Anal Sphincter Research Articles

Subtyping irritable bowel syndrome using cluster analysis: a systematic review

BackgroundIrritable bowel syndrome (IBS) is a common chronic functional gastrointestinal disorder associated with a wide range of clinical symptoms. Some researchers have used cluster analysis (CA), a group of non-supervised learning methods that identifies homogenous clusters within different entities based on their similarity.Objective and methodsThis literature review aims to identify published articles that apply CA to IBS patients. We searched relevant keywords in PubMed, Embase, Web of Science, and Scopus. We reviewed studies in terms of the selected variables, participants’ characteristics, data collection, methodology, number of clusters, clusters’ profiles, and results.ResultsAmong the 14 articles focused on the heterogeneity of IBS, eight of them utilized K-means Cluster Analysis (K-means CA), four employed Hierarchical Cluster Analysis, and only two studies utilized Latent Class Analysis. Seven studies focused on clinical symptoms, while four articles examined anocolorectal functions. Two studies were centered around immunological findings, and only one study explored microbial composition. The number of clusters obtained ranged from two to seven, showing variation across the studies. Males exhibited lower symptom severity and fewer psychological findings. The association between symptom severity and rectal perception suggests that altered rectal perception serves as a biological indicator of IBS. Ultra-slow waves observed in IBS patients are linked to increased activity of the anal sphincter, higher anal pressure, dystonia, and dyschezia.ConclusionIBS has different subgroups based on different factors. Most IBS patients have low clinical severity, good QoL, high rectal sensitivity, delayed left colon transit time, increased systemic cytokines, and changes in microbial composition, including increased Firmicutes-associated taxa and depleted Bacteroidetes-related taxa. However, the number of clusters is inconsistent across studies due to the methodological heterogeneity. CA, a valuable non-supervised learning method, is sensitive to hyperparameters like the number of clusters and random initialization of cluster centers. The random nature of these parameters leads to diverse outcomes even with the same algorithm. This has implications for future research and practical applications, necessitating further studies to improve our understanding of IBS and develop personalized treatments.

Distalization of perianal fistulas after loose silicone seton drainage is a myth

BackgroundIt is often stated that loose seton drainage results in distal migration of a fistula tract in perianal fistula. The aim of the present study was to assess this distalization of trans- and suprasphincteric perianal fistulas after a silicone seton has been inserted.MethodsConsecutive patients who underwent loose seton placement for the management of a transsphincteric or suprasphincteric fistula between January 2016 and December 2021 with a pre- and postoperative magnetic resonance imaging (MRI) were included in the present retrospective study. The height of the external anal sphincter (EAS) and the level of penetration of perianal fistula through the EAS or puborectal muscle (PRM) were determined on MRI. Primary outcome was migration of the fistula tract through the EAS and PRM.ResultsThirty-eight patients with perianal fistulas were included. Median height of the EAS was 28 (IQR 25–34) mm before seton placement and 27 (IQR 24–33) mm afterward. Median level of perforation was 32 (IQR 17–40) mm before seton placement and 28 (IQR 17–40) mm afterward (p = 0.37). One fistula (3%) was downgraded from mid to low transsphincteric and was laid open after 14.9 months of loose seton drainage.ConclusionsNo statistically significant distalization of complex fistula tracts after loose silicone seton drainage was found. Some complex fistulas may downgrade to a less complex fistula after long-term seton drainage. However, loose silicone seton drainage should not be offered to patients as a treatment option to downgrade a complex fistula to a simple one or even have the hope to heal it.

Anal sphincter injury by bullfighting trauma.

Anal sphincter injury by bullfighting trauma.

