Gallbladder volvulus: a case report.

BACKGROUND: Gallbladder volvulus is a rare pathology first reported by Wendel in 1898. Although the main pathological process associated with gallbladder volvulus is not known, there is clinical evidence suggesting that lack of gallbladder adhesions to the liver leads to an eventual twisting around the cystic bile duct (a process that seems to favor older female populations). CASE PRESENTATION: In this report, an 81-year-old Caucasian elderly female presented to the emergency department with acute/severe right upper quadrant pain, which was also accompanied by an elevated leukocyte count. Relevant imaging showed a distended gallbladder with gallbladder wall thickening and a dilated common bile duct. The patient was subsequently admitted to the hospital for acute cholecystitis and scheduled for surgery the next day. Upon laparoscopic surgery, the gallbladder was black and gangrenous with no visible adhesions to the liver. Further inspection demonstrated that the gallbladder had twisted clockwise around the cystic bile duct. CONCLUSIONS: While many previous cases have been reported since Wendel, further case studies are nevertheless important to help guide proper clinic evaluation and pinpoint the potential for a gallbladder volvulus.

Therapeutic Potentials of Localized Blood-Brain Barrier Disruption by Noninvasive Transcranial Focused Ultrasound: A Technical Review.

The demands for region-specific, noninvasive therapies for neurologic/psychiatric conditions are growing. The rise of transcranial focused ultrasound technology has witnessed temporary and reversible disruptions of the blood-brain barrier in the brain with exceptional control over the spatial precisions and depth, all in a noninvasive manner. Starting with small animal studies about a decade ago, the technique is now being explored in nonhuman primates and humans for the assessment of its efficacy and safety. The ability to transfer exogenous/endogenous therapeutic agents, cells, and biomolecules across the blood-brain barrier opens up new therapeutic avenues for various neurologic conditions, with a possibility to modulate the excitability of regional brain function. This review addresses the technical fundamentals, sonication parameters, experimental protocols, and monitoring techniques to examine the efficacy/safety in focused ultrasound-mediated blood-brain barrier disruption and discuss its potential translations to clinical use.

Effects of sonication parameters on transcranial focused ultrasound brain stimulation in an ovine model.

Low-intensity focused ultrasound (FUS) has significant potential as a non-invasive brain stimulation modality and novel technique for functional brain mapping, particularly with its advantage of greater spatial selectivity and depth penetration compared to existing non-invasive brain stimulation techniques. As previous studies, primarily carried out in small animals, have demonstrated that sonication parameters affect the stimulation efficiency, further investigation in large animals is necessary to translate this technique into clinical practice. In the present study, we examined the effects of sonication parameters on the transient modification of excitability of cortical and thalamic areas in an ovine model. Guided by anatomical and functional neuroimaging data specific to each animal, 250 kHz FUS was transcranially applied to the primary sensorimotor area associated with the right hind limb and its thalamic projection in sheep (n = 10) across multiple sessions using various combinations of sonication parameters. The degree of effect from FUS was assessed through electrophysiological responses, through analysis of electromyogram and electroencephalographic somatosensory evoked potentials for evaluation of excitatory and suppressive effects, respectively. We found that the modulatory effects were transient and reversible, with specific sonication parameters outperforming others in modulating regional brain activity. Magnetic resonance imaging and histological analysis conducted at different time points after the final sonication session, as well as behavioral observations, showed that repeated exposure to FUS did not damage the underlying brain tissue. Our results suggest that FUS-mediated, non-invasive, region-specific bimodal neuromodulation can be safely achieved in an ovine model, indicating its potential for translation into human studies.

Localized Blood-Brain Barrier Opening in Ovine Model Using Image-Guided Transcranial Focused Ultrasound.

Transcranial application of focused ultrasound (FUS) combined with vascular introduction of microbubble contrast agents (MBs) has emerged as a non-invasive technique that can temporarily create a localized opening in the blood-brain barrier (BBB). Under image-guidance, we administered FUS to sheep brain after intravenous injection of microbubbles. BBB opening was confirmed by performing dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to detect the extravasated gadolinium-based magnetic resonance contrast agents. Through pharmacokinetic analysis as well as independent component analysis of the DCE-MRI data, we observed localized enhancement in BBB permeability at the area that subjected to acoustic pressure of 0.48 MPa (mechanical index = 0.96). On the other hand, application of a higher pressure at 0.58 MPa resulted in localized, minor cerebral hemorrhage. No animals exhibited abnormal behavior during the post-FUS survival periods up to 2 mo. Our data suggest that monitoring for excessive BBB disruption is important for safe translation of the method to humans.

Transcranial focused ultrasound stimulation of motor cortical areas in freely-moving awake rats.

BACKGROUND: Low-intensity transcranial focused ultrasound (tFUS) has emerged as a new non-invasive modality of brain stimulation with the potential for high spatial selectivity and penetration depth. Anesthesia is typically applied in animal-based tFUS brain stimulation models; however, the type and depth of anesthesia are known to introduce variability in responsiveness to the stimulation. Therefore, the ability to conduct sonication experiments on awake small animals, such as rats, is warranted to avoid confounding effects of anesthesia. RESULTS: We developed a miniature tFUS headgear, operating at 600 kHz, which can be attached to the skull of Sprague-Dawley rats through an implanted pedestal, allowing the ultrasound to be transcranially delivered to motor cortical areas of unanesthetized freely-moving rats. Video recordings were obtained to monitor physical responses from the rat during acoustic brain stimulation. The stimulation elicited body movements from various areas, such as the tail, limbs, and whiskers. Movement of the head, including chewing behavior, was also observed. When compared to the light ketamine/xylazine and isoflurane anesthetic conditions, the response rate increased while the latency to stimulation decreased in the awake condition. The individual variability in response rates was smaller during the awake condition compared to the anesthetic conditions. Our analysis of latency distribution of responses also suggested possible presence of acoustic startle responses mixed with stimulation-related physical movement. Post-tFUS monitoring of animal behaviors and histological analysis performed on the brain did not reveal any abnormalities after the repeated tFUS sessions. CONCLUSIONS: The wearable miniature tFUS configuration allowed for the stimulation of motor cortical areas in rats and elicited sonication-related movements under both awake and anesthetized conditions. The awake condition yielded diverse physical responses compared to those reported in existing literatures. The ability to conduct an experiment in freely-moving awake animals can be gainfully used to investigate the effects of acoustic neuromodulation free from the confounding effects of anesthesia, thus, may serve as a translational platform to large animals and humans.

