Computed tomographic age estimation from the iliac crest and ischial tuberosity in an Indian population using supervised machine learning approaches

Within the pelvis the iliac crest and ischial tuberosity display delayed ossification and fusion, thus, presenting as reliable maturity indicators. Amongst the different iliac crest and ischial tuberosity age estimation methods, the modified Kreitner-Kellinghaus stages constitute one of the more promising methods. The present study was directed towards establishing the applicability of the modified Kreitner-Kellinghaus method using five supervised machine learning approaches. Clinical CT scans of consenting individuals were collected and scored using the modified Kreitner-Kellinghaus method for the iliac crest and ischial tuberosity, independently. Age was subsequently estimated using different machine learning models. Cumulative scores computed from both markers were additionally employed for age estimation using machine learning. For iliac crest age estimation, Random Forest and Gradient Boosting Regression furnished lowest mean absolute error (2.42 years) and root mean square error (3.06 years). For ischial tuberosity age estimation, Gradient Boosting Regression garnered the lowest computations of mean absolute error (2.60 years) and root mean square error (3.09 years). For cumulative score based age estimation, Support Vector Regression and Gradient Boosting Regression yielded lowest mean absolute error (2.48 years) and root mean square error (3.07 years). Obtained error computations indicate that the iliac crest is a more accurate age marker in comparison to the ischial tuberosity. Additionally, cumulative score-based approaches garnered similar/ marginally more precise results in comparison to the iliac crest with all five models. This marginal improvement is not sufficient to justify employing the relatively more complicated cumulative score-based approach for age estimation. Hence, whenever available, the iliac crest should be preferred over the ischial tuberosity/ cumulative score-based approaches for age estimation.

Multimodality imaging in cerebral venous thrombosis: a synopsis for emergency radiologist

Cerebral venous thrombosis (CVT) is an uncommon but potentially fatal condition which presents with a wide range of symptoms. Some of these presenting features are vague thus contributing to the delay in diagnosis. A prompt diagnosis and initiation of appropriate therapy are therefore of paramount importance. In this pictorial, we have tried to illustrate the direct and indirect imaging features of CVT in detail on multiple imaging modalities, along with the potential pitfalls of imaging.

Circulating miRNA-21 Levels in Breast Cancer Patients Before and After Chemotherapy and Its Association with Clinical Improvement

Breast cancer is the most frequent type of cancer in women, many patients experience recurrences and metastasis. miR-21 (microRNA-21) as biomarker is under investigation for breast cancer. At present, there is very limited information available regarding effect of chemotherapy on miR-21 expression in breast cancer and its correlation with the clinical improvement. Hence, this study was planned to evaluate the effect of chemotherapy on miR-21 in metastatic breast cancer and its relationship with the clinical outcome. Females, aged-18-90 years diagnosed with Invasive Ductal Carcinoma of breast and candidate of neoadjuvant chemotherapy including Adriamycin (60 mg/m2), Cyclophosphamide (600 mg/m2) with or without Taxane (75-175 mg/m2) were included in the study. Before and after 42 days of staring of chemotherapy sample was collected for circulatory miR-21 and RECIST 1.1 criteria was applied to assess the clinical status. Blood samples for routine clinical biomarkers including liver function test and renal function tests was also collected. miR-21 expression before and after chemotherapy was assessed using standard method based on real time PCR. Expression of miR-21, RECIST criteria and other liver and kidney related biomarkers were compared before and after chemotherapy. After neoadjuvant chemotherapy expression of miR-21 was significantly increased by 5.65-fold. There was significant improvement in clinical scores based on RECIST criteria (0.046). No significant correlation was observed between miR-21 expression and difference in RECIST score (r = - 0.122, p = 0.570). Neoadjuvant chemotherapy causes clinical improvement in breast cancer patients however it is not correlated with the miR-21 expression which significantly increased after chemotherapy.

Applicability of the Suchey-Brooks method for age estimation in an Indian population: A computed tomography-based exploration using Bayesian analysis and machine learning

Age estimation occupies a prominent niche in the identification process. In cases where skeletal remains present for examination, age is often estimated from markers distributed throughout the skeletal framework. Within the pelvis, the pubic symphysis constitutes one of the more commonly utilized skeletal markers for age estimation, with the Suchey-Brooks method comprising one of the more commonly employed methods for pubic symphyseal age estimation. The present study was targeted towards assessing the applicability of the Suchey-Brooks method for pubic symphyseal age estimation, an aspect largely unreported for an Indian population. In order to do so, clinically undertaken pelvic computed tomography scans of individuals were evaluated using the Suchey-Brooks method, and the error associated with the method was established using Bayesian analysis and different machine learning regression models. Amongst different supervised machine learning models, support vector regression and random forest furnished lowest error computations in both sexes. Using both Bayesian analysis and machine learning, lower error computations were observed in females, suggesting that the method demonstrates greater applicability for this sex. Inaccuracy and root mean square error obtained with Bayesian analysis and machine learning illustrates that both statistical modalities furnish comparable error computations for pubic symphyseal age estimation using the Suchey-Brooks method. However, given the numerous advantages associated with machine learning, it is recommended to use the same within medicolegal settings. Error computations obtained with the Suchey-Brooks method, regardless of the statistical modality utilized, indicate that the method should be used in amalgamation with additional markers to garner accurate estimates of age.

MDCT evaluation of Dorsal Pancreatic Artery and Intrapancreatic arcade anatomy

OBJECTIVE

The purpose of the study was to analyze the anatomy and variations in the origin of the dorsal pancreatic artery, greater pancreatic artery and to study the various types of arterial arcades supplying the pancreas on multidetector CT (MDCT).

METHODS

A retrospective analysis of 747 MDCT scans was performed in patients who underwent triple phase or dual phase CT abdomen between December 2020 and October 2022. Variations in origin of Dorsal pancreatic artery (DPA), greater pancreatic artery (GPA), uncinate process branch were studied. Intrapancreatic arcade anatomy was classified according to Roman Ramos et al. into 4 types-small arcades (type I), small and large arcades (type II), large arcades (type III) and straight branches (type IV).

RESULTS

The DPA was visualized in 65.3% (n = 488) of cases. The most common origin was from the splenic artery in 58.2% (n = 284) cases. The mean calibre of DPA was 2.05 mm (1.0-4.8 mm). The uncinate branch was seen in 21.7% (n = 106) with an average diameter of 1.3 mm. The greater pancreatic artery was seen in 57.3% (n = 428) predominantly seen arising from the splenic artery. The most common arcade anatomy was of Type II in 52.1% (n = 63) cases.

