Biomedical subjects
M D Cusimano
Publications and source records attributed to M D Cusimano.
Princess Diana's tragic legacy.
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Defining standards of competent performance on an OSCE.
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A compendium of higher education opportunities in health professions education.
The authors assembled a compendium of programs world-wide that are dedicated to teaching individuals how to direct, research, or improve the education of health professionals. To accomplish this task, in 1996 and 1997 they interviewed and corresponded with researchers in the health professions and with staffs of faculty development fellowship programs listed in the 1966 Fellowship Directory for Family Physicians, and consulted several postings on the DR-ED listserv. To be included in the compendium, the program had to be specifically focused on health professions education. Out of 51 possible programs, 17 were identified. The authors then sent a questionnaire to the staffs of these 17 programs, asking for program descriptions and information about curricula, students, graduates, costs, and financial aid. Detailed data were received from 15 programs from three continents. Eleven programs offered master's-level degrees and five offered PhD degrees. The majority had flexible study-time arrangements. Graduates of such courses have already assumed leadership position in health professions education and research around the world. The authors hope that their compendium of programs will help guide health professionals who seek to improve their skills in health professions education.
Serial magnetic resonance imaging findings for a spontaneously resolving spinal subdural hematoma: case report.
OBJECTIVE AND IMPORTANCE: Spinal subdural hematoma (SSDH) is a rare entity, and cases are usually managed as surgical emergencies. We describe a patient with a SSDH who demonstrated incomplete clinical resolution with nonsurgical management, despite continued anticoagulation treatment. We provide the most complete demonstration of the magnetic resonance imaging (MRI) characteristics of a large SSDH from its initiation to its radiological resolution. CLINICAL PRESENTATION: A 61-year-old woman developed a large SSDH as a complication of a lumbar puncture. Her only neurological deficit was urinary retention. INTERVENTION: Because of the extensiveness of the hematoma and the relative neurological preservation of the patient, she was treated conservatively. Serial MRI scans were obtained at 4, 7, 13, and 25 days. The evolution of deoxyhemoglobin in the hematoma to methemoglobin was observed. By 25 days, MRI scans showed virtual resolution. CONCLUSION: SSDHs undergo MRI signal changes that are similar to those of brain hematomas. In certain cases, even large SSDHs demonstrate swift and dramatic spontaneous resolution, despite continued anticoagulation treatment. This report suggests that there is a role for conservative management for selected cases of SSDHs.
Malignant transformation of ganglioneuroma into spinal neuroblastoma in an adult. Case report.
Ganglioneuroma is generally considered to be a benign tumor and potentially surgically curable. The authors present a case of a 21-year-old woman who underwent resection of a retroperitoneal ganglioneuroma and developed spinal neuroblastoma 11 years later. She has survived 10 more years with only recent development of metastases. To the authors' knowledge, this is the first report of malignant transformation of a ganglioneuroma into a neuroblastoma. Also, such long-term survival in an adult with spinal neuroblastoma has not been reported previously. This case raises the possibility of a dedifferentiating potential for ganglion cells in a ganglioneuroma or the presence of a long-term, quiescent form of neuroblastoma.
Hydroxyurea for treatment of meningioma.
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Schwannoma of the cauda equina.
OBJECTIVE: To review the features of spinal schwannoma in a case that mimicked a lumbar disc herniation. CLINICAL FEATURES: A 37-yr-old woman suffered from a 4-yr history of progressive low back and leg pain, with progressive neurological involvement of several nerve roots. Noteworthy symptomatology included increased pain when lying recumbent and urinary and fecal incontinence. Several health care practitioners diagnosed her with a lumbar disc herniation. Investigations with myelography, computed tomography (CT) with myelographic contrast and magnetic resonance imaging (MRI) revealed the presence of an intradural tumor at the T12-L2 region. INTERVENTION AND OUTCOME: The tumor was surgically resected via laminectomies at T12-L2. The patient experienced a decrease of pain intensity but continued to complain about the low back and posterior thigh pain and has been unable to return to work. She continues to suffer from urinary incontinence, which is controlled by medication. There has been no recurrence of the tumor. CONCLUSION: Spinal pathology such as schwannoma of the cauda equina can mimic common complaints of low back pain seen in clinical practice. Differentiating features of cauda equina tumors from lumbar disc prolapse include: pain on lying recumbent, progressive nature of the pain and neurological deficit, involvement of several nerve root levels and intractability of the condition to conservative therapy. The most appropriate methods for imaging these tumors are CT with myelography or MRI. Patient prognosis is improved with early detection and removal. Chiropractors can play a pivotal role in the care of these patients by being suspicious of patients who do not respond as expected to a course of manipulative therapy, by investigating or referring appropriately and by aiding in active rehabilitation postoperatively.