Focused ultrasound brain stimulation to anesthetized rats induces long-term changes in somatosensory evoked potentials.

Low-intensity transcranial focused ultrasound (FUS) has emerged as a non-invasive brain stimulation modality that can reach deep brain areas with high spatial specificity. Previous studies have identified transient effects of FUS on the brain excitability and accompanying physiological responses. Yet the presence of long-lasting effects of FUS, which extend on the order of half an hour or more, has not been probed. We transcranially applied FUS to the somatosensory areas of the anesthetized rats for 10 min at a low duty cycle (5%) and intensity, far below the level that could alter the tissue temperature. Concurrently, we measured electroencephalographic (EEG) somatosensory evoked potentials (SEP) induced by the unilateral electrical stimulation of the hind limb before and after the sonication. Compared to the control sham condition that did not involve sonication, differential SEP features were evident and persisted beyond 35 min after the administration of FUS. The presence of this non-transient neuromodulatory effect may provide early evidence that FUS-mediated brain stimulation has the potential to induce neuroplasticity.

Multi-resolution simulation of focused ultrasound propagation through ovine skull from a single-element transducer.

Transcranial focused ultrasound (tFUS) is emerging as a non-invasive brain stimulation modality. Complicated interactions between acoustic pressure waves and osseous tissue introduce many challenges in the accurate targeting of an acoustic focus through the cranium. Image-guidance accompanied by a numerical simulation is desired to predict the intracranial acoustic propagation through the skull; however, such simulations typically demand heavy computation, which warrants an expedited processing method to provide on-site feedback for the user in guiding the acoustic focus to a particular brain region. In this paper, we present a multi-resolution simulation method based on the finite-difference time-domain formulation to model the transcranial propagation of acoustic waves from a single-element transducer (250 kHz). The multi-resolution approach improved computational efficiency by providing the flexibility in adjusting the spatial resolution. The simulation was also accelerated by utilizing parallelized computation through the graphic processing unit. To evaluate the accuracy of the method, we measured the actual acoustic fields through ex vivo sheep skulls with different sonication incident angles. The measured acoustic fields were compared to the simulation results in terms of focal location, dimensions, and pressure levels. The computational efficiency of the presented method was also assessed by comparing simulation speeds at various combinations of resolution grid settings. The multi-resolution grids consisting of 0.5 and 1.0 mm resolutions gave acceptable accuracy (under 3 mm in terms of focal position and dimension, less than 5% difference in peak pressure ratio) with a speed compatible with semi real-time user feedback (within 30 s). The proposed multi-resolution approach may serve as a novel tool for simulation-based guidance for tFUS applications.

Bioprinting of biomimetic skin containing melanocytes.

This study reports a three-dimensional (3D) bioprinting technique that is capable of producing a full-thickness skin model containing pigmentation. Multiple layers of fibroblast (FB)-containing collagen hydrogel precursor were printed and crosslinked through neutralization using sodium bicarbonate, constituting the dermal layer. Melanocytes (MCs) and keratinocytes (KCs) were sequentially printed on top of the dermal layer to induce skin pigmentation upon subsequent air-liquid interface culture. Histological analysis was performed not only to confirm the formation of distinct skin layers, but also to identify the presence of pigmentation. The bioprinted skin structure showed the dermal and epidermal layers as well as the terminal differentiation of the KC that formed the stratum corneum. Moreover, the MC-containing epidermal layer showed freckle-like pigmentations at the dermal-epidermal junction, without the use of external ultraviolet light or chemical stimuli. The presented method offers the capability of producing engineered ephelides in biomimetic skin, thus rendering 3D bioprinting techniques as productive on-demand options for the creation of skin models available for therapeutic or research use.

Pulsed focused ultrasound changes nerve conduction of earthworm giant axonal fibers.

This study examined the effects of pulsed focused ultrasound (FUS) in disrupting nerve conduction. FUS operating at a 210 kHz fundamental frequency was administered to the medial and lateral giant axonal nerve fibers of earthworms in a burst of pulses (1 ms tone burst duration, 20 Hz pulse repetition frequency). The magnitude and latencies of the nerve potentials induced by electrical stimulation were measured under three experimental conditions - (I) no sonication, (II) sonication at 600 mW/cm spatial-peak temporal-average intensity (Ispta), and (III) sonication at 200 mW/cm Ispta. The sonication at 600 mW/cm temporarily decreased the magnitude of the action potential peak (~16%), whereas the baseline peak level was quickly restored in postsonication sessions. Sonication administered at a lower intensity (i.e. 200 mW/cm) did not alter the peak magnitude. The sonication did not alter the nerve conduction velocity. The acoustic intensities used in the experiment did not increase the temperature of the sonicated tissue. The results indicate that axonal neurotransmission can be disrupted temporarily by the application of pulsed FUS, suggesting its potential utility in modulating the functional connectivity established by white matter tracts in the brain.