronic watery diarrhea and unique histopathologic features. Spontaneous colonic perforation in the setting of collagenous colitis is a highly unusual complication, with only three cases reported in the literature to date. We present a fourth case and propose a potential pathologic mechanism for acute colonic perforation in this patient population.

Review of automatic pulmonary lobe segmentation methods from CT

The computational detection of pulmonary lobes from CT images is a challenging segmentation problem with important respiratory health care applications, including surgical planning and regional image analysis. Several authors have proposed automated algorithms and we present a methodological review. These algorithms share a number of common stages and we consider each stage in turn, comparing the methods applied by each author and discussing their relative strengths. No standard method has yet emerged and none of the published methods have been demonstrated across a full range of clinical pathologies and imaging protocols. We discuss how improved methods could be developed by combining different approaches, and we use this to propose a workflow for the development of new algorithms.

Clinical Manifestations among Children with Chronic Functional Constipation

BACKGROUND Constipation is one of the most frequent cause of patient visits to pediatric gastroenterology clinics. Early diagnosis and treatment is important. There are few studies about clinical manifestations of constipation in children. We aimed to find the relative frequency of gastrointestinal manifestations of constipation among constipated children. METHODS This cross-sectional study was carried out on children aged < 18 years old with chronic functional constipation referred to Imam Reza Clinic of Shiraz University of Medical Sciences. Children with organic causes of chronic constipation were excluded from study. Rome III criteria were used for defining constipation. The duration of study was 1 year starting from September 2010. Abdominal pain, fecal mass, rectal bleeding, anorexia, fecal soiling, retentive posture, withholding behavior, anal fissure, and peri-anal erythema were recorded for each case based on history and physical examination. Data were analyzed using SPSS software, version 13.0 (Chicago, IL, USA). RESULTS Of 222 children with functional constipation, 124(55.9%) were girls and 98 (44.1%) were boys with a mean ± SD age of 5±3.12 years. The mean ± SD duration of constipation was 2.2±1.9 years. Large and hard stool was present in 93.7% of the patients. Painful defecation and withholding behavior were seen in 92.3% and 91.9% of the patients, respectively. Fecal impaction was more frequent among boys compared with girls (p<0.01). Fecal soiling was present in 40.8% of the boys and 28.2% of the girls (p=0.04). CONCLUSION Large and hard stool, painful defecation and withholding behavior were the most frequent signs or symptoms among children with chronic functional constipation. Fresh rectal bleeding and anal fissure were the least frequent signs and symptoms in this group.

Morphological variations of the lungs: a study conducted on Indian cadavers

Awareness of anatomical variations in lungs is essential during segmental or lobar resections of lungs. We studied the variations of fissures, lobes and hilar structures in 65 right and 73 left isolated lungs from the dissection hall. Horizontal fissure was absent in 3.07% and incomplete in 35.38% of right lungs. Four point six one percentage of right lungs had 3 fissures and 4 lobes. Three point zero seven percentage of right lungs had 3 arteries, 67.69% had 2 arteries, and 29.23% had only one artery in the hilum. Sixty-three point zero seven percentage of right lungs had two veins in the hilum; 32.30% had 3 veins in the hilum; and 4.61% had more than 3 veins in the hilum. Ninety-eight point four six percentage of right lungs showed 2 bronchi in the hilum, and 1.53% of them showed 3 bronchi in the hilum. Two of the right lungs (3.07%) had an artery passing across the oblique fissure. Fifteen point zero six percentage of left lungs showed incomplete oblique fissure and 2.73% showed 2 fissures and 3 lobes. Five point four seven percentage of left lungs showed 2 arteries and 94.52% had only one artery in the hilum. Eighty point eight two percentage of left lungs had two veins in the hilum and 19.17% had 3 veins in the hilum. Twenty-one point nine one percent of left lungs had 2 bronchi and 78.08% had only one bronchus in the hilum. The knowledge of variations in the lobar and hilar anatomy of the lung presented in this study is clinically important while interpreting the radiological images and performing surgical procedures.

Monitoring and staging abdominal aortic aneurysm disease with pulse wave imaging

The abdominal aortic aneurysm (AAA) is a silent and often deadly vascular disease caused by the localized weakening of the arterial wall. Previous work has indicated that local changes in wall stiffness can be detected with pulse wave imaging (PWI), which is a non-invasive technique for tracking the propagation of pulse waves along the aorta at high spatial and temporal resolutions. The aim of this study was to assess the capability of PWI to monitor and stage AAA progression in a murine model of the disease. ApoE/TIMP-1 knockout mice (N = 18) were given angiotensin II for 30 days via subcutaneously implanted osmotic pumps. The suprarenal sections of the abdominal aortas were imaged every 2-3 d after implantation using a 30-MHz VisualSonics Vevo 770 with 15-μm lateral resolution. Pulse wave propagation was monitored at an effective frame rate of 8 kHz by using retrospective electrocardiogram gating and by performing 1-D cross-correlation on the radiofrequency signals to obtain the displacements induced by the waves. In normal aortas, the pulse waves propagated at constant velocities (2.8 ± 0.9 m/s, r(2) = 0.89 ± 0.11), indicating that the composition of these vessels was relatively homogeneous. In the mice that developed AAAs (N = 10), the wave speeds in the aneurysm sac were 45% lower (1.6 ± 0.6 m/s) and were more variable (r(2) = 0.66 ± 0.23). Moreover, the wave-induced wall displacements were at least 80% lower within the sacs compared with the surrounding vessel. Finally, in mice that developed fissures (N = 5) or ruptures (N = 3) at the sites of their AAA, higher displacements directed out of the lumen and with no discernible wave pattern (r(2) < 0.20) were observed throughout the cardiac cycle. These findings indicate that PWI can be used to distinguish normal murine aortas from aneurysmal, fissured and ruptured ones. Hence, PWI could potentially be used to monitor and stage human aneurysms by providing information complementary to standard B-mode ultrasound.

Significance of left ventricular clefts-A case report

We describe the case of a 48-year-old patient who presented with an out-of-hospital cardiac arrest due to an acute ST-elevation myocardial infarction. Left ventriculography performed during the initial coronary angiography revealed the presence of structural abnormalities in the myocardial wall which subsequently, with the use of contrast echocardiography and cardiac magnetic resonance imaging, were confirmed to represent ventricular clefts. We reviewed the pathophysiological significance of these defects and compared them with similarly looking abnormalities such as aneurysms, pseudoaneurysms, and diverticula. In conclusion, recognition of ventricular clefts is needed to allow clinicians to differentiate them from other myocardial wall defects with different pathological profile and clinical significance. <Learning objective: With emerging techniques in cardiac imaging some cardiac abnormalities such as left ventricular (LV) clefts are recognized more frequently. This case report describes an incidental finding of LV cleft and provides an extensive review of the literature regarding the clinical significance and differential from other similar findings of different pathology. That will help physicians to distinguish these overlapping findings and tailor patients' management accordingly.>.