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Biomedical subjects

L A Gray

Publications and source records attributed to L A Gray.

At least 73 records · Page 4Linked to original sources
PubMed1983

Management of patent ductus arteriosus in the premature infant: indomethacin versus ligation.

A previous report from our institution analyzed the results of pharmacological (indomethacin) closure of patent ductus arteriosus (PDA) in 82 neonates. Closure was achieved in 54 patients. However, gastrointestinal complications occurred in 21, necrotizing enterocolitis in 13, and focal perforation in 8. Overall mortality in the indomethacin group was 40%. This paper compares the results of that pharmacological experience with our subsequent surgical experience with 86 low-birth-weight neonates for whom gestational age, size, illness, and mode of diagnosis were comparable. Mean weight at operation for this study was 1.1 kg; mean gestational age was 29.1 weeks. All infants required endotracheal-assisted ventilation for severe radiographic and clinical hyaline membrane disease. Range-gated Doppler study, retrograde flush aortography, and echocardiographic measurement of the ratio between the left atrium and the aortic root were used to confirm the diagnosis of PDA. Ligation was done in the neonatal intensive care unit using local anesthesia supplemented with morphine. Ventilation was controlled by an inhalation therapist; drug and blood administration were controlled by the infant's nurse. Surgical ligation was employed in all infants except for 7 in whom hemoclip ductal closure was chosen because of extreme instability, coagulopathy, or ductal perforation. There were no operative deaths. Surgical morbidity included ductal perforation (2 patients), wound infection (1), and phrenic nerve injury (1). Necrotizing enterocolitis occurred in 9 patients. The overall mortality was 17%. Patients with preoperative pneumo-thorax had a 32% overall mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesia, Local↗
PubMed1983

Intraoperative autotransfusion. Experience in 725 consecutive cases.

Autologous intraoperative transfusion employing the Haemonetics Cell Saver is reported in 725 patients from a general hospital population, of which 75% were cardiovascular patients. The remaining cases included various orthopedic procedures, splenectomy, craniotomy, ectopic pregnancies, Caesarian sections, and exploratory laparotomy. On occasion, this method was utilized in trauma and in pediatric surgery. The product of washed red blood cells gave an average yield of 573 cc per case with an average hematocrit of 55 cc/dl available for autologous infusion. In 100 consecutive open heart procedures operated prior to the Cell Saver period, an average of 1.97 units of bank blood was utilized during operation, as compared with 0.75 units in 100 consecutive cases studied employing the Cell Saver (p less than 0.0001). Homologous blood utilization during cardiac surgery declined more than 50% with the use of the Cell Saver. Quality control was monitored scrupulously and included special precautions against air embolism, abnormal coagulation, and sepsis. The overall mortality rate was 2.8%, and in no instance was mortality or morbidity ascribable to the autologous transfusion. Numerous advantages offered by autotransfusion include prevention of sensitization of the recipient to various antigens in donor erythrocytes, leucocytes, platelets, and plasma, and avoidance of transfusion-transmitted diseases, especially viral hepatitis. Additionally, autologous blood, the only perfectly compatible product, provided immediate availability while conserving blood bank resources. In circumstances in which the intraoperative blood loss exceeded 1000 cc in the adult, its use was observed to be cost-effective. In the present study, autotransfusion proved safe, efficient, and in some instances life saving.

Blood Specimen Collection↗
PubMed1983

Reconstruction of complex thoracic defects with myocutaneous and muscle flaps. Applications of new flap refinements.

