Biomedical subjects
Publications and source records attributed to M J Shapiro.
A total of 95 cases of metastasizing basal cell carcinomas have been recorded in the literature with 20 of these metastatic to bone. Two additional cases of metastasizing basal cell carcinoma with osseous metastases are presented, with a review of the literature.
Out of the discovery of concurrent multiple endocrine neoplasms has evolved the concept of multiple endocrine adenomatosis (MEA1 and MEA2). Medullary carcinoma of the thyroid gland is the most constant facet of MEA2 and is derived from C-cells of the neural crest. These cells, resembling parafollicular cells of lower animals, elaborate calcitonin which acts as a sensitive signal of the presence of the tumor. Ninety per cent of MCT occurs sporadically; in 10% the tumor presents as an atuosomal dominant trait. Other endocrinopathies, especially pheochromocytomas, are present in 70% of cases. The lesions are "cold" on iodine radioisotope scan. On microscopic examination, the appearance of amyloid is characteristic. Regional lymph node metastasis occurs early. The tumor deserves appropriate aggressive management. Surgical therapy should begin early and vigorously with the minimum procedure being total thyroidectomy. Frequent lymph node metastasis speaks for the need for regional neck dissection extended into the superior mediastinum. The search for, and the treatment of, the frequently associated endocrinopathies is essential. Pheochromocytoma must be suspected and eradicated before treatment of the thyroid tumor. A genetic workup should be included.
Endocrine as well as oncologic attributes mark this rare tumor as unique. It is derived from "C cells" resembling the parafollicular cells of lower animals; these cells elaborate Calcitonin which acts as a sensitive signal of the presence of the tumor. Other endocrinopathies are present in 70 percent of cases so that the tumor may present as part of a complex but increasing well known clinical picture. In 10 percent the tumor occurs as an autosomal dominant trait; in the remainder, the occurrence is sporadic. As expected the lesions are "cold" on I131 scan. The histologic appearance of amyloid is characteristic. Regional lymph node metastasis occurs early. The tumor deserves appropriate aggressive management. Essentially surgical therapy should begin early and vigorously; the minimum procedure should be total thyroidectomy. Frequent lymph node metastasis speaks for the need for radical neck dissection which should be extended into the superior mediastinum. Management should also include the frequently associated endocrinopathies, particularly pheochromocytomas which must be suspected and eradicted prior to treatment of the thyroid tumor. A genetic workup should be included. Six cases are described, ranging in age from the third to the eighth decade. Only two were free of disease at this writing, two were alive with their disease and two were dead of their disease. All were of the sporadic group, and only one had associated endocrinopathies. None of these cases were diagnosed preoperatively.
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High-resolution magic angle spinning (hr-MAS) NMR is a powerful tool for characterizing organic reactions on solid support. Because magic angle spinning reduces the line-broadening due to dipolar coupling and variations in bulk magnetic susceptibility, line widths approaching those obtained in solution-phase NMR can be obtained. The magic angle spinning method is amenable for use in conjunction with a variety of NMR-pulse sequences, making it possible to perform full-structure determinations and conformational analysis on compounds attached to a polymer support. Diffusion-weighted MAS-NMR methods such as SPEEDY (Spin-Echo-Enhanced Diffusion-Filtered Spectroscopy) can be used to remove unwanted signals from the solvent, residual reactants, and the polymer support from the MAS-NMR spectrum, leaving only those signals arising from the resin-bound product. This review will present the applications of high-resolution magic angle spinning NMR for use in combinatorial chemistry research.
Magnetic resonance (MR) imaging with arterial portography (MRAP) was compared with computed tomography with arterial portography (CTAP) and conventional MR imaging for preoperative evaluation of hepatic masses in eight patients (nine studies). Twenty contiguous, 10-mm-thick-section CTAP images were obtained. MR imaging included T1- and T2-weighted spin-echo and fast multiplanar SPGR (spoiled gradient-recalled acquisition in the steady state) techniques. For MRAP, 0.1 mmol/kg gadopentetate dimeglumine was injected into the superior mesenteric artery. Portographic-phase, 8-mm-thick-section, axial SPGR images were first obtained, followed by "systemic phase" SPGR images. Lesions were seen best on the portographic-phase MRAP images and were less conspicuous on the systemic-phase MRAP, CTAP and conventional MR images. Of 19 visualized lesions, 18 were seen with MRAP; however; five subcentimeter lesions seen with MRAP were not seen with conventional MR imaging or CTAP. Systemic recirculation of iodinated contrast material from the bolus and from previous angiography is a potential limitation of CTAP. For both CTAP and MRAP, optimal results are expected if all images are obtained during a single breath hold, within seconds of the onset of contrast agent administration.