An acquired recto-perineal fistula as the outcome of sacrococcygeal teratoma treatment

Introduction. An acquired recto-perineal fistula in childhood is a quite rare pathology. One of its main causes is trauma of the perineal part of the rectum and anal canal. That is why, acquired rectoperineal fistulas most often develop after the correction of Hirschsprung’s disease and anorectal malformations.
 Material and methods. The publication presents a rare case of a newborn child with recurrent course of an acquired rectoperineal fistula which developed after sacrococcygeal teratoma treatment. The teratoma was removed when the child was 3 days old. The surgery was complicated with suture dehiscence in the rectal wall defect. After suturing, a separate sigmostoma was placed. At the age of 6 months, the sigmostoma was closed, but after a few days, fistulas were found in the area of drainage and postoperative scar, which required sigmostoma restoration. After the prescribed therapy, the fistulas were obliterated; the stoma was closed again. In 2 weeks, child’s general condition deteriorated, and newly appeared fistulas were noted. It was decided to perform demucosation of the disconnected rectum above the level of anal sphincter and to make fistula through drainage via the rectum lumen.
 Conclusion. Acquired recto-perineal fistulas in childhood is a rare recurrent disease. Though postoperative complications were detected in time, authors could not get independent closure of the fistula, despite numerous interventions. In fact, only the rectum extirpation allowed to separate the fistulous tract from the intestinal lumen. This type of intervention is considered a quite rare one; usually, such complication can be eliminated in a less radical way.

Prevention of obstetric anal sphincter injuries with perineal support and lateral episiotomy: A historical cohort study.

There are many risk factors for obstetric anal sphincter injury (OASIS) and the interaction between these risk factors is complex and understudied. The many observational studies that have shown a reduction of OASIS rates after implementation of perineal support have short follow-up time. We aimed to study the effect of integration of active perineal support and lateral episiotomy on OASIS rates over a 15-year period and to study interactions between risk factors known before delivery. We performed a historical cohort study over the periods 1999-2006 and 2007-2021 at Stavanger University Hospital, Norway. The main outcome was OASIS rates. Women without a previous cesarean section and a live singleton fetus in cephalic presentation at term were eligible. The department implemented in 2007 the Finnish concept of active perineal protection, which includes support of perineum, control of fetal expulsion, good communication with the mother and observation of perineal stretching. The practice of mediolateral episiotomy was replaced with lateral episiotomy when indicated. We analyzed the OASIS rates in groups with and without episiotomy stratified for delivery mode, fetal position at delivery and for parity, and adjusted for possible confounders (maternal age, gestational age, oxytocin augmentation and epidural analgesia). We observed a long-lasting reduction in OASIS rates from 4.9% to 1.9% and an increase in episiotomy rates from 14.4% to 21.8%. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with instrumental vaginal deliveries and occiput anterior (OA) position; 3.4% vs 10.1% (OR 0.31; 95% CI: 0.24-0.40) and 6.1 vs 13.9% (OR 0.40; 95% CI: 0.19-0.82) in women with occiput posterior (OP) position. Lateral episiotomy was also associated with lower OASIS rates in nulliparous women with spontaneous deliveries and OA position; 2.1% vs 3.2% (OR 0.62; 95% CI: 0.49-0.80). The possible confounders had little confounding effects on the risk of OASIS in groups with and without episiotomy. We observed a long-lasting reduction in OASIS rates after implementation of preventive procedures. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with an instrumental delivery. Special attention should be paid to deliveries with persistent OP position.

Development of 3D printed snap-fit connection for a magnetic anal sphincter

Development of 3D printed snap-fit connection for a magnetic anal sphincter

A Comprehensive Approach to Treating Acute Fissure-in-ano (Parikartika) with the AYUHEAL Suppository


