Training Requirements in Point-of-Care Ultrasonography of the Upper Airway: A Feasibility Study.

OBJECTIVES: Point-of-care ultrasonography of the upper airway can be a useful supplement to conventional pre-anesthetic clinical evaluations. However, the reliability of such examinations is highly operator-dependent and proper training in sonoanatomy and ultrasound operational skills are required. The objective of this study aims to assess the minimum training requirements for applying a predefined upper airway scanning protocol in healthy volunteers by anesthesia trainees. METHODS: Twenty-two healthy volunteer members of the Operating Room staff participated in the study. A predefined scanning protocol that included the identification of specific structures (hyoid bone, vocal cords, thyrohyoid membrane/epiglottis/pre-epiglottic space, cricothyroid membrane, and thyroid gland), as well as the performance of specific measurements (distance from the hyoid bone to skin, anterior commissure to skin, epiglottis to skin, and thyroid isthmus to skin) was taught in a single-day training course. The trainees' competence was assessed after multiple scanning repetitions performed over a week. Mixed effects regression models were applied for the trainee-instructor differences in all ultrasound measurements. RESULTS: Cricothyroid membrane visualization had the lowest success rate (88%). Trainee-instructor differences were statistically significant for hyoid bone-to-skin (P < .001) and epiglottis-to-skin distances (P = .016). Measurement of the distance from the epiglottis to the skin required more scanning repetitions to achieve minimum deviance compared with other measurements. Ten or fewer scanning repetitions were sufficient to achieve minimum deviance for all four measurements. CONCLUSIONS: At least 10 scanning repetitions of a pre-defined upper airway scanning protocol can be used as the minimum standard for training.

Is brucellosis a great mimic of tuberculosis? A case report.

Tuberculosis (TB) can manifest prolonged fever or fever of unknown origin, especially when it is located extrapulmonary. We report a case of disseminated TB complicated by iliac bone osteolysis and a gluteal abscess in a 75-year-old female patient with fever and bone marrow dysplasia. Diagnosis of TB was made despite transient false-positive high-titer agglutination tests and ELISA antibodies to Brucella. The case presented shows that in a highly suggestive case of TB, positive agglutination tests or ELISA antibodies to Brucella should be interpreted with caution, and repeated testing should be performed to assess their persistence and fluctuation over time.

At-risk brain tissue identified with arterial spin labeling in neurotuberculosis.

A 13-year-old immunocompromised girl developed neurotuberculosis. Arterial spin labeling technique indicated areas of hypoperfusion in the vascular territories of the left posterior cerebral artery and superior cerebellar artery without restricted diffusion, suggesting early tuberculous arteritis. MR angiography confirmed vascular involvement, so adjunctive anticoagulant therapy was initiated. Complete resolution of arterial spin labeling findings was observed 1 month later. This documents early tuberculous vasculopathy revealed by arterial spin labeling in a child with neurotuberculosis. Since there may be a paucity of clinical symptoms in the evolution of arteritis in neurotuberculosis, arterial spin labeling may help indicate early hypoperfusion and alert for modification of treatment before irreversible vascular damage occurs.

Solitary juvenile xanthogranuloma in the parotid gland.

Juvenile xanthogranuloma (JX) is a non-Langerhans cell histiocytosis. Although precipitating factors remain unclear, it has been described mainly in infancy and early childhood. The giant variant of JX is a rare form that presents in infancy, measures over 2 cm and tends to involute only partly. Herein, we report a very rare localization of a giant JX in the parotid gland, discovered at age 1 month in an infant of a twin pregnancy and studied with ultrasound and magnetic resonance imaging.

Small bowel obstruction due to a congenital adhesion: a rare case report.

The exact incidence of small bowel obstruction (SBO) due to congenital adhesions remains unclear. Herein, we report a 59-year-old male who appeared in the emergency department with diffuse abdominal pain associated with vomiting. The patient reported no previous medical or surgical history. Clinical examination revealed a soft, distended abdomen and diffuse tenderness. Computed tomography indicated a close loop obstruction. A congenital band extending from mesentery to ileum and causing an internal hernia was identified via a midline incision. The band was ligated and divided. There is no difference in the clinical presentation, and the initial work-up of SBO on account of congenital adhesions was compared to other bowel obstruction causes. Surgical exploration is crucial for the diagnosis and treatment of congenital adhesions. Although laparotomy is considered the cornerstone of surgical management, laparoscopy has emerged as a feasible and safe alternative for the diagnosis and treatment of these congenital bands.

Temporomandibular joint involvement in juvenile idiopathic arthritis: clinical predictors of magnetic resonance imaging signs.

The aim of the study was to define clinical predictors of magnetic resonance imaging (MRI) findings of temporomandibular joint (TMJ) involvement in juvenile idiopathic arthritis (JIA). Forty-six patients, aged 2.08-36.7 years, with JIA (oligoartitular 18, polyarticular 17, systemic type 11) were examined with standard plain and contrast-enhanced sequences. Of 88 TMJs examined, an abnormal condyle was observed in 32%, flattened articular eminence in 27%, flattened articular disk in 17%, intra-articular fluid in 10%, enhancing pannus in 45% and restricted condylar motion in 9%. Logistic regression analysis revealed that for abnormal condyle and flattened articular eminence, independent predictors were type of JIA (P < 0.015), age at onset (P < 0.038), and duration of disease activity (P < 0.001). Plots of the logistic regression models showed that TMJ involvement approached certainty for systemic sooner than for the other JIA types. Pannus was present with probability >0.5 when the disease started before 4 years of age. In conclusion, the systemic type of JIA, young age at onset and long duration of activity are risk factors for TMJ damage. MRI of the TMJ should be performed in patients who are less than 4 years of age at the onset of JIA, and in those with the systemic type, whatever the age of onset.

