Biomedical subjects

G A Gomez

Publications and source records attributed to G A Gomez.

At least 19 recordsLinked to original sources

PubMed1992

Neurologic consequences of cerebrovascular injury.

Because of ongoing controversy, the issue of vascular repair or ligation for patients with cerebrovascular injuries and preoperative central neurologic deficits is frequently debated. A total of 133 patients with penetrating cerebrovascular injuries were analyzed. The frequency of preoperative neurologic deficit was 20% (27 patients). The common carotid and internal carotid arteries were the most frequently injured structures, with a 29% and 15% incidence of preoperative neurologic deficits, respectively. The results of carotid repair in all patients whose preoperative deficit was limited to weakness or paralysis were favorable (seven patients normal or improved, two patients unchanged). The results of repair in patients whose preoperative deficit was characterized by obtundation were variable (four patients improved, four patients worsened or died). The results of carotid ligation were also variable (one improved, one unchanged, three worsened or died). Limited numbers of patients with preoperative neurologic deficits and the retrospective nature of this review prohibit definite conclusions. Therefore a multicenter, prospective, randomized trial of ligation or vascular repair for comatose patients with cerebrovascular injuries is proposed.

Carotid Artery Injuries↗

PubMed1992

The use of an absorbable mesh wrap in the management of major liver injuries.

Uncontrollable hemorrhage remains the predominant cause of death in patients with complex liver injuries. In view of the recently reported success in control of hemorrhage from and salvage of the injured spleen and kidney with an absorbable mesh wrap, we have begun to use a similar technique in the management of major hepatic parenchymal injuries, as an alternative to suture hepatorrhaphy, lobar resection, and perihepatic packing. The technique of mesh-wrap hepatorrhaphy is described in detail. Our initial experience with four cases is reported, demonstrating the unique features of the mesh and the technical ease with which it can be applied. Advantages over conventional techniques are discussed. These include avoidance of reoperation for removal of perihepatic packing, avoidance of hepatic necrosis after wide suture hepatorrhaphy, and avoidance of the morbidity associated with lobar resections.

Accidents, Traffic↗

PubMed1991

Nautical accidents. Unique injuries.

Not much has been written about nautical injuries, although the increasingly popular recreational boating activities and other water sports are becoming a significant source of injury and death. The authors review common and not-so-common nautical injuries and possible preventive measures.

Accidents↗

PubMed1991

Whipple procedure for trauma: is duct ligation a safe alternative to pancreaticojejunostomy?

The use of pancreatic duct ligation (DL) during a Whipple procedure for trauma has been reported but not analyzed. We reviewed 13 cases of DL and compared the results with that reported for the Whipple procedure for trauma with pancreaticojejunostomy (PJ). The mortality rate of DL was 53.8%. Pancreatitis occurred in three cases (23.1%) and caused one death. Pancreatic fistulae occurred in 50% of patients surviving two or more days after DL. No long-term survivor developed overt diabetes mellitus. Malabsorption occurred in 50% of the long-term survivors of DL. When the DL and PJ groups were compared no statistically significant difference could be found in either mortality or pancreatic morbidity. The 46.2% survival rate for DL warrants its consideration as a technique available to trauma surgeons when faced with an unstable patient unable to tolerate further operative therapy.

Abdominal Injuries↗

PubMed1990

A new technique for exposure of injuries at the confluence of the retrohepatic veins and the retrohepatic vena cava.

Because of difficulties in rapid exposure and control, injuries of the retrohepatic veins and retrohepatic vena cava continue to have mortality rates approaching 100%. Current strategies include shunt and finger fracture techniques, with controversy continuing over the optimal approach. We describe a new technique which involves mobilization of the liver by transecting the superhepatic vena cava, and affords a posterior approach to these injuries. Cadaveric dissection and clinical experience are described.

Adult↗

PubMed1990

Continuous arteriovenous rewarming: experimental results and thermodynamic model simulation of treatment for hypothermia.

We evaluated a technique for treating hypothermia that uses extracorporeal circulation but does not require heparin or pump assistance. Hypothermia to 29.5 degrees C was induced in eight anesthetized dogs, and thermistors placed in the pulmonary artery, liver, bladder, esophagus, rectum, muscle, and skin. Four experimental animals were rewarmed by creating a fistula which connected arterial and venous femoral lines to an interposed counter-current heat exchanger. External rewarming was used in four controls. Bleeding time (BT), coagulation profile (PT, PTT, TT), and cardiac output (CO) were measured during rewarming. Core temperature (T) rose significantly faster with CAVR (0.00001). Average time to rewarming was 45 min, vs. 4 hrs in controls. Haptoglobin, platelet, fibrinogen, and fibrin split product levels were unaffected. Continuous arteriovenous rewarming (CAVR) improved T, CO, BT, and coagulation profile faster than any method yet reported not requiring heparin or cardiac bypass. The application of CAVR in post-traumatic hypothermia warrants further investigation.

