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BACKGROUND: A diagnosis in acute abdomen may remain elusive especially when the cause is rare. We report this interesting case of a fighter pilot presenting with acute abdominal pain. The case posed significant challenges in reaching the correct diagnosis of abdominal crunch syndrome. The syndrome is rare with only seven reports in the literature so far. To the best of our knowledge, this is the first ever report of this condition in an aircrew.CASE REPORT: A 37-yr-old pilot presented with severe upper abdominal pain and sweating. During examination, he developed bradycardia and was admitted with a presumptive diagnosis of acute coronary syndrome. Investigations revealed no myocardial ischemia on ECG, transaminitis, raised CPK, CKMB, and LDH. A CECT scan of chest and abdomen was normal. A GI surgery consult was sought where we connected the transaminitis and raised CPK and considered the possibility of rhabdomyolysis. On specific inquiry, the aviator gave history of unaccustomed exercise with a vigorous session of abdominal crunches a day prior. Thus, a diagnosis of abdominal crunch syndrome was concluded.DISCUSSION: The aviator did not associate his vigorous exercise with the occurrence of pain and, therefore, did not mention it. It would have avoided unnecessary investigations and delay in treatment. From the aeromedical safety aspect, had the aviator flown on the day he developed pain, there was a possibility of developing severe pain exacerbated by the G force and G suit and sudden in-flight incapacitation. From the perspective of the aircrew, it is advisable that they avoid sudden, unaccustomed exercise.Kumar A, Kaistha S. Abdominal crunch syndrome creates a diagnostic challenge in treating a pilot with acute upper abdominal pain. Aerosp Med Hum Perform. 2023; 94(2):86–89.

Cutaneous endometriosis is not a very often seen condition and is broadly classified as primary (spontaneous) and secondary. While perineal endometriosis arising in a previous scar has been reported, spontaneous cutaneous endometriosis in perineum is extremely rare and only three cases occurring in mons pubis have been reported in literature. We report a case of 34-year-old lady presented with a swelling in pubic region and associated dull aching pain of 1-year duration with no history of cyclical variation of symptoms. Investigations finally concluded a diagnosis of endometriosis and a Complete excision with clear margins. Clinicians should be aware that a spontaneous endometriosis in the perineum can occur and can have atypical presentation with no increase in size or pain during menstruation.

Owing to its rarity and non-specific clinical features, a diagnosis of obturator hernia is often delayed until the patient presents with intestinal obstruction. Often the diagnosis is made on a Computed Tomography (CT) scan or during exploratory laparotomy. While a laparoscopic approach is well described in an elective scenario, open surgery through a midline laparotomy has been the preferred approach for obturator hernia with intestinal obstruction. However, a few cases of obstructed obturator hernia have been reported that have been managed laparoscopically. We present our experience of two elderly patients who presented with intestinal obstruction. A CT scan helped clinch the diagnosis of obturator hernia as the cause and both were managed laparoscopically.

Carcinoid syndrome consists of the classic symptom triad of flushing, diarrhoea, and valvular heart disease. It occurs in the majority of patients with liver metastases. This report presents a 68-year-old female who suffered from chronic diarrhoea with a history of multiple admissions for the same. On evaluation, a Computed Tomography (CT) scan showed a terminal ileal lesion and bulky ovaries. Suspecting Neuroendocrine Tumour (NET) with carcinoid syndrome, a Gallium 68 DOTANOC (DOTA-1-Nal3- octreotide) scan was done which revealed somatostatin receptor expression in enhancing soft tissue lesion in terminal ileum as well as in bilateral adnexa. This confirmed the diagnosis of NET of the ileum and bilateral ovarian metastases. The patient underwent laparoscopic curative resection of the primary tumour along with bilateral oophorectomy. The patient was diagnosed with ileal NET and presented with clinical symptoms of carcinoid syndrome, yet did not have evidence of hepatic metastasis, but instead had bilateral ovarian metastasis which itself is a rare entity.