CONCLUSION

Pancreatic arterial variations are not very uncommon in daily practice. Knowledge of these variations before pancreatic surgery and endovascular intervention procedure is important for surgeons and interventional radiologist.

Applicability of the six-phase method for auricular age estimation in an Indian population: A CT-based study

Age estimation plays a crucial role in human identification. Amongst numerous age markers located throughout the skeletal framework, the auricular surface of the ilium presents as a resilient structure, with different methods for auricular age estimation currently in practice. Amongst these methods, the Osborne method is believed to permit accurate age estimation through its use of robust age categories and discrete phase descriptors. The present study aimed to assess the applicability of the Osborne method in an Indian population through a computed tomographic (CT) examination of the auricular surface, an aspect presently unreported. In order to do so, CT scans of 380 individuals were collected and evaluated using the Osborne method. A CT-based examination indicated that surface texture described by Osborne is difficult to appreciate through 3D CT images. Indistinct definitions associated with certain features, and the mosaic display of features within each phase further prevents applying the method effectively. Overall accuracy percentages of 99.47% and 98.90% were obtained using the method in males and females, respectively, with corresponding inaccuracy values of 10.10 years and 9.04 years. Significantly reduced accuracy percentages were obtained with alternate, more robust age brackets presented within the original study, demonstrating the limited reliability associated with the method. Inaccuracy and bias values computed for each decade indicate the relative utility of the method in aging 40-59-year-old individuals. Low accuracy percentages, high error rates and different methodological hindrances encountered within the present study illustrate the limited applicability of the Osborne method in aging an Indian population.

Programmed cell death ligand 1 (PD-L1) expression in non-small cell lung cancer: Findings from a tertiary care institute in western part of India

BACKGROUND

Immune checkpoint inhibitors targeting either programmed cell death protein 1 (PD-1) or programmed cell death ligand 1 (PD-L1) have been established as a novel target for immunotherapy in non-small cell lung cancer (NSCLC). Prevalence of PD-L1 expression in NSCLC varies from 13% to 70%, with sparse data from the Indian subcontinent. In this study, we looked at PD-L1 expression and its association with demographic, clinical, radiologic and pathologic parameters in NSCLC patients.

METHODS

This was an observational study carried over a period of 18 months in which 65 patients of NSCLC were included. Immunohistochemistry (IHC) for PD-L1 was done using an automated IHC stainer and testing was performed using PD-L1 IHC CAL10. For statistical analysis, unpaired t test, Chi square test, Fisher's exact test and binomial logistic regression were used. P < 0.05 was taken to be statistically significant.

RESULTS

Mean age of the patients was 62.9 ± 9.2 years, and majority (87.3%) of them were males. Seventeen (26.2%) patients expressed PD-L1, among whom 10 had high PD-L1 expression (≥50%) and 7 had low PD-L1 expression (1-49%). PD-L1 expression was seen in 13 out of 43 cases of squamous cell carcinoma (SCC) and 4 out of 15 cases of adenocarcinoma. On applying binomial logistic regression analysis, association between smoking and PD-L1 expression was found to be insignificant.

CONCLUSION

Almost a quarter of NSCLC cases were PD-L1 positive without any difference in expression between SCC and adenocarcinoma. PD-L1 status was not associated with any specific demographic, clinical or radiologic parameter including the histologic subtype.

Pediatric Renovascular Hypertension: A Pediatric Interventional Radiologist's Perspective

Renovascular hypertension (RVH) contributes close to one-fourth of the secondary etiologies of hypertension in children and a delay in diagnosis can result in adverse clinical outcomes. RVH in children is clinically silent with elevations in blood pressure measurements sometimes as its sole manifestation. Only a high index of suspicion by the clinician can prompt its detection. Despite the availability of other imaging modalities like ultrasound, computed tomography, and magnetic resonance imaging, digital subtraction angiography is still considered the gold standard to make a diagnosis of RVH. Angioplasty is considered the treatment of choice in appropriately selected patients. In this article, we shall focus on the various imaging findings, and management of RVH in children, which requires a multidisciplinary approach with a special focus on the role of interventional radiology.

Machine learning and regression analysis for age estimation from the iliac crest based on computed tomographic explorations in an Indian population

Age estimation constitutes an integral parameter of identification. In children, sub-adults, and young adults, accurate age estimation is vital on various aspects of civil, criminal, and immigration law. The iliac crest presents as a suitable age marker within these age cohorts, and the modified Risser method constitutes a relatively novel and unexplored method for iliac crest age estimation. The present study attempted to ascertain the applicability of this modified method for age estimation in the Indian population, an aspect previously unexplored, through computed tomographic examination of the iliac crest. Computed tomography scans of consenting individuals undergoing routine examinations of the pelvis/ abdomen for various clinically indicated reasons were collected and scored using the modified Risser stages. Computed tomographic examinations of the iliac crest indicate that the recalibrated method accurately depicts the temporal progression of ossification and fusion changes. Different regression and machine learning models were subsequently derived and/or trained to evaluate the accuracy and precision associated with the method. Amongst the ten regression models derived herein, compound regression exhibited the lowest inaccuracy (4.78 years) and root mean squared error values (5.46 years). Machine learning yielded further reduced error rates, with decision tree regression achieving inaccuracy and root mean squared error values of 1.88 years and 2.28 years, respectively. A comparative evaluation of error computations obtained from regression analysis and machine learning illustrates the statistical superiority of machine learning for forensic age estimation. Error computations obtained with machine learning suggest that the modified Risser method is capable of permitting reliable age estimation within criminal and civil proceedings.

