Biomedical subjects
Publications and source records attributed to A S Goldstein.
The imaging evaluation of the patient with genitourinary injuries must be tailored to provide accurate and clinically relevant data that can be used to make treatment decisions. This radiologic evaluation should consider the patient's hemodynamic status, the mechanism of injury, and the possible associated injuries.
Penetrating trauma of the neck has been divided into three anatomic locations. Zone III, the subject of this paper, is defined as the area between the base of the skull and the lower border of the mandible. Management of these injuries remains problematic. Clinical assessment may be misleading, exploration may damage surrounding neurovascular structures, and injuries may go undetected. This has led us and others to advocate mandatory angiography before any surgical exploration. This report reviews 46 patients with Zone III injuries with respect to types of injuries, therapy and outcome. Angiography was normal in 22 patients who were treated conservatively with no complications. The remaining 24 patients sustained 39 arterial injuries diagnosed by contrast studies. Eighteen internal carotid injuries were identified in 16 patients. At operation ligation was performed in four patients and revascularization in two patients. One of the repairs subsequently thrombosed. Ten patients were managed nonoperatively by observation (seven patients) or angiographic embolization (three patients). Catheter embolization of the external carotid or its branches was performed to control bleeding (eight vessels) or close arteriovenous fistulas (two patients). Seven nonbleeding external vessels were successfully managed by observation. Two vertebral artery injuries were diagnosed. One required proximal embolization and distal ligation via occipital craniectomy to control a fistula between the vertebral artery and the jugular vein. Overall mortality was 8.6%. Three of the four deaths were in patients with neurologic deficit on admission. Another died of respiratory arrest. An air embolism resulting in hemiparesis was the only complication of the angiographic studies. We conclude that angiography is essential in Zone III neck wounds. It facilitates triage decisions and, combined with transcatheter embolization, enables the majority of these injuries to be managed without surgical exploration.
One hundred three patients with blunt abdominal trauma were studied using computerized tomography (CT). By protocol CT was performed in hemodynamically stable adults either: before tap and lavage (T&L)--32 patients; after 'negative' (less than 20,000 RBC/mm3) or 'borderline' (20,000-50,000 RBC/mm3) lavage--28 patients; or to evaluate hematuria--43 patients. CT was performed after administration of oral and intravenous contrast. A comparison of T&L and CT was made in 60 patients. 16 of 42 patients with negative lavage had 22 injuries identified by CT. One of these patients with bilateral renal artery transection, mesenteric and pararenal hematomas died of a closed head injury. Six of 14 patients with borderline lavage results had nine injuries found on CT, including two with actively bleeding spleens confirmed at operation or angiography. One patient with a large retroperitoneal hematoma underwent successful control of hemorrhage by embolization. Only one injury, a paranephric hematoma found at operation was not identified preoperatively by CT. Seventeen of 85 patients with hematuria had GU abnormalities identified by CT. Findings included seven intrarenal hematomas or contusions, three fractures, three major renovascular injuries, four para- and six perinephric hematomas, and three collection system injuries with extravasation. The majority of these injuries were found in patients with more than 50 RBC/HPF; however, six of 47 patients with less than 20 RBC/HPF had abnormalities including a retroperitoneal bladder perforation and a renal mass (hypernephroma). Two bladder perforations and one urethral injury were identified by CT cystogram. Abdominal CT is more sensitive and specific than T&L or IVP.(ABSTRACT TRUNCATED AT 250 WORDS)
With increasing technologic advances in interventional radiology, the vascular surgeon should be well versed in the indications, limitations, complications, and results of percutaneous transcatheter embolization for arterial trauma. Three hundred twenty-eight angiographically determined arterial injuries occurred in 242 patients from 1977 to 1984 in a major city hospital trauma center and were studied prospectively. Transcatheter embolizations performed for 107 arterial injuries in 100 patients were successful in 82.2% of injuries. Gelfoam, minicoils, microcoils, intimal dissections, or a combination of modalities was utilized. Anterior and posterior element pelvic fractures associated with hypotension and transfusion of 6 units or more of blood required embolization in 28 patients. Bleeding was controlled in 85.7% of patients. Percutaneous transcatheter embolization was also effective in controlling 84.2% of arteriovenous fistulas, 88.9% of penetrating neck arterial injuries, and 73.3% of postoperative intra-abdominal hemorrhage. Therapeutic transcatheter embolization is a valuable adjunct to the vascular surgeon dealing with the spectrum of vascular trauma.
