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Significant progress has now been made in diagnosing, treating, reducing complications and lethality at liver abscesses. This is due to the displacement from the arsenal of surgery of complex and traumatic abdominal or trans thoraces approach to abscesses, which themselves created the problem of the postoperative period, complicated the course of an already severe infectious pathology. Modern minimally invasive technologies have significant advantages, especially with regard to interventional sonography, that is, the combined properties of diagnosis and treatment. Purpose of the study. To objectify the choice of the method of surgical intervention of liver abscesses on the basis of a new self-developed ultrasound semiotics of the stage of the formation of abscesses. Materials and methods. A comprehensive examination of 62 patients with liver abscesses was based on the study of the clinical picture of the liver abscesses, a bacteriological study of the contents, CT scan, and especially ultrasound, on the basis of which the ultrasound semiotics of the stages of the formation of abscesses was developed and implemented. Results and discussion. According to the possibilities of ultrasound diagnosis of abscesses of the liver from the first signs of local inflammation in the liver to the final stage of formation of the pyogenic capsule, we identified four stages of their development: 1 stage – local inflammatory changes of the parenchyma without its destruction; Stage 2 – destructive changes of parenchyma without signs of distinct boundaries; Stage 3 – clear boundaries of destructive changes with a non-expressed capsule; Stage 4 – clear formation of a capsule with complete destruction of tissues. The proposed ultrasonic semiotics allows us to determine the method of operation. Thus, at stages 1 and 2, and in some cases in 3 stages, there is no alternative to puncture-drainage methods in residual postoperative cavities. At stages 3 and 4, there are more advantages in laparoscopic operations, in some cases laparotomic. Conclusions. the proposed classification of ultrasonic semiotics stages of the formation of liver abscesses most pathogenetically corresponds to the morphological changes of the abscess zone and, most importantly, is adapted to the choice of the method of operation.

Purpose: To identify different morphological types of amebic liver abscess (ALA) based on CT findings and to assess whether they have different clinical features. Method: CT images of 112 symptomatic patients with ALA were analyzed to identify the imaging features distinctive of each morphological type. The following CT findings were investigated: the presence of abscess wall, rim enhancement, edge characteristic, septa, intermediate density zone, and peripheral hypodensity. Abscesses from each type were further evaluated for their clinical presentations, laboratory findings and outcomes. Results: We identified three types of ALAs: type I, II and III. Type I abscesses (66%) were characterized by absent or incomplete walls, ragged edges and peripheral septa; their edges exhibited irregular and interrupted enhancement. Type II (28%) had a complete wall characterized by rim enhancement and peripheral hypodense halo. Type III (6%) demonstrated a wall but without enhancement. Clinically, type I abscesses presented acutely with severe disease. They had significantly deranged laboratory parameters, higher incidence of rupture and higher rate of inpatient or intensive care unit admission. The severity of the disease prompted immediate percutaneous drainage in most type I abscesses (81%). Two of them died from multiple organ failure. The type II or III abscesses, on the other hand, had delayed presentations with mild to moderate disease, with near normal laboratory findings. Conclusion: ALAs have three different CT morphological types, with different clinical and laboratory features. Percutaneous drainage is indicated in most of type I abscesses. [ABSTRACT FROM AUTHOR]

Anticoagulation plays a major role in reducing the risk of systematic thrombosis in patients with severe COVID-19. Serious hemorrhagic complications, such as intracranial hemorrhage, have also been recognized. However, intra-abdominal hemorrhage is under-recognized because of its rare occurrence, despite high mortality. Here, we discuss two cases of spontaneous iliopsoas hematoma (IPH) likely caused by anticoagulants during the clinical course of COVID-19. We also explored published case reports to identify clinical characteristics of IPH in COVID-19 patients. The use of anticoagulants may increase the risk of lethal IPH among COVID-19 patients becsuse of scarce data on optimal dosage and adequate monitoring of anticoagulant effects. Rapid diagnosis and timely intervention are crucial to ensure good patient outcomes.

Background and Objectives : The diverticular disease includes a broad spectrum of different "clinical situations" from diverticulosis to acute diverticulitis (AD), with a full spectrum of severity ranging from self-limiting infection to abscess or fistula formation to free perforation. The present work aimed to assess the burden of complicated diverticulitis through a comparative analysis of the hospitalizations based on the national administrative databases. Materials and Methods : A review of the international and national administrative databases concerning admissions for complicated AD was performed. Results : Ten studies met the inclusion criteria and were included in the analysis. No definition of acute complicated diverticulitis was reported in any study. Complicated AD accounted for approximately 42% and 79% of the hospitalizations. The reported rates of abscess varied between 1% and 10% from all admissions for AD and 5-29% of the cases with complicated AD. An increasing temporal trend was found in one study-from 6% to 10%. The rates of diffuse peritonitis ranged from 1.6% to 10.2% of all hospitalizations and 11% and 47% of the complicated cases and were stable in the time. Conclusions : The available data precluded definitive conclusions because of the significant discrepancy between the included studies. The leading cause was the presence of heterogeneity due to coding inaccuracies in all databases, absence of ICD codes to distinguish the different type of complications, and the lack of coding data about some general conditions such as sepsis, shock, malnutrition, steroid therapy, diabetes, pulmonary, and heart failure.