Spontaneous hepatic arterioportal fistula in extrahepatic portal vein obstruction: Combined endovascular and surgical management

Hepatic arterioportal fistulae are abnormal communications between the hepatic artery and portal vein. They are reported to be congenital or acquired secondary to trauma, iatrogenic procedures, hepatic cirrhosis, and hepatocellular carcinoma, but less likely to occur spontaneously. Extrahepatic portal venous obstruction (EHPVO) can lead to pre-hepatic portal hypertension. A spontaneous superimposed hepatic arterioportal fistula can lead to pre-sinusoidal portal hypertension, further exacerbating its physiology. This report describes a young woman with long-standing EHPVO presenting with repeated upper gastrointestinal variceal bleeding and symptomatic hypersplenism. Computed tomography scan demonstrated a cavernous transformation of the portal vein and a macroscopic hepatic arterioportal fistula between the left hepatic artery and portal vein collateral in the central liver. The hepatic arterioportal fistula was associated with a flow-related left hepatic artery aneurysm and a portal venous collateral aneurysm proximal and distal to the fistula, respectively. Endovascular coiling was performed for the hepatic arterioportal fistula, followed by proximal splenorenal shunt procedure. This case illustrates an uncommon association of a spontaneous hepatic arterioportal fistula with EHPVO and the utility of a combined endovascular and surgical approach for managing multifactorial non-cirrhotic portal hypertension in such patients.

Neuroimaging Spectrum in COVID-19 Infection: A Single-Center Experience

Background and Purpose  The ongoing coronavirus disease 2019 (COVID-19) pandemic is a multisystemic disease and involvement of the nervous system is well established. The neurological and neuroimaging features of the disease have been extensively evaluated. Our study aimed to elucidate the neuroradiological findings in COVID-19 infected patients admitted to our institute during the first and second waves of the pandemic in India. Methods  This was a single-center retrospective study of all COVID-19 positive patients who underwent neuroimaging between March 2020 and May 2021. The presenting neurological complaints, the imaging findings in computed tomography (CT) imaging, and/or magnetic resonance imaging (MRI) were recorded. They recorded the findings in the subheadings of ischemic stroke, hemorrhagic stroke, parainfectious demyelination, acute encephalitis syndrome, and changes of global hypoxic changes. Patients with age-related, chronic, and incidental findings were excluded. Results  The study comprised of 180 COVID-19 positive patients who underwent neuroimaging. CT scan was performed for 169 patients, MRI for 28, and a combination of both CT and MRI was performed for 17 patients. Seventy percent of patients were males, and median age was 61.5 years (interquartile range: 48.25-70.75). Out of the 180 patients, 66 patients had nonspecific findings that could not be attributed to COVID-19 infection. In the remaining 114 patients, 77 (42.7%) had ischemic findings, while 22 (12.2%) had hemorrhagic stroke. Hypoxic ischemic changes were noted in five patients. The rest of the patients had a spectrum of changes including, cerebellitis (3), tumefactive demyelination (1), COVID-19-associated encephalitis (1), hemorrhagic acute demyelinating encephalomyelitis (1), transverse myelitis (1), cytotoxic lesions of corpus callosum (1), Guillain-Barre syndrome (1), and COVID-19-associated microhemorrhages (1). Conclusion  Neurological manifestations of COVID-19 infection are not uncommon, and our understanding of this topic is expanding. A complex interplay of neurotropism and direct central nervous system invasion, immune activation and cytokine storm, vasculitis, and parainfectious processes are implicated in the pathophysiology. While the most common imaging finding was ischemic stroke, followed by hemorrhagic stroke, a diverse range of parainfectious findings was also noted in our study.

An evaluation of the Gilbert-McKern pubic symphyseal age estimation method using Bayesian statistics and principal component analysis: A computed tomographic exploration in an Indian population

Age of an individual constitutes a primary facet of human identification. In cases where skeletal remains present for examination, bony markers distributed throughout the skeletal framework are employed for age estimation. Amongst these markers, the pubic symphysis constitutes one of the more commonly utilized structures. Gilbert-McKern's pubic symphyseal age estimation method was derived to complement the original three component method, and permit accurate age estimation in females. However, subsequent investigations with the Gilbert-McKern method are limited, and completely lacking for an Indian population. In the present study, CT scans of 380 consenting individuals (190 males and 190 females) undergoing CT examinations for therapeutic purposes, aged 10 years and above, were scored according to Gilbert-McKern's three component method. A significant sexual dimorphism was observed with the scoring of the ventral rampart and symphyseal rim. An overall accuracy of 29.50% was obtained in females, indicating that the method lacks forensic utility in its primal form. Highest posterior density and highest posterior density region values were computed for each component using Bayesian analysis in both sexes, to enable age estimation from individual components, whilst overcoming issues of age mimicry. Amongst the three components, symphyseal rim furnished the most accurate and precise estimates of age, whereas the ventral rampart garnered highest error computations, in both sexes. Principal component analysis was utilized for multivariate age estimation by taking into consideration this differential contribution of individual components. Weighted summary age models, derived using principal component analysis, furnished inaccuracy values of 12.19 years and 12.30 years in females and males, respectively. Bayesian error computations obtained with the symphyseal rim in both sexes were even lower than those obtained with weighted summary age models, demonstrating its suitability as an independent age marker. Despite the use of statistical modalities of Bayesian inference and principal component analysis for age estimation, the method did not yield significantly reduced error rates in females, demonstrating its limited forensic applicability. While, statistically significant sex differences were observed with the scoring of Gilbert-McKern's components, concordant correlations, comparable accuracy and absolute error values were obtained for both sexes, indicating that the Gilbert-McKern method can be utilized to age either sex. However, inaccuracy and bias values obtained with different statistical modalities, as well as broad age intervals furnished with Bayesian analysis demonstrate the overall limited applicability of the Gilbert-McKern method in aging males and females of an Indian population.

Age estimation from iliac auricular surface using Bayesian inference and principal component analysis: a CT-based study in an Indian population

Age estimation constitutes one of the pillars of human identification. The auricular surface of the ilium presents as a durable and robust structure within the human skeletal framework, capable of enabling accurate age estimation in older adults. Amongst different documented auricular age estimation methods, the Buckberry-Chamberlain method offers greater objectivity through its component-based approach. The present study aimed to test the applicability of the Buckberry-Chamberlain method in an Indian population through a CT-based examination of the auricular surface. CT scans of 435 participants undergoing CT examinations following the advice of their treating physicians were scrutinized for different age-related auricular changes. Three of the five morphological features described by Buckberry-Chamberlain could be appreciated on CT scans, and thus further statistical analysis was restricted to these features. Transition analysis coupled with Bayesian inference was undertaken individually for each feature to enable age estimation from individual features, while circumventing age mimicry. A Bayesian analysis of individual features yielded highest accuracy percentages (98.64%) and error rates (12.99 years) with macroporosity. Transverse organization and apical changes yielded accuracy percentages of 91.67% and 94.84%, respectively, with inaccuracy computations of 10.18 years and 11.74 years, respectively. Summary age models, i.e. multivariate age estimation models, derived by taking this differential accuracy and inaccuracy into consideration yielded a reduced inaccuracy value of 8.52 years. While Bayesian analysis undertaken within the present study enables age estimation from individual morphological features, summary age models appropriately weigh all appreciable features to yield more accurate and reliable estimates of age.

