A Rare Variant of Zinner Syndrome Involving Ectopic Ureteral Implantation into the Seminal Vesicle Causing Recurrent Epididymitis.

Zinner syndrome is a rare congenital anomaly characterized by a triad of renal dysgenesis/agenesis, cysts in the ipsilateral seminal vesicle, and ejaculatory duct obstruction. Though often diagnosed in infancy, the diagnoses can be incidentally found in adults who present with nonspecific genitourinary symptoms including dysuria, ejaculatory dysfunction, or genital pain. We present an unusual case of a 29-year-old male patient who presented to the emergency department with recurrent testicular pain and hematospermia and was found to have an atrophic right kidney with an ectopic ureter implanting into a cystic seminal vesicle. These findings were consistent with a rare subvariant of Zinner syndrome only previously described four times in the literature. We performed a robotic-assisted laparoscopic ectopic nephroureterectomy with sparing of his seminal vesicle. To our knowledge, this is the first report to describe the safe and effective use of robotic surgery in this setting to remove affected anatomy while preserving the patient's seminal vesicle.

Isoflurane anesthesia disrupts the cortical metabolome.

Identifying similarities and differences in the brain metabolome during different states of consciousness has broad relevance for neuroscience and state-dependent autonomic function. This study focused on the prefrontal cortex (PFC) as a brain region known to modulate states of consciousness. Anesthesia was used as a tool to eliminate wakefulness. Untargeted metabolomic analyses were performed on microdialysis samples obtained from mouse PFC during wakefulness and during isoflurane anesthesia. Analyses detected 2,153 molecules, 91 of which could be identified. Analytes were grouped as detected during both wakefulness and anesthesia (n = 61) and as unique to wakefulness (n = 23) or anesthesia (n = 7). Data were analyzed using univariate and multivariate approaches. Relative to wakefulness, during anesthesia there was a significant (q < 0.0001) fourfold change in 21 metabolites. During anesthesia 11 of these 21 molecules decreased and 10 increased. The Kyoto Encyclopedia of Genes and Genomes database was used to relate behavioral state-specific changes in the metabolome to metabolic pathways. Relative to wakefulness, most of the amino acids and analogs measured were significantly decreased during isoflurane anesthesia. Nucleosides and analogs were significantly increased during anesthesia. Molecules associated with carbohydrate metabolism, maintenance of lipid membranes, and normal cell functions were significantly decreased during anesthesia. Significant state-specific changes were also discovered among molecules comprising lipids and fatty acids, monosaccharides, and organic acids. Considered together, these molecules regulate point-to-point transmission, volume conduction, and cellular metabolism. The results identify a novel ensemble of candidate molecules in PFC as putative modulators of wakefulness and the loss of wakefulness.NEW & NOTEWORTHY The loss of wakefulness caused by a single concentration of isoflurane significantly altered levels of interrelated metabolites in the prefrontal cortex. The results support the interpretation that states of consciousness reflect dynamic interactions among cortical neuronal networks involving a humbling number of molecules that comprise the brain metabolome.

Neurotransmitter networks in mouse prefrontal cortex are reconfigured by isoflurane anesthesia.