 Parikartika refers to a medical condition characterized by sharp pain in the anal region. Parikartika, in the context of Western medicine, can be understood as being similar to Fissure-in-ano. This condition is characterized by a combination of increased tension in the internal anal sphincter and reduced blood supply in the posterior midline area of the anal canal. This clinical study examines the effectiveness of the AYUHEAL suppository. This poly-herbal compound is designed to have both local and systemic effects in treating patients with Parikartika, explicitly focusing on acute Fissure-in-ano. A total of fifty patients were subjected to clinical examination and diagnosed with acute Fissure-in-ano based on symptoms including anal pain, per rectum bleeding, burning sensation during and after defecation and constipation. The AYUHEAL suppository was administered thrice daily for seven days. The therapeutic effects of the suppository were evaluated by assessing various parameters on days 1, 3, 5 and 7. The findings demonstrated a notable amelioration in the symptoms, encompassing anal pain, rectal bleeding, post-defecation burning sensation, and constipation throughout the treatment period. Subsequent evaluations on the 21st day showed no reappearance of Fissure-in-ano, indicating a consistently favorable result. This study shows that using AYUHEAL suppository as the cutting-edge treatment for seven days effectively reduced the symptoms of Parikartika, specifically acute Fissure-in-ano. The suppository's poly-herbal composition allows it to have an effect both at the local site and throughout the entire body, indicating its potential as a comprehensive approach to managing this condition. Additional research and extensive clinical trials are necessary to confirm these findings and investigate the long-term effectiveness of AYUHEAL suppositories in treating Parikartika.

Episiotomy: Are Indian Obstetricians Getting the Angle Right?

BackgroundA mediolateral episiotomy is recommended when indicated at a 60° angle at crowning, to avoid obstetric anal sphincter injuries (OASIs) by episiotomies angled too close or distant to the anus. This study surveyed obstetricians in India regarding the recommended episiotomy angle and their ability to correctly draw the angle.MethodsWorkshops were conducted in India to share knowledge in the prevention and repair of OASIs. A questionnaire was distributed prior to the workshop. Participants were asked to describe the recommended episiotomy angle and to draw this on a paper replica of the perineum. The intra-class correlation coefficient (ICC) was calculated to assess the inter-rater reliability between the angle stated and drawn. A 2° difference was deemed acceptable. Standard errors of measurement (SEM) were calculated to measure the range of error of each measurement.ResultsOne hundred and forty doctors participated. 47.9% described the angle of an episiotomy to be 60°. Only 2.2% drew an angle of 60°, but 8.7% (n = 12) drew between 58 and 62°. Only 5.8% (n = 6) of doctors correctly drew the episiotomy angle they described. There was poor agreement ICC = 0.18 (− 0.01 to 0.36) with a SEM of ± 12.2°ConclusionsKnowledge surrounding the recommended episiotomy angle is lacking. Doctors are failing to estimate their desired episiotomy angle. This highlights the need for national guidelines, the creation and validation of structured training programmes to improve accuracy, or using fixed-angle devices such as the EPISCISSORS-60 or other proven measurement aids to minimise preventable harm due to human error.

Predelivery sonographic predictors of obstetric anal sphincter injury among nulliparous women.

Data available at admission to delivery of nulliparous has rarely been investigated for prediction of obstetric anal sphincter injury (OASI). The aim of the present study was to study risk factors for OASI in nulliparous based on information available at admission. A retrospective study of all nulliparous women undergoing labor, during March 2011 to January 2021 was performed. We compared women with OASI following delivery to those without by univariate and multivariable regression. A total of 30 262 deliveries were included and 4181 (13.4%) of those were delivered by an emergent cesarean delivery. OASI followed 453 (1.5%) deliveries. Women in the OASI group were younger 29 ± 4.4 versus 30 ± 4.8, P = 0.001. In a multivariable regression analysis, higher sonographic estimated fetal weight was positively associated with OASI occurrence (aOR, 95% CI: 1.13 [1.00-1.29]). Maternal age was inversely associated with OASI occurrence (adjusted odds ratio [aOR], 95% confidence interval [CI] 0.95 [0.92-0.97]). Sonographic fetal weight estimation is an independent risk factor for OASI occurrence that may be available at admission for delivery among nulliparous women.

