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Objectives With the advent of new optical technologies, early pharyngolaryngeal cancerous lesions can be better visualized. Although the conventional transnasal approach offers great views of the hypopharynx and larynx, the visualization of the oropharynx and palatine tonsils is limited. Through the transoral insertion of a flexible video-laryngoscope, direct views of the oropharynx and oral cavity can be obtained. Thus, transoral examination may contribute to primary detection of cancers of unknown primary (CUP). Methods Eighty-five CUP patients from Tokai University were included retrospectively in this study, from 2006 to 2017. Starting in 2010, we employed the transoral examination in addition to our conventional method. The primary detection rates were compared before and after 2010. Oropharyngeal primaries were further analyzed for tumor subsite and p16 status. Results The overall primary detection rate did not improve with the addition of transoral examination. However, greater numbers of oropharyngeal primaries were detected. The oropharyngeal lesions detected by transoral examination were mainly p16 positive, located on the palatine tonsil. Conclusion Transoral examination is a noninvasive, easy method to adopt in an outpatient setting, and a promising technique to improve tumor detection in this era of human papillomavirus-associated head and neck cancers. Level of evidence 3.

OBJECTIVEThe overall goal of this study was to develop an image-guided spinal stereotactic setup for intraoperative intraspinal microstimulation (ISMS). System requirements were as follows: 1) ability to place implants in various segments of the spinal cord, targeting the gray matter with a < 0.5-mm error; 2) modularity; and 3) compatibility with standard surgical tools.METHODSA spine-mounted stereotactic system was developed, optimized, and tested in pigs. The system consists of a platform supporting a micromanipulator with 6 degrees of freedom. It is modular and flexible in design and can be applied to various regions of the spine. An intraoperative ultrasound imaging technique was also developed and assessed for guidance of electrode alignment prior to and after electrode insertion into the spinal cord. Performance of the ultrasound-guided stereotactic system was assessed both in pigs (1 live and 6 fresh cadaveric pigs) and on the bench using four gelatin-based surrogate spinal cords. Pig experiments were conducted to evaluate the performance of ultrasound imaging in aligning the electrode trajectory using three techniques and under two conditions. Benchtop experiments were performed to assess the performance of ultrasound-guided targeting more directly. These experiments were used to quantify the accuracy of electrode alignment as well as assess the accuracy of the implantation depth and the error in spatial targeting within the gray matter of the spinal cord. As proof of concept, an intraoperative ISMS experiment was also conducted in an additional live pig using the stereotactic system, and the resulting movements and electromyographic responses were recorded.RESULTSThe stereotactic system was quick to set up (< 10 minutes) and provided sufficient stability and range of motion to reach the ISMS targets reliably in the pigs. Transverse ultrasound images with the probe angled at 25°–45° provided acceptable contrast between the gray and white matter of the spinal cord. In pigs, the largest electrode alignment error using ultrasound guidance, relative to the minor axis of the spinal cord, was ≤ 3.57° (upper bound of the 95% confidence interval). The targeting error with ultrasound guidance in bench testing for targets 4 mm deep into the surrogate spinal cords was 0.2 ± 0.02 mm (mean ± standard deviation).CONCLUSIONSThe authors developed and evaluated an ultrasound-guided spinal stereotactic system for precise insertion of intraspinal implants. The system is compatible with existing spinal instrumentation. Intraoperative ultrasound imaging of the spinal cord aids in alignment of the implants before insertion and provides feedback during and after implantation. The ability of ultrasound imaging to distinguish between spinal cord gray and white matter also improves confidence in the localization of targets within the gray matter. This system would be suitable for accurate guidance of intraspinal electrodes and drug or cell injections.