This study quantified eight small-molecule neurotransmitters collected simultaneously from prefrontal cortex of C57BL/6J mice (n = 23) during wakefulness and during isoflurane anesthesia (1.3%). Using isoflurane anesthesia as an independent variable enabled evaluation of the hypothesis that isoflurane anesthesia differentially alters concentrations of multiple neurotransmitters and their interactions. Machine learning was applied to reveal higher order interactions among neurotransmitters. Using a between-subjects design, microdialysis was performed during wakefulness and during anesthesia. Concentrations (nM) of acetylcholine, adenosine, dopamine, GABA, glutamate, histamine, norepinephrine, and serotonin in the dialysis samples are reported (means ± SD). Relative to wakefulness, acetylcholine concentration was lower during isoflurane anesthesia (1.254 ± 1.118 vs. 0.401 ± 0.134, P = 0.009), and concentrations of adenosine (29.456 ± 29.756 vs. 101.321 ± 38.603, P < 0.001), dopamine (0.0578 ± 0.0384 vs. 0.113 ± 0.084, P = 0.036), and norepinephrine (0.126 ± 0.080 vs. 0.219 ± 0.066, P = 0.010) were higher during anesthesia. Isoflurane reconfigured neurotransmitter interactions in prefrontal cortex, and the state of isoflurane anesthesia was reliably predicted by prefrontal cortex concentrations of adenosine, norepinephrine, and acetylcholine. A novel finding to emerge from machine learning analyses is that neurotransmitter concentration profiles in mouse prefrontal cortex undergo functional reconfiguration during isoflurane anesthesia. Adenosine, norepinephrine, and acetylcholine showed high feature importance, supporting the interpretation that interactions among these three transmitters may play a key role in modulating levels of cortical and behavioral arousal.NEW & NOTEWORTHY This study discovered that interactions between neurotransmitters in mouse prefrontal cortex were altered during isoflurane anesthesia relative to wakefulness. Machine learning further demonstrated that, relative to wakefulness, higher order interactions among neurotransmitters were disrupted during isoflurane administration. These findings extend to the neurochemical domain the concept that anesthetic-induced loss of wakefulness results from a disruption of neural network connectivity.

Imaging of Patients with Head and Neck Cancer: From Staging to Surveillance.

In this review, the authors summarize the latest imaging methods and recommendations for each of the various steps in managing patients with head and neck cancer, from staging of disease to posttreatment surveillance. Because staging of head and neck cancers is different for various subsites of the head and neck, imaging is discussed separately for each. A separate discussion of imaging of perineural spread, occult primary tumors, and lymph nodes is followed by a discussion of paradigms for surveillance imaging in the posttreatment neck.

Adaptive statistical iterative reconstruction: reducing dose while preserving image quality in the pediatric head CT examination.

BACKGROUND: Over the last decade there has been escalating concern regarding the increasing radiation exposure stemming from CT exams, particularly in children. Adaptive statistical iterative reconstruction (ASIR) is a relatively new and promising tool to reduce radiation dose while preserving image quality. While encouraging results have been found in adult head and chest and body imaging, validation of this technique in pediatric population is limited. OBJECTIVE: The objective of our study was to retrospectively compare the image quality and radiation dose of pediatric head CT examinations obtained with ASIR compared to pediatric head CT examinations without ASIR in a large patient population. MATERIALS AND METHODS: Retrospective analysis was performed on 82 pediatric head CT examinations. This group included 33 pediatric head CT examinations obtained with ASIR and 49 pediatric head CT examinations without ASIR. Computed tomography dose index (CTDIvol) was recorded on all examinations. Quantitative analysis consisted of standardized measurement of attenuation and the standard deviation at the bilateral centrum semiovale and cerebellar white matter to evaluate objective noise. Qualitative analysis consisted of independent assessment by two radiologists in a blinded manner of gray-white differentiation, sharpness and overall diagnostic quality. RESULTS: The average CTDIvol value of the ASIR group was 21.8 mGy (SD = 4.0) while the average CTDIvol for the non-ASIR group was 29.7 mGy (SD = 13.8), reflecting a statistically significant reduction in CTDIvol in the ASIR group (P < 0.01). There were statistically significant reductions in CTDI for the 3- to 12-year-old ASIR group as compared to the 3- to 12-year-old non-ASIR group (21.5 mGy vs. 30.0 mGy; P = 0.004) as well as statistically significant reductions in CTDI for the >12-year-old ASIR group as compared to the >12-year-old non-ASIR group (29.7 mGy vs. 49.9 mGy; P = 0.0002). Quantitative analysis revealed no significant difference in the homogeneity of variance in the ASIR group compared to the non-ASIR group. Radiologist assessment of gray-white differentiation, sharpness and overall diagnostic quality in ASIR examinations was not substantially different compared to non-ASIR examinations. CONCLUSION: The use of ASIR in pediatric head CT examinations allows for a 28% CTDIvol reduction in the 3- to 12-year-old age group and a 48% reduction in the >12-year-old age group without substantially affecting image quality.