Survey of rectal cancer MRI technique and reporting tumour descriptors in the UK: a multi-centre British Society of Gastrointestinal and Abdominal Radiology (BSGAR) audit

To evaluate variation in magnetic resonance imaging (MRI) technique and reporting of rectal cancer staging examinations across the UK. A retrospective, multi-centre audit was undertaken of imaging protocols and information documented within consecutive MRI rectal cancer reports between March 2020 and August 2021, which were compared against American and European guidelines. Inclusion criteria included histologically proven rectal adenocarcinoma and baseline staging MRI rectum only. Fully anonymised data from 924 MRI reports by 78 radiologists at 24 centres were evaluated. Thirty-two per cent of radiologists used template reporting, but these reports offered superior documentation of 13 out of 18 key tumour features compared to free-text reports including T-stage, relation to peritoneal reflection and mesorectal fascia (MRF), nodal status, and presence of extramural venous invasion (EMVI; p<0.027 in each). There was no significant differences in the remaining five features. Across all tumour locations, the tumour relationship to the MRF, the presence of EMVI, and the presence of tumour deposits were reported in 79.5%, 85.6%, and 44% of cases, respectively, and tumour, nodal, and distant metastatic stage documented in 94.4%, 97.7%, and 78.3%. In low rectal tumours, the relationship to the anal sphincter complex was reported in only 54.6%. Considerable variation exists in rectal cancer MRI acquisition and reporting in this sample of UK centres. Inclusion of key radiological features in reports must be improved for risk stratification and treatment decisions. Template reporting is superior to free-text reporting. Routine adoption of standardised radiology practices should now be considered to improve standards to facilitate personalised precision treatment for patients to improve outcomes.

Increased Grades of Rectal Intussusception: Role of Decline in Pelvic Floor Integrity and Association With Dyssynergic Defecation.

The natural history of rectal intussusception (RI) is poorly understood. We hypothesized that decline in pelvic floor integrity and function leads to increasing RI grades. Retrospective analysis of a registry of patients with defecatory disorders with high-resolution anorectal manometry and magnetic resonance defecography was performed. Association of risk factors on increasing RI grades was assessed using logistic regression. Analysis included a total of 238 women: 90 had no RI, 43 Oxford 1-2, 49 Oxford 3, and 56 Oxford 4-5. Age ( P = 0.017), vaginal delivery ( P = 0.008), and prior pelvic surgery ( P = 0.032) were associated with increased Oxford grades. Obstructive defecation symptoms and dyssynergic defecation were observed at relatively high rates across groups. Increased RI grades were associated with less anal relaxation at simulated defecation yet, higher rates of normal balloon expulsion ( P < 0.05), linked to diminished anal sphincter. Indeed, increased RI grades were associated with worsening fecal incontinence severity, attributed to higher rates of anal hypotension. Levator ani laxity, defined by increased levator hiatus length and its excessive descent at straining, was associated with increasing RI grades, independent of age, history of vaginal delivery, and pelvic surgeries and could independently predict increased RI grades. Concurrent anterior and posterior compartments, and visceral prolapse were associated with higher Oxford grades. Our data suggest that decline in pelvic floor integrity with abnormal levator ani laxity is associated with increased RI grades, a process that is independent of age, history of vaginal deliveries, and/or pelvic surgeries, and perhaps related to dyssynergic defecation.

Hemoroid Interna Grade III Pada Pasien Laki-Laki Usia 49 Tahun

Hemorrhoids are swellings of tissue containing veins located in the walls of the rectum and anus. Mass or bulge in the anal area accompanied by anal bleeding is the main symptom. Proper diagnosis and management of hemorrhoids is very important to reduce morbidity and improve the patient's quality of life. This case report was obtained from primary data through history taking, physical examination and supporting examination. The patient complains of a lump in the anus accompanied by bloody stools since 5 years. Initially the lump came out if the patient strained and could still go in on its own if the patient was not straining anymore. But since 1 year, the lump can't go in on its own, but must be helped to push it with a finger. Heavy bleeding from the anus since 2 months ago. On physical examination the rectal toucher found: good anal sphincter tone, palpable mass with a flat surface, solid, chewy consistency, reddish color, firm boundaries, tenderness (+), lumps can be inserted with fingers, blood on gloves (-), mucus (-), feces (-). Colonoscopy examination revealed grade III internal hemorrhoids. The treatment is hemorrhoidectomy.