Brain activation during repeated imagining of chocolate consumption: a functional magnetic resonance imaging study.

OBJECTIVE: To assess brain activation during mental visualization of eating chocolate. DESIGN: Twenty-one subjects were included. FMRI was acquired with a single-shot, multislice, gradient echo-planar sequence, while subjects were performing two specific imaginary tasks. RESULTS: Activation of motor-associated brain areas was observed during both mental visualization tasks. Increased activation of the right dorsolateral prefrontal cortex, the thalamus, the postcentral gyrus and the left anterior cingulate cortex, and the precuneus was observed during imagining eating chocolate. CONCLUSIONS: Repeated imagination of chocolate consumption results in activation of brain areas associated with hedonic effects of food and satiety and inhibition of orexigenic areas.

Voxel-based morphometry and Voxel-based relaxometry in parkinsonian variant of multiple system atrophy.

BACKGROUND AND PURPOSE: Multiple system atrophy (MSA) is a progressive neurodegenerative disorder divided into a parkinsonian (MSA-P) and a cerebellar variant. The purpose of this study was to assess regional brain atrophy and iron content using Voxel-based morphometry (VBM) and Voxel-based relaxometry (VBR) respectively, in MSA-P. METHODS: Using biological parametric mapping the effect of brain atrophy was evaluated in T2 relaxation time (T2) measurements by applying analysis of covariance (ANCOVA) and correlation analysis to the VBM and VBR data. Eleven patients with MSA-P (aged 61.9 +/- 11.7 years, disease duration 5.42 +/- 2.5 years) and 11 controls were studied. RESULTS: In comparison to the controls the patients showed decreased gray matter in the putamen, the caudate nuclei, the thalami, the anterior cerebellar lobes, and the cerebral cortex, and white matter atrophy in the pons, midbrain, and peduncles. VBR analysis showed prolonged T2 in various cortical regions. On ANCOVA, when controlling for gray and white matter volume, these regions of prolonged T2 were shrunk. Negative correlation was demonstrated between T2 and gray and white matter volume. CONCLUSIONS: Diffuse brain atrophy, mainly in the motor circuitry is observed in MSA-P. Normalization for atrophy should always be performed in T2 measurements.

Magnetization transfer ratio and volumetric analysis of the brain in macrocephalic patients with neurofibromatosis type 1.

The purpose of the study was to evaluate brain myelination by measuring the magnetization transfer ratio (MTR) and to measure grey (GMV) and white matter volume (WMV) in macrocephalic children with neurofibromatosis type 1 (NF1). Seven NF1 patients (aged 0.65-16.67 years) and seven age- and gender-matched controls were studied. A three-dimensional (3D) gradient echo sequence with and without magnetization transfer (MT) prepulse was used for MTR assessment. Volume measurements of GM and WM were performed by applying segmentation techniques on T2-weighted turbo spin echo images (T2WI). MTR of unidentified bright objects (UBOs) on T2WI in cerebellar white matter (52.8+/-3.3), cerebral peduncles (48.5+/-1.5), hippocampus (52.6+/-1.1), internal capsule (55.7+/-0.3), globus pallidus (52.7+/-3.9), and periventricular white matter (52.6+/-1.2) was lower than in the corresponding areas of controls (64.6+/-2.5, 60.8+/-1.3, 56.4+/-0.9, 64.7+/-1.9, 59.2+/-2.3, 63.6+/-1.7, respectively; p<0.05). MTR of normal-appearing brain tissue in patients was not significantly different than in controls. Surface area (mm(2)) of the corpus callosum (809.1+/-62.8), GMV (cm(3)) (850.7+/-42.9), and white matter volume (WMV) (cm(3)) (785.1+/-85.2) were greater in patients than in controls (652.5+/-52.6 mm(2), 611.2+/-92.1 cm(3), 622.5+/-108.7 cm(3), respectively; p<0.05). To conclude, macrocephaly in NF1 patients is related to increased GMV and WMV and corpus callosum enlargement. MTR of UBOs is lower than that of normal brain tissue.

Non-arteritic anterior ischaemic optic neuropathy: evaluation of the brain and optic pathway by conventional MRI and magnetisation transfer imaging.

The purpose of the study was to examine the brain and the visual pathway of patients with non-arteritic anterior ischaemic optic neuropathy (NAION) by using conventional MRI (cMRI) and volumetric magnetisation transfer imaging (MTI). Thirty NAION patients, aged 67.5 +/- 8.14 years, and 28 age- and gender-matched controls were studied. MTI was used to measure the magnetisation transfer ratio (MTR) of the chiasm and for MTR histograms of the brain. The presence of areas of white matter hyperintensity (WMH) was evaluated on fluid-attenuated inversion recovery (FLAIR) images. Area of the optic nerves (ONs) and volume of the chiasm were assessed, as were coronal short-tau inversion recovery (STIR) and MTI images, respectively. More areas of WMH were observed in patients (total 419; mean 14.4; SD 19) than in controls (total 127; mean 4.7; SD 5.7), P < 0.001. Area (in square millimetres) of the affected ONs, volume(in cubic millimetres) and MTR (in percent) of the chiasm (10.7 +/- 4.6), (75.8 +/- 20.2), (56.4 +/- 6.5), respectively, were lower in patients than in controls (13.6 +/- 4.3), (158.2 +/- 75.3) (62.1 +/- 6.2), respectively, P < 0.05. Mean MTR of brain histograms was lower in patients (53.0 +/- 8.0) than in controls (58.0 +/- 5.6), P < 0.05. NAION is characterised by decreased ON and chiasmatic size. The low MTR of the chiasm and brain associated with increased areas of WMH may be suggestive of demyelination and axonal damage due to generalised cerebral vascular disease.