Introduction: Over the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs)., Methods: This multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability., Results: 1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well., Conclusion: This validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes., Level of Evidence: Prognostic/Epidemiologic retrospective multicenter trial, level III.

Introduction: In recent years, Klebsiella pneumonia ( KP ) has emerged as the predominant cause of pyogenic liver abscess in Asia. KP - as the causative microorganism in other visceral organ abscesses-is less described. In this study, we seeked to describe the clinical characteristics of KP visceral organ abscesses in our institution and evaluated the prescription practices of physicians with regard to antibiotic therapy., Materials and Methods: A retrospective analysis of patients with culture positive (blood or abscess aspirate) KP visceral organ abscesses from May 2014 to April 2016 requiring hospitalisation in Changi General Hospital was conducted., Results: A total of 140 adult patients with KP visceral organ abscesses were identified. The commonest site of involvement was the liver (77.9%), followed by genitourinary tract (20.7%). Diabetic patients were more likely to have liver abscesses, genitourinary abscesses, abscesses in 2 or more organs, genitourinary disease with abscess formation outside of the genitourinary tract, and endovascular infection. Patients with extended spectrum beta-lactamase producing KP , were more likely to have an obstructive lesion related to the site of the abscess. Overall mortality rate was 7.1%. Amongst survivors, the mean total duration of parenteral antimicrobial therapy was 2.5 weeks before switching to oral antimicrobial agents., Conclusion: Genitourinary tract is the commonest extra-hepatic site for visceral organ abscess in KP infections. Parenteral to oral switch of antimicrobial agents appears to be a safe and effective treatment option.

Background and Objectives: Dissecting folliculitis (DF) or dissecting cellulitis of the scalp is regarded as a rare disease with disfiguring scarring alopecia. This study aimed to analyze the features of DF and to propose a classification to define its severity., Patients and Methods: A hospital-based retrospective study was conducted. Patients with a histopathological diagnosis or clinical features leading to diagnosis of DF were included and classified into three stages., Results: Among the 66 patients recruited (63 men / 3 women, mean age 24.9 years), multiple interconnected alopecic nodules involving the vertex scalp were the main feature. Histopathology showed an extensive inflamed granulation abscess forming a dissection plane in the lower dermis/subcutis in the acute stage. Lymphocytic infiltration was predominant in seven of 21 histology specimens. Overweight and obesity were noted in 29 of 45 patients examined. No association with smoking was found. There was comorbidity with acne conglobata in 15 of 66 patients, two of whom had acne inversa. Longer disease duration and greater number of nodules were associated with higher severity of DF (p < 0.05). A complete remission rate of 25 % was achieved by any treatment, and a rate of 37.5 % was achieved with oral isotretinoin alone., Conclusions: DF is not uncommon in Taiwan. An association with obesity needs to be clarified., (© 2018 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd.)

Vulvovaginal cysts are a common problem for women, causing significant pain, discomfort and impact on quality of life. For clinicians, classifying and differentiating these cysts from each other and selecting appropriate management can be challenging, yet there is no integrated classification system and little literature that broadly summarises a clinical approach. We aimed to create a useful tool for clinicians by providing a detailed summary of various vulvovaginal cysts and abscesses with a clear novel classification system and hierarchy for diagnosis and management, to aid clinicians in this process., (© 2018 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Purpose  Transperineal ultrasound (TPUS) is a practical tool for assessing perianal inflammatory lesions. We systematically review its accuracy for detecting and classifying perianal fistulae and abscesses. Method  The National Library of Medicine and Embase were searched for articles on TPUS for the assessment of idiopathic and Crohn's perianal fistulae and abscesses. Two reviewers independently reviewed eligible studies and rated them for quality using the QUADAS tool. The primary outcome measure was the accuracy of TPUS as measured by its sensitivity and positive predictive value (PPV) in detecting and classifying perianal fistulae, internal openings and perianal abscesses. Results  We included 12 studies (565 patients). Overall, the methodological quality of the studies was suboptimal. 3 studies were retrospective and 4 showed significant risks of bias in the application of the reference standard. The sensitivity of TPUS in detecting perianal fistulae on a per-lesion basis was 98 % (95 % CI 96 - 100 %) and the PPV was 95 % (95 % CI 90 - 98 %). The detection of internal openings had a sensitivity of 91 % (95 % CI 84 - 97 %) with a PPV of 87 % (95 % CI 76 - 95 %). The classification of fistulae yielded a sensitivity of 92 % (95 % CI 85 - 97 %) and a PPV of 92 % (95 % CI 83 - 98 %). TPUS had a sensitivity of 86 % (95 % CI 67 - 99 %) and PPV of 90 % (95 % CI 76 - 99 %) in the detection of perianal abscesses. Conclusion  The current literature on TPUS illustrates good overall accuracy in the assessment of perianal fistulae and abscesses. However, many studies had methodological flaws suggesting that further research is required., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Acute haematogenous osteomyelitis (AHO) in children is a severe condition. A delay in diagnosis and insufficient treatment may result in deformities, chronicity and sepsis. Therefore a structured diagnostic workup has to be followed in order to diagnose or rule out osteomyelitis. To identify the causative agent for targeted antibiotic treatment, a bone biopsy or puncture should be performed. However, approximately 25% of cases are culture-negative even after biopsy. The knowledge of the typical age-dependent bacterial spectrum is essential for empirical antibiotic therapy. The principal causative organism is Staphylococcus aureus. Surgery is not routinely required in paediatric acute osteomyelitis but surgical intervention is indicated if an abscess is detected. Secondary septic arthritis is a serious complication which has to be treated immediately by surgical intervention. Nevertheless, complete regeneration can be expected in up to 80% of children with AHO.

