High complex anal fistula managed by the modified transanal opening of the intersphincteric space via the inter-sphincteric approach:A case report

BACKGROUND High complex anal fistulas are epithelialized tunnels,with the main fistula piercing above the deep external sphincter and the internal opening approaching the dentate line.Conventional surgical procedures for high complex anal fistulas remove most of the external sphincter and damage the anorectal ring.Postoperative loss of anal function can cause physical and mental damage.Transanal opening of the intersphincteric space(TROPIS)is an effective procedure that completely preserves the external anal sphincter.However,its clinical application is limited by challenges in the localization of the internal opening of a fistula and the high risk of complications.On the basis of our clinical experience,we modified the TROPIS procedure for the treatment of treating high complex anal fistulas.CASE SUMMARY A patient with a high complex anal fistula located above the anorectal ring underwent modified TROPIS,which involved sepsis drainage and identification of the internal opening in the intersphincteric space.The patient with the high complex anal fistula recovered well postoperatively,without any postoperative complications or anal dysfunction.Anal function returned to normal after 17 months of follow-up.CONCLUSION The modified TROPIS procedure is the most minimally invasive surgery for anal fistulas that minimally impairs anal function.It allows the complete removal of infected anal glands and reduces the risk of postoperative complications.Modified TROPIS via the intersphincteric approach is an alternative sphincter-preserving treatment for high complex anal fistulas.

Comparison between recent sphincter-sparing procedures for complex anal fistulas-ligation of intersphincteric tract vs transanal opening of intersphincteric space

Complex anal fistulas are difficult to treat.The main reasons for this are a higher recurrence rate and the risk of disrupting the continence mechanism because of sphincter involvement.Due to this,several sphincter-sparing procedures have been developed in the last two decades.Though moderately successful in simple fistulas(50%-75%healing rate),the healing rates in complex fistulas for most of these procedures has been dismal.Only two procedures,ligation of intersphincteric fistula tract and transanal opening of intersphincteric space have been shown to have good success rates in complex fistulas(60%-95%).Both of these procedures preserve continence while achieving high success rates.In this opinion review,I shall outline the history,compare the pros and cons,indications and contraindications and future application of both these procedures for the management of complex anal fistulas.

Relationship of public preferences and behavior in residential outdoor spaces using analytic hierarchy process and principal component analysis—a case study of Hangzhou City, China

This study examined public attitudes concerning the value of outdoor spaces which people use daily. Two successive analyses were performed based on data from common residents and college students in the city of Hangzhou, China. First, citizens registered various items constituting desirable values of residential outdoor spaces through a preliminary questionnaire. The result proposed three general attributes (functional, aesthetic and ecological) and ten specific qualities of residential outdoor spaces. An analytic hierarchy process (AHP) was applied to an interview survey in order to clarify the weights among these attributes and qualities. Second, principal factors were extracted from the ten specific qualities with principal component analysis (PCA) for both the common case and the campus case. In addition, the variations of respondents’ groups were classified with cluster analysis (CA) using the results of the PCA. The results of the AHP application found that the public prefers the functional attribute, rather than the aesthetic attribute. The latter is always viewed as the core value of open spaces in the eyes of architects and designers. Fur-thermore, comparisons of ten specific qualities showed that the public prefers the open spaces that can be utilized conveniently and easily for group activities, because such spaces keep an active lifestyle of neighborhood communication, which is also seen to protect human-regarding residential environments. Moreover, different groups of respondents diverge largely in terms of gender, age, behavior and preference.