An evaluation of the three-component pubic symphyseal human age estimation method: a CT-based exploration in an Indian population

Age estimation constitutes an important facet of human identification within forensic, bioarchaeological, repatriation, and humanitarian contexts. Within the human skeletal framework, the pubic symphysis comprises one of the more commonly utilized structures for age estimation. The present investigation was aimed at establishing the applicability of the McKern-Stewart pubic symphyseal age estimation method in males and females of an Indian population, an aspect previously unreported. Three hundred and eighty clinical CT scans of the pubic symphysis were collected and scored in accordance with the McKern-Stewart method. An overall accuracy of 68.90% was obtained on applying the method to males, demonstrating a limited applicability of the method in its primal form. Subsequently, Bayesian analysis was undertaken to enable accurate age estimation from individual components in both sexes. Bayesian parameters obtained with females suggest that McKern-Stewart's components fail to accommodate for age-related changes within the female pubic bone. Improved accuracy percentages and reduced inaccuracy values were obtained with Bayesian analysis in males. With females, the error computations were high. Weighted summary age models were utilized for multivariate age estimation, and furnished inaccuracy values of 11.51 years (males) and 17.92 years (females). Error computations obtained with descriptive analysis, Bayesian analysis, and principal component analysis demonstrate the limited applicability of McKern-Stewart's components in generating accurate age profiles for Indian males and females. The onset and progression of age-related changes within the male and female pubic bone may be of interest to biological anthropologists and anatomists involved in exploring the underlying basis for aging.

Malignant rhabdoid tumour of liver: Conundrum on ascitic fluid

Ascitic fluid analysis is an important tool for diagnosis and staging. Cytological analysis is routinely done as a part of workup for ascites. This is challenging in paediatric malignancies where multiple differentials need to be considered at times with limited cellularity. We present a case of malignant rhabdoid tumour of liver in a young child presenting with abdominal lump and ascites. The diagnosis was offered on ascitic fluid cytology based on cytomorphology, supporting immunohistochemistry and later confirmed on biopsy. This report briefly discusses its differentials and approach to diagnosis.

Prognostic significance of soft tissue deposits in head and neck squamous cell carcinoma: a systematic review and meta-analysis

Soft tissue deposits, also known as tumour deposits (TDs), have not been studied well in head and neck squamous cell carcinoma (HNSCC) and are not included in any of the staging systems or treatment guidelines. The aim of this systematic review was to determine the prevalence and prognostic implications of TDs in patients with HNSCC. This systematic review of the literature was conducted following the PRISMA guidelines. The PubMed, Embase, and Scopus electronic databases were searched for relevant studies, from inception to August 2022. Although 14 studies qualified for inclusion, only eight were finally included in the review due to the considerable overlap of patients in several studies. Data from 7127 patients were analysed. The pooled prevalence of TDs was 21% (95% confidence interval (CI) 9-33%). The presence of TDs was adversely associated with overall survival and disease-free survival, with hazard ratios of 2.08 (95% CI 1.60-2.70) and 2.56 (95% CI 1.97-3.32), respectively. TDs are detected in a significant number of patients with HNSCC and adversely affect survival. Longitudinal prospective studies are needed to evaluate the prognostic implications of TDs in HNSCC for their potential role in cancer staging and adjuvant treatment planning.

Chondrosarcoma Skull Base - A Case Report

INTRODUCTION

Chondrosarcomas are primary malignant bone tumor that rarely occurs in the head and neck region. Squash cytology of skull base neoplasm shows atypical chondrocytes and myxoid stroma, which suggests many possibilities like chordoma, chordoid glioma, chordoid meningioma and chondrosarcoma. Isocitrate dehydrogenase gene (IDH) mutations have been reported in 50% to 60% of the head and neck region chondrosarcoma.

CASE PRESENTATION

A 37-year-old female came to the outpatient department and complaint of difficulty in walking and swaying to the right side for one year. The radiology was suggestive of right-sided trigeminal schwannoma. However, the squash cytology showed the presence of necrosis, and pink to bluish-coloured myxoid stroma. The tumor cells were pleomorphic and had a hyperchromatic nucleus, hyalinized condensed to granular cytoplasm. The histopathological examination of intraoperative soft tissue showed the presence of cellular lobules of atypical chondrocytes arranged in the myxoid background. The features were of Chondrosarcoma. No parenchymal invasion was found.

CONCLUSIONS

This case report aims to create awareness about a rare tumor, which rarely forms a differential diagnosis for skull base neoplasms. As chondrosarcoma are immunoreactive to IDH1 so this marker can be useful in clinching the diagnosis in conjunction with other immunohistochemical markers in a small biopsy from skull base neoplasms.

An Unusual Presentation of Ludwig's Angina with Empyema Thoracis and External Carotid Artery Pseudoaneurysm

Ludwig's angina is a rapidly spreading soft-tissue infection and commonly occurs following odontogenic infection. A 30-year-old male presented to the emergency department, 7 days after the extraction of molar teeth with a sudden onset of mandibular swelling. He was diagnosed with Ludwig's angina with empyema thoracis and external carotid artery (ECA) pseudoaneurysm. He was successfully managed with video-assisted thoracoscopic surgery-guided drainage and endovascular embolization of ECA pseudoaneurysm. We share our experience of challenges faced during the management of unusual presentation of complicated Ludwig's angina.

Assessment and comparison of distal radial artery diameter in anatomical snuff box with conventional radial artery before coronary catheterization

Background

The distal radial artery (dRA) approach at anatomical snuff box has gained attention of the interventional cardiologist in last few years. The procedural success rate by this novel approach depends on size of the radial artery and therefore the study was planned to study the size of distal radial artery.

Methods

Total of 1004 patients of >18 years of age undergoing coronary catheterization were included in the study. The vessel diameter was measured from media to media in the anatomical snuff box a day prior to coronary catheterization.