The remediation of organic and inorganic pollutants from the aqueous environment has touched a certain level with the development of research. Environmental pollution is increasing day by day due to industrial activities which cause a negative effect on human health and the ecosystem. Nowadays, heavy metals have a special concern due to its toxicity, persistence and bioaccumulation in nature. Toxic metals like chromium, nickel, arsenic, lead, mercury, cadmium are the main contaminants of water because they are non-biodegradable in nature. Nickel is also a toxic metal, mostly used in industries because of its anticorrosion behaviour. As a consequence nickel is present in the wastage of electroplating, tableware, metal finishing, plastics manufacturing, nickel-cadmium batteries, fertilizers and mining industries and these waste have dangerous impact on the human health and environment and causes the diseases i.e. diarrhea, anemia, hepatitis, kidney damage, gastrointestinal distress, skin dermatitis, and central nervous system dysfunction. In the present review article, several techniques are discussed for the treatment of nickel from the industrial environment. The elimination of nickel from wastewater is not important only for economic purposes but also for environmental safety.

This study aims to investigate the influence of institutional capacity on the relationship between financial development and environmental quality and also examines the moderating role of corruption on the link between institutional quality and environmental quality. By using yearly data from 33 developing countries for 7 years from 2011 to 2017, this paper applies a dynamic technique system GMM. The results suggest that financial development increases environmental degradation due to possible higher energy-intensive investment. However, institutional capacity moderates its impact on environmental quality by channelizing the funds to energy-efficient investment. The findings of this study suggest that financial development improves the environmental quality when institutional capacity is higher than 3.5 on the scale of 0 to 6. Interestingly, institutional capacity is unable to control environmental degradation in the presence of corruption. The results propose that financial development has a positive relation with environmental degradation in the presence of corruption. Nevertheless, relationship between institutional capacity and environmental degradation turns to negative when corruption improves in the economies. Furthermore, the findings show that institutional capacity may only control environmental degradation when corruption improves to 40 or higher on a scale of 0 to 100. The policy implications of this study are useful for policy departments, environmental regulatory bodies, and financial institutions.

Summary Background Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. Methods We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124. Findings Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). Interpretation We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial. Funding UK National Institute for Health Research Health Technology Assessment Programme.

Background Laparoscopic cholecystectomy (LC) is the most common surgery done in general surgical practice worldwide. Despite clear guidelines recommending against the routine use of antibiotic prophylaxis (ABP) for elective LC by professional entities such as the Scottish Intercollegiate Guidelines Network (SIGN), Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) etc., most surgeons are not convinced about omitting ABP in low-risk LC. Thus, this study aimed at capturing the practice of administering ABP in elective LC among surgeons of Armed Forces Medical Services (AFMS). Methods This was a survey based on an electronic, cross-sectional, self-completion questionnaire that was designed and disseminated amongst 184 surgeons of the AFMS, online, and the data was collated centrally. Results 64% of surgeons completed the survey. The majority (85%) of surgeons used ABP routinely in elective LC. In the univariate analysis, only the number of years of surgical experience and the total number of LC done in an entire career, and in the multivariate analysis age group of the surgeon, surgical experience and designation were significant factors for avoiding routine ABP in elective LC. Amongst the surgeons administering ABP, only 30% administered a single dose, 73% chose a single agent and Cefotaxime (57%) was the commonest antibiotic used. Conclusion This study found that there is a high prevalence of use of antibiotic prophylaxis in elective laparoscopic cholecystectomy amongst the surgeons of the AFMS. There was a wide variation in terms of choice of antibiotics, administering single or multiple doses and as a single agent or combination therapy. Registered with clinical trials registry of India CTRI/2019/03/018092.

In this study, nano-sized ITO supported Pt-Pd bimetallic catalyst was synthesized for the degradation of methyl parathion pesticide, a common extremely toxic contaminant in aqueous solution. On the characterization with different techniques, a beautiful scenario of honeycomb architecture composed of ultra-small nanoneedles or fine hairs was found. Average size of nanocatalyst also confirmed which was in the range of 3–5 nm. High percent degradation (94%) was obtained in 30 s using 1.5 × 10− 1 mg of synthesized nanocatalyst, 0.5 mM NaBH4, and 110 W microwave radiations power. Recyclability of nanocatalyst was efficient till 4th cycle observed during study of reusability. The supported Pt-Pd bimetallic nanocatalyst on ITO displayed many advantages over conventional methods for degradation of methyl parathion pesticide, such as high percent degradation, short reaction time, small amount of nanocatalyst, and multitime reusability.