This report describes reconstructions of complex thoracic defects with myocutaneous and muscle flaps that were modified by several recent refinements of flap design. These refinements comprise a second generation of myocutaneous and muscle flaps, which have substantially increased versatility and extended applications, as compared with the originally described flaps. These refinements include the following: (1) segmentally split latissimus dorsi and pectoralis major flaps, which transfer only one muscle segment as the flap and leave other segments of the same muscle in situ to preserve motor function; (2) pectoralis major fasciocutaneous flaps, which are extended by abdominal skin and fascia to provide longer, larger flaps; (3) reversed pectoralis major and latissimus dorsi flaps, which are supplied by secondary, distal vascular pedicles that permit flap use when the primary vascular supply is interrupted; and (4) island vascular pedicle muscle flaps, which allow intercostal passage for reconstruction of intrathoracic defects and cavities. The anatomic bases for these flap refinements are described, and the advantages provided are discussed.

Adult↗
PubMed1982

A clinicopathologic correlation of mammographic parenchymal patterns and associated risk factors for human mammary carcinoma.

The five-year screening experience for 10,131 asymptomatic women evaluated at the Louisville Breast Cancer Detection Demonstration Project (LBCDDP) disclosed 144 breast carcinomas in 1,209 patients (12%) aged 35 to 74 years in whom 904 biopsies and 305 aspirations were performed. This study included 44,711 high-quality xeromammograms (XM) prospectively classified by the modified Wolfe mammographic parenchymal patterns into low-risk (N(1), P(1)) versus high-risk (P(2), DY) groups, with expansion of the P(2) cohort into three additional categories. Using BMDP computer-program analysis, each XM pattern was collated with 21 nonneoplastic and 18 malignant pathologic variables and commonly associated risk factors. A separate analysis of epithelial proliferative and nonproliferative fibrocystic disease of the breast (FCDB) was performed. The histopathology for each biopsy, with distinction of FCDB and neoplasms, was analyzed with regard to the statistical probability of influencing the XM pattern. An average of 1.05 biopsies per patient were performed in women with findings suggestive of carcinoma at clinical and/or XM examinations. An equal distribution of the N(1), P(1), and P(2) DYXM patterns was observed in the 10,131 screenees. Of 8.5% of the screened population having biopsies, 623 were observed to have nonproliferative FCDB and 137, proliferative FCDB. For women 50 years of age or younger, these pathologic variables were seen more frequently in the P(2) DY patterns (p < 0.001), whereas no difference in XM pattern distribution was observed for the screenee 50 years of age or older for proliferative FCDB (p = 0.65). Sixteen percent of the biopsied/aspirated lesions were carcinomas, yielding a biopsy/cancer ratio of 6.25:1. These in situ and invasive neoplasms were more commonly (p < 0.04) observed in 55% of the P(2) (P(2f), P(2n), P(2c)) categories, while 64% of all cancers appeared more frequently in the P(2) DY subgroup (p <0.001), compared with this pattern in the screened population. An equal distribution frequency of the XM classification existed for screenees 50 years of age or older with cancer (p = 0.50), while screenees 35-49 years of age were more often observed to have the high-risk P(2), DY patterns (p <0.001). Analysis of 1,759 histologic characteristics in biopsies of 863 patients with FCDB revealed ductal and lobular hyperplastic lesions, sclerosing adenosis, or epithelial cyst(s) to be the major constituents of 64-69% of the high-risk P(2) (P(2f), P(2n), P(2c)) image (p < 0.001). These data suggest that XM parenchymal patterns observed in asymptomatic screenees incompletely correlate with known pathologic variables and risk factors. Additionally, benefit for recognition of these preinvasive proliferative pathologic factors and carcinomas appears restricted to the younger screenee. The clinical integration of these risk factors with XM patterns may allow preselection of patients deserving of frequent follow-up for breast cancer; however, these data do not support the contention that Wolfe XM patterns are predictors for screening strategies or that they decisively enhance patient management.

Adult↗
PubMed1982

Thoracic empyema.

Explore the source record for details and available documents.

Adolescent↗
PubMed1981

Selected prognostic variables for mammographic parenchymal patterns.

