Loma Linda University

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Nephtali Gomez, MD
Assistant Professor, Surgery
School of Medicine
Publications    Book Review - Scholarly Journals--Published
  • Outcomes in the Management of Appendicitis and Cholecystitis in the Setting of a New Acute Care Surgery Service Model: Impact in Timing and Cost Cubas RF, Gomez N, Rodriguez S, Wanis M, Garberoglio CA.   JACS August 2012 ( 8/2012 )
  Scholarly Journals--Published
  • Abou-Zamzam AM Jr., Gomez NR, Molkara A, Banta JE, Teruya TH, Killeen JD, and Bianchi C.  A prospective analysis of critical limb ischemia: factors leading to major primary amputation versus revascularization.  Annals of Vascular Surgery 2007;  21(4):458-463 ( 3/2007 )
    In our aging population, primary major amputations (AMP, below-knee or above-knee) continue to be performed despite advances in revascularization. We hypothesized that not only patient comorbidities but also the system of health-care delivery affected the treatment of patients with critical limb ischemia (CLI). A prospective analysis of patients presenting with CLI was undertaken to determine whether patient-specific factors or healthcare delivery factors (system-related) influenced treatment with primary AMP versus lower extremity revascularization (LER). The patient-specific factors age, gender, race/ethnicity, presence of coronary artery disease, cerebrovascular disease, tobacco use, diabetes mellitus (DM), dialysis dependence (end-stage renal disease, ESRD), hypertension, hyperlipidemia, stage of CLI (rest pain, minor or major tissue loss), history of revascularization, and functional status (living situation and ambulatory status) were recorded. The system-related factors time from onset of CLI to vascular surgery evaluation and type of insurance (managed care/other insurance) were also noted. The influence of patient-specific and system-related factors on the primary treatment modality (AMP versus LER) was determined with univariate and multivariate analyses. A total of 224 patients presented with CLI between March 1, 2001, and March 1, 2005. Patients were treated with primary major AMP in 97 cases (43%) and revascularization in 127 cases (57%). On univariate analysis, nonwhite race/ethnicity, DM, ESRD, major tissue loss, dependent living situation, and nonambulatory status were all significant predictors of AMP versus LER (all P < 0.01). On multivariate analysis, major tissue loss, ESRD, DM, and nonambulatory status remained independent predictors of AMP versus LER (all P < 0.05). The system-related factors of time to vascular surgery evaluation (mean 8.6 weeks, 7.1 vs. 9.3 weeks AMP versus LER, P = 0.60) and type of insurance (managed care, 17% vs. 24% AMP vs. LER, P = 0.15) had no influence on treatment. Fifty-four percent of all primary major AMPs were performed due to extensive gangrene or infection present at initial vascular evaluation which precluded limb salvage. Major tissue loss, ESRD, DM, and nonambulatory status are all independent predictors of treatment with primary AMP as opposed to revascularization. Treatment of CLI is determined by patient-specific factors and does not appear to be adversely influenced by system-related factors. Efforts toward improving limb salvage may be best directed at aggressive treatment of medical comorbidities to prevent the late complications of CLI. Earlier recognition of tissue loss and referral to the vascular specialist may lead to improved limb salvage.
  Scholarly Journals--Accepted
  • Tumor Size and Presence of Calcifications on Ultrasonography are Pre-Operative Predictors of Lymph Node Metastases in Patients with Papillary Thyroid Cancer Nephtali R. Gomez, MD1, Guennadi Kouniavsky, MD1, Hua-Ling Tsai, MSc2, Helina Somervell, NP1, Sara I. Pai, MD, PhD3, Ralph P. Tufano, MD3, Christopher Umbricht, MD, PhD1, 4, 5, Jeanne Kowalski, PhD2, Alan P.B. Dackiw, MD, PhD1, Martha A. Zeiger, MD1, 5   Journal of Surgical Oncology Anticipated date of publication: unknown ( 1/2003 - 8/2009 )
    Abstract Background and Objectives:  Lymph node metastases in papillary thyroid cancer (PTC) are common and their presence significantly alters the course of treatment for the patient.  We sought to identify preoperative predictors of lymph node metastases in PTC.   Methods:  A pathology database was queried to identify patients with a preoperative diagnosis of PTC and who underwent thyroidectomy between January 2006 and August 2009. We identified 103 patients who had a preoperative ultrasound and had lymph nodes resected at surgery. Clinical factors and tumor ultrasound characteristics were recorded.  The preoperative ultrasound results, type of operation and final pathology were also recorded. Results: Of the 103 patients 74 (72%) were women and 29 (28%) were men with an age range of 15-78 years (median age of 43). Of the ultrasound characteristics evaluated only calcifications (p=0.007) and size (p=0.003) were statistically significantly associated with the presence of positive cervical lymph nodes.  None of the demographic or clinical factors were significantly associated with lymph node metastases. Conclusions: Thyroid nodule size and presence of calcifications on ultrasound were found to have a statistically significant association with lymph node metastases.  This information can be used to guide preoperative and intra-operative decision making and patient counseling.