Lyme's disease also known as Erythema chronicum Migrans, is a multisystem infectious disease caused by the spirochete "Borrelia burgdorferi" which is transmitted by "Ixodes" tick, with both specific and nonspecific manifestations. Nervous system involvement occurs in 10%-15% of untreated patients and typically involves lymphocytic meningitis, cranial neuritis, and/or polyradiculitis. Here, we are reporting an interesting and challenging case of Neuro-Borreliosis in a young officer cadet, meeting the description for Bannwarth's syndrome and presenting initially as a surgical emergency followed by paraparesis. The diagnosis was finally clinched based on clinical profile of Chronic Myeloradiculopathy with focal myositis in the setting of recent outdoor camping, and confirmed by demonstrating high IgG antibody titres in serum and Cerebro spinal fluid (CSF). The officer cadet was treated successfully with a 6 week course of Ceftriaxone and Doxycycline, and went back to full training.

Wg Cdr Ameet Kumar , Brig C.K. Jakhmola , Maj Gen N.C. Arora, VSM**, Col S.S. Chauhan d a Assistant Professor (Surgery), Army College of Medical Sciences and Classified Specialist (Surgery) and GI Surgeon, Base Hospital, New Delhi 10, India b Professor and Head (Surgery), Army College of Medical Sciences and Consultant (Surgery) and GI Surgery, Base Hospital, New Delhi 10, India c Consultant (Surgery and Orthopaedic Surgery) and Commandant, Base Hospital, New Delhi 10, India d Professor (Surgery), Army College of Medical Sciences and Classified Specialist (Surgery) and GI Surgeon, Base Hospital, New Delhi 10, India

Introduction: Trauma is a modern day epidemic. Abdominal trauma is the most common cause of trauma-related death that is preventable. Non operative Management (NOM) is increasingly being done in Blunt Abdominal Trauma (BAT). However, for high grade injuries, the risk of failure of NOM has been shown to be higher. Aim: To assess the feasibility and success rate of NOM in abdominal trauma with high grade solid organ injury. Materials and Methods: The present study was a retrospective review of a prospectively maintained database at a Tertiary Care Centre. 17 blunt trauma abdomen cases with high grade solid organ Injuries over a period of four and a half years without peritoneal signs or persistent haemodynamic instability after initial resuscitation were included. Data was analysed using online statistical software (graphpad). Results: Of the 17 cases with high grade injuries, two had contrast extravasation on imaging. Predominant organ involved was spleen in 11 (64.8%), liver in 10 (58.8%) and pancreas in one patient, respectively. NOM was successful in 100% of patients. Three patients had rebleeding and all were successfully managed non-operatively. There was no mortality. Conclusion: The NOM is feasible and safe even in high grade injuries in BAT. This decision is based on a sound clinical judgment and should be attempted at centers with facilities for critical care, interventional radiology and adequate blood bank facilities. The patient condition and not the grade of injury on imaging should dictate the line of management.

Background Laparoscopic surgery has expanded exponentially in the last two decades but, somehow it is limited in pancreatic surgery by virtue of the pancreas being a friable, retroperitoneal organ with difficult access and adjacent major vessels risking torrential bleed. It is thought to be unforgiving if not handled well. However, improvements in technology and surgeon's expertise have pushed the boundaries of minimal access surgery (MAS) to include pancreas in its domain. We present our series of laparoscopic pancreatic surgery (LPS) with an aim to look at the feasibility and outcomes. Methods This is a retrospective review of all LPS done at the Gastrointestinal Surgery (GIS) centre of a tertiary care Armed Forces Hospital over a period of 3 years. Results A total of 24 LPS were done during this period. The median age of the patients was 46 years (range; 13–81). There were 14 male and 10 female patients. Nine patients had at least one co-morbidity. Three patients underwent laparoscopic lateral pancreaticojejunostomy, 4 distal pancreatectomy, 4 laparoscopic Whipples pancreaticoduodenectomy, 6 laparoscopic pancreatic necrosectomy, 6 laparoscopic cystogastrostomy and 1 roux en y cystojejunostomy. Conclusion LPS can be performed for almost all open pancreatic surgeries and can be done with reasonable outcomes. However, it has a steep learning curve and therefore, a hybrid approach leading to a totally laparoscopic approach may be the way forward.