This article provides a current overview on clinical anatomy, pathophysiology, workup and surgical management of anorectal abscesses. Based on the three-dimensional nature of anorectal abscesses, a novel treatment-based classification is proposed. It examines the basis of a philosophic shift from simple drainage to concomitant definitive treatment of abscesses and their underlying primary fistulous trajectories. Complications are discussed specifically in this context.

Pulpotomy is the most performed and controversial therapeutic in pediatric dentistry. Formocresol is known to have a toxic effect on living tissues, a mutagenic and carcinogenic potential with a systemic uptake of formocresol via pulpotomized teeth, other alternative products have been investigated. 40 molars were pulpotomized using Micro Mega Mineral Trioxide Aggregate (MM-MTA), which eliminates the need for the use of formocresol. The effects of this material were evaluated both clinically and radiographically. Post-operative control examinations were performed at 1, 6, 12, and 18 months trying to detect spontaneous or stimulated pain, pathological tooth mobility, abscesses or fistulas, internal or external pathological tooth resorption, periapical bone destruction, or canal obliteration. Pain was absent at 18 months post operatively. Thirty six molar treated with the MM-MTA didn't show any mobility or pain, one molar presented a pathological resorption and one molar presented an abscess without a fistula at 12 month. The observations were compared to others related to formocresol, ferric sulfate, MTA, and laser pulpotomies, using the Chi-square test x2. The abundance of positive result strongly demonstrate that the MM-MTA pulpotomy on carious temporary molars is a promising technique.

Perianal sepsis is a common condition ranging from acute abscess to chronic fistula formation. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. The key to successful treatment is the eradication of the primary track. As surgery may lead to a disturbance of continence, several sphincter-preserving techniques have been developed. This consensus statement examines the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

Objectives: In literature, most of the published data regarding prostatic abscess (PA) are case reports, whereas there is no standardization of the diagnostic and therapeutic routines. The purpose of this study is a new classification of ultrasound imaging of PA with clinical features correlation., Material and Methods: We retrospectively analysed the ultrasound database archives and performed a MEDLINE® research of the peer reviewed literature on diagnosis and case reports of PA using the terms "prostate and abscess"., Results: PA can be classified into five Types: Type I - PA is present focally in a prostate lobe (≤ 10 mm). Type II - PA is present in a prostate lobe (&gt; 10 mm) and/or partially overcrosses the border of the midline prostatic glandular. Type III - PA is present in both glandular lobes form of multifocal areas (≤ 10 mm). Type IV - PA is present in both glandular lobes form of multifocal areas (&gt; 10 mm). Type V - PA involving intra or extraprostatic structures (bladder, urethra, seminal vesicles and prostatic capsule). The different ultrasound imaging and diagnostic criteria are listed for each type and subtype., Conclusions: The sonographic pattern of PA is usually characteristic and easily differentiated from other glandular lesions. The purpose of the study was to associate the use of TRUS to a clinical standardized classification in order to facilitate PA diagnosis and localization directing the clinician treatment to the correct management and adequate therapeutic treatment.

Neutrophilic dermatoses (NDs) are inflammatory skin conditions that are not associated with infection. The classification and clinical approach to these conditions in children is poorly described. This review classifies these conditions into five nosological subtypes: Sweet's syndrome, pyoderma gangrenosum, aseptic pustules, neutrophilic urticarial dermatoses, and Marshall's syndrome. In addition, we review the various secondary diseases that need to be excluded in the clinical management of the NDs of childhood, with a focus on the autoinflammatory conditions that the reader may not be familiar with. We propose a practical clinical approach to these disorders., (© 2015 Wiley Periodicals, Inc.)

