Biomedical subjects
Publications and source records attributed to M J Pais.
The osseous lesions of disseminated coccidioidomycosis may be detected by bone but not by gallium scintigraphy or vice versa. This case emphasizes the need for performing both bone and gallium scans to avoid missing potentially serious bone lesions.
A new type of bone biopsy unit that uses standard engineering and machinery principles of self cleaning and clearance allows for greater ease and more accurate performance of biopsy. Its use consistently yields excellent biopsy material. Included is a semi-rigid K wire, which may be used with a drill, for ease of insertion and a stylet in a cannula, which allows for multiple biopsies without reinsertion. The needle is compared with standard saw tips (trephines) and sharpened cannulas.
Tuberculous spondylitis in the United States is a disease of decreasing incidence and, when the incidence is compared to that of developing nations, affects an older population. The thoracic and lumbar spine is most frequently involved, and in advanced disease several vertebrae may be destroyed with resulting significant morbidity and mortality. The usual clinical presentation consists of fever, back pain, and nonspecific systemic symptoms of varying duration. More advanced disease presents with neurological deficits, kyphotic deformities of the spinal column, and paravertebral cold abscesses. Treatment has changed in the past 50 years not only because of the introduction of highly effective anti-tuberculous chemotherapeutic agents, but also because of the development of new surgical approaches. Controlled studies comparing various surgical and more conservative therapeutic regimens have been conducted within the past decade. Despite these new data, controversy remains regarding the indications for surgical treatment, since anti-tuberculous chemotherapy alone is successful in a large proportion of cases. However, in situations where rapid loss of neurologic function is evident or in which progressive deterioration in spinal cord function continues in the face of apparently adequate drug therapy, it appears that anterior surgical decompression of the spinal cord is indicated to prevent irreversible neurologic deficits. Needle biopsy of bone lesions under fluoroscopic or computed tomographic control is essential in the initial evaluation of patients in order to obtain cultural confirmation of tuberculosis.
To help curb excessive radiography, we developed a protocol for selecting patients with injured extremities who need x-ray examination, and we tested the protocol prospectively in 848 patients to determine its safety and effectiveness. Strict adherence to the protocol would have reduced x-ray usage by 12 per cent for upper extremities and 19 per cent for lower extremities. The actual reductions were 5 per cent and 16 per cent, respectively, since further reductions were limited by patient's demands for x-ray examinations. One fracture in 287 were missed, but the treatment was appropriate and the outcome satisfactory. By eliminating superfluous x-ray procedures, the protocol could reduce charges by $79 million to $139 million nationwide, without compromising quality of care or increasing malpractice liability. Nevertheless, even the best protocol cannot eliminate all negative x-ray studies. These results should serve as a stimulus for judicious use of radiography, but also as a warning to avoid overzealous cost-containment strategies that would reduce x-ray usage to below a safe threshold.
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Acrylic spacers and cubes of cortical bone of known dimensions were placed in predetermined locations in cadaver hip joints, which were then studied with plain radiography and linear, hypocycloidal, and computed tomography (CT). Joint space widening was not measurable on plain radiographs of the pelvis when 2-mm spacers were placed anywhere within the hip joint. When 4-mm spacers were used, widening measured 2 mm in the axis of measurement corresponding to the location of the spacer. Linear tomography did not permit identification of the 2-mm cubes; however, hypocycloidal tomography and CT consistently showed them anywhere within the hip joint. Radiation dose and clinical recommendations are discussed.
The spinous process (SP) is often neglected in the radiologic examination of the spine. Proper coning decreases scattered radiation to the SP's in the lateral view. Lateral zonography (thick cut tomography) is occasionally needed in the thoracic region. In the anteroposterior view paying attention to alignment of the SP's and the distance between them will help in the diagnosis of fracture and/or dislocation. Examination of the spinolaminal line (i.e. the line joining the base of the SP's) on the lateral view is also important in looking for the alignment of the vertebra in trauma. Local absence of indistinctiveness of the spinolaminal line may be recognized in spina bifida or when an osteolytic process involves the cortex in this area. The SP itself is involved, with or without the remainder of the vertebra, in metastatic or primary carcinoma, in trauma, rheumatoid arthritis and Paget's disease and in primary benign tumors.
The skeletal system may be profoundly affected by chronic liver disease, resulting in a variety of conditions that may include osteomalacia, osteoporosis, hypertrophic osteoarthropathy, and osteonecrosis. Additionally, many diseases, including glycogen storage disease, Gaucher's disease, and hypervitaminosis A, cause concomitant changes in both liver and bone.
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A case of inflammatory pseudotumor of the sternum resulting from the application of polyurethane foam is discussed. The past use of polymers in bone repair is reviewed.
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An unusually prominent soleal line (a normal anatomic variant) may mimic periosteal reaction along the posterior margin of the proximal tibial shaft. This area of pseudoperiostitis is differentiated from hyperostoses arising from the anterior tibial tubercle and the interosseous membrane. It is always associated with normal, undisturbed architecture of the underlying bone.
Erosion of progressive resorption of the distal clavicle following trauma has been described but merits greater attention due to its frequency. Six cases of posttraumatic osteolysis of the distal clavicle are reported with emphasis on early radiographic detection. Soft tissue swelling, deminerlization, and loss of the subarticular cortex at the injured clavicular tip antecede the more commonly recognized gross erosion. Recognition of this early stage, with consequent immobilization, may shorten the course of this process and decrease the prolonged disability. The pathogenesis of the process is discussed and illustrated.
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Split notochord syndrome with dorsal enteric fistula is an extremely rare congenital anomaly that may be associated with meningomyelocele or meningocele, and genitourinary anomalies. This case presented with an additional finding of bladder exstrophy, raising the possibility of a relationship between this syndrome and the OEIS complex.
Cutaneous cytomegalovirus (CMV) infection has been observed in a variety of nonspecific skin lesions. Because of this fact, its diagnosis is rare and frequently accidental. The presence of the virus has also been observed in apparently normal skin, from both a clinical and histological point of view. In this context, skin biopsy and immunohistochemistry are often the first means of diagnosis of systemic CMV infection. In 180 skin biopsies carried out on HIV patients in the Infectious and Parasitic Diseases Unit, typical histopathological findings of CMV infection in a nonspecific skin lesion were observed in only one patient. Although the patient showed no extracutaneous manifestations at this time, she died soon after this diagnosis. Because of this fact, we review the literature and discuss the difficulties and implications of the diagnosis of cutaneous CMV infection in AIDS patients.