Intranodal lymphangiography and interstitial lymphatic embolization to treat chyluria caused by a lymphatic malformation in a pediatric patient.

Chyluria is characterized by chyle in the urinary tract and often presents as milky-white urine. We present a case of chyluria from a lymphatic malformation in a 13-year-old boy diagnosed using dynamic intranodal contrast-enhanced magnetic resonance (MR) lymphangiography. This report demonstrates the utility of intranodal lymphangiography and interstitial lymphatic embolization to treat a pediatric patient presenting with persistent chyluria. Glue migration into the urinary collecting system is a potential complication of this procedure that can be mitigated by adjusting the n-butyl cyanoacrylate dilution with Lipiodol.

Diagnostic Approach to Intrinsic Abnormality of Spinal Cord Signal Intensity.

Intramedullary cord hyperintensity at T2-weighted MRI is a common imaging feature of disease in the spinal cord, but it is nonspecific. Radiologists play a valuable role in helping narrow the differential diagnosis by integrating patient history and laboratory test results with key imaging characteristics. The authors present an algorithmic approach to evaluating intrinsic abnormality of spinal cord signal intensity (SI), which incorporates clinical evaluation results, time of onset (acute vs nonacute), cord expansion, and pattern of T2 SI abnormality. This diagnostic approach provides a practical framework to aid both trainees and practicing radiologists in workup of myelopathy.©RSNA, 2019.

A Biomechanical Study of Hyoid Bone and Laryngeal Movements During Swallowing Comparing the Blom Low Profile Voice Inner Cannula and Passy-Muir One Way Tracheotomy Tube Speaking Valves.

The aim of this prospective, consecutive, cohort study was to investigate the biomechanical effects, if any, of the Blom low profile voice inner cannula and Passy-Muir one-way tracheotomy tube speaking valves on movement of the hyoid bone and larynx during swallowing. Ten adult patients (8 male, 2 female) with an age range of 61-89 years (mean 71 years) participated. Criteria for inclusion were ≥18 years of age, English speaking, and ability to tolerate both changing to a Blom tracheotomy tube and placement of a one-way tracheotomy tube speaking valve with a fully deflated tracheotomy tube cuff. Digitized videofluoroscopic swallow studies were performed at 30 frames/s and with each patient seated upright in the lateral plane. A total of 18 swallows (three each with 5 cc bolus volumes of single contrast barium and puree + barium × 3 conditions) were analyzed for each participant. Variables evaluated included larynx-to-hyoid bone excursion (mm), maximum hyoid bone displacement (mm), and aspiration status under three randomized conditions: 1. Tracheotomy tube open with no inner cannula; 2. Tracheotomy tube with Blom valve; and 3. Tracheotomy tube with Passy-Muir valve. Blinded reliability testing with a Pearson product moment correlation was performed on 20 % of the data. Intra- and inter-rater reliability for combined measurements of larynx-to-hyoid bone excursion and maximum hyoid bone displacement was r = 0.98. Intra- and inter-rater reliability for aspiration status was 100 %. No significant differences (p > 0.05) were found for larynx-to-hyoid bone excursion and maximum hyoid bone displacement during swallowing based upon an open tracheotomy tube, Blom valve, or Passy-Muir valve. Aspiration status was identical for all three randomized conditions. The presence of a one-way tracheotomy tube speaking valve did not significantly alter two important components of normal pharyngeal swallow biomechanics, i.e., hyoid bone and laryngeal movements. Aspiration status was similarly unaffected by valve use. Clinicians should be aware that the data do not support placement of a one-way tracheotomy tube speaking valve to reduce prandial aspiration.

Verbal communication with the Blom low profile and Passy-Muir one-way tracheotomy tube speaking valves.

OBJECTIVE: To investigate physiologic parameters, voice production abilities, and functional verbal communication ratings of the Blom low profile voice inner cannula and Passy-Muir one-way tracheotomy tube speaking valves. STUDY DESIGN: Case series with planned data collection. SETTING: Large, urban, tertiary care teaching hospital. SUBJECTS AND METHODS: Referred sample of 30 consecutively enrolled adults requiring a tracheotomy tube and tested with Blom and Passy-Muir valves. Physiologic parameters recorded were oxygen saturation, respiration rate, and heart rate. Voice production abilities included maximum voice intensity in relation to ambient room noise and maximum phonation duration of the vowel/a/. Functional verbal communication was determined from randomized and blinded listener ratings of counting 1-10, saying the days of the week, and reading aloud the sentence, "There is according to legend a boiling pot of gold at one end." RESULTS: There were no significant differences (p>0.05) between the Blom and Passy-Muir valves for the physiologic parameters of oxygen saturation, respiration rate, and heart rate; voice production abilities of both maximum intensity and duration of/a/; and functional verbal communication ratings. Both valves allowed for significantly greater maximum voice intensity over ambient room noise (p<0.001). CONCLUSIONS: The Blom low profile voice inner cannula and Passy-Muir one-way speaking valves exhibited equipoise regarding patient physiologic parameters, voice production abilities, and functional verbal communication ratings. LEARNING OUTCOMES: Readers will understand the importance of verbal communication for patients who require a tracheotomy tube; will be able to determine the differences between the Blom low profile voice inner cannula and Passy-Muir one-way tracheotomy tube speaking valves; and will be confident in knowing that both the Blom and Passy-Muir one-way tracheotomy tube speaking valves are equivalent regarding physiological functioning and speech production abilities.