Periproctal inflammations related to the anus are characterized by the rapid spread of the infection to the surrounding tissue, which is determined by the anatomical characteristics and infectious agents. Inflammation, which starts as a phlegmon, quickly forms boundaries and an abscess develops in most cases. Up to 80-90% of anorectal abscesses develop according to the crypto-glandular theory on the basis of infection of the anal glands, spilling into the Morgagni crypts in the anal canal. Up to two-thirds of such abscesses are associated with the emergence of anorectal fistulas. Anorectal abscesses can be divided into marginal and subcutaneous perianal abscesses, submucosal, intersphincteric, ischiorectal and supralevator abscesses. Their diagnosis is based on thorough physical examination, sometimes also with the help of imaging methods such as computed tomography, magnetic resonance imaging and endoanal ultrasound. What is decisive for the successful treatment of anorectal abscessess is their early and adequate surgical drainage. Adjuvant antibiotic therapy is necessary only when the overall signs of sepsis are present and for patients with a comorbidity such as diabetes, valvular heart disease, or immunodeficiency.

Purpose: This study aims to analyze the difference between the aged patients and non-elderly with multi-space infections of the head and neck., Materials and Methods: A retrospective study was conducted on 242 patients receiving treatment for severe multi-space infections of the head and neck region. Demographics, clinical parameters (the coexisting conditions, the etiology, the length between first symptomatic onset and admission, the number of spaces affected, and the distribution of involved spaces), laboratory values (bacteriology, admission blood glucose level, admission white blood cell count, and percent of neutrophil on admission) and treatment parameters (the number of incisions, complications and length of hospital stay) were collected and analyzed for clinical significance. Statistical analyses of the results between groups were performed using the Student t test, Fisher's exact test, and chi-square., Results: Compared with the non-elderly, the elderly had more system diseases (P = 0.0002), had longer hospital stays (P = 0.02), and developed more frequent complications (P = 0.04)., Conclusion: This study has determined the differences in clinical features of patients with multi-space infections of the head and neck by comparing the aged patients to non-elder patients., (Copyright © 2013 European Association for Cranio-Maxillo-Facial Surgery. All rights reserved.)

The prostatitis syndrome is a frequent and complex disease. During the last 40 years the scientific perception has shifted between sometimes success and sometimes disappointment. Whereas acute prostatitis is most frequently considered an infectious disease, in only about 10% of cases with a chronic prostatitis syndrome can pathogens be identified. The bacterial spectrum is similar to that of complicated urinary tract infections with mainly Gram-negative pathogens. In some studies atypical pathogens, such as Chlamydia trachomatis and mycoplasmas, can be found in a considerable proportion. In most cases, however, a multifactorial aetiology is discussed. This has lead to a phenotyping directed multimodal treatment approach, considering the main symptoms. In prostatitis of microbial origin antibiotics, particulary fluorquinolones, are still the therapy of first choice. In the other cases multimodal treatment strategies are used considering evidence-based monotherapeutic studies. The evidence for multimodal combination treatment is still sparse., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The incidence of anal abscess is relatively high, and the condition is most common in young men., Methods: A systematic review of the literature was undertaken., Results: This abscess usually originates in the proctodeal glands of the intersphincteric space. A distinction is made between subanodermal, intersphincteric, ischioanal, and supralevator abscesses. The patient history and clinical examination are diagnostically sufficient to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in recurrent abscesses or supralevator abscesses. The timing of the surgical intervention is primarily determined by the patient's symptoms, and acute abscess is generally an indication for emergency treatment. Anal abscesses are treated surgically. The type of access (transrectal or perianal) depends on the abscess location. The goal of surgery is thorough drainage of the focus of infection while preserving the sphincter muscles. The wound should be rinsed regularly (using tap water). The use of local antiseptics is associated with a risk of cytotoxicity. Antibiotic treatment is only necessary in exceptional cases. Intraoperative fistula exploration should be conducted with extreme care if at all; no requirement to detect fistula should be imposed. The risk of abscess recurrence or secondary fistula formation is low overall, but they can result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas and by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure., Conclusion: In this clinical S3 guideline, instructions for diagnosis and treatment of anal abscess are described for the first time in Germany.

Despite modern diagnostic imaging options pyogenic infections of the spine are often detected tardily and therefore accompanied by a high mortality rate. To ensure an efficient and adequate therapy it is necessary to identify and treat the focus of inflammation. The recommendations for the operative strategy are still a highly controversial issue. On the other hand no classification and guidelines for surgical treatment and treatment strategies of pyogenic spinal infection have yet been published.Pyogenic spinal infections are often underestimated in frequency of occurrence and severity of symptoms. From 1994 until 2008, 269 patients suffering from an infection of the thoracic and lumbar spine were treated in the Department of Orthopedic Surgery Heidelberg and 221 patients underwent surgery. Within the scope of a clinical trial clinical aspects and therapeutic consequences of patients with pyogenic spinal infections were retrospectively investigated. Based on the study data a classification of pyogenic spinal infections of the thoracic and lumbar spine and a guide for surgical decision-making was developed.