Conjecture exists about the influence of numerous risk-factors for breast cancer on mammographic parenchymal patterns. To allow more precise documentation of the common variables considered influential in alterations of breast parenchyma, we conducted a randomized retrospective analysis. Of 10,132 women participants in the Louisville Breast Cancer Detection Demonstration Project, every tenth participant was randomly selected for evaluation using SPSS statistical programming. Each accessioned patient had discriminant analysis for the risk factors of age, parity, age at birth of first child, family history, personal history, previous history of breast biopsy, and exogenous estrogen therapy. One-thousand-and-two women were examined for the significance of the selected prognostic variable association with Wolfe mammographic parenchymal patterns (WMPP). Each prognostic factor was tested by chi-square analysis for the low-risk pattern (N1P1) versus the high-risk pattern (P2DY). A high correlation existed between the age of patient and WMPP (P = 0.0002) in the subjects evaluated (50--85 years, mean 60). Similarly, a very significant correlation was evident between WMPP and parity (P = 0.0002), age at birth of first child (P = 0.0014), family history of breast cancer (P = 0.097), and history of previous breast biopsy (P = 0.0066). Little correlation existed between the Wolfe parenchymal pattern classification and a personal history of breast cancer (P = 0.7779) or the use of exogenous estrogens (P = 0.5776).

Age Factors↗
PubMed1981

Effect of sodium nitroprusside on postoperative blood loss in the cardiac surgical patient.

Sodium nitroprusside (SNP) is known to inhibit platelet aggregation and has been implicated in postoperative hemorrhagic complications. Because it is a useful agent for treating postoperative hypertension and low cardiac output in the cardiac surgical patient, the authors retrospectively reviewed the course of 53 patients undergoing open heart procedures on cardiopulmonary bypass. Twenty-three patients received SNP and 30 did not. There were no differences in baseline hematological or clotting profiles, liver functions, bypass or cross-clamping times or heparin/protamine requirements between the two groups. Analysis revealed no significant differences between the groups in blood product requirements, actual mediastinal drainage, or postoperative measurements of routine clotting parameters. Although biochemical inhibition of platelet aggregation can be demonstrated, the use of SNP in the cardiac surgical patient has no apparent clinical effects which sould detract from its utility in treating hypertension or low cardiac output.

Cardiac Output, Low↗
PubMed1981

Management of transmediastinal gunshot wounds.

Gunshot wounds that transverse the mediastinum are major management problems for two primary reasons: (1) multiple injuries to vital structures are common and (2) the operative approach to control hemorrhage may not afford the optimum exposure to repair the various injuries encountered. We devised a management plan whereby patients in hemodynamically unstable condition underwent immediate operation and patients in stable condition underwent a rapid work-up to evaluate the organs at risk for injury including angiography, esophagoscopy, esophagography, bronchoscopy, and pericardial exploratory surgery while under local anesthesia. A total of 76 patients were treated. Thirty-three patients in unstable condition underwent immediate thoracotomy for hemorrhage or shock or median sternotomy for cardiac tamponade. Multiple organs were injured (average 2.7) and the mortality rate was high (12 of 33) because of the severity of the injuries. Twenty-seven of 43 patients in stable condition required operation after the systematic evaluation disclosed injuries to the great vessels (11), esophagus (9), trachea and bronchi (6), and heart (6). Three patients died of delayed complications (6.9%). The 16 patients who were in stable conditions and had no demonstrable injury were closely followed without operation with one complication and one death from an associated abdominal injury. A management plan for this difficult subset of patients with penetrating thoracic trauma is detailed.

Adult↗
PubMed1980

The effects of exogenous estrogen replacement therapy of the breast: breast cancer risk and mammographic parenchymal patterns.