Animals↗

PubMed1990

HIV, trauma, and infection control: universal precautions are universally ignored.

The medical, legal, and ethical problems associated with routine HIV screening have led to the recommendation that all patients should be presumed to be seropositive and thus protective measures should be taken by all health care workers. This philosophy, termed "universal precautions," has been difficult to adhere to or enforce, however. Nevertheless, in some trauma population subsets, the prevalence of HIV seropositivity runs as high as 19%, and thus presents an occupational hazard to the trauma health care worker. The mainstays of universal precautions (UP) are barrier techniques against body fluid contact and protection from inadvertent needlestick. To judge compliance with a strict UP protocol, surgical residents engaged in trauma room resuscitations were observed on a random basis by trauma nurse coordinators. Previously, UP had been discussed in conferences and by memo. Over 2 months, 81 trauma rooms were observed, involving 18 house officers. Overall, there was only 16% compliance with strict UP. The most common protocol variations involved sharps technique. While glove use was nearly universal, protective eye wear, ankle and foot protection, and body protection such as gowns or aprons were commonly ignored. Even in the presence of invasive procedures such as endotracheal intubation or insertion of chest tubes, compliance was less than 40%. The reasons most commonly given by house officers for the lapse in UP were not knowing the protocol, forgetting the protocol, or not having time to implement the protocol. Even for the nine patients residents identified as suspected of being in a high-risk category, UP was strictly adhered to only once. Compliance with universal precautions is difficult to achieve under the best of circumstances. It cannot be assumed that passive informational measures can achieve this goal. Active infection control surveillance and ongoing housestaff inservice are required to minimize the risk of inadvertent injury or contamination.

Acquired Immunodeficiency Syndrome↗

PubMed1989

Wide-field radiation therapy plus simultaneous chemotherapy for refractory Hodgkin's disease.

Nine male patients with disseminated Hodgkin's disease who had relapsed and/or were refractory to two or more non-"cross-resistant" programs of combination chemotherapy (range, two to five previous programs; median, three) were admitted into a study of treatment with wide-field low-dose radiation therapy (2,000 cGy), to all lymph node bearing areas, the liver, the spleen, and in selected cases the lungs (1,000 cGy). Simultaneous with each course of radiation therapy, chemotherapy with BCNU and procarbazine given at 50% doses of a known program of chemotherapy (BOPP) with vincristine and prednisone was given. Treatment was completed in five patients. Three of these achieved a complete remission; the other two had a partial response. Of the other four, two died during treatment with interstitial pneumonitis (probably radiation induced), and two failed to respond. Remission durations were 18+, 38, and 44+ months. Pulmonary toxicity was severe; however, hematologic and other toxicities were acceptable. The incorporation of wide-field low-dose radiation should be considered in programs of rescue for patients with Hodgkin's disease who relapse or are refractory to standard combination chemotherapy.

Adolescent↗

PubMed1989

Blunt pancreatic trauma: prospective evaluation of early endoscopic retrograde pancreatography.

Major ductal injury is a determining factor in the outcome after pancreatic trauma. The purpose of this study was to determine the value of early endoscopic retrograde pancreatography (ERP) in patients with blunt pancreatic trauma. We attempted ERP in nine patients. Indications were abnormal pancreatic findings on CT scanning in five patients, a suboptimal view on CT scanning in three patients, and a high index of suspicion in one patient. ERP was successful in eight patients. Two had major ductal injury treated operatively and were discharged without complications. In six, ERP showed a normal pancreatic duct. These patients were treated conservatively; five were eventually discharged, and one died of necrotizing pneumonia. Our results suggest that ERP is safe and accurate in the diagnosis of blunt pancreatic ductal injuries. If the pancreatic ductal system is intact, conservative management is appropriate, but if ERP shows major ductal injury, surgical intervention is indicated.

Adolescent↗

PubMed1988

Primary prostatic involvement in non-Hodgkin lymphoma.

We report 3 cases of primary extranodal lymphoma of the prostate, an unusual extranodal presentation rarely diagnosed antemortem. Symptoms of prostatism associated with an enlarged hard prostate with pyuria and hematuria in younger patients should suggest the diagnosis. Urine cytologic examination should aid in the diagnosis of this condition.

Adult↗

PubMed1988

A prospective evaluation of field categorization of trauma patients.