Detection and genotype of high-risk human papillomavirus in fine-needle aspirates of patients with metastatic squamous cell carcinoma is helpful in determining tumor origin.

OBJECTIVES: Recent studies have shown that human papillomavirus (HPV) is associated with a certain subset of head and neck squamous cell carcinoma (HNSCC)-namely, those arising in the oropharynx. The objective of this study is to determine the efficacy, detection, and genotype of high-risk (HR) HPV using the Roche cobas 4800 system (Roche Molecular System, Pleasanton, CA). METHODS: Forty-two fine-needle aspirate (FNA) specimens from 37 patients with cervical (n = 36) or mediastinal (n = 5) lymphadenopathy or a left parapharyngeal mass (n =1) were included in this prospective study. HR-HPV testing was performed on residual FNA material after direct smear preparation and, if positive, was further delineated into HPV 16/18 genotypes using the Roche cobas 4800 system. Follow-up included review of histologic material and/or electronic health records. RESULTS: Among those HNSCCs that were positive for HR-HPV, 18 (100%) of 18 originated from the oropharynx, whereas only two (13%) of 15 HR-HPV-negative HNSCCs originated from the oropharynx (χ(2) test, P < .05). p16 immunohistochemical assay and HPV 16 in situ hybridization on corresponding histologic specimens were concordant with cytologic HR-HPV results. CONCLUSIONS: HR-HPV detection and genotyping can be performed on lymph node FNAs with metastatic squamous cell carcinoma using the Roche cobas 4800 system. The presence of HR-HPV and/or HPV 16 is a reliable indicator of the metastatic squamous cell carcinoma originating from the oropharynx.

Esophageal perforation caused by edible foreign bodies: a systematic review of the literature.

OBJECTIVES/HYPOTHESIS: Presentation of a case of esophageal perforation caused by ingestion of a foreign body that was difficult to visualize endoscopically, and systematic review of the current literature with a focus on available diagnostic modalities and missed diagnoses. DATA SOURCES: MEDLINE (1946-2014). REVIEW METHODS: We conducted a systematic review of MEDLINE for cases and studies of esophageal perforation due to foreign bodies. RESULTS: A systematic review of esophageal perforations caused by foreign bodies revealed 40 studies that included 168 patients. Neck/chest pain, odynophagia, and dysphagia were the most common presenting symptoms--each occurring in the majority of patients. Where reported, diagnostic sensitivity of lateral neck X-rays was 56%, and computed tomography (CT) scan was 100%. Nine of 168 cases specifically mentioned a missed diagnosis. Very few studies reported a failure to visualize the foreign object at the time of primary rigid or flexible esophagoscopy. No studies reported nonvisualization of the foreign body at the time of open surgery. CONCLUSION: Esophageal perforations due to foreign bodies are rare but carry potentially devastating complications. Delays in diagnosis are common, and no standard diagnostic algorithm exists. Lateral neck X-rays are an easy but insensitive screening test. Laryngoscopy is an excellent screening test but not always diagnostic. CT is a more sensitive diagnostic method, which can also help guide management based on the detection of complications. Although seldom described, if an object is not visualized at the time of endoscopic or surgical intervention, follow-up CT may be useful in determining the persistence of effects of the perforation or the foreign body.

Performance monitoring by presupplementary and supplementary motor area during an arm movement countermanding task.

A key component of executive control and decision making is the ability to use the consequences of chosen actions to update and inform the process of future action selection. Evaluative signals, which monitor the outcomes of actions, are critical for this ability. Signals related to the evaluation of actions have been identified in eye movement-related areas of the medial frontal cortex. Here we examined whether such evaluative signals are also present in areas of the medial frontal cortex related to arm movements. To answer this question, we recorded from cells in the supplementary motor area (SMA) and pre-SMA, while monkeys performed an arm movement version of the countermanding paradigm. SMA and pre-SMA have been implicated in the higher-order control of movement selection and execution, although their precise role within the skeletomotor control circuit is unclear. We found evaluative signals that encode information about the expected outcome of the reward, the actual outcome, and the mismatch between actual and intended outcome. These findings suggest that signals that monitor and evaluate movement outcomes are represented throughout the medial frontal cortex, playing a general role across effector systems. These evaluation signals supervise the relationship between intentional motor behavior and reward expectation and could be used to adaptively shape future goal-directed behavior.