Treatment Approaches for the Effective Management of Anal Fistula in the Modern Era

A complication of incision drainage or abscess ulceration around the anus and rectum is anal fistula which manifests as the creation of irregular channels linking the rectum and anal canal with the skin circumambient to the anus. It mostly affects the male population having a yearly frequency of two cases per ten thousand individuals. Histologically in anal fistula chronic inflammatory cells and fibrous tissues are surrounded by epithelialization of variable degree, which are categorized as squamous, columnar, or transitional zone epithelium. Anal fistula influences the psychological condition of the patients, which leads to depression or anxiety symptoms, in addition to severely impacting their standards of living. In general, anal fistula cannot be treated without medical intervention and the most efficient treatment for anal fistula is surgery. The optimal treatment in the modern era includes the elimination of the infected lesion, adequate drainage, and fistula closure while minimizing injury to the anal sphincter which includes treatment with fibrin glue, fistula plug, LIFT, etc.

Mathematical Model of Anal Canal for Anal Fistula Surgery

Abstract: Purpose: Surgery is necessary for the treatment of an anal fistula. However, excision of some sphincter muscle would compromise sphincter integrity or function, which is the cause of a reduced success rate in the long term. In order to develop an appropriate surgical plan, a mathematical model that describes the relationship between the internal pressure of the anal canal and the structure of anal sphincters is required.&#x0D; Methods: The anatomical structure of the anal canal and the corresponding sphincter pressure can be measured by endoanal ultrasound (EAUS) imaging and manometry, respectively. Length-tension relationships for skeletal and smooth muscles, two major components of the external and internal anal sphincter, respectively, were reviewed first. &#x0D; Results: Based on the information about the internal and external sphincters, two mathematical models, the thick-wall cylinder model and the two-layer model, have been created, from which the influence of complete or partial excision of the sphincter muscle can be estimated.&#x0D; Conclusions: The proposed thick-wall cylinder and two-layer models could describe the relationship between the internal anal canal pressure and the structure of anal sphincters, from which the influence of complete or partial excision of the sphincter muscle may be estimated.

Intraoperative Monitoring of the External Urethral Sphincter Reflex: A Novel Adjunct to Bulbocavernosus Reflex Neuromonitoring for Protecting the Sacral Neural Pathways Responsible for Urination, Defecation and Sexual Function.

Intraoperative bulbocavernosus reflex neuromonitoring has been utilized to protect bowel, bladder, and sexual function, providing a continuous functional assessment of the somatic sacral nervous system during surgeries where it is at risk. Bulbocavernosus reflex data may also provide additional functional insight, including an evaluation for spinal shock, distinguishing upper versus lower motor neuron injury (conus vs. cauda syndromes) and prognosis for postoperative bowel and bladder function. Continuous intraoperative bulbocavernosus reflex monitoring has been utilized to provide the surgeon with an ongoing functional assessment of the anatomical elements involved in the S2-S4 mediated reflex arc including the conus, cauda equina and pudendal nerves. Intraoperative bulbocavernosus reflex monitoring typically includes the electrical activation of the dorsal nerves of the genitals to initiate the afferent component of the reflex, followed by recording the resulting muscle response using needle electromyography recordings from the external anal sphincter. Herein we describe a complementary and novel technique that includes recording electromyography responses from the external urethral sphincter to monitor the external urethral sphincter reflex. Specialized foley catheters embedded with recording electrodes have recently become commercially available that provide the ability to perform intraoperative external urethral sphincter muscle recordings. We describe technical details and the potential utility of incorporating external urethral sphincter reflex recordings into existing sacral neuromonitoring paradigms to provide redundant yet complementary data streams. We present two illustrative neurosurgical oncology cases to demonstrate the utility of the external urethral sphincter reflex technique in the setting of the necessary surgical sacrifice of sacral nerve roots.