Efficacy of Kegel exercises in preventing incontinence after partial division of internal anal sphincter during anal fistula surgery

BACKGROUND The transanal opening of intersphincteric space(TROPIS)procedure,performed to treat complex anal fistulas,preserves the external anal sphincter(EAS)but involves partial incision of the internal anal sphincter(IAS).AIM To ascertain the incidence of incontinence after the division of the IAS as is done in TROPIS and to evaluate whether regular Kegel exercises(KE)in the postoperative period can prevent incontinence due to IAS division.METHODS Patients operated on for high complex fistulas and having no preoperative continence problem(score=0)were included in the study.All patients were operated on by the TROPIS procedure and were recommended KE(pelvic contraction exercises)50 times/day.KE were commenced on the 10^(th)postoperative day and continued for 1 year.Incontinence was evaluated objectively(by modified Vaizey’s scores)in the immediate postoperative period(Pre-KE group)and on long-term follow-up(Post-KE group).The incontinence scores in both groups were compared to evaluate the efficacy of KE.RESULTS Of 102 anal fistula patients operated on between July 2018 and July 2020 were included in this study.There were 90 males,the mean age was 42.3±12.8,and the median follow-up was 30 mo(18-42 mo).Three patients were lost to follow-up.There were 65 recurrent fistulas,92 had multiple tracts,42 had associated abscess,46 had horseshoe fistula and 34 were supralevator fistulas.All were magnetic resonance imaging-documented high fistulas(>1/3 EAS involved).Overall incontinence occurred in 31%patients(Pre-KE group)with urge and gas incontinence accounting for the majority of cases(28.3%).The mean incontinence scores in the Pre-KE group were 1.19±1.96(in 31 patients,solid=0,liquid=7,gas=8,urge=24)and in the Post-KE group were 0.26±0.77(in 13 patients,solid=0,liquid=2,gas=3,urge=10)(P=0.00001,t-test).CONCLUSION Division of the IAS led to incontinence,mainly urge incontinence,and also to a mild degree of gas and liquid incontinence.However,regular KE led to a significant reduction in incontinence(both in the number of affected patients and the severity of scores in these patients).

An Urban Open Space Extraction Method: Combining Spectral and Geometric Characteristics

This paper introduces an advanced method based on remote sensing and Geographic Information System for urban open space extraction combining spectral and geometric characteristics. From both semantic and remote sensing perspectives, a hybrid hierarchy structure and class organization of open space are issues and mapped from one to another. Based on per-pixel and segmentation mechanism separately, two classification approaches are performed. Owing to prior of spatial aggregation and spectral contribution, the segmentation-based classification exhibits its superiority over a pixel-based classification. Finally a GIS-based post procedure is hired to eliminate some unsuitable open space components in both spatial and numerical constraints on the one hand, and separate open space some fabrics from fused remote sensing classes by defining their Shape Index on the other hand. The case study of Beer Sheva based on ASTER data proves this method is a feasible way for open space extraction.

High-Density Block Transformation to Increase Natural Ventilation Based on CFD Simulation

Many countries in the world have experienced extremely rapid urbanization during recent decades. The rapiddevelopment of densely populated areas has produced many urban environmental problems. This researchexplores the relationship between urban morphology and ventilation conditions. Through 3D modeling andComputational Fluid Dynamics (CFD) simulation, we focus on the large scale ventilation of an extended area withseveral buildings. As a testbed, in particular, the core part of Kwun Tong industrial park in Hong Kong is examined, and in order to validate the approach, 10 measurement points are used to get experimental values to be usedfor comparison (such points are located in different positions involving traffic road, pedestrian path and openspace). The error range (±0.7 m/s) indicates that the agreement between field measurement and CFD calculationis good. On the basis of design guidelines and earlier studies, the effective configuration (in terms of building) ofthis area is partially transformed (virtually, i.e., in the numerical simulations) in order to assess the ensuingchanges in terms of wind speed in different locations. This results in a general design and analysis methodologypotentially applicable to other areas.

Human Behavior in Downtown Public Spaces during Cooling Periods in Winter Cities

There is an urban design problem that outdoor public spaces are not used for long periods of time within a year due to coldness and snow cover in cities with severe winter climates （winter cities）. Therefore, an urban design that promotes activities in these spaces is required for winter cities. The purpose of this paper is to clarify the relationship between outdoor environmental conditions and the behaviors of people in outdoor public spaces. This six-month study conducted a field survey in six kinds of public spaces in downtown Sapporo and analyzed the changes of microclimates and sitting behaviors in these spaces. The analysis revealed that sitting behaviors decreased with temperature drops during the cooling period （20 ~C-8 ~C）, that sunlight could suppress the reduction in the number of sitting behaviors, and that wind speed could suppress the reduction in the duration of sitting behaviors.