Necrotizing pancreatitis occurs in 10 to 25% of patients requiring hospital admission for acute pancreatitis and carries a high mortality rate. Necrotizing pancreatitis can cause a spectrum of complications. However, we report an extremely rare complication of necrotizing pancreatitis: necrotizing fasciitis of the abdominal wall. A 56-year-old male patient presented to our center with discoloration of skin over left flank of 15 days duration and pus discharge from it since three days. Two months back he was managed at a private hospital as a case of acute necrotizing pancreatitis and was discharged after one week of inpatient treatment. After discharge patient continued to have malaise and weakness but was able to do his routine day to day activity. On presentation at our hospital, patient was in septic shock and was taken emergently to operating theatre for debridement. However, later, the patient succumbed to his illness. Necrotizing fasciitis is an extremely uncommon complication of necrotizing pancreatitis and has a fulminant course. Timely detection and debridement can avert a potential mortality.

Solitary fibrous tumor of kidney is an unusual condition. It is spindle cell tumor with mesenchymal in origin so most commonly reported cases are in pleura, and extra-pleural sites are very rare. It is mostly benign in nature but malignant variant are also reported. Treatment is en bloc resection as in other sites whether pleural or extra-pleural. Prognosis is excellent. This tumor is difficult to diagnose only on imaging features; so for diagnosis, histopathology is needed mostly with immunohistochemical markers like CD34, CD99, Bcl2 proteins. A middle-aged male presented initially with clinical and radiological features, suspected of renal cell carcinoma. Surgery was performed, which proved solitary fibrous tumor on histopathology; and patient on follow-up remained tumor-free till the last follow-up.

Pancreaticoduodenectomy is a formidable surgery and was associated with high morbidity and mortality. Though the mortality rates have steadily improved, morbidity continues to be high. There is lack of published data on outcomes following pancreaticoduodenectomy in Armed Forces hospitals. The aim of this study was to analyze the short term outcomes at our center and to compare it with the published literature.A retrospective review of prospectively maintained data base was done. Preoperative, intraoperative and postoperative data was analyzed with emphasis on the morbidity and mortality rates. Follow up data was analyzed to look at disease recurrence.Between Jan 2008 and March 2014, 69 patients underwent Whipple's pancreaticoduodenectomy with a median age of 64 years. All had a malignant etiology with periampullary carcinoma being the commonest (42%). Overall, intra-abdominal complications occurred in 46% of patients which included postoperative pancreatic fistula (20%) and delayed gastric emptying (24%). The mortality rate for the whole was 11% which reduced to 8% in the second half of the study.The short term outcomes at our center were comparable to those in published literature. The mortality rates showed a decreasing trend with time.

Acute pancreatitis (AP) in the early postlaparoscopic cholecystectomy (LC) period is a rare complication. The cause is often a missed common bile duct stone. Having been reported only once before, we present a second case of AP after LC caused by hemobilia secondary to hepatic artery pseudoaneurysm. The management of this complication is distinctly different from the treatment for AP caused by a stone and must be done on an emergency basis.

Background: Health care workers (HCWs) are at substantial risk of acquiring blood borne infections such as HIV, Hepatitis-B and Hepatitis-C through needle stick injuries (NSIs). This study aimed to assess the proportion of NSIs and their associated factors among HCWs and also to identify the areas in which preventive efforts might be directed to protect against this occupational hazard. Methodology: A cross-sectional study was conducted in two tertiary care hospitals of Pakistan representing both private and public health sector. A total of 497 HCWs (doctors and nurses) were interviewed using a structured questionnaire. Data was collected from January to May 2008. Results: Overall, 64% of the HCWs were exposed to at least one NSI during their career; among them 73% reported NSIs for two or more times. Factors found to be highly associated with NSIs were those practicing this occupation for more than five years (p < 0.001: OR = 5.92; 95% CI = 3.45-10.16) and working as nurse than doctor (p 0.001: OR = 2.12; 95% CI = 1.35-3.32). Having received booster dose of hepatitis B vaccine (p 0.02: OR = 1.85; 95% CI = 1.10-3.11), working in surgical specialty (p < 0.01: OR = 1.6; 95% CI = 1.09-2.51) and being a female (p 0.03: OR = 1.52; 95% CI = 1.04-2.22) were also found to be associated with NSIs. Most commonly reported reason for NSIs was injecting medicine and drawing blood (42%) followed by two-handed recapping of needle (37%). Only, 34% of study subjects were vaccinated against hepatitis B infection. Overall, HCWs had inadequate practices regarding standard precautions such as availability of gloves/protective cloths (40%) and infection control guidelines/protocols (10%) respectively in their working places. Conclusion: In addition to very high rates of NSIs, low safety practices including inadequate vaccination coverage, unavailability of infection control guidelines and other preventive facilities were reported in this study. Prevention of occupational infections among HCWs should be a priority. Formal training, by health authorities in the local area, about safe practices and availability of preventive facilities should be ensured regarding NSIs among HCWs.