Results

The mean diameter of right radial artery at conventional access site was 2.56 ± 0.35 mm and at distal access site 2.23 ± 0.39 mm (p < 0.001). Females had significantly smaller radial artery diameter as compared to males at right conventional access site (2.42 ± 0.36 mm vs 2.60 ± 0.34 mm; p < 0.001) and distal access site (2.09 ± 0.38 mm vs 2.27 ± 0.39 mm; p < 0.001). The diameter of the right dRA was not significantly correlated with age (r² linear = 0.002, p = 0.0475) but was positively correlated with height and weight (r² linear = 0.076, p = <0.001 and r² linear = 0.005, p = <0.001) and negatively correlated with BMI (r² linear = 0.076, p = 0.519).

Conclusions

This study has shown the size of right dRA 2.27 + 0.39 mm in males and 2.09 + 0.38 mm in females. Diabetes, hypertension, height and weight are important predictors of dRA diameter.

Chronic groin pain in Desarda versus Lichtenstein hernia repair - a randomised controlled study

BACKGROUND

Chronic pain after inguinal hernia repair is a common complication. This study compared the difference between Desarda repair and Lichtenstein repair for inguinal hernia in chronic groin pain.

METHODS

One hundred patients with unilateral uncomplicated inguinal hernia were randomised to either Desarda repair (n = 50) or Lichtenstein repair (n = 50) under local anaesthesia and were evaluated for pain postoperatively. Operative time, surgical complications, time to return to normal gait and work, and overall patient satisfaction were recorded. The patient was blinded to the procedure. Any pain at three months (numerical rating scale 1 or more) was considered chronic pain.

RESULTS

Mean operation time was approximately 5 minutes less for Desarda (p = 0.33). There was no significant difference in terms of pain level postoperatively between Lichtenstein and Desarda groups. Twenty-two (44%) patients in the Lichtenstein group had chronic pain, and twenty-one (45.7%) patients had chronic pain in the Desarda group (p = 0.871). No significant difference was observed in haematoma formation, wound infection, recurrence rate, seroma, or foreign body sensation. The mean time for patients to return to normal gait was approximately 0.5 day earlier for the Desarda group (p = 0.29). The mean time for patients to return to normal work was comparable (p = 0.99). Desarda group had a slightly higher satisfaction rate than the Lichtenstein group (9.1%).

CONCLUSION

Desarda repair is not inferior to Lichtenstein repair in the short-term concerning complications or pain.

Cystic Echinococcosis of Liver and Spleen Communicating to the Lung: A Rare Case

The annual cystic echinococcosis (CE) incidence in endemic countries is between 1 and 200 per 100,000 population. The clinical manifestations of CE are associated with damage or dysfunction of target organs and affect primarily the liver in around 70% of cases and lungs in around 20% of cases. The involvement of the spleen is rarely seen, representing 2 to 6% of all CE cases. We describe a 60-year-old female patient who presented with 15 days' history of intermittent fever and abdominal distension, having significant hepatosplenomegaly. CE was diagnosed involving the liver, spleen, and lungs and was confirmed radiologically and microbiologically. CE is caused by the larval or cystic stage of the zoonotic dog-tapeworm. Humans can be infected by ingestion of contaminated food or water. At present, there are nine species under the genus Echinococcus with E. granulosus sensu stricto having worldwide distribution, while the rest are focally distributed. CE involving multiple organs is rare. CE should be taken into consideration in patients with these symptoms in endemic areas.

CT-based evaluation of the acetabulum for age estimation in an Indian population

Age estimation constitutes an important aspect of forensic research, investigation and human identification. For the purpose of age estimation, various markers within the skeletal framework are employed. Degenerative morphological changes in the skeleton can be used for age estimation in adults. Amongst the various bones, age-progressive changes in the innominate bone are of particular significance in age estimation. Within the pelvis, the acetabulum presents as a durable and well-preserved evidence, characteristic manifestations of which can be employed for age estimation. The present study aimed at a CT-based evaluation of acetabular changes for the purpose of age estimation in an Indian population. CT images of 250 individuals aged 10-88 years were scrutinized according to the features defined in the Calce method of acetabular age estimation. Scores were allotted to the various features and a cumulative score was calculated. No significant bilateral and sex differences were observed. Significant correlation was obtained between the scores for these defined characteristics and the chronological age of individuals. Population-specific regression models were generated for age estimation. The scoring method devised in the present research requires further validation as it represents a new tool for age estimation in medico-legal cases.

Forgotten Chemo-Port Leading to Chylothorax: A Rare Presentation

Chylothorax is an uncommon cause of pleural effusion in routine clinical practice. Thoracic surgery, trauma and malignancy are the leading causes of chylothorax accounting for more than 90% of cases.1,2 We report this rare case of a middle aged lady with treated carcinoma breast who presented with left-sided chylothorax secondary to subclavian vein and superior vena cava thrombosis caused by a longstanding indwelling chemo-port in the right internal jugular vein. Patient was managed on total parenteral nutrition (TPN) leading to complete resolution of chylothorax.

Age-related changes in the hyoid bone: An autopsy-based radiological analysis

Forensic age estimation is a crucial aspect of the biological profile of unidentified cadavers. The utility of age-related changes of hyoid bone fusion in forensic age estimation has not been explored much in the past. These age-related changes can be visualised in both the living and the dead using conventional radiography. These changes can assist medico-legal professionals and forensic anthropologists in the identification of unknown deceased, especially when the cadaver is mutilated or charred or when the other well-established indicators of skeletal and dental maturity are absent. The aims of this study were to evaluate age-related changes in the hyoid bone and to ascertain whether these changes may be utilised for age estimation in forensic examinations. The hyoid bone was carefully dissected using a standard procedure from 75 cadavers during post-mortem examination. The hyoid bone was radiographed, and the bone was replaced in the body cavity before the post-mortem examination was completed. Hyoid bone fusion was studied by using a standard grading method. Spearman's correlation coefficient was calculated between the fusion scores and chronological age to assess their relationship. Box and whisker plots of fusion stage-wise age distribution were constructed to demonstrate the gradual linear relationship between hyoid bone fusion and the chronological age of the study participants. The present study concludes that hyoid bone fusion is an indicator of the chronological age of an individual and can be used in conjunction with other methods of age estimation such as the skeletal and dental age.

Magnetic Resonance Imaging in Coronavirus Disease - 2019 Associated Rhino-Orbital-Cerebral Mucormycosis (CA-ROCM) - Imaging Analysis of 50 Consecutive Patients

BACKGROUND AND PURPOSE

Rhino-orbital-cerebral mucormycosis has emerged as a major opportunistic infection in patients with COVID-19. High clinical suspicion and prompt imaging are crucial for early diagnosis and management. Our study evaluates imaging characteristics of patients with COVID-19 associated Rhino-orbital-cerebral Mucormycosis (CA-ROCM) in a tertiary care hospital in India.