The purpose of this study was to investigate the effect of performance jewelry embedded with both a hologram and negative ions on maximal oxygen uptake (V[Combining Dot Above]O2max), V[Combining Dot Above]O2 at ventilatory threshold (V[Combining Dot Above]O2VT), or heart rate at ventilatory threshold (HRVT) measured through metabolic gas exchange. Eight males and 10 females (age = 26.5 ± 7.18 years) volunteered to participate in this study. Silicone bracelets with both hologram technology and negative ions were used as the “programmed” device. An identical silicone bracelet that did not contain the negative ion or hologram technology was used as the “nonprogrammed” device. A third condition in which the participants did not wear a band served as a control trial. The type of band worn during testing sessions was blinded from the participants and researchers. The order of testing was randomized. Subjects underwent 3 maximal graded exercise tests separated by 1 week. A repeated measure analysis of variance was used to test for mean differences across the 3 trials. The mean V[Combining Dot Above]O2max when wearing the programmed band (52.32 ± 4.79 ml·kg-1·min-1), when wearing the nonprogrammed band (51.47 ± 5.89), and without a band (53.32 ± 7.63 ml·kg-1·min-1) were found to be of no significant difference (p = 0.494). Assessment of the subjects HRVT under the 3 conditions (programmed, nonprogrammed, and no band) yielded no significant difference (p = 0.633). The HRVT of the above-mentioned 3 conditions were 136.06 ± 16.33, 135.00 ± 19.48, and 130.41 ± 24.39, respectively. The V[Combining Dot Above]O2VT for the programmed band (30.04 ± 6.91 ml·kg-1·min-1), nonprogrammed (30.77 ± 8.125 ml·kg-1·min-1), and no band (27.27 ± 8.66 ml·kg-1·min-1) were not significantly different (p = 0.221). The results of this study provide data that holographic and negative ion technology wristbands may have no effect on V[Combining Dot Above]O2max, V[Combining Dot Above]O2 at ventilatory threshold, or HRVT, and thus may have no positive effect on exercise endurance.

Laura Dean, MEd,1 Ilan H. Meyer, PhD,1 Kevin Robinson, MHA, MSW,1 Randall L. Sell, ScD,1 Robert Sember, PhD,1 Vincent M.B. Silenzio, MPH, MD,1 Deborah J. Bowen, PhD,2 Judith Bradford, PhD,2 Esther Rothblum, PhD,2 Scout, MA,2 Jocelyn White, MD,2 Patricia Dunn, MSW, JD,3 Anne Lawrence, M.D., Ph.D.(c),4 Daniel Wolfe,1 Jessica Xavier,5 and With acknowledgment to Darren Carter, MD, Jennifer Pittman, and Ronald Tierney

Bilateral chylothorax following thoracic duct injury is a rare occurrence. Since 1907 there have been only six reports in the literature of this potentially serious complication. We report a case of bilateral chylothorax following ligation of the cervical thoracic duct during a left subclavian to carotid artery transposition.

Statistical partitioning of images into meaningful areas is the goal of all region-based segmentation algorithms. The clustering or creation of these meaningful partitions can be achieved in number of ways but in most cases it is achieved through the minimization or maximization of some function of the image intensity properties. Commonly these optimization schemes are locally convergent, therefore initialization of the parameters of the function plays a very important role in the final solution. In this paper we perform an automatically initialized expectation-maximization algorithm to partition the data in medical MRI images. We present analysis and illustrate results against manual initialization and apply the algorithm to some common medical image processing tasks.

Evolving protocols in Whole Body MRI (WB-MRI) present new challenges in the application of automated image processing and analysis procedures. We address two issues relating to sectionally acquired coronal WBMRI: greyscale non-uniformity correction and accurate data merging. The body is scanned in a number of slightly overlapping coronal sections, each containing 32 eight mm thick slices. Adjacent coronal sub-section often demonstrate a significant greyscale mismatch resulting in sharp discontinuities within homogeneous tissue regions in the body. This presents problems for automatic segmentation and classification approaches. Similarly a simplistic reconstruction procedure can lead to inaccuracies in the relative alignment of the data from each DICOM image in the reconstructed volume, resulting in the dislocation of small structures