Background Surgery for inguinal hernia continues to evolve. The most recent development in the field of surgery for inguinal hernia is the emergence of laparoscopic inguinal hernia surgery (LIHS) which is challenging the gold standard Lichtenstein's tension free mesh repair. Our centre has the largest series of LIHS from any Armed Forces hospital. The aim of this study was to analyze the short and long term outcomes at our center since its inception. Methods Retrospective review of prospectively maintained data base of 501 LIHS done in 434 patients by a single surgeon between April 2008 and October 2013. Preoperative, intraoperative, postoperative and follow-up data was analyzed with emphasis on the recurrence rates and the incidence of inguinodynia. Results 402 (92.6%) patients had primary hernias and 367 (84.6%) patients had unilateral hernias. Of the 501 repairs, 453 (90.4 %) were done totally extraperitoneal approach and 48 (9.6 %) were done by the transabdominal preperitoneal approach. The mean operative time for unilateral and bilateral repairs was 40.9 ± 11.2 and 76.2 ± 15.0 minutes, respectively. The conversion rate to open surgery was 0.6%. The intraoperative, and early and late postoperative complication rates were 1.7%, 6.2% and 3%, respectively. The incidence of chronic groin pain was 0.7% and the recurrence rate was 1.6%. The median hospital stay was 1 day (1–5 days). Conclusion We, in this series of over 500 repairs have demonstrated that feasibility as well as safety of LIHS at our centre with good short and long term outcomes.

The branchial cyst, fistula, and sinuses are the anomalies of the branchial apparatus which consists of five mesodermal arches separated by invaginations of the ectoderm called as clefts. The branchial fistula is not a true fistula as it rarely has two openings. More often even if both ends are patent there is a thin membrane covering the internal opening.1 Demonstration of a complete branchial fistula on imaging studies is uncommon.2 We present a case of a complete branchial fistula in a young lady with a special emphasis on imaging.

The incidence of obstruction of large bowel is 3-4 times less frequent than the small bowel. The main causes of large bowel obstruction are malignancy, volvulus, diverticulae, inflammatory bowel disease and pseudo-obstruction [1]. Anomalous congenital bands (ACB) causing large bowel obstruction is a rare occurrence and to best of our knowledge, only three such cases has been reported in literature [2, 3, 4]. There is no report of congenital band causing both large bowel obstruction and jejunal ischemia. We report an unusual case of intestinal obstruction in a 76 year old lady who had an ACB obstructing the transverse colon causing a closed loop obstruction, caecal perforation and ischemia of proximal jejunum along with formation of pneumatosis cystoides intestinalis (PCI).

Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction that is usually diagnosed during a laparotomy; however, a preoperative diagnosis is possible. Sclerosing encapsulating peritonitis can be classified as primary or idiopathic and secondary types and only about 70 cases of idiopathic type have been reported since it was first described. It is characterized by a total or partial encasement of the small bowel by a thick fibrotic membrane. This report presents a series of three cases in which a diagnosis of idiopathic SEP was made preoperatively based on the clinical features and radiological findings, which were confirmed by a laparotomy and histopathology. All of the cases were successfully managed by the excision of the membrane. This report demonstrates that based on the clinical features and radiological investigations, in the absence of other plausible etiologies for intestinal obstruction, it is possible to suspect a preoperative diagnosis of SEP, thereby preventing a “surprise“ finding during a laparotomy and allowing for better management.