The effectiveness of transcatheter embolization was studied prospectively from January 1977 through July 1984 in 31 patients with extensive pelvic fractures, hypotension, and large retroperitoneal hematomas. The indications for angiography in patients with pelvic fractures included: four or more units of blood transfusion within 24 hours, six or more units of blood transfusion within 48 hours, negative or borderline peritoneal tap and lavage in an unstable patient, or large pelvic retroperitoneal hematoma discovered at time of celiotomy. Successful embolization with complete control of hemorrhage was achieved in 27 patients (87.1%). Overall mortality was 35.5%, but was primarily due to associated injuries. Percutaneous transcatheter embolization was the procedure of choice for controlling massive pelvic retroperitoneal hemorrhage. Early embolization was imperative in reducing transfusion requirements and associated complications.
In an effort to settle the controversy regarding the optimal management of penetrating trauma to the neck, a randomized prospective study was conducted in which 160 patients with penetrating neck injuries admitted to Kings County Hospital between 1977 and 1982 were placed, by protocol, into two groups. Group A patients were explored routinely for all injuries to the neck violating the platysma muscle. Group B patients were managed selectively with operation based on clinical or radiographic evidence of major vascular, visceral, or airway injury. Data were collected retrospectively. Length of hospital stay, morbidity, and mortality were compared between groups A and B, as well as between patients explored or not, and no statistical difference was noted. Since there is no clear advantage to either routine or selective exploration in the management of penetrating neck wounds, we conclude that surgeons should base their treatment on their own experience, house staff and nursing support, and radiologic and operating room availability.
This report describes the successful utilization of interventional radiology to treat two complications of a gunshot wound to the ureter. A disrupted ureteral anastomosis was managed by a percutaneously placed antegrade nephrostomy with internal urinary drainage and ureteral stenting. The associated infected urinoma was also radiologically drained.
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Twenty-seven patients with post-traumatic abscesses treated by percutaneous drainage using radiologic localization and guidance were reviewed. Twenty-six patients were successfully drained and operation was avoided in twenty-one. Our results, which parallel those previously reported, indicate that radiologic drainage is safe and effective. Associated with lower rates of mortality, morbidity, and recurrence, it should be attempted before surgical reexploration in most situations after diagnostic procedures have demonstrated an accessible collection.
Freezing lymphocytes in microtest plates instead of vials for the purpose of screening sera for HLA or other cytotoxic antibodies offers the same technical advantages as freezing sera in microtest plates for tissue typing. Plate-loading errors and cell wastage are minimized, and time required for serum screening is greatly reduced. A method for freezing lymphocytes in large numbers of microtest plates for use in serum screening that is simple, reproducible, and inexpensive is described. Cryoprotected lymphocytes dispensed into microtest plates are placed on a metal table that is lowered onto a tray containing 1 cm of liquid nitrogen in a Styrofoam box. The amount of liquid nitrogen in the tray and the height of the metal table above the tray determine the freezing rate of the lymphocytes. Over 100 microtest plates can be frozen per cycle with total cooling uniformity. The materials required for this freezing device can be assembled for less than $400. Commercial freezing units typically cost over $4,000.
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Light microscopy of a benign clear cell tumor of the lung showed considerable central necrosis, making the differential diagnosis from metastatic clear cell tumor of the kidney difficult. Nevertheless, distinguishing features were seen on both light and electron microscopy that helped make this important distinction.
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This is a case report of a patient who had one of the first Hufnagel ball-valve prostheses inserted in 1954 for severe aortic incompetence. He obtained relief of symptoms for 14 years before recurrence necessitated the insertion of a Starr-Edwards valve. The patients was symptom-free for another seven years before the original valve, which had been left in place, caused his death by eroding through the aorta.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.