The course of acute pancreatitis is in the initial phase dominated by a systemic inflammatory response, later by local complications. A new classification defines three specific types of pancreatitis: 1) interstitial oedematous pancreatitis and 2) necrotizing pancreatitis with pancreatic parenchymal necrosis, or 3) peripancreatic necrosis alone. The classification also defines four types of collections: 1) Acute peripancreatic fluid collection, 2) pseudocyst, 3) acute post-necrotic collection, and 4) walled-off necrosis. This article summarizes the terminology of the revised Atlanta classification.

Introduction: The aim of this study was to evaluate the subcutaneous connective tissue reaction to mineral trioxide aggregate (MTA)-based sealer (Endo CPM Sealer; CPM Sealer; EGEO SRL, Buenos Aires, Argentina), MTA, and an epoxy resin-based sealer (AH Plus; Dentsply HERO Indústria e Comércio Ltda, Petrópolis, RJ, Brazil)., Methods: Polyethylene tubes containing the test materials and empty tubes (control group) were implanted in the subcutaneous tissue of 18 rats. After 7, 30, and 60 days, observations were made for cellular inflammatory components, fibrous condensation, and abscess formation. Comparisons between groups and periods of time were made using the Friedman test and the Kruskall-Wallis test., Results: Lymphocytes and plasmacytes were more intensely observed in the reaction to AH Plus sealer after 30 days (p < 0.05). MTA and the Endo CPM Sealer presented a behavior similar to that of the control group throughout the whole experiment., Conclusion: The Endo CPM Sealer presented biological potential. Characteristics of the inflammatory reaction were equivalent to those produced by MTA., (Copyright 2010 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

The management of anorectal abscess and anal fistula has changed markedly with time. Invasive methods with high resulting rates of incontinence have given way to sphincter-sparing methods that have a much lower associated morbidity. There has been an increase in reports in the medical literature describing the success rates of the varying methods of dealing with this condition. This article reviews the various methods of treatment and evidence supporting their use and explores advances that may lead to new therapies., (Published by Elsevier Inc.)

Unlabelled: There are different names: perianal abscesses and fistulae, periproctitis, paraproctitis, pararectal inflammatory and fistulous processes, etc. It is our opinion that the name perianal and anal fistulae does not correspond to the origin of the fistulae from an abscess of the rectal wall, although it is fairly common., Objective: To offer a name, based on the patophysiological mechanism and anatomic localization of the inflammatory process in the pararectal area through study of the origin and the way of development of ano - rectal abscesses and fistulae., Material and Methods: A group of 430 (4%) patients with recto - perineal abscesses and fistulae has been analyzed out of a total of 10 726 hospitalized patients for the 1986 - 2005 period. Of them 241 patients (56,1 %) have been with recto - perineal fistulae, and 189 (43,9%) with recto - perineal abscesses., Conclusion: The process starts in the rectal wall, in the Morgan's crypts - cryptitis, after which the process transits to the perineal connective tissue. This succession in the development of the inflammatory process allows us to put the term " rectum" before "perineum" in the name adopted by us "recto - perineal abscesses and fistulae". It is our opinion that it is more appropriate to consider fistulae as a consequence from the abscesses, united in a single name recto - perineal abscesses and fistulae.

Objective: Intersphincteric abscesses are relatively rare, and in some cases of upward extensions in the supralevator plane, can be difficult to manage. The aim of this study was to analyse the type of treatment used in these abscesses., Methods: Twenty-one intersphincteric abscesses treated by endoanal drainage in our colorectal unit between 1992 and 2004 were reviewed from our database; location and extension of the abscess, type of treatment and recurrence rates and the use of endoanal ultrasound were studied., Results: Ninety per cent of patients were male; 10 had a previous history of surgery for perianal abscess and suppuration (48%); 16 (76%) had a posterior location and five were anterolateral. Twelve patients had low intersphincteric abscesses and were treated by laying open the abscess and dividing the internal sphincter. Nine were found to have high extensions into the intermuscular planes and were treated by staged procedures: a temporary transanal mushroom catheter was used in seven patients. Endoanal ultrasound was used initially in seven patients (33.3%) and for the evaluation of definitive treatment in 11 (52%)., Conclusions: Low intersphincteric abscesses should be treated by de-roofing of the abscess and division of the internal sphincter up to a level of the dentate line. High intersphincteric abscesses are relatively frequent and mostly require staged surgery with a temporary mushroom (de Pezzer) catheter. Accurate anatomical ultrasound localization and proper drainage become important to avoid recurrences or extrasphincteric fistulas.