C-arm fluoroscopy is ubiquitous in contemporary surgery, but it lacks the ability to accurately reconstruct three-dimensional (3D) information. A major obstacle in fluoroscopic reconstruction is discerning the pose of the x-ray image, in 3D space. Optical/magnetic trackers tend to be prohibitively expensive, intrusive and cumbersome in many applications. We present single-image-based fluoroscope tracking (FTRAC) with the use of an external radiographic fiducial consisting of a mathematically optimized set of ellipses, lines, and points. This is an improvement over contemporary fiducials, which use only points. The fiducial encodes six degrees of freedom in a single image by creating a unique view from any direction. A nonlinear optimizer can rapidly compute the pose of the fiducial using this image. The current embodiment has salient attributes: small dimensions (3x3x5 cm); need not be close to the anatomy of interest; and accurately segmentable. We tested the fiducial and the pose recovery method on synthetic data and also experimentally on a precisely machined mechanical phantom. Pose recovery in phantom experiments had an accuracy of 0.56 mm in translation and 0.33 deg. in orientation. Object reconstruction had a mean error of 0.53 mm with 0.16 mm STD. The method offers accuracies similar to commercial tracking systems,more » and appears to be sufficiently robust for intraoperative quantitative C-arm fluoroscopy. Simulation experiments indicate that the size can be further reduced to 1x1x2 cm, with only a marginal drop in accuracy.« less

Intraoperative dosimetric quality assurance in prostate brachytherapy critically depends on discerning the three-dimensional (3D) locations of implanted seeds. The ability to reconstruct the implanted seeds intraoperatively will allow us to make immediate provisions for dosimetric deviations from the optimal implant plan. A method for seed reconstruction from segmented C-arm fluoroscopy images is proposed. The 3D coordinates of the implanted seeds can be calculated upon resolving the correspondence of seeds in multiple x-ray images. We formalize seed-matching as a combinatorial optimization problem, which has salient features: (a) extensively studied solutions by the computer science community; (b) proof for the nonexistence of any polynomial time exact algorithm; and (c) a practical pseudo-polynomial algorithm that mostly runs in O(N3) time using any number of images. We prove that two images are insufficient to correctly match the seeds, while a third image renders the matching problem to be of nonpolynomial complexity. We utilize the special structure of the problem and propose a pseudopolynomial time algorithm. Using three presegmented images, matching and reconstruction of brachytherapy seeds using the Hungarian algorithm achieved complete matching in simulation experiments; and 98.5% in phantom experiments. 3D reconstruction error for correctly matched seeds has a mean of 0.63 mm, and 0.9 mm for incorrectly matched seeds. The maximum seed reconstruction error in each implant was typically around 1.32 mm. Both on synthetic data and in phantom experiments, matching rate and reconstruction error achieved using presegmented images was found to be sufficient for prostate brachytherapy. The algorithm is extendable to deal with arbitrary number of images without any loss in speed or accuracy. The algorithm is sufficiently generic to provide a practical solution to any correspondence problem, across different imaging modalities and features.

Epiploic appendagitis is a rare condition that may present with acute abdominal pain and it mimics appendicitis when it occurs on the right side [1]. In a series of 1320 cases of acute abdominal pain by Golash only eight cases were due to acute epiploic appendagitis [2]. Though there are case reports of epiploic appendagitis presenting as acute abdomen, it is seldom considered as a differential diagnosis for appendicitis. We report one such case which presented with right lower abdominal quadrant pain and was diagnosed as acute appendicitis but had torsion of an appendix epiploica of the proximal ascending colon on surgery.

Appendectomy is a common surgery and incisional hernia following appendectomy is uncommon, occurring in less than 0.12% of patients [1]. Post appendectomy interstitial incisional hernia is extremely rare [2]. In 1911, Hoguet first called attention to the occurrence of right inguinal hernia following appendectomy with drained wounds. Many of these had not only a right inguinal hernia but also an associated postoperative hernia at the site of the appendectomy scar. Hoguet and Watson attributed the occurrence of the inguinal hernia to a weakening of the abdominal wall following injury to the ilio-inguinal and ilio-hypogastric nerves [3]. A case of post appendectomy interstitial hernia is reported for the rarity of the condition and review of literature.

