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Biomedical subjects

C Enger

Publications and source records attributed to C Enger.

At least 37 records · Page 2Linked to original sources
PubMed1997

Influence of prognostic groupings and treatment results in the management of unresectable hepatoma: experience with Cisplatinum-based chemoradiotherapy in 76 patients.

PURPOSE: Internationally, hepatoma is a common cause of cancer death. Although the only curative therapy is surgical, most tumors are unresectable and cause death. The value of nonsurgical, antineoplastic therapy for such tumors is controversial. This study was undertaken to extend and confirm promising, but preliminary, treatment observations in the unresectable context. METHODS AND MATERIALS: From 1988 to 1993, 76 patients with unresectable, biopsy proven, hepatoma underwent uniform pretreatment assessment followed by induction therapy with external beam radiotherapy (21 Gy/7 fractions/10 days) and intravenous Cisplatinum, 50 mg/m2. One month later patients began monthly intrahepatic artery Cisplatinum, 50 mg/m2. Clinical course and treatment outcomes were correlated with previously published prognostic factors and groupings (Nomura et al., Okuda et al., Stillwagon, et al.). RESULTS: The toxicity of this therapy was modest and nonlimiting. Twenty-four patients (32%) progressed during induction and prior to receiving two cycles of intrahepatic artery Cisplatinum without evidence of benefit. Patients showing this early progression were more likely to be Stillwagon unfavorable than favorable (p = 0.013), Okuda Stage II than Stage I (p = 0.024), and slightly but not statistically more likely to be alpha-fetoprotein positive than alpha-fetoprotein negative (p = 0.098). The overall objective response rate was 43% (38% among AFP positive and 62% among AFP negative patients) (p = 0.15). Although 21 patients had evidence of extra hepatic metastases, survival for these patients did not differ from patients without metastases (p = 0.09) and patients with extra hepatic metastases were just as likely to show intrahepatic response (p = 0.84). CONCLUSION: The chemoradiotherapy program utilized produced objective response and minimal toxicity. One-third of patients progressed rapidly in spite of treatment. Among the remaining patients, response occurred frequently. This treatment appears to represent an important therapeutic option for many, but not all, patients with unresectable hepatoma.

Adult↗
PubMed1997

Depression and cognitive decline after coronary artery bypass grafting.

BACKGROUND: Depression is commonly reported after coronary artery bypass grafting (CABG), and after cardiac surgery in general. Many earlier reports relied on non-standard assessments of depression, which may have overestimated its frequency. Cognitive decline has also been reported after CABG. We assessed the frequency of depression after CABG by a validated depression measure (Center for Epidemiological Study of Depression, CES-D), and examined the relation between depression and cognitive decline. METHODS: Patients were tested before CABG and 1 month and 1 year after surgery with a series of neuropsychological tests that assessed a range of cognitive areas. Depressed mood was measured by the CES-D scale, and defined as a score above 16. FINDINGS: 90 (73%) of the 124 patients were not depressed before surgery, and 34 were depressed at that time. Only 12 (13%) of patients not depressed before surgery were depressed at 1 month afterwards, whereas 18 (53%) of those who were depressed before surgery were depressed at 1 month (p < 0.001). 8 (9%) patients not depressed before surgery were depressed at 1 year; 16 (47%) of patients who were depressed before CABG were depressed at 1 year (p < 0.001). Statistical analysis showed only minimal correlation-or none at all-between depression and eight areas of cognitive outcome, or between changes in depressed status and cognitive scores. INTERPRETATION: Of those patients who were depressed after CABG, the large majority were depressed before surgery. There was no correlation, moreover, between depressed mood and cognitive decline after CABG, which suggests that depression alone cannot account for cognitive decline.

Adult↗
PubMed1997

Short course radiotherapy is an appropriate option for most malignant glioma patients.