A retrospective pilot study was implemented to better define the potential carcinogenic role of conjugated equine estrogen (Premarin) on the breast, and the influence of these hormone analogues on proliferative and atrophic breast parenchyma as determined by high-quality serial xeromammograms. Four hundred and five postmenopausal (spontaneous and surgical) women (mean age 59.7 years) were group matched for the risk factors of age and parity. The dominant parenchymal pattern (N1P1P2DY) as disclosed mammographically was determined for each patient, who was then categorized into one of four groups: Group 1 Asymptomatic-no hormones, 124 patients; Group 2 Symptomatic-no hormones, 75 patients; Group 3 Asymptomatic-hormones; 152 patients; and Group 4 Symptomatic-hormones, 54 patients. Patients in Groups 3 and 4 were treated with therapeutic estrogens a minimum of 18 months (mean 79 months) and follow-up ranged from 39-344 months. In the entire series, 25 carcinomas (6.2%) were detected. In Group 3, five carcinomas (2.4%) were detected, but two cancers (1.0%) were found in symptomatic estrogen users. The occurrence of carcinoma in Group 2 was greater than the remaining categories; however, cancer risk was not statistically greater in any category with regard to hormone replacement therapy. Patients treated with therapeutic estrogens were observed to have an increase of 8.9% in the frequency of a more glandular (P2,DY) mammographic parenchymal pattern and this was noted to be within the range of interpretation error of the mammographer. This suggests a physiologic effect of therapeutic estrogens on atrophic breast parenchyma with conversion to a glandular, proliferative state. This study suggests that long-term replacement estrogen therapy for postmenopausal symptoms does not significantly alter mammographic parenchymal patterns and that the use of these compounds in therapeutic doses does not increase the risk of breast cancer.

Adult↗
PubMed1979

Noninvasive precursor lesions of adenocarcinoma and mixed adenosquamous carcinoma of the cervix uteri.

It is postulated that squamous cell carcinoma, adenocarcinoma, and mixed adenosquamous cell carcinoma of the uterine cervix all have a common cell or origin, the subcolumnar reserve cell. The relative frequency with which the various types of carcinoma in situ are seen is in part explained by the ubiquitous nature of squamous metaplasia in the region of the transformation zone in women of reproductive age. It is suggested that squamous metaplasia is the soil on which most squamous carcinomas of the cervix evolve. The relatively low frequency with which adenocarcinoma and adenosquamous carcinoma in situ are encountered may also be dependent on their less accessible location in the endocervix.

Adenocarcinoma↗
PubMed1979

Principles for the management of penetrating cardiac wounds.

An experience with penetrating cardiac injuries between 1974 and 1977 has permitted designation of particular findings as indications for emergent operations and appropriate therapeutic approaches. Of the 46 patients with cardiac trauma, 28 suffered gunshot wounds. Seventeen patients died, and 14 of the deaths occurred as a result of asystole, ventricular fibrillation or exsanguination during operation. Two patients died of neurologic sequelae following successful cardiac repair, and one died secondary to injury not disclosed by physical examination or roentgenogram. The surviving 29 patients had five major complications. Sepsis, organ system failure and cardiac defects rarely occurred despite rapidly performed thoracotomy and severe shock. Since delayed operation has been uniformly associated with adverse outcome and because postoperative complications of emergent pericardial exploration are mild, the following conclusions have been reached: 1) Mediastinal entrance wounds, severe hypotension and signs of cardiac tamponade are demonstrative of cardiac trauma. Therefore, virtually any combination of these physical signs mandates pericardial exploration. 2) Subxiphoid or transdiaphragmatic exploration (during laparotomy) of the pericardium has been valuable in diagnosis of suspected heart wounds. 3) Emergent cardiorrhaphy is the treatment of choice. Pericardiocentesis is at best only temporarily effective. Thoracotomies performed in the emergency room were uniformly unsuccessful. If possible, cardiorrhaphy should be done in the operating room. 4) Median sternotomy is the approach of choice. 5) The basic principles of management of cardiac injury are rapid diagnosis, relief of tamponade, control of hemorrhage, repair of cardiac defects and restoration of blood volume.

Adolescent↗