We prospectively evaluated the efficacy of comprehensive field triage in 8,891 trauma patients transported to trauma centers in Dade County, Florida, over a 1-year period ending in September 1986. There were 5,685 males (63.9%) and 3,206 females (36.1%) with a mean age of 32.4 +/- 18.4 years. The overall accuracy for identifying severe injury for the entire group was 30.2%. A Trauma Score less than or equal to 12 was the most accurate predictor of severe injury. Of 669 patients in this group, 617 (92.2%) sustained severe injury and 361 died (54.0%). High-speed (greater than 40 m.p.h.) motor vehicle accident was the most common reason for triage; however, of 2,277 in this group 201 patients (9.0%) had severe injury and four patients (0.2%) died. Only nine deaths (0.9%) occurred in 1,004 patients with penetrating trauma whose Trauma Scores were greater than 12. Of the 8,891 patients 4,791 (53.9%) had moderate to severe injury. The overtriage rate was therefore 46.1% using this field categorization system.

Adolescent↗

PubMed1988

Prognostic significance of additional cytogenetic abnormalities at diagnosis of Philadelphia chromosome-positive chronic granulocytic leukemia.

Of 661 patients with Philadelphia chromosome (Ph)-positive, nonblastic chronic granulocytic leukemia, 58 had cytogenetic abnormalities in addition to the Ph at the time of diagnosis. Twenty patients had reduplication of the Ph in one or more metaphases. Twenty-one patients with a single Ph exhibited hyperdiploidy in one or more metaphases. Eleven patients had two or more hypodiploid metaphases as their only numerical abnormality. The remaining six patients had a variety of abnormalities. Many patients had more than one type of abnormality. Survival of patients in the different subgroups was similar, but these 58 patients had a shorter course than the 603 patients without additional cytogenetic abnormalities (P less than .02). Survival curves for the two populations did not diverge until the 2-year point, after which the annual death rate among patients with additional cytogenetic abnormalities was approximately 40% higher than that of patients without such abnormalities. The two populations had similar relative risk values according to a hazard ratio formula previously described by the International CGL Prognosis Study Group. Thus, they would have been expected to have essentially identical survival curves. We conclude that the presence of additional cytogenetic abnormalities at the time of diagnosis constitutes an independently significant prognostic feature with an unusually delayed influence on survival.

Adolescent↗

PubMed1987

An autopsy study of 1206 acute and chronic leukemias (1958 to 1982).

Autopsy data on 1,206 children and adult patients with acute myelocytic leukemia (AML) (585), chronic granulocytic leukemia (CGL) (204), acute lymphocytic leukemia (ALL) (308), and chronic lymphocytic leukemia (CLL) (109) obtained from 1958 to 1982 were reviewed. This analysis has shown that, whereas the proportion of patients with residual AML at any anatomic site decreased significantly and uniformly over the entire study period, significant corresponding decreases in patients with CGL and ALL occurred only since 1976 and 1978, respectively. No significant corresponding decreases were noted in patients with CLL at any time. Significant decreases were also noted over time in the rates of extramedullary site involvement by AML, CGL, and ALL. Whereas the lymphoreticular organs, kidneys, adrenals, and pituitary were most often involved at autopsy by CLL, the testes, leptomeninges, dura mater, uterus, large bowel, and pancreas were most often involved by ALL. In general, patients with AML and CGL showed the lowest relative rates of involvement of the various organs by leukemia during the 24-year period. Whereas patients with AML and ALL showed significant decreases in the rates of involvement of nearly all anatomic sites during the most recent study periods, those with CGL and CLL showed corresponding decreases in only a few organ sites. The lower rates of organ involvement in patients with AML and ALL attest to the more aggressive eradication of leukemic cells by therapeutic regimens in these diseases over time. In particular, the significant decrease in the rate of meningeal involvement by ALL during the most recent period is probably attributable to central nervous system prophylaxis.

Adolescent↗

PubMed1987

Cyclophosphamide, vincristine, adriamycin, and prednisone (CHOP) with and without intermediate dose methotrexate for the treatment of non-Hodgkin's lymphomas of diffuse histology.

Seventy three patients with disseminated diffuse non-Hodgkin's lymphomas were treated with combinations of cyclophosphamide, vincristine sulfate, prednisone, and doxorubicin with and without 2 weekly doses of oral methotrexate in "intermediate" doses, followed by calcium leucovorin rescue. The addition of methotrexate did not increase the complete remission rate, the remission duration, or the survival (P value = 1.0, 0.74, and 0.78, respectively) in patients who did not have previous chemotherapy treatment. In previously treated patients, the complete remission rate was somewhat higher and the remission duration and survival were longer among those patients treated with the methotrexate containing program; however these differences were not statistically significant (P values = 0.88, 0.81, and 0.46, respectively). There was substantial morbidity and mortality during treatment with both treatment arms, among patients aged more than 60 years.