Purpose: Intra‐operative dosimetryoptimization of TRUS‐guided prostate brachytherapy requires localization of seeds relative to the prostate [Todor et al. PMB 48(9):1153–71]. Method and Materials: Seeds were reconstructed from C‐arm fluoroscopy, registered to TRUS, and exported to commercial brachytherapy system for dosimetryoptimization. Technical obstacles included pose‐dependant C‐arm calibration; distortion correction; pose estimation of C‐arm images; registering C‐arm to TRUS; and seed reconstruction. We proved that calibration is not critical and distortion correction in AP suffices. A radiographic tracking fiducial was attached in known pose over the template to recover the C‐arm pose from a single image, relative to the template. The 3D coordinates of the segmented seeds are calculated upon resolving the correspondence of seeds in the multiple C‐arm images, by formalizing seed‐matching as a network‐flow problem [Jain et al. Med Phys, 32(11):3475–92]. The seed locations are exported in template coordinates to the Interplant® commercial system for dosimetry analysis and optimization.Results: In precision‐machined hard phantoms with 40–100 seeds, we correctly reconstructed 98.5% seeds with a mean 3D accuracy of 0.63mm (0.91mm error for mismatched seeds). In soft tissue phantoms with 45–87 seeds and clinically realistic 15° C‐arm motion, we correctly reconstructed 100% seeds with 1.5mm absolute accuracy (0.25mm relative accuracy), and registered them to the prostate segmented from TRUS with an accuracy of 3.4mm (0.82mm relative). In a Phase‐1 clinical trial, so far on 4 patients with 66–84 seeds, we achieved intra‐operative monitoring of seed distribution and dosimetry. We optimized the V100 dose by inserting 3–9 additional seeds. Conclusion: Intra‐operative doseoptimization is possible with an average C‐arm, at negligible additional cost to existing clinical installations. Conflict of Interest: The work has been done in collaboration with Acoustic MedSystems for seed import into the Interplant®. Keywords: Prostate Brachytherapy, Intra‐operative Dosimetry.Support: DoD/PC‐050170, DoD/PC‐050042, NIH‐1R43CA099374, NSF‐9731478.

Purpose: Intraoperative quantitative C‐arm fluoroscopy guidance depends on discerning the relative pose of images (pose recovery). A possible method is to use radiographic fiducials visible in fluoro images [1,2]. We propose a robust and fast method for segmenting fiducials designed for brachytherapy applications. Methods and materials: The fiducial contains points, lines and ellipses made from BBs and wires[1]. The algorithm integrates the a‐priori knowledge of fiducial's mechanical construction in a cleverly devised workflow. The BB segmentation is achieved using morphological top‐hat transform. This information serves as a heuristic input to line segmentation realized by a curve tracing algorithm which operates on edge image, followed by augmenting information from intensity image. Once the lines are segmented, this information feeds to the ellipse extraction step. For ellipse segmentation, intensity image is morphologically processed to eliminate background noise, followed by elimination of BB‐s and lines from the information obtained in prior steps. The resulting image consists of only ellipse segments. A fast variation of Hough transform is used to rectify the full ellipse from the segments. Results: The fiducial algorithm identified all the features (BBs, lines and ellipses) visible to human eye in all ten clinical images. Next the accuracy of fiducial segmentation was assessed numerically by feeding the results to the pose recovery algorithm of [1]. The fiducial was moved on an accurate mechanical platform (as ground truth) while the C‐arm was stationary. We reconstructed the relative poses with an accuracy of 1.2 mm in translation and 0.3 degrees in rotational based on the segmented fiducials. Conclusions: The algorithm makes effective use of a‐priori knowledge and combines the techniques of morphological segmentation, curve tracing, and Hough transform, resulting in a novel curve segmentation strategy.

Purpose: Intra‐operative dosimetry in prostate brachytherapy critically depends on discerning the 3‐D locations of implanted seeds. The accuracy of 3‐D seed reconstruction step is, in turn, limited by the accuracy with which the position and orientation of individual implanted seed in the fluoroscopic images can be found. A method for robustly segmenting the seeds in fluoroscopic images is proposed here. Methods and Materials: The process of determining the locations and orientations of implanted seeds is sub‐divided into three main steps. In the first step, the image is segmented by shape‐size based morphological approach to eliminate background noise and do away with non‐uniform brightness of the image, to get seed‐like regions. These regions are either single seeds or overlapping multiple seed clusters. In the second step, the regions are analyzed and classified definitively, in a two‐phase statistical process coupled with information extraction from original intensity image, into two classes: single seed and overlapping multiple seed cluster. In the third step, the region belonging to overlapping multiple seed cluster is resolved into its constituent individual seeds through a simple and novel technique. Results: The proposed algorithm was tested on a set of ten clinical fluoroscopic images. The algorithm correctly determines the seeds with overall average of 99.57%. The clusters are not correctly resolved only in two images (2 clusters each, 1.7% and 1.6% of total seeds in respective implants). One false positive (noise labeled as seed) each is reported in two images, both the cases being where the tip of catheter appears to be of the size and shape of seed. Conclusions: The algorithm builds on an existing framework of morphological processing and provides further improvements in classification and cluster resolution. The algorithm appears to be robust and accurate despite the poor resolution of clinical images.