PURPOSE: To determine whether a shortened course of radiotherapy (RT) is an appropriate treatment option for malignant glioma patients. METHODS AND MATERIALS: Prognostic groups published by the Radiation Therapy Oncology Group (RTOG) are used to compare results for a short radiotherapy regimen with results of aggressive protocol treatment. The study group includes 219 patients treated during 1975-1993 with 51 Gy in 17 fractions. Patients were retrospectively assigned to six prognostic groups previously identified in a recursive partitioning analysis of the RTOG. The prognostic groups are based on age, histology, performance status, mental status, neurologic function, resection extent, length of symptoms, and RT dose. RESULTS: The six RTOG prognostic groupings were significantly predictive of outcome for patients treated with this shortened regimen (log-rank, p < 0.001). The median survival for our patients by RTOG groups 1-6 were 68, 57, 22, 13, 8, and 5 months, respectively. Two-year survival results were 64, 67, 45, 8, 3, and 3%. The median and two-year survival results for each prognostic grouping were similar to the results achieved by aggressive treatment on RTOG malignant glioma trials for selected patients. Treatment toxicity was uncommon. CONCLUSION: This shortened regimen is an appropriate treatment option for most malignant glioma patients (RTOG groups 4-6), resulting in similar survival as standard regimens with reduced patient effort and cost. Although acute side effects are acceptable and the risk of brain necrosis is low, we do not recommend this treatment to the minority of patients who have a substantial long term survival probability (RTOG groups 1-3) because long term neurocognitive assessment is lacking.

Brain Neoplasms↗
PubMed1997

Cognitive outcome after coronary artery bypass: a one-year prospective study.

BACKGROUND: Cognitive deficits have been reported in patients after coronary artery bypass grafting, but the incidence of these deficits varies widely. We studied prospectively the incidence of cognitive change and whether the changes persisted over time. METHODS: Cognitive testing was done preoperatively and 1 month and 1 year postoperatively in 127 patients undergoing coronary artery bypass grafting. Tests were grouped into eight cognitive domains. A change of 0.5 standard deviation or more at 1 month and 1 year from patient's preoperative Z score was the outcome measure. RESULTS: We identified four main outcomes for each cognitive domain: no decline; decline and improvement; persistent decline; and late decline. Only 12% of patients showed no decline across all domains tested; 82% to 90% of patients had no decline in visual memory, psychomotor speed, motor speed, and executive function; 21% and 26% had decline and improvement in verbal memory and language; approximately 10% had persistent decline in the domains of verbal memory, visual memory, attention, and visuoconstruction; and 24% had late decline (between 1 month and 1 year) in visuoconstruction. CONCLUSIONS: This study establishes that the incidence of cognitive decline varies according to the cognitive domain studied and that some patients have persistent and late cognitive changes in specific domains after coronary artery bypass grafting.

Aged↗
PubMed1997

Prospective, randomized vector analysis of astigmatism after three-, one-, and no-suture phacoemulsification.

PURPOSE: To compare surgically induced astigmatism and visual outcomes after three-, one-, and no-suture phacoemulsification. SETTING: Johns Hopkins Hospital, Baltimore, Maryland and Manhattan Eye, Ear, and Throat Hospital, New York, New York, USA. METHODS: This prospective, randomized study followed 131 patients treated with phacoemulsification with a 5.5 mm self-sealing scleral tunnel and implantation of a 5.5 mm poly(methyl methacrylate) posterior chamber lens. Radial 10-0 nylon sutures were used in the three- and one-suture groups. RESULTS: Mean astigmatism was greatest in the first postoperative week in all groups and stabilized after 8 weeks. The percentage of patients with with-the-rule (WTR) astigmatism increased from baseline in the one- and three-suture groups and decreased in the sutureless group. Mean uncorrected Snellen acuity was significantly better in the no- and one-suture groups than in the three-suture group at 1 week. There were no significant differences in uncorrected acuity at other times. No statistically significant differences in the surgically induced spherical equivalent were noted among the three groups during the 1 year follow-up. There was significantly less surgically induced keratometric astigmatism in the one-suture group at 4 (P = .03) and 8 (P = .007) weeks postoperatively. At all follow-ups, the sutureless group had the greatest proportion of patients, with significant ATR astigmatic shift (1 week, 17%; 4 weeks, 32%); and the lowest proportion of patients with significant WTR astigmatic shift (10% after 1 week). At 4 weeks, the percentage of patients with significant WTR shift in the one-suture group dropped to that in the sutureless group (10%); however, those in the one-suture group had less ATR astigmatic shift (16%). CONCLUSION: Sutureless and one-suture surgery resulted in a low percentage of WTR induced astigmatism 4 weeks postoperatively. Compared with sutureless surgery, the one-suture surgery resulted in less ATR shift.