Objectives: Our intent was to review the clinical signs, computed tomography (CT) scans, treatment, and outcome of parapharyngeal space infections (PPIs), and to define 2 types of infections of the parapharyngeal space (PPS) according to the location of the infectious process., Methods: We performed a retrospective analysis of patients hospitalized in a tertiary university hospital with a diagnosis of PPI, abscess, or deep neck abscess between 1988 and 2004. Files and CT scans were reviewed after classification into 2 groups: 1) infection located in the posterior part of the PPS (PostPPI); and 2) infection located in the anterior part of the PPS (AntPPI)., Results: Twenty-two patients had a PostPPI; their ages ranged from 10 months to 24 years. Five patients underwent surgical drainage, and 17 others were treated solely with intravenous antibiotic therapy. No pus was found during surgery in 2 patients. The average time of hospitalization was 10 days. Only 1 complication (aspiration pneumonia) was observed. Seven patients had an AntPPI; their ages ranged from 1.5 years to 65 years. All patients underwent surgical drainage, and pus was detected in all cases. The average time of hospitalization was 35 days. Complications (septic shock, respiratory arrest, mediastinitis, pleural empyema, pericarditis) were observed in 4 patients., Conclusions: The term "parapharyngeal abscess" was assigned long before the CT scan era, and was based on physical examination and plain film radiology. In essence, the entity PPS "abscess" or "infection" is composed of 2 different disorders. Infection located in the posterior part of the PPS with no invasion into the parapharyngeal fat and with no extension into other cervical spaces except the adjacent retropharyngeal space may be termed posterior parapharyngeal infection or parapharyngeal lymphadenitis. This is a relatively benign condition, and nonsurgical treatment should be considered. Infection involving the parapharyngeal fat may be termed parapharyngeal abscess or deep neck abscess. Diffusion into the mediastinum and other severe complications are frequent. Urgent surgical drainage is therefore mandatory.

Purpose: To prospectively evaluate the relative accuracy of digital examination, anal endosonography, and magnetic resonance (MR) imaging for preoperative assessment of fistula in ano by comparison to an outcome-derived reference standard., Materials and Methods: Ethical committee approval and informed consent were obtained. A total of 104 patients who were suspected of having fistula in ano underwent preoperative digital examination, 10-MHz anal endosonography, and body-coil MR imaging. Fistula classification was determined with each modality, with reviewers blinded to findings of other assessments. For fistula classification, an outcome-derived reference standard was based on a combination of subsequent surgical and MR imaging findings and clinical outcome after surgery. The proportion of patients correctly classified and agreement between the preoperative assessment and reference standard were determined with trend tests and kappa statistics, respectively., Results: There was a significant linear trend (P < .001) in the proportion of fistula tracks (n = 108) correctly classified with each modality, as follows: clinical examination, 66 (61%) patients; endosonography, 87 (81%) patients; MR imaging, 97 (90%) patients. Similar trends were found for the correct anatomic classification of abscesses (P < .001), horseshoe extensions (P = .003), and internal openings (n = 99, P < .001); endosonography was used to correctly identify the internal opening in 90 (91%) patients versus 96 (97%) patients with MR imaging. Agreement between the outcome-derived reference standard and digital examination, endosonography, and MR imaging for classification of the primary track was fair (kappa = 0.38), good (kappa = 0.68), and very good (kappa = 0.84), respectively, and fair (kappa = 0.29), good (kappa = 0.64), and very good (kappa = 0.88), respectively, for classification of abscesses and horseshoe extensions combined., Conclusion: Endosonography with a high-frequency transducer is superior to digital examination for the preoperative classification of fistula in ano. While MR imaging remains superior in all respects, endosonography is a viable alternative for identification of the internal opening., ((c) RSNA, 2004.)

Purpose of the Study: We present our experience with a rare localization of tuberculosis, the wrist, focusing on symptoms and outcome after treatment., Material and Methods: Our series included eleven patients, eight men and three women, mean age 42 Years, who presented tuberculosis of the wrist. Tuberculosis was known in four patients who were being treated and a context of tuberculosis was recognized in three others. One patient on long-term corticosteroid therapy was immunodepressed. Mean time from symptom onset to consultation was fifteen months indicating a slow and progressive disease process. An inflammatory syndrome was noted in nine patients. Based on the standard x-rays, the David-Chausse classification was: stage I n=1; stage II n=1; stage III n=3; stage IV n=4. The AP view of the wrist was normal in two patients. Diagnosis of tuberculosis was confirmed on the surgical biopsy specimen which revealed epithelio-gigantocellulary granuloma with caseous necrosis. In only five patients Koch bacilli developed in culture on Lowenstein-Jensen. Patients were given anti-tuberculous antibiotics and the wrist was immobilized in a plaster splint., Results: Mean follow-up was two years. The disease course was blunted by the antituberculosis treatment. Surgical drainage was only required to clear abscesses. Wrist stiffness was frequent and had a significant functional impact., Discussion: These eleven cases of a rare localization of tuberculosis illustrate the slow progressive course of clinical symptoms and radiological signs of tuberculosis, emphasizing the difficulties encountered in establishing early diagnosis of such isolated non-abscessed localizations. Anti-tuberculous treatment is effective but the functional outcome depends on early diagnosis before the development of radiological evidence of joint destruction.