Hemangiomas and vascular malformations of the head and neck: a simplified approach.

This article is a review of vascular tumors and malformations that occur in infancy and childhood. It discusses anomalies of arterial, venous, capillary, lymphatic, and mixed vascular endothelium in terms of their varying forms, clinical course, imaging characteristics, complications, and treatment. The comparative utility of various imaging modalities is simplified.

Fully automated processing of fMRI data in SPM: from MRI scanner to PACS.

Here we describe the Wake Forest University Pipeline, a fully automated method for the processing of fMRI data using SPM. The method includes fully automated data transfer and archiving from the point of acquisition, real-time batch script generation, distributed grid processing, interface to SPM in MATLAB, error recovery and data provenance, DICOM conversion and PACS insertion. It has been used for automated processing of fMRI experiments, as well as for the clinical implementation of fMRI and spin-tag perfusion imaging. The pipeline requires no manual intervention, and can be extended to any studies requiring offline processing.

Biological parametric mapping: A statistical toolbox for multimodality brain image analysis.

In recent years, multiple brain MR imaging modalities have emerged; however, analysis methodologies have mainly remained modality-specific. In addition, when comparing across imaging modalities, most researchers have been forced to rely on simple region-of-interest type analyses, which do not allow the voxel-by-voxel comparisons necessary to answer more sophisticated neuroscience questions. To overcome these limitations, we developed a toolbox for multimodal image analysis called biological parametric mapping (BPM), based on a voxel-wise use of the general linear model. The BPM toolbox incorporates information obtained from other modalities as regressors in a voxel-wise analysis, thereby permitting investigation of more sophisticated hypotheses. The BPM toolbox has been developed in Matlab with a user-friendly interface for performing analyses, including voxel-wise multimodal correlation, ANCOVA, and multiple regression. It has a high degree of integration with the SPM (statistical parametric mapping) software relying on it for visualization and statistical inference. Furthermore, statistical inference for a correlation field, rather than a widely used T-field, has been implemented in the correlation analysis for more accurate results. An example with in vivo data is presented, demonstrating the potential of the BPM methodology as a tool for multimodal image analysis.

White matter hemisphere asymmetries in healthy subjects and in schizophrenia: a diffusion tensor MRI study.

Hemisphere asymmetry was explored in normal healthy subjects and in patients with schizophrenia using a novel voxel-based tensor analysis applied to fractional anisotropy (FA) of the diffusion tensor. Our voxel-based approach, which requires precise spatial normalization to remove the misalignment of fiber tracts, includes generating a symmetrical group average template of the diffusion tensor by applying nonlinear elastic warping of the demons algorithm. We then normalized all 32 diffusion tensor MRIs from healthy subjects and 23 from schizophrenic subjects to the symmetrical average template. For each brain, six channels of tensor component images and one T2-weighted image were used for registration to match tensor orientation and shape between images. A statistical evaluation of white matter asymmetry was then conducted on the normalized FA images and their flipped images. In controls, we found left-higher-than-right anisotropic asymmetry in the anterior part of the corpus callosum, cingulum bundle, the optic radiation, and the superior cerebellar peduncle, and right-higher-than-left anisotropic asymmetry in the anterior limb of the internal capsule and the anterior limb's prefrontal regions, in the uncinate fasciculus, and in the superior longitudinal fasciculus. In patients, the asymmetry was lower, although still present, in the cingulum bundle and the anterior corpus callosum, and not found in the anterior limb of the internal capsule, the uncinate fasciculus, and the superior cerebellar peduncle compared to healthy subjects. These findings of anisotropic asymmetry pattern differences between healthy controls and patients with schizophrenia are likely related to neurodevelopmental abnormalities in schizophrenia.