Adult↗
PubMed1997

T cell subsets and cytomegalovirus retinitis in human immunodeficiency virus-infected patients.

A case-control study was done to investigate the relationship between T cell subsets and cytomegalovirus (CMV) retinitis in human immunodeficiency virus (HIV)-infected subjects with or without CMV retinitis and CD4+ cell counts of <0.050 x 10(9)/L. Cell surface markers on peripheral blood lymphocytes were evaluated using flow cytometry. Patients with CMV retinitis had significantly lower levels of CD8+ cells (median: 0.152 x 10(9)/L) compared with levels for controls (median: 0.296 x 10(9)/L, P < .001). Significant down-regulation of costimulatory molecule CD28+ and lymphocyte function-associated antigen-1 (LFA-1) expression was observed in patients versus controls (CD28+: 0.048 x 10(9)/L vs. 0.143 x 10(9)/L, P < .001; LFA-1: 0.238 x 10(9)/L vs. 0.400 x 10(9)/L, P < .001), but no significant differences were noted for NK cells. We propose that progressive loss of the CD3+ CD8+ cell subset and down-regulation of CD28 and LFA-1 accessory molecules are associated with an increased risk of CMV retinitis in HIV-infected patients.

AIDS-Related Opportunistic Infections↗
PubMed1997

Viral resistance and CMV retinitis: design and methods of a prospective study. CRVR Research Groups. Cytomegalovirus Retinitis Viral Resistance Research Group.

A prospective study following a cohort of patients with newly diagnosed, previously untreated cytomegalovirus (CMV) retinitis is being conducted to study drug resistant CMV. Prior to initiation of treatment, patients undergo a baseline eye examination, fundus photography, and blood and urine culture for presence of CMV, and drug susceptibility testing against positive isolates. Patients are followed monthly with a detailed eye examination to diagnose progression of retinitis, and for fundus photography. Cultures are repeated at 1 and 3 months after enrollment, every 3 months thereafter, and at the time of treatment reinduction for the progression of retinitis. This study was designed to determine the prevalence and incidence of drug resistant CMV, as well as risk factors for the development of resistant CMV. It also will determine the correlation between clinical outcome, as measured both by eye examination and fundus photography, and viral resistance.

AIDS-Related Opportunistic Infections↗
PubMed1997

Oltipraz chemoprevention trial in Qidong, People's Republic of China: study design and clinical outcomes.

In 1995, 234 adults from Qidong, Jiangsu Province, People's Republic of China, where hepatocellular carcinoma is the leading cause of cancer deaths and exposure to dietary aflatoxins is widespread, were enrolled and followed in a Phase II chemoprevention trial. The goals of the study were to define a dose and schedule of oltipraz for reducing levels of validated aflatoxin biomarkers and to characterize dose-limiting toxicities. Healthy eligible individuals, including those infected with hepatitis B virus, were randomized to receive either 125 mg of oltipraz daily, 500 mg of oltipraz weekly, or placebo. Blood and urine specimens were collected to monitor toxicities and evaluate biomarkers over the 8-week intervention period and subsequent 8-week follow-up period. Unique trial aspects included a synchronous follow-up schedule, daily observed administration of all medications, timely international data transference, and use of biomarkers as outcomes. One hundred thirty-two participants took their medications without interruptions, approximately 77% contributed all nine urine samples, and 78% contributed all seven blood samples. Fifty-one participants (21.8%) reported clinical adverse events. An extremity syndrome, developing soon after the start of treatment, was the only event that occurred more frequently (P = 0.002) among the active groups (18.4 and 14.1% of the daily 125 and weekly 500 mg arms, respectively) compared with placebo (2.5%). The oltipraz arms did not differ in symptom type or severity, and there were no indications of exacerbated drug intolerance among the few participants infected with hepatitis B virus. The good compliance with an intense follow-up schedule shows that chemoprevention trials with biomarker end points may be conducted in such populations.

Adult↗
PubMed1996

Survival from early, intermediate, and late stages of HIV infection.