MATERIALS AND METHODS

A retrospective analysis of clinical and imaging data of patients with CA-ROCM who presented between December 2020 to June 2021 was performed. All patients had microbiologically or histologically proven sino-nasal mucormycosis along with documented SARS-CoV-2 positive RT-PCR test and/or classical lung imaging features of COVID-19 infection. The extent of sinus involvement, bony erosions, extra-sinus soft tissue extension, orbital-intracranial invasion, perineural spread, and vascular complications were assessed.

RESULTS

Fifty patients were included for the final analysis. Diabetes was the most common associated comorbidity. Seven patients presented with stage I disease, 18 patients with stage II, and 25 patients with stage III disease. The stage of disease showed a positive statistical correlation with HbA1c levels using Pearson's correlation. The common imaging features were "Black turbinate sign" and nonenhancing sino-nasal mucosa (82%), orbital involvement (76%), and diffusion restriction in the optic nerve (24%). Intracranial involvement was seen as perineural extension into the brain (42%), cerebritis (30%), and internal carotid artery involvement (16%).

CONCLUSIONS

CA-ROCM is an acute invasive fungal sinusitis with an aggressive clinical course. Black-turbinate sign and peri-antral soft tissue infiltration are early features, whereas extra-nasal tissue infarction, optic nerve diffusion restriction, and vascular invasion are seen with advanced disease.

Age related changes in thyroid and cricoid cartilages: An autopsy based radiological analysis

Forensic age estimation is an invaluable aspect of human identification. Out of these many means of age estimation, few regions with untapped potential for assistance in forensic age estimation are the age-related changes in the laryngeal cartilages. As the age advances, the thyroid and cricoid cartilages undergo gradual calcification in an individual. These age-related changes can be visualized in both the living and the dead using conventional radiography and can be objectively assessed. The objective of the present study was to evaluate the age-related changes in the laryngeal cartilages and the results may be utilized for age estimation in forensic examinations. The laryngeal cartilages were carefully dissected using standard procedures from 75 cadavers of age ranging from 17 to 65 years, during the post-mortem examination. The laryngeal cartilages were radiographed and replaced in the body cavity before culminating the post-mortem examination. The calcification of both cartilages was studied by using the standard grading method. Calcification scores of individual regions of both the laryngeal cartilages show a statistically significant positive correlation with chronological age (P < 0.05). Regression models derived from the degree of calcification of thyroid and cricoid cartilages showed standard error of estimates that ranged between 9.90 and 11.07 years. Considering the standard error of estimates of the regression analysis, the present study concludes that these regression models can be used in adjunct with other methods of age estimation such as the skeletal and dental age or when such methods are not viable as in cases of charred or mutilated remains.

Abbreviated MRI in patients with suspected acute appendicitis in emergency: a prospective study

PURPOSE

To determine the diagnostic performance of an abbreviated non-contrast MRI protocol in diagnosing acute appendicitis.

METHODS

Prospectively, a total of 67 consenting consecutive patients with clinical suspicion of acute appendicitis (Alvarado score ≥ 5) were evaluated with an abbreviated three-sequence non-contrast MRI protocol (axial T2WI, coronal T2WI, axial DWI) at a single tertiary care center. MRI was interpreted by two radiologists blinded to the clinical details, other investigations, and outcome of the patients. Diagnostic performance of MRI was determined using either histopathological examination (HPE) results as the reference standard in surgical cases (n = 39), or final clinical diagnosis at discharge and 3-months follow-up in non-operatively managed cases (n = 28).

RESULTS

Sixty-seven patients comprising 42 males, 25 females including 1 pregnant patient were enrolled (median age 24 years; age range 6-70 years). The median acquisition duration of the MRI protocol was 12.5 min. In the analysis of the complete cohort including both surgical and non-operatively managed cases (n = 67), MRI showed sensitivity of 93.3% (95% CI 81.7-98.6%), specificity of 86.4% (95% CI 65.1-97.1%), and diagnostic accuracy of 91.0% (95% CI 81.5-96.6%) (p < 0.001). In the subset of surgical cases with HPE as the reference standard (n = 39), MRI showed sensitivity of 97.1% (95% CI 84.7-99.9%), specificity of 100% (95% CI 47.8-100%), and diagnostic accuracy of 98% (95% CI 87.5-100%) (p < 0.001).

CONCLUSION

MRI may be performed to diagnose acute appendicitis or alternative causes of right iliac fossa pain. An abbreviated MRI protocol consisting of only three sequences without IV contrast, patient preparation, or antiperistaltic agents could shorten the examination duration while retaining diagnostic accuracy.

Reappraisal of Limited Duration Tourniquet in Total Knee Arthroplasty: A Double-Blinded RCT

BACKGROUND

The majority of arthroplasty surgeons use a full duration of tourniquet while doing total knee arthroplasty. Recent literature suggests clinical dilemma about superior function with limited duration use of a tourniquet. The purpose of this study is to evaluate the time-dependent effects and clinical outcome of tourniquet in patients undergoing total knee arthroplasty (TKA) and to assess the incidence of adverse vascular events of the limb in TKA. This study is the first of its kind to evaluate all the serious vascular events prospectively.

METHODS

Sixty participants who underwent TKA in the duration of 1.5 years at a large single tertiary care centre were recruited and randomly allocated in two groups: Full duration tourniquet (n = 30) and tourniquet only during cementation (n = 30). All patients underwent preoperative and postoperative arterial and venous Doppler to evaluate the presence of thrombosis. The operative duration, blood loss, and clinical outcome (visual analogue scale, active knee range of motion, Knee Society score, and duration of stay) were recorded.

RESULTS

The incidence of vascular complications was not statistically significant in either group (P = 0.99). Tourniquet during cementation only group exhibited decreased postoperative pain on days 1, 2, and 3 (P < 0.01). But postoperative knee active range of motion was the same between the two groups with no significant postoperative complications.

CONCLUSION

Tourniquet use only during cementation could result in faster recovery and less pain during the early rehabilitation period with no influence over the incidence of serious vascular events.