Motivation: Intraoperative dosimetric optimization of TRUS-guided prostate brachytherapy implants requires localization of seeds relative to prostate[1], for which radiographic fiducial-based registration of fluoroscopy and TRUS seems appropriate[2,3]. It is critical to mount the fiducials rigidly and stabilize the prostate, because TRUS and fluoroscopy are sequential and the moving TRUS probe may dislocate the prostate. Transrectal approach provides the shortest distance to the implanted seeds and prostate, thereby maximizing registration accuracy. Method and Materials: A precision-machined transrectal sheath containing fiducials is mounted rigidly on the stepper and wraps around the TRUS probe. It mechanically decouples the prostate from the TRUS probe and thus stabilizes the prostate. Acoustic impedance, wall thickness, and diameter were optimized. Acoustic coupling is maintained by circulating liquid gel. The system is depressurized during probe motion. Two embodiments accommodate various types of radiographic fiducial markers. A closed 360-degree sheath of 30mm diameter was developed for conics that are extremely robust to segmentation and image distortion, being mathematically invariant to projective transformation. A partial 180-degree sheath was developed for straight lines and point fiducials that are computationally simpler to localize but inherently less accurate. The sheath connects to a commercially available TRUS stepper. Results: Phantom and in-vivo canine tests were performed. Prostate motion and sheath stability were quantitatively analyzed with volume CT by tracking both structures and implanted markers while the TRUS probe was retracted by 5mm increments. With the sheath in place, prostate and sheath both were stationary in CT imaging and the fiducials did not interfere with the TRUS image. Excellent acoustic coupling was achieved during probe motion with acceptable degradation of ultrasound image quality. Funding: NIH-1R41CA106152-01A, NIH-1R43CA099374-01, NSF-9731478.

Purpose: Intra‐operative dosimetric optimization of TRUS‐guided prostate brachytherapy implants requires localization of seeds relative to prostate [1]. Analytical tools are available to intra‐operatively tailor an implant‐plan, thereby accounting for inevitable deviations [2]. Method and Materials: The majority of the practitioners have C‐arm fluoroscopes in the treatment room, making intra‐operative dosimetry feasible with little additional cost. The obstacles towards intra‐operative dosimetry are: (a) discerning the 3D poses of fluoro images, (b) registering fluoroscopy to TRUS, and (c) establish seed correspondences in multiple fluoro images. We address the first two issues by single‐image‐based fluoroscope tracking (FTRAC) fiducial with salient attributes: small dimensions (3×3×5cm); need not be close to the anatomy of interest; auto‐segmentable; and mathematically robust to segmentation, calibration, and image distortion errors. The 3D coordinates of the segmented seeds are calculated upon resolving the correspondence of seeds in the multiple X‐ray images, achieved by an algorithm called MARSHAL. We formalize seed‐matching as a network flow problem, which has salient features: (a) extensively studied exact solutions, (b) performance claims on the space‐time complexity, (c) optimality bounds on the final solution. Results: The FTRAC fiducial tracks a C‐arm to an accuracy of 0.56mm in translation and 0.33° in orientation, comparable to commercial tracking systems. On pre‐segmented images, MARSHAL achieved 100% correct matching in simulation experiments. In experiments on a precision‐machined phantom, the FTRAC and MARSHAL correctly matched and reconstructed 98.5% of the seeds with a mean 3D accuracy of 0.63mm, while the mean error for the mismatched 1.5% of seeds was only 0.91mm. Conclusion: Performance of FTRAC and MARSHAL appear to be adequate for intra‐operative dosimetry in brachytherapy.