OBJECTIVE: To estimate expected survival time among homosexual men infected with the human immunodeficiency virus type 1 (HIV-1) by (1) the calendar period before (1985-1988) and after (1989-1993) the widespread availability of acquired immunodeficiency syndrome (AIDS) treatments with antiretroviral and prophylactic interventions, and (2) stage of HIV disease. DESIGN: A prospective cohort study. A group of HIV-1-infected homosexual men were followed from July 1985 through June 1993 and evaluated every 6 months for the presence of clinical symptoms and measurement of the CD4 cell count. To measure the effectiveness of AIDS therapies in this nonrandomized study, we used 2 calendar periods as proxy measures of relative intensity of exposure to antiretroviral therapy. Stage of infection was defined by CD4 cell count and presence of HIV-related clinical symptoms or AIDS. SETTING AND STUDY PARTICIPANTS: Homosexual men infected with HIV-1 from the Multicenter AIDS Cohort Study. MAIN OUTCOME MEASURE: Survival time based on stage of HIV infection. RESULTS: The percentage of HIV-1-infected individuals free of AIDS and clinical symptoms at baseline who survived 2.5 years according to baseline CD4 cell counts of 0 to 0.100, 0.101 to 0.200, and 0.201 to 0.350 x 10(9)/L was 22%, 53%, and 83%, respectively, for the 1985-1988 calendar period, compared with 54%, 71%, and 91%, respectively, for men in the 1989-1993 calendar period. Among men free of AIDS with CD4 cell counts of greater than 0.350 x 10(9)/L, the relative hazard of mortality was 1.6 to 2.3 times higher for those with clinical symptoms compared with those free of clinical symptoms. CONCLUSIONS: Survival of AIDS-free HIV-1-infected individuals with CD4 cell counts of less than 0.350 x 10(9)/L has improved since antiretroviral and HIV prophylactic treatments have become available, but the long-term prognosis remains poor.

Antiviral Agents↗
PubMed1996

Risk factors for ocular injuries caused by air guns.

OBJECTIVE: To identify factors associated with an increased risk of ocular air gun injury among 5- to 19-year-olds. DESIGN: Case-control study. STUDY PARTICIPANTS: Cases of ocular air gun injury were identified through two ocular trauma registries. Two randomly selected control groups were identified, both through random digit dialing. Air gun-exposed controls had handled an air gun in the previous 12 months, whereas community controls had not. Parents of the cases and controls were contacted for a standardized telephone interview. The study included 124 cases, 237 air gun controls, and 159 community controls. MAIN OUTCOME MEASUREMENTS: Circumstances of the event, typical air gun use, and demographic characteristics. RESULTS: Cases were 24 times (95% confidence interval, 6.3 to 93.6) more likely to have no adult supervision at the time of air gun use than the air gun controls, almost 12 times (95% confidence interval, 3.3 to 41.1) more likely to have been at a friend's home rather than their own, and five times (95% confidence interval, 1.4 to 20.9) more likely to have been indoors at the time of air gun use. This may indicate that the air gun was handled without a specified purpose, supported by the almost six-fold (95% confidence interval, 2.2 to 14.8) increased risk of injury when the air gun was used for a purpose other than target practice. CONCLUSIONS: Unsupervised access to air guns and unstructured air gun use are the principal risk factors for ocular injury. Strategies to educate parents concerning the need to supervise such access may help to reduce this source of preventable vision loss.

Adolescent↗
PubMed1996

Cytomegalovirus retinitis and viral resistance. Prevalence of resistance at diagnosis, 1994. Cytomegalovirus Retinitis and Viral Resistance Study Group.

OBJECTIVE: To determine the prevalence of cytomegalovirus (CMV) isolates resistant to ganciclovir sodium or foscarnet sodium at the time of diagnosis of CMV retinitis, prior to the initiation of therapy. DESIGN: Prospective epidemiologic study. SETTING: An acquired immunodeficiency syndrome ophthalmology clinic. PATIENTS: Patients with acquired immunodeficiency syndrome and newly diagnosed CMV retinitis. INTERVENTION: Culturing blood and urine samples for CMV and testing of all positive isolates for sensitivity to ganciclovir and foscarnet. MAIN OUTCOME MEASURE: Prevalence of the following: blood culture isolates resistant to ganciclovir (inhibitory concentration 50% [IC50] > 5.5 mumol/L) or foscarnet (IC50 > 400 mumol/L) and urine culture isolates resistant to ganciclovir or foscarnet. RESULTS: Forty-nine patients were enrolled during a 13-month period. Forty-four patients had blood culture samples that could be evaluated; of these, 66% were positive (59% of patients). Thirty-four patients had urine cultures that were evaluable; of these, 82% were positive (57% of patients). Overall, 78% of patients had either a urine or blood culture sample positive for CMV. No blood culture isolates were resistant to ganciclovir, and only 1 urine culture isolate (2% of patients) was resistant to ganciclovir. Three percent of blood culture isolates and 4% of urine culture isolates (2% and 2% of patients, respectively) were resistant to foscarnet. Overall, 4% of patients had either a blood or urine culture isolate resistant to foscarnet. CONCLUSION: Resistance to ganciclovir or foscarnet at the time of diagnosis of CMV retinitis is uncommon.