PURPOSE: The purpose of this study was to evaluate the feasibility, safety, and potential role of carbon dioxide (CO2) as a contrast agent for venography. METHODS: Consecutive patients with contraindications to iodinated contrast agents or with unsatisfactory iodinated contrast studies underwent CO2 digital subtraction venography. The images were rated by three experienced angiographers. Image quality and complications were assessed. RESULTS: Over a 14-month period, 66 vein segments were studied in 21 patients. There was good correlation between experienced angiographers on CO2 image quality (Ri = 0.80) and good agreement on diagnosis (k = 0.62). In 91% of the vein segments evaluated with C02 there was interobserver agreement on the diagnosis. Upper extremity veins were adequately imaged with CO2 alone in all (6/6) patients with contraindications to iodinated contrast. Following suboptimal iodinated contrast studies in six patients, CO2 produced significantly better quality upper extremity central vein images (p < 0.05). Pain following injection into peripheral veins was the only CO2-related complication. Inferior vena cava (IVC) filters were successfully deployed with CO2 alone in 78% (7/9) of patients; two required iodinated contrast. CONCLUSIONS: Based upon initial experience, CO2 venography can be recommended in patients with contraindications to iodinated contrast or unsatisfactory iodinated contrast studies.
Bungee jumping is a relatively new recreational sport. Most emergency physicians and trauma surgeons have limited experience with its associated injuries. We report the case of a bungee cord attachment apparatus malfunctioning, resulting in a free fall of the jumper of approximately 240 feet. The presence of an air cushion on the ground prevented significant injury. Knowledge of the potential injuries of this new sport is crucial for effective management.
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Intramural pseudodiverticulosis of the esophagus is a rare benign disease, developing most frequently in older males, but occurring in both sexes, at all ages. In some patients symptoms from early childhood suggest congenital origin. The characteristic appearance of "pinhead" outpouching from the lumen of the esophagus is seen with contrast esophagram. The major symptom is dysphagia with episodic exacerbations, often with foreign body lodgement. The pseudodiverticula are formed by abnormally dilated adnexal glands and ducts which lie in the submucosa of the esophagus. Secondary infection, most commonly monilial, is the rule, and surrounding inflammatory infiltration may progress to submucosal fibrosis and stenosis. Treatment with dilatation and appropriate antibiotics usually produces rapid relief. Prognosis is good.
A malignant parapharyngeal neurilemmoma developed in a 45-year-old woman who had had a benign solitary neurilemmoma removed from the same area nine years previously. Incomplete excision was achieved through a mandibulotomy approach. Malignant schwannoma usually is associated with neurofibromatosis and has a poor prognosis, spreading along the nerve of origin or by blood stream. Small localized tumors should be treated aggressively by surgery. The possibility that a previously benign schwannoma underwent malignant transformation must be considered.
In this past few years myocutaneous (MC) flaps have, to a large extent, replaced other flaps. Because of axial blood supply, they may be used without delay. The MC flaps, useful in head and neck reconstruction, are based on the latissimus dorsi, the pectoralis major, the sternomastoid, and the trapezius. All have discrete independent vasculature that acts as a pedicle for the muscle and skin flap. The sternomastoid MC flaps have limited range and only special areas of usefulness. The latissimus dorsi flap, because it requires special positioning of the patient, has not been as popular as the pectoralis major flap, but both have excellent blood supplies and will reach almost any area of the face and neck to fill defects and cover internal or external surfaces. In addition, the pectoralis major MC flap may be able to carry a segment of rib as a bone graft. The trapezius MC flap does not have as great a range as the others and has a long vascular pedicle that must be carefully handled, but it has the distinct advantage of being able to carry viable bone from the scapular spine to the mandible.
A 39-year-old woman had a large asymptomatic left parotid mass that she had apparently not noticed. The clinical appearance suggested a parotid tumor. Aspirated tissue revealed numerous giant cells, histiocytes, and hemosiderin pigment. At surgical exploration a tumor was found deep to the facial nerve involving the temporomandibular joint, which had a brown-stained roughened synovial membrane. The resected specimen histologically was a proliferative lesion composed of epithelioid histiocytes, spindle cells, and multinucleated giant cells. The appearance was typical of the family of lesions that includes pigmented villonodular synovitis, bursitis, and tenosynovitis (giant cell "tumor" of tendon sheath). In view of the origin from the temporomandibular joint, reinforced by a characteristic radiologic appearance, we interpret this as a case of pigmented villonodular synovitis. This is the fifth case reported from this site.