Evaluation and Promotion of the Service Capacity of Urban Public Open Spaces Based on Improving Accessibility:A Case Study of Shenyang City,China

The service capacity of urban public open spaces is an important indicator of the justness and soundness of the allocation of public space resources,such as parks and green spaces,in the process of urban development.Improving the service capacity of urban public open spaces is conductive to healthy,sustainable urban development.In this study,taking Shengyang City,China as a case study,a Gaussian-based two-step floating catchment area method(2 SFCA)is used to calculate an accessibility index and identify residential areas with a poor accessibility to urban public open spaces.Then,a particle swarm algorithm(PSA)is used to optimize the locations of new open space developments.Finally,the optimization results are verified using the analytic network process(ANP).The results show that the service capacity of public open spaces in the center of Shenyang City(covering six districts)is relatively low and exhibits an uneven spatial distribution.In the service scope of the existing urban public open spaces,the accessibility for 48.6%of the residential estates is moderately poor or poor.The layout is optimized when the number of optimization points is set to 8.These points are mainly located in old town areas such as the Tiexi,Huanggu,and Dadong districts.The optimization increases the green space area accessible by motor vehicles(60 min),bicycles(60 min),and walking(30 min)by 4.67%,5.38%,and 8.03%of the study area,respectively.Finally,green space planning recommendations are offered from two perspectives:spatial layout and transport system optimization.

On the Porosity of Au and Ag Coatings Formed in Earth-Based and Space Conditions

It has been accomplished comparative survey of the structure, substructure and submicro porosity of coatings of fine metals with face-centered cubic lattice Au and Ag being condensed in both conditions of space flights of orbital stations and earth-based conditions. Urgency of such surveys are concerned with the necessity of settling the issues of creation of the advanced technologies for developing and recovery of different coatings-thermostatic, protective, optical etc. in space-based conditions.

Research on Age-friendly Open Spaces Design in Residential Areas of Small Towns

Taking the accelerating aging and newly promoted urbanization as backdrops, this paper, on one side, analyzed the demands for parks, squares, fi tness facilities, chairs, etc. of elders in small towns from perspectives of unique physical, psychological and social features of elders. On the other side, it also tackled the inadequacies of open spaces in small towns. Moreover, it proposed strategies such as creating social activity spaces, cultivating therapeutic green landscapes, constructing diversely secure fi tness spaces and building age integrated environments, etc. for designing age-friendly open spaces in small towns.

Road-Spine versus Road-Tube： Roads as Space Generators

Arteries devoted to sustain streams of users, resources and debris, are a foremost factor and pre-condition of the development of urban areas and of the transformation of landscapes. Roadscapes reflect outcomes related to super urbanization tendencies. Often conceived as isolated tubes, roads cut and obscure form, structure, biotic and abiotic factors of sites, urban fabrics and spaces. A broad vision of landscape is a basis for reconceiving roads. The concept of road-spine emerges： the road is conceived as the basis of a bundle of routes, nodes, surfaces, poles and tiles, devised to frame and shape a mosaic of open spaces, crops, farms, stores, basins and service areas. The road-spine entails the idea of a permeable infrastructure devised to integrate diverse functions： from serving various forms of motion, by ordering an isotropic grid of routes, to framing a porous urbanscape; from disposing surfaces meant to preserve biocenosis and biotopes, to favoring osmosis amid land uses. It also prefigures a distribution of land uses dependent on site vocations, and a mosaic of scenarios open to encounter, evasion, rest, amusement, participation, and to spontaneous practices of space.

Improving Open Spaces for a Sustainable City

The feasibility of city living with nature as a way to restore the balance between human uses and natural processes is the focus of this paper about the city of Maringa in Southern Brazil. This urban form, a planned new town founded in 1947 upon a previous, comprehensive British land-development scheme, originally offered a friendly interaction between urban settlement and nature. Hence, this paper outlines how open spaces can be enhanced as an ecological structure, bringing parks, squares, gardens and urban farming into a productive system, both for nature＇s and for people＇s sakes. Following a morphological study, the proposed ecological structure will maintain ecological processes within the urban grid and help to preserve historical and social values, by linking a wide variety of natural and restored ecosystems and landscape features. The adoption of this kind of ecological planning will certainly result in an increase of the urban landscape quality, changing actual planning paradigm and preventing the city from environmental quality decrease.