TRIAL REGISTRY NUMBER

AIIMS/IEC/2018/475. This study was approved by the Research Ethics Committee at All India Institute of Medical Sciences, Jodhpur and was carried out at AIIMS (Jodhpur), India.

Neuroendocrine tumors of the urinary bladder - Report of two cases

Primary paraganglioma and small cell neuroendocrine carcinoma of the urinary bladder are rare tumors, comprising 0.05% of all bladder tumors and <1% of all malignant bladder tumors, respectively. These tumors can be the cause of a diagnostic dilemma or misdiagnosis on morphology. Paraganglioma is often mistaken for urothelial carcinoma and small cell carcinoma for poorly differentiated carcinoma or lymphoma. Herein, we report a case of primary paraganglioma and another of a small cell carcinoma of the urinary bladder and discuss their closest differential diagnoses. The diagnostic pitfalls should be kept in mind so that correct, timely diagnosis of these entities can be made due to implications in the management and prognosis.

Age estimation from sternebral fusion in an Indian population - A computed tomographic evaluation

Forensic age estimation is a crucial aspect of the human identification process. Sternebral fusion is one of the skeletal indicators of age that has not been thoroughly researched for the purpose of age estimation. The present study was conducted with the aim of assessing the utility of each of the sternebral fusion in age estimation, and to ascertain if these fusion stages can help in identifying whether an individual has attained the medicolegally significant ages of 16 and 18 years. Thoracic CT images of 148 study participants (74 females, 74 males) were analysed to evaluate the fusion of sternebrae 1-2, sternebrae 2-3, and sternebrae 3-4. The fusion scores for these were found to be statistically significant (P < 0.001) with sternebrae 1-2 fusion showing the highest coefficient of correlation at R = 0.900. Linear regression models were generated using each of the sternebral fusions separately and together for estimation of age. The standard error of estimate for the regression models ranged from 1.51 to 2.86 years. Box and Whisker plots were constructed to see the fusion score wise age distribution of the study population, and it was observed that sternebral fusion has the ability to indicate whether an individual has attained the age of 16 and 18 years. Our study concludes that sternebral fusion can act as an accurate method of forensic age estimation of juveniles and young adults.

Apixaban or enoxaparin: Which is better for thromboprophylaxis after total hip and total knee arthroplasty in Indian patients?

Both apixaban and enoxaparin are Food and Drug Administration-approved standard therapy for prophylaxis of deep-vein thrombosis; however, the superiority of one over the other is still controversial. With an objective to observe efficacy and safety outcomes of apixaban and enoxaparin in patients undergoing total hip (THA) and knee (TKA) arthroplasty, 96 patients undergoing THA/TKA (October 2018 to August 2019) were randomly allocated into 2 groups; (n = 48) apixaban; and (n = 48) enoxaparin. Efficacy outcomes and safety outcomes were recorded at 2 and 5 weeks post-TKA/THA. Follow-up functional scoring was done at 6 months postoperatively. Apixaban and enoxaparin were found to be equally efficacious in preventing venous thromboembolism; however, apixaban had a better safety profile. The apixaban group had nonsignificant higher tendency for wound discharge, atrial fibrillation and transient ischaemic attack. Enoxaparin had nonsignificant greater tendency for bleeding, wound dehiscence and pulmonary complications. Apixaban is a safe alternative to conventionally used enoxaparin for chemoprophylaxis in patients undergoing THA or TKA.

Role of radiology in RT-PCR negative COVID-19 pneumonia: Review and recommendations

Currently, RT-PCR is the gold standard for diagnosing SARS-CoV-2 infection. However, due to the time-consuming laboratory tests and the low positivity rate of RT-PCR, it cannot be an ideal screening tool for infected population. In this review article, we have reviewed studies related to RT-PCR and CT chest and we would like to give our recommendations. Depending upon the patient's clinical symptoms and radiology imaging typical of viral pneumonia compatible with COVID-19 infection, clinicians need to consider isolation of these patients early even if the RT-PCR test is negative.

Reference Charts of Fetal Biometric Parameters at Different Gestational Age Groups in Indian Population

To develop, a reference charts of fetal abdominal circumference and femur length in normal pregnant women by using ultrasonography for Indian population. Further comparison of our findings with data derived from different population. This retrospective cross-sectional study included 300 normal singleton pregnancies and was carried out in the department of Anatomy, All India Institute of Medical Sciences, Jodhpur (Rajasthan), India from September 2017 to April 2019. Ultrasonography measurements included Abdominal circumference (AC) and Femur length (FL). Reference charts with mean AC and FL for corresponding Gestational age (GA) in weeks were developed. Also reference centiles (10th, 50th, 90th and 95th) were derived from this model and compared with similar studies done on different population. There was no statistically significant difference in age distribution of pregnant women (p=0.87). Both AC and FL were found to have statistically significant linear relationship with advancing gestational age (p=0.0005 & p=0.0003 respectively). There is significant difference observed between the values obtained in present study with studies concluded on Chinese and European population. Measurement of AC and FL are used to predict gestational age of fetus by using various regression formulae, also AC is known to be good predictor of nutritional status of fetus in utero. A separate chart is required for every different population because ethnicity, nutrition and environmental factor can have impact on normal values. Therefore, a reference chart for these parameters according to Indian population standards is essential to avoid misinterpretation of data. This would help to avoid misdiagnosis of intrauterine growth retardation or macrosomia during prenatal and perinatal period.

Primary clear cell carcinoma of gallbladder arising in porcelain gallbladder

Gallbladder carcinomas (GBCs) are the most common carcinomas of the biliary tract. The clear cell variant is encountered rarely, accounting for approximately 1% of all GBCs.Due to its rarity, the exact incidence and pathogenesis of this variant are unknown. Though hyalinising cholecystitis (porcelain gallbladder) is an established risk factor for development of conventional adenocarcinomas of the gallbladder, its role in the pathogenesis of the rare variants of GBC is not well-established. The current case raises the possibility that clear cell carcinoma of the gallbladder may arise through the same pathways as conventional adenocarcinomas of the gallbladder.

MDCT evaluation of pancreatic contour variations in head, neck, body and tail: surgical and radiological significance

OBJECTIVE

The purpose of the study was to investigate the incidence of pancreatic contour variations on multidetector CT (MDCT) for abdominal examinations.