Standard setting in medical education.
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Shunt removal by choroid plexus coagulation.
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Vertebral artery injury associated with a Jefferson fracture.
BACKGROUND: The evaluation and treatment of Jefferson fractures, a burst fracture of the ring of Cl, has been well documented in the medical literature. Vertebral artery injury associated with a Jefferson fracture is very rare. METHODS: The case study technique was used to summarize the case. Review of the literature was performed to discuss the case. Retrospective chart review of the 174 patients with cervical fractures admitted to St. Michael's Hospital from 1989-1994 was also performed. RESULTS: The case of a patient with a Jefferson fracture, with bilateral lateral displacement of the lateral masses causing bilateral vertebral artery occlusions resulting in a lateral medullary and cerebellar infarction is reported. A review of the literature is provided. CONCLUSION: A high index of suspicion for this injury is paramount, especially in patients with multiple trauma, where the diagnosis of Jefferson fractures can be delayed.
The results of surgery for benign tumors of the cavernous sinus.
CAVERNOUS SINUS SURGERY has been performed increasingly in the last 2 decades because of new knowledge and technologies. With increasing international expertise in cavernous sinus surgery, the results must be analyzed critically to search for accurate prognosticators of outcome. We performed a retrospective review of 124 patients (40 male, 84 female; mean age, 45 years) who underwent cavernous sinus surgery for benign tumors from 1983 to 1992. Sixty-five percent had tumors encasing the internal carotid artery. Mean follow-up was 29 months (median, 26 mo). Gross total or near-total resection was possible in 80%. Patients with neurilemomas, angiofibromas, epidermoids, chondroblastomas, and hemangiomas were more likely to have total or near-total resection (100% versus 75%, P < 0.025). Disabling complications (five cerebral infarctions, two meningitis, and one hydrocephalus with chiasmal prolapse) occurred only in patients with meningiomas or pituitary adenomas. On follow-up, excellent/good binocular vision was achieved in 53% of patients entering surgery with excellent/good function versus 25% who entered surgery with fair/poor binocular vision (P < 0.025). Ninety-three percent of patients had a Karnofsky score > or = 70 on follow-up. There were a total of 12 recurrences (10%), 6 in patients with meningiomas, 2 in patients with angiofibromas, 2 in patients with craniopharyngiomas, 1 in a patient with a pituitary adenoma, and 1 in a patient with an osteoblastoma. Patients with tumor growth or neurological symptoms indicative of progressive cavernous sinus involvement should undergo cavernous sinus exploration. This surgery has acceptable morbidity and mortality and, if the tumor can be removed easily, the surgeon should try to perform radical tumor resection. To avoid major complications, the surgeon must exercise utmost care to preserve the neurovascular structures of the cavernous sinus, with special attention to tumors that extend into the petroclival region. Better results from surgery can be expected in those patients with neurilemomas, hemangiomas, or epidermoids than in patients with meningiomas, craniopharyngiomas, or pituitary adenomas. Good functional outcome can be expected, particularly if the patient's preoperative clinical status is good. Particular attention must be paid to the reconstruction of anatomic barriers in order to prevent cerebrospinal fluid leakage and subsequent meningitis.
Extreme lateral disc herniation manifesting as nerve sheath tumor. Case report.