Adult↗

PubMed1987

Preferential inhibition by cytarabine of CFU-GM from patients with chronic granulocytic leukemia.

Granulocyte-macrophage colony-forming (CFU-GM) cells from peripheral blood of normal subjects and patients with chronic granulocytic leukemia (CGL) were cultured in soft agar. Drugs under study were added in a liquid overlay 2 days after initiation of cultures, providing prolonged exposure to these agents thereafter. Dose-dependent inhibition of colony growth was recorded with each of eleven agents examined, and at the higher concentrations tested, colony formation was often completely suppressed. Cytarabine showed selectivity against CFU-GM from patients in the chronic stage of CGL (P = 0.006); the median 50% inhibitory concentration for 12 such patients was 3.4 ng/ml versus 11.8 ng/ml for 15 healthy subjects. Such selectivity was not found with busulfan, hydroxyurea, mercaptopurine, thioguanine, daunorubicin, vincristine, vinblastine, methotrexate, desacetylmethylcolchicine, and trimethylcolchicinic acid. One other group has also reported a preferential effect of cytarabine against colony-forming cells from patients with CGL, and this appears to be the only drug for which such selective activity has been recorded to date.

Cell Division↗

PubMed1987

Salvage chemotherapy for advanced Hodgkin's disease.

Eleven patients with Hodgkin's disease refractory to chemotherapy were treated with six cycles of intermediate-dose methotrexate with calcium leucovorin rescue, followed by cyclophosphamide, doxorubicin, vincristine, and prednisone (MTX-CHOP). Three other patients were treated with a similar program of treatment minus doxorubicin (MTX-COP). The overall response rate was 57%, with four (29%) patients achieving a complete response and four patients achieving a partial response. None of the three patients treated with MTX-COP had a complete remission (CR); thus the complete remission rate with MTX-CHOP was somewhat higher (36%). Only one of the CR's is in continuous complete remission and free of disease at 99+ months. One patient died of overwhelming sepsis and pancytopenia during treatment. Hematologic toxicity in the other patients was acceptable. The overall median survival was 18 months. The search for an effective treatment program for this group of patients remains a major challenge.

Adolescent↗

PubMed1987

Diagnostic peritoneal lavage in the management of blunt abdominal trauma: a reassessment.

In order to reassess the value of diagnostic peritoneal lavage (DPL) in patients with blunt abdominal trauma, we conducted a prospective study over a 15-month period involving 138 patients. There were 29 (28.3%) patients with positive DPL and 103 (71.7%) with negative DPL in this series. Of the 29 patients with positive DPL, 28 (96.5%) were found to have significant intra-abdominal injuries; 27 by exploratory laparotomy and in one case at autopsy. One patient with a grossly positive DPL had a negative exploratory laparotomy (3.4% false positive rate). All 109 patients with negative DPL were admitted. In only one case a significant intra-abdominal injury was demonstrated (0.9% false negative rate). The overall mortality in this series was 11.6% and there were no complications related to the DPL. Our results suggest that DPL is indeed an accurate indicator of significant intra-abdominal injuries in patients with blunt abdominal trauma.

Abdominal Injuries↗

PubMed1987

Diagnosis related groups and the critically injured.

We reviewed the records of 59 patients with trauma treated in the surgical intensive care unit in 1983 to attempt to identify a diagnosis related group (DRG) modifier in order to eliminate major losses which would be incurred in caring for the critically injured. There were 22 females and 37 males. Payment based upon a DRG system would have resulted in hospital losses for the following subgroups: surgical treatment (n = 44) $1,348,009; no operation (n = 15) $125,085; length of stay (LOS) of more than ten days (n = 35) $1,124,778; LOS equal to or less than ten days (n = 24) $348,316; nonsurvivors plus LOS equal to or less than ten days plus operation (n = 12) $269,778, and survivor plus LOS greater than ten days plus operation (n = 29) $1,022,284. No useful modifier was identified for these subgroups using regression analysis. We believe that some immediate DRG modifier, based upon the total hospital charges (or costs if known) relationship to total DRG payments, should be created until further refinements in payment systems evolve. If some correction is not attempted, the considerable disadvantage which would result to participating hospitals may result in curtailing availability of effective long term intensive care unit trauma care at a time when the public is becoming aware of trauma systems and the improvement in survival seems to be a realizable goal.

Cost Control↗