METHODS

A retrospective analysis of 700 MDCT scans was performed in patients who underwent triple phase CT abdomen between October 2018 and January 2021. After excluding 176 patients, finally total of 524 patients were included in the study. For simplification, we classified the pancreatic contour variations as classified by Ross et al. and Omeri et al. Pancreatic head-neck variations was classified into Type I-anterior, Type II-posterior and Type III-horizontal variety. Pancreatic body-tail variation was divided into Type Ia-anterior projection; Ib-posterior projection and Type IIa-globular, IIb-lobulated, IIc-tapered, and IId-bifid pancreatic tail.

RESULTS

The most common type of variation in the head was Type II (n = 112, 21.3%) followed by Type III (n = 37, 7%) and Type I (n = 21, 4%). The most common type of variation in the body of pancreas was Type Ia (n = 33, 6.2%) followed by Type Ib (n = 13, 2.4%). In the tail region of pancreas, the most common variation was Type IIb (n = 21, 4%) followed by Type IIa (n = 19, 3.6%).

CONCLUSION

Pancreatic contour variations are not very uncommon in daily practice. Knowledge of these variations is important for surgeons, radiologists and avoids misjudgement of normal pancreatic tissue as tumor or lymph node especially on unenhanced or single phase MDCT.

Unpredictable Outcome of Large Traumatic Oesophageal Injury: An Experience and Challenges

Oesophageal injury following blunt or penetrating injury due to road traffic accidents is a rare cause of morbidity and mortality. The outcome of delayed diagnosis of oesophageal injury is mostly life threatening conditions. A 23-year-old female presented with respiratory distress, fever, chest pain and facial deformity, following road traffic accident 15 days back. After evaluation, the patient was diagnosed with septicaemia due to large thoracic oesophageal perforation with left pyothorax. The patient was managed by Video Assisted Thoracoscopic Surgery (VATS) decortication with feeding jejunostomy followed by diversion cervical oesophagostomy. The patient was planned for oesophageal reconstructive surgery electively in follow-up period. After six weeks in the follow-up period, surprisingly large thoracic oesophagus perforation and cervical oesophagostomy was healed spontaneously which was confirmed by gastrograffin study. Spontaneous closure of large thoracic oesophageal perforation is the rare outcome of this injury.

Can combined multiparametric magnetic resonance imaging of the prostate and prostate-specific antigen density improve the detection of clinically significant prostate cancer: A prospective single-center cross-sectional study

Objective

The objective of the study was to validate PIRADS v2 on 3T MRI with secondary assessment if combination of the PIRADS v2 and PSA density improves detection of clinically significant prostate cancer.

Materials and Methods

We conducted a prospective study evaluating 58 patients with PSA value of >4 ng/ml from July 2017 to December 2019. Transrectal ultrasonography (TRUS) guided targeted biopsy was performed via cognitive targeting followed by systemic 12 core biopsy. Two cognitive fusion-targeted biopsy cores were added for each lesion in patients who had suspicious or equivocal lesions on mpMRI. The PI-RADS scoring system version 2.0 (PI-RADS v2) was used to describe the MRI findings.

Results

Total of 112 lesions of 58 patients were assessed via mpMRI followed by TRUS guided biopsy. A PI-RADS v2 score of ≥4 irrespective of PSA density categories and a PI-RADS v2 score of 3 with PSA density of ≥0.15 ng/mL/cc, yielded the highest overall prostate cancer and clinically significant prostate cancer detection rate. Contrary to, a PI-RADS v2 score of ≤3 and a PSA densitay of <0.15 ng/ mL/mL(low risk group), which yielded no clinically significant prostate cancer.

Conclusion

Both PIRADS v2 score and PSA density are eminently sensitive and specific in the detection of clinically significant prostate cancers individually. However the combination of PIRADS v2 and PSA density significantly improved the accuracy of clinically significant prostate cancer detection. Patients with combination of PIRADS v2 score ³3 and PSA density ³0.15 ng/ml/cc should undergo prostate biopsy.

Laparoscopic retrieval of impacted and broken dormia basket using a novel approach

We encountered a 73-year-old patient who presented with right upper abdominal pain and jaundice. On evaluation, he was found to have cholelithiasis with choledocholithiasis. Endoscopic retrograde cholangiography was attempted, but during the procedure, the wire snapped and the dormia basket got retained in the common bile duct (CBD). Laparoscopic CBD exploration was performed and the basket with calculus was found impacted in the lower CBD. The basket was disengaged by holding its tip through another dormia introduced through choledochoscope and basket with all calculi retrieved. Clearance of CBD was ascertained with choledochoscopy and CBD was closed primarily. He did well in the post-operative period and was discharged on the 5^th post-operative day. At 1-year follow-up, the patient was doing well. Laparoscopic CBD exploration is a feasible and safe option for the retained dormia basket. We utilised the 'dormia with dormia technique' to retrieve the impacted basket which has not been reported before.

Endoscopic Biliary Stenting for Portal Biliopathy Perforating Paracholedochal Collateral: A Rare Complication

Extrahepatic portal venous obstruction (EHPVO) usually presents with upper gastrointestinal bleed in the first decade of life. Symptomatic portal hypertensive biliopathy is seen in a minority of patients with EHPVO. With use of endoscopic intervention, biliary drainage is maintained in these patients. Various procedural complications have been linked while performing endoscopic retrograde cholangiography and stenting; however, these are managed conservatively. Here, we are highlighting a case of EHPVO with symptomatic portal biliopathy in which the patient bled from paracholedochal collateral after biliary stenting and was managed successfully with a multidisciplinary approach.

Splenic Abscess Caused by Salmonella Typhi: an Uncommon Presentation

Splenic abscess is an uncommon extra-intestinal complication of Salmonella Typhi infection in the post-antibiotic era. The condition is associated with high morbidity and mortality if not diagnosed in a timely manner. We report the case of a 20-year-old man who presented with left upper abdominal pain, high-grade fever, and a lump in the abdomen. Ultrasound and computed tomography scan of the abdomen revealed a large solitary splenic abscess. The abscess was drained percutaneously and Salmonella Typhi was isolated on a culture board, which was an unexpected finding. The patient was prescribed the appropriate antibiotics based on an antimicrobial susceptibility report and periodic follow-up was planned. The clinical condition of the patient improved along with complete resolution of the abscess. This report reiterates the importance of clinical diagnosis and radiological imaging even for common diseases presenting in an unusual fashion. Percutaneous drainage and microbial culture, with antibiotics prescribed based on susceptibility are key to the treatment of such abscesses.