Study of the Relationship between Building Arrangement and Visibility of Open Spaces Based on a Simplified Area Evaluation

This paper studies which building arrangement will provide the maximum visibility to an example of open space proposed in the Abu Dhabi 2030 Master Plan. The building forms, the distance between the buildings, the setback and the building heights would all affect visibility and were considered closely. Although this research methodology could be applied to any site in different situations, it remains simple and interesting. It can be applied in general, with a change of the variables （setback, distance between buildings, building height, building form）, to any site by both professionals and students who can simply use any CAD program for producing drawing in both the architectural or urban designs phases, hence the importance of this research. Two different building arrangements were proposed and studied： a linear and an L-shaped arrangement. After applying the simulations, it appears that the L-shape offers more visibility to the open space. The outcomes of this study were combined with another research project that studies the same building arrangements to test the possible climatic comfort provided in outdoor spaces in order to encourage the use of open spaces and walkability in the studied area.

Optimization Design of Open Spaces Based on Wind Tunnel and CFD Simulation： Case Study of a Street Canyon in Northern China

Airflow in open spaces can significantly affect spatial quality. Therefore, according to the type of building structures, the airflow also has different forms. Studies have been conducted on the relation between airflow and pedestrian comfort; however, only few of them have focused on comprehensive urban planning that considers different weather conditions and people＇s ability to adapt. This research focuses on the differences in wind conditions caused by different spatial forms in different seasons. On the basis of a field survey in both summer and winter in a public open space, evaluation standards developed from environmental meteorological data and public feedback were used to evaluate simulation results. Next, several assumptions about canyon orientation and building types were proposed. Wind tunnel and CFD （computational fluid dynamics） simulations were conducted to evaluate the assumptions. The results showed that the canyon orientation significantly affected overall wind conditions and different building structures affected airflow. This research also provides a method to evaluate urban areas that have complicated wind environments.

The Importance of Legibility and Its Relationship with the West End Regeneration Programme

Legibility is a significant quality of urban spaces. It affects people's knowledge of space and options available to them. This paper focused on the importance of the legibility of urban spaces and its relationship with urban design projects, and took the regeneration of Oxford's West End for example to il ustrate how to make urban open green spaces clearly legible.

Research on Open Campus Space Evaluation System Based on CSOA Theory

As an important part of urban open space,campus space plays an important role in connecting urban traffic environment with the gradual improvement of urban space quality today.Based on CSOA(Campus Space Openness Assessment)theory,the paper calculates the current situation of walking space and vehicle crossing space in the campus,including entrance coupling degree(ξ),campus crossing degree(ε)and campus space opening degree(∑).The coupling relationship between campus entrance layout and campus road form for campus space openness is analyzed and the strategies are optimized respectively.The conclusions are as follows:①the location of campus entrances and exits can be reflected by the coupling degree of campus entrance,which is affected by the number and nodes,and the coupling degree is positively correlated with the number;②the closer the azimuth distance between the two entrances and exits on the campus to the linear distance,the higher the crossing rate;③the higher the product of campus entrance coupling degree and campus crossing degree,the higher the campus space opening degree.The results of this study provide quantitative guidance for modern campus design from the perspective of open campus space evaluation system.

Urban Open Space as a Place for Social and Physical Well-being:Narratives from two Different Urban Settings of Kathmandu,Nepal

Increasing population and densification of the cities lead to increasing land value by the high demand of land for housing and other infrastructure developments are the reasons that tend to decreasing open spaces in Kathmandu Valley in general,and Kathmandu Metropolitan City(KMC)in particular.Urban open space has been considered as a place that is accessible to all residents and is important in the urban context as such space provides an opportunity as a place for social interaction,networking,recreation,and various physical health exercises.However,different social and economic contexts of the society reflect different patterns of its uses.Two different urban settings(core urban areas having indigenous dominant population and fringe urban areas having migrants’dominant population)have been taken as a basis for analysis in this paper to look at how different urban societies use open spaces differently.Open spaces are not only important for maintaining urban greenery and beauty for the city but are valued for accumulating social capital and enhancing physical well-being to urban communities.These issues are analyzed through the interpretative research methodology by collecting the data through in-depth interviews,key informants’interviews,informal conversational interviews,and nonparticipatory observation from two different urban settings of KMC.