A good digital examination is usually sufficient for the diagnosis and the treatment planning of anal fistulae. Cross-sectional imaging techniques, however, can accurately identify deep abscesses and characterize complex fistulae. MRI is well suited for this examination, with almost no motion artifact, excellent contrast between muscles and fatty spaces, and multiplanar acquisition. A fistula starts from an internal opening in the digestive tube and can end in an abscess cavity or open at the skin at an external opening. The cryptoglandular anal fistulae (fistula-in-ano) are non-specific in origin and are usually simple, whereas specific fistulae are due to many diseases such as Crohn's disease, tuberculosis, trauma, radiation, colloid carcinoma, hidradenitis suppurative, actinomycosis or lymphoma and are often complex. MRI appears useful in the cases with recurrent fistulae, Crohn's disease, when the secondary orifice is atypically placed, during a multistep treatment for complex fistulae, or when an anal stenosis forbids a clinical or ultrasound examination. A good knowledge of the perineum anatomy is required for analysing the fistula tracts. The muscle planes separate fatty spaces which have an important role in the spread of the disease: sub-mucosal space, marginal space, intersphincteric space, postanal space of Courtney, supralevator space, and the two ischioanal spaces on both sides of the anal canal. The anal canal is surrounded by the ring-like internal sphincter, which continues the internal muscularis propria of the rectum, and the external sphincter, which is intermingled with the puborectalis muscle. We perform our MRI examination with an external phased array coil, and we place a cannula to identify the anal canal. The T2W sequences give the more interesting information, but the sequences with fat-suppression and gadolinium chelate injection are also very useful. The MRI examination allows the analysis of: 1) the location of the fistula tracts according to Park's classification, 2) the location of the internal opening, 3) the locations of the external opening(s), 4) the location of deep abscesses, 5) the long distance extensions, 6) the state of the ano-rectal wall and the perirectal spaces, 6) the damages of the anal sphincter.

Pulp tissue reactions to a fluoride-releasing all-in-one resin bonding system (Reactmer Bond and Reactmer Paste) in non-exposed monkey teeth were histopathologically evaluated at three, 30, and 90 days after restoration. No serious inflammatory reactions of the pulp, such as necrosis or abscess formation, were observed. At 90 days in the Reactmer group, odontoblastic change and inflammatory cell infiltration were not observed, and slight irritation dentin formation was formed. The pulpal response of the Reactmer group was minimally different from that of the control group. Consequently, the Reactmer system was determined as being biologically compatible with vital pulps.

Anal fistulae are an often neglected and underevaluated disease. They are painful and invalidating. Surgeons must be aware of the pathophysiological aspects to achieve successful treatment. The anatomical classification is established to better understand anal anatomy and physiology of anal abscessess and fistulae. The Diagnosis of a perianal abscess is usually easy except in case of deep abscess. Clinical signs of chronic fisula may be misleading. Modern imaging (MRI and endoscopic ultrasonography) may be useful to detail the fistular anatomy in difficult cases. Several operative procedures have been proposed to treat anal fistulae and abscesses. Besides old procedures such as fistulotomy, cutting or draining, seton, we can also mention recently proposed preservative sphincter surgery. This new concept is believed to improve wound healing and decrease functional deficiency. Particularly, the rectal flap seems to be attractive but its superiority has not been proven with a randomized trial. So far, our preference goes to the well-known procedures such as prolonged seton drainage and/or slow cutting seton.

According to the Atlanta classification, the most widely accepted clinically based classification system for acute pancreatitis, four pathologic entities of fluid collections and necrosis are recognized. Acute fluid collections occur early as an exudative reaction to the pancreatic inflammation, have no fibrous wall, and resolve spontaneously. Pancreatic necrosis, the most severe form of acute pancreatitis, is diagnosed on dynamic contrast-enhanced computerized tomography and requires early aggressive cardiorespiratory resuscitation, nutritional support, and appropriate systemic antibiotics to prevent superinfection. Development of infection (infected necrosis) is the indication for operative debridement, preferably as late in the course of the disease as possible. Acute pseudocysts are collections of pancreatic, enzyme-rich fluid caused by pancreatic ductal disruption that occur 3 to 6 weeks after onset of acute pancreatitis and have a well-defined, nonepithelial fibrous wall. If communication with the ductal system is present, internal enteric drainage (either operative or endoscopic) is more effective; if communication is not present, the pseudocysts are amenable to percutaneous drainage. A pancreatic abscess is an infected, circumscribed peripancreatic collection, associated with minimal or no parenchymal necrosis, that occurs late (4 to 6 weeks) after onset of severe pancreatitis and may represent an infected pseudocyst; percutaneous drainage is the treatment of choice.