Features of reparative myogenesis of the internal anal sphincter locally exposed to humic acids

Aim to evaluate the effect of local exposure to humic substances on the repair of smooth muscle tissue of the internal anal sphincter.&#x0D; Material and methods. Laboratory male rats were subjects for experimental study. The tissues were studied using light-electron microscopy and immunocytochemistry.&#x0D; Results. The study revealed the features of myocyte survival in the wound and near-wound zones, the connective tissue scar formation rate. The phenomenon of the transformation of contractile myocytes into contractile-secretory ones was confirmed. The experiment has registered several features of the compensatory processes occurring with the use of humic acids as a local therapeutic agent. Specifically, the presence of a more pronounced edema of the interstitium, prolongation in time, in comparison with the control, filling the interstitium with connective tissue, as a result of which the architectonics of collagen fibers was adequate to the direction of myocyte contraction and relaxation. In addition, mitotically dividing cells were found among the muscle layer of the wound zone in the experimental group.&#x0D; Conclusion. The experimental data suggests that humic acids, being a natural factor, can contribute to the processes of intracellular and cellular regeneration, resulting in better restoration of the internal sphincter structure. Further development of humic substances along with the research on their action at the cellular and tissue levels should be encouraged.

Low Rectal Cancers at Initial Staging MRI.

Low rectal cancers, which are associated with increased risk of local recurrent disease and poorer prognosis, have unique anatomic considerations and issues for staging and treatment that do not apply to mid and high rectal cancers. Although tumor histology help drive the staging and treatment of all rectal cancers, it is of particular importance in low rectal cancers, which may involve the anal canal, to help establish whether a low rectal mass should be staged and treated as a rectal cancer (ie, adenocarcinoma) or an anal cancer (ie, squamous cell carcinoma). Optimal staging and treatment of rectal cancer are contingent on tumor location and local extent, which help guide management decisions including neoadjuvant therapy and curative surgical treatment strategies. Tumor location in the low rectum and local involvement of the anal canal, sphincter, and pelvic floor help determine whether a patient can undergo sphincter-preserving resection such as a low anterior resection versus abdominoperineal resection to achieve negative surgical margins. Issues exist related to the anatomy and patterns of disease spread that are unique to the low rectum and include how to determine and stage anal sphincter involvement, mesorectal fascia status at the pelvic floor, and nodal status of extramesorectal nodes such as the external iliac and inguinal lymph nodes. For these reasons, it is imperative that radiologists who interpret rectal cancer staging MRI examinations feel comfortable with the unique anatomy of the low rectum and anal canal, nuances of low rectal cancer local disease spread, and treatment paradigms for low rectal cancer. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center. See the invited commentary by Gollub in this issue.

Conformal sphincteric resection for ultra-low rectal cancer located below the dentate line: A pilot report.