Temperature Comfort, Recreation and Historical Features in Open Spaces;the Path of Remembrance and Comradeship (PATH) in Ljubljana, Slovenia

The built environment has a great impact on the quality of urban climate,a comfortable living environment,overheating,and detection of changes in Urban Heat Islands(UHI).Despite the effects that raised outdoor temperatures have on human well-being and health,being in open outdoor spaces is strongly encouraged.This article deals with open green urban areas.The study was focused on searching for the relationships between the various elements,such us outdoor thermal comfort,the urban heat island,green areas,and active leisure time.The well-being in open spaces has be studied on the case of The Path of Remembrance and Comradeship(PATH)in the city of Ljubljana,Slovenia.PATH is a circular recreation ground(almost 33 km long)and passes from the urban to the natural landscape area.PATH constitutes an important element of the urban space and confirms the identity and image of Ljubljana.It is most popular for walking and jogging.Overheating at the PATH was studied using multiple indicators,which were broken down into detail at five sites with different urban morphology,green areas,water,and paved areas.

The Role of Open Space in Human Settlement Development in the Tamale Metropolis of Northern Ghana

Most parts of the world are rapidly urbanizing. In sub-Saharan Africa, towns are urbanizing at a faster pace than earlier predicted. Also, large portions of rural settings have been gradually moving towards urbanization. The Tamale Metropolis has been rated as the fastest-growing metropolis in Sub-Saharan Africa. City planning and concerns about the need for open-space creation have been a major challenge due to poor adherence to standards in the building codes. This study was conducted to assess the role of open space in human settlement development in the Tamale Metropolis. The study sampled the views of 157 residents who stay closed to community open spaces in five suburbs of the metropolis. Key informant interviews were also conducted with officials from the Town and Country Planning Department. The study revealed that most residents spend leisure by taking a walk in the neighborhood or idling in outdoor spaces. Also, the majority of the residents had poor knowledge of institutional and land administration. This often led to non-adherence to regulations and this affects open spaces in the metropolis. Common among residents is also a poor appreciation of the importance of open space and this results in encroachment. The Town and Country Planning Department should institute sanctions and stringent measures to deter offenders. Also, public seminars should be used to educate residents on the need to adhere to planning and building codes. Lastly, the study recommends strong collaboration between the various institutions engaged in land administration to facilitate effective provision and preservation of quality open spaces in the metropolis.

Open Space Implications in Urban Development: Reflections in Recent Urban Planning Practices in Nepal

Open space has various implications in urban development planning and has been integrated in recent urban planning approaches and practices in Nepal.The open spaces are not only important for(re)shaping the urban form but are also important for enhancing urban social life and disaster risk management,particularly for dense cities.As most of the cities in Nepal have been growing haphazardly,the cities lack sufficient open space.However,the value of open space in dense cities like Kathmandu has been recognized more after the Gorkha Earthquake 2015 as the open spaces were extensively used for risk relief,treatment,recovery,and rehabilitation during and after the earthquake.With this background,this paper presents the major planning initiatives in Nepal and discusses how recent urban plans have provisioned and initiated open spaces development by reviewing concurrent urban planning practices,particularly reviewing Periodic Plans,Integrated Urban Development Plan,Smart City Plan,and Land Development Plan.The development of open areas has not been given much attention in the earlier urban planning practice but recent urban development planning has emphasized with a special focus which is very important for sustainable and safer city development and is expected to address the current bulging urban issues of spatiality and sociability.Therefore,it is very important for integrating open space implications in city planning and such open space should be conceptualized according to the city’s geography,landscape as well as socio-cultural contexts.