This report discusses the clinical features of a patient who presented with an L-3 radiculopathy in whom magnetic resonance imaging demonstrated what appeared to be a nerve sheath tumor in an extraforaminal location on the L-3 nerve root. A lateral intermuscular approach to excise the lesion was used to preserve the facet joint. Histological examination of the intraneural lesion revealed degenerative disc fragments. The authors hypothesize that the structure of the annulus fibrosus in the upper lumbar region predisposes these regions to lateral herniation. Furthermore, it is proposed that the lateral disc herniation allowed the disc fragments to erode through the epineurium of the neural sheath. This case expands the differential diagnosis of fusiform enlargement of nerves to include disc herniation.
A comparative analysis of the costs of administration of an OSCE (objective structured clinical examination).
BACKGROUND: The objective structured clinical examination (OSCE) has become an accepted technique for the evaluation of clinical competence in medicine. Although advances have been made in our knowledge of the psychometric aspects of the OSCE, extremely little has been written about feasibility and cost issues. Given the current economic imperative to control costs and the extremely scant literature on the costs of developing and administering an examination in medicine, the authors felt it timely and relevant to explore issues related to the cost of the OSCE. METHOD: In 1991-92 and in 1992-93, costs and time requirements to implement and administer a structured oral (SO) examination and a six-station OSCE for a surgical clerkship at the University of Toronto Faculty of Medicine were gathered by review of invoices, interviews with those involved, and perusal of diaries kept by staff. RESULTS: To develop and administer the six-station OSCE, 327.5 hours of staff and faculty time were required for each rotation of surgical clerks (8.2 hours per student). The SO examination required 110 hours of staff and faculty time (2.75 hours per student). Direct expenses for the OSCE amounted to U.S. $6.90 per student per station, compared with no direct expense for the SO examination. CONCLUSION: The OSCE was more time-consuming and more expensive in human and material costs than the SO examination. However, costs of the OSCE can be substantially reduced from approximately U.S. $35 to U.S. ! per student per station if test developers, standardized patients, support staff, and examiners can donate their time. The authors compare the costs and time requirements of their OSCE with those of other OSCEs reported in the literature, and they provide guidelines to assist educators in deciding whether the costs of an OSCE are justifiable in the educators' individual settings.
Grade zero removal of supratentorial convexity meningiomas.
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Partial hypoglossal to facial nerve anastomosis for reinnervation of the paralyzed face in patients with lower cranial nerve palsies: technical note.
Reanimation of the paralyzed face in patients who have coexisting lower cranial nerve palsies is a difficult management problem. Classic hypoglossal to facial nerve anastomosis may be devastating in these already compromised patients. We describe a technique of partial hypoglossal to facial anastomosis that can preserve hypoglossal nerve function and provide adequate facial reanimation.
Pseudo-cerebrospinal fluid rhinorrhea.
Because of its potentially serious sequelae, cerebrospinal fluid (CSF) leakage following surgery for lesions of the cranial base is given immediate attention by neurosurgeons. Despite a multitude of approaches used to prevent its occurrence, CSF leakage complicates up to 30% of difficult skull-base tumor operations. The authors describe the cases of 11 patients who developed a syndrome, not previously described in the literature, termed "pseudo-CSF rhinorrhea." This syndrome occurs after surgery of the cranial base, usually involving dissection or removal of the petrous or cavernous carotid artery, the greater superficial petrosal nerve, and the pericarotid sympathetic plexus. It is characterized by nasal stuffiness and nasal hypersecretion and is sometimes accompanied by facial flushing. The symptoms are characteristically exacerbated by exertion or by elevated ambient room temperatures. Lacrimation is typically absent ipsilateral to the pseudo-CSF rhinorrhea. It is believed that pseudo-CSF rhinorrhea developed in these patients because of a relative imbalance of the regulatory autonomic supply of the nasal mucosa.
Arteriovenous malformation of the pyriformis muscle manifesting as a sciatic nerve tumor.
We present a patient with an intramuscular pelvic arteriovenous malformation that was initially diagnosed as a tumor of the sciatic nerve sheath. Endovascular embolization, attempted as a preoperative maneuver, was complicated by diffuse pulmonary emboli and death. To our knowledge, this is the first such reported case. Its presentation here broadens the differential diagnosis of sciatic nerve sheath tumors, emphasizes the diagnostic and management issues of masses presenting as peripheral nerve tumors, and provides clinicopathological evidence regarding the cause of neurological symptoms.