Sphincter-sparing surgery can be achieved in most cases of low rectal cancer with the development of intersphincteric resection. However, abdominoperineal resection is still inevitable for patients with tumours located below the dentate line. To address this, we have developed a procedure called conformal sphincteric resection (CSR) in which the corresponding part of the subcutaneous portion of the external anal sphincter and the perianal skin on the tumour side is removed to achieve a safe distal resection margin and lateral resection margin while the dentate line and the internal anal sphincter on the tumour-free side are preserved as much as possible, to achieve sphincter preservation without compromising oncological safety and functional acceptability, and to render tumour location no longer a contraindication for sphincter-sparing surgery. This is the first study to describe the concept, indication and surgical procedure of CSR and to report its preliminary surgical, oncological and functional results. This is a retrospective, single-centre, single-arm pilot study conducted at Huashan Hospital, Fudan University. Demographic, clinicopathological, oncological and functional follow-up data were collected from 20 consecutive patients with rectal tumours located below the dentate line who underwent laparoscopic CSR by the same surgical team from June 2018 to March 2022. The mean distance of the tumour's lower edge from the anal verge was 13.1 ± 6.0 mm. The mean distal resection margin was 10.6 ± 4.3 mm. All circumferential resection margins were negative. There were no instances of perioperative mortality. The complication rate was 25% but all were Clavien-Dindo Grade I. Among the 20 cases, 17 were diagnosed with adenocarcinoma, one with squamous cell carcinoma and two with adenoma featuring high-grade intraepithelial neoplasia. Pathological TNM staging revealed two, seven, five, five and one case(s) in Stages 0, I, II, III and IV, respectively. The median follow-up period was 20 months (interquartile range 22 months), with no withdrawals. The overall and disease-free survival rates were both 95%. The mean Wexner incontinence score and low anterior resection syndrome score recorded 18 months following diverting ileostomy closure were 6.3 ± 3.8 and 27.3 ± 3.6, respectively. This study has proposed the CSR procedure for the first time, which is a technically feasible, oncologically safe and functionally acceptable procedure for carefully selected patients with rectal tumours located below the dentate line.

Tags for Tears: The Obstetric Anal Sphincter Injury Hashtag Ontology Project.

Social media is a powerful outlet for the dissemination of health care information. Adoption of a hashtag ontology-a standardized list of terms-may help better organize information and improve access to educational materials for health care providers (HCPs) and patients. The primary objective was to create a hashtag ontology specific to obstetric anal sphincter injuries (OASIS) based on Twitter usage. Secondary objectives included (1) performing a thematic analysis of OASIS-related tweet content and (2) reporting the type of users posting about OASIS. This study was an analysis of tweets related to OASIS posted between June 1, 2019, and June 1, 2022. Symplur Signals (a Twitter analytics software) (Symplur LLC, Los Angeles, CA) was used to identify relevant tweets based on predetermined search terms. Hashtags were reviewed by social media influencers to create a finalized ontology list. The top 100 tweets underwent thematic analysis and were grouped based on emergent themes. Types of users posting about OASIS were also analyzed. Symplur identified 660 tweets related to OASIS. The final ontology included the following 8 hashtags: #OASIS, #perinealtrauma, #birthtrauma, #3rddegreetear, #4thdegreetear, #episiotomy, #operativedelivery, and #postpartumbody. Major tweet content themes included education, self-promotion, patient experience, medical-legal, research, and opinions. Educational tweets surrounded prevention, risk factors, complications, and educational events related to OASIS and perineal trauma. Of the educational tweets, only 30% were posted by HCPs. This study created a standardized hashtag ontology related to OASIS. Less than one third of educational tweets were posted by HCPs.

Bir Yavru Kedide Tip 2 Atresia Ani ve Rectovajinal Fistülün Cerrahi Tedavisi Olgusu

3. Congenital type 2 atresia ani, accompanied by a rectovaginal fistula, is a rare condition in cats that forms an abnormal connection between the rectum and vagina. This case presentation involves a 4 week old female British Shorthair kitten brought to Istanbul University Cerrahpasa Faculty of Veterinary Medicine Hospital Surgical Clinics with complaints of congenital type 2 atresia ani and the accompanying rectovaginal fistula. The owners of the kitten sought veterinary care due to difficulties with defecation since birth. Upon clinical examination, the absence of an anal opening and contamination of the vulvar cavity with feces were observed. Contrast X-ray confirming that the anus was closed and surgery was decided. During the surgery, anal sphincters were preserved, and a "+" shaped incision was made in the anus to reach the rectum. The rectum was separated from the vaginal connection, and the fistula was closed. The kitten recovered smoothly and, during a one-year follow-up, was able to defecate normally by going to the litter box on its own. This case presentation highlights the importance of surgical interventions in the diagnosis and treatment of atresia ani and rectovaginal fistula