The frequency of biopsies with different types of mastitis among all patients with benign breast diseases in twenty years was 3%. About 2/3 of the patients were younger than 50 years, the average age was 46.7 years. Comparing the frequency of the different types of mastitis the puerperal mastitis is very rare in contrast to the increasing non-puerperal and granulomatous inflammatory breast lesions. The diagnosis "granulomatous mastitis" is one of exclusion. Both non-infectious and infectious causes must be considered. The origin of the granulomatous mastitis often is unknown, but it is supposed to be an autoimmune localized response due to the retained and extravasated fat and protein rich secretions in the ducts in cases of hyperprolactinemia (drug induced or by microprolactinomas) or hormonal imbalances characterized by epitheloid cell granulomas with giant cells microabscesses around lipid drops, but without necroses. An idiopathic type of granulomatous mastitis concerns young women in relationship to parturition with a similar histological pattern predominantly of the lobules. Special types of mastitis are the B-lymphocytic autoimmune mastitis associated with a longstanding insulin-dependent diabetes mellitus type I, the sarcoidosis, panniculitis and the rare but very different infectious diseases with breast involvement. Particularly in cases without features of secretory activity a carefully bacterioscopic and microbiologic work-up of fresh material from the surgical specimens is necessary for a final diagnostic report.

Deep neck abscesses are serious complications of common upper respiratory tract infections in children. Children are especially prone to airway obstruction complicating deep neck abscess. Pediatricians must understand the presentations and treatment of deep neck abscesses to avoid potentially life-threatening complications.

Hematogenous spread is the most common cause for vertebral osteomyelitis. S. aureus is the most common organism in pyogenic vertebral osteomyelitis. Hematogenous osteomyelitis is common among diabetics and intravenous drug abusers. Tuberculous spondylitis remains common worldwide. In general, vertebral body infections not responding to antibiotic treatment and those creating unacceptable deformity or neurologic compromise require debridement via an anterior approach with strut grafting. Posterior infections are almost always postsurgical and require posterior irrigation and debridement in addition to antibiotics. Abscesses within the canal require antibiotics and surgical debridement especially when neurologic symptoms are present. Infections within the canal are approached posteriorly unless the pathology involves the anterior spine. Use of metal fixation within the site of an adequately debrided spinal infection is controversial but necessary on rare occasions. Posterior fixation for anterior infections is preferred. Much has been written about spinal infections and their treatment. Landmark articles and additional comprehensive sources on spinal infections have been included in the references.

Background: The diagnosis of intraperitoneal abscesses is difficult, resulting in delay in treatment and poor prognosis. Although recent advances in the management have led to significant improvement in prognosis, the choice of therapeutic modality is unclear., Aims: The role of clinical features and investigations in the diagnosis of intraperitoneal abscesses was studied. The relation of prognosis to delay in diagnosis was also analyzed. Also assessed was the efficacy of various therapeutic modalities., Methods: Thirty consecutive patients diagnosed to have intraperitoneal abscesses were analyzed. Abscesses were analyzed. Abscesses were divided on the basis of ultrasonography findings into simple and complex (with or without fecal fistula). The following points were evaluated: clinical features, and hematological, biochemical and microbiological reports, imaging findings and the role of therapeutic modalities like percutaneous aspiration (single or multiple), catheter drainage and operative drainage (transperitoneal, extraperitoneal and percutaneous)., Results: Clinical features and hematological investigations, though sensitive, were non-specific in diagnosis. Klebsiella was the commonest organism cultured, followed by Proteus, E coli and Pseudomonas. Blood culture was positive in only 6 percent of cases. Real-time ultrasonography had an accuracy of 84%. Contrast X-rays were required in 43% of cases. All the deaths (4 of 30) occurred when the diagnosis and treatment were delayed by more than 4 days. USG-guided aspiration (single and multiple) and USG-guided catheter drainage were effective in simple abscesses but failed in complex abscesses. Transperitoneal operative drainage was successful in 15 of 18 cases (6 of 8 simple abscesses and 9 of 10 complex abscesses). The mortality in patients with simple and complex abscesses was 2 of 17 and 2 of 13 respectively., Conclusions: Early detection with consequent early treatment is vital for good prognosis of intraperitoneal abscesses. Early diagnosis requires a high degree of clinical suspicion and appropriate use of imaging modalities. USG-guided percutaneous drainage is effective for simple abscesses whereas complex abscesses require operative drainage, sometimes in combination with initial USG-guided drainage.

Non puerperal abscess associated with periductal mastitis assumes increasing importance. US is an excellent tool for detection of an abscess cavity, which many have a variety of scanographic findings. Mammography may be difficult to perform properly because of pain and edema of the breast.

Assessment of the efficacy of therapeutic approaches to anal lesions of Crohn's disease is frustrated by the lack of precise definition of its various manifestations. A classification that is clinical and based on anatomic and pathologic aspects is presented; it has been derived from a 20-year prospective study of anal Crohn's disease in Cardiff. Conceptually, the classification is analogous to the TNM system for cancer. The main classification (U.F.S.) defines the presence of Ulceration, Fistula/abscess, and Stricture, qualified by numeric values reflecting severity (0 = not present, 1 = limited clinical impact, and 2 = severe). A subsidiary classification (A.P.D.) defines Associated conditions, Proximal intestinal involvement, and Disease activity. In addition, the classification may be used in a detailed form for research or comparative purposes or in a simple form defining only the dominant lesions for routine clinical use. General use of the classification would make it possible to compare in detail incidence, management, and results of treatment in different centers.