AIDS-Related Opportunistic Infections↗
PubMed1996

Interobserver and intraobserver variability in the detection of glaucomatous progression of the optic disc.

PURPOSE: To evaluate the potential value of obtaining follow-up stereoscopic photographs on glaucoma suspects in identifying progressive optic nerve damage. METHODS: Nineteen sets of stereoscopic optic disc photographs, reflecting one eye from each of 19 patients at two time points, were selected from the records of subjects enrolled in the Glaucoma Screening Study. By consensus, three experts judged 13 of these eyes to have progressive glaucomatous optic nerve damage. Four other ophthalmologists who were masked to the expert panel evaluation then assessed glaucomatous progression in the same eyes. They were asked to evaluate glaucomatous progression in three ways: first, by drawing the optic nerve head appearance from initial stereoscopic photographs and later comparing their own drawings to follow-up stereoscopic photographs; second, by comparing serial stereoscopic photographs directly; and third, by comparing drawings of the optic nerve head made by another examiner to the follow-up photographs. RESULTS: Neither sensitivity nor specificity was consistently better for serial stereoscopic photographs than for drawings. Individual ophthalmologist agreement rates with the expert panel's determinations of progression were 23-62% when examiners compared their own drawings to follow-up photographs, 54-71% when examiners compared serial stereoscopic photographs, and 38-85% when comparing another ophthalmologist's drawings to follow-up photographs. CONCLUSION: Baseline stereoscopic photographs of the optic nerve head did not substantially improve recognition of progressive glaucomatous optic nerve damage when compared with the use of baseline drawings of the optic nerve head made from photographs in subjects who developed visual loss in the interim.

Disease Progression↗
PubMed1995

The association of lymphocytotoxic antibodies with corneal allograft rejection in high risk patients. The Collaborative Corneal Transplantation Studies Research Group.

The Collaborative Corneal Transplantation Studies are a pair of multicenter prospective clinical trials evaluating the effectiveness of histocompatibility matching in high risk keratoplasty patients. The antigen matching study (AMS) evaluated HLA matching in patients without circulating lymphocytotoxic antibody to HLA antigens and the cross-match study (CS) evaluated the effect of using cross-match-negative donors in patients with identified circulating lymphocytotoxic antibodies to HLA antigens. Sera from 510 patients considered for enrollment in the studies were screened preoperatively for the presence of anti-class I lymphocytotoxic antibodies (LA). The 42 patients (8%) found to have detectable LA entered the CS. The 468 patients found not to have detectable LA preoperatively entered the AMS. Fifteen of the 37 transplanted CS patients were found to have donor-specific anti-class I antibody (before or after surgery). These patients were also screened for anti-class II LA and 25 had anti-class II panel reactive antibody > or = 5%. Forty-nine of the 419 transplanted AMS patients (12%) were found to have produced anti-class I LA after surgery, and in 19 patients, antibody specificities were those of donor HLA antigens. There was a significant association between the number of mismatched class I antigens and the number of donor-specific LA produced. The production of LA by AMS patients was significantly associated with reaction episodes; eighty-two percent of patients (40 of 49) with LA had reaction, compared with 63% of patients (230 of 365) without LA (P = 0.02). Likewise, production of donor-specific LA was significantly associated with immune-mediated graft failure (P = 0.025). For CS patients, there was no correlation between the production of donor-specific anti-class I or nonspecific anti-class II antibodies and graft outcome. However, the CS patients had poorer graft survival than did AMS patients at 3 years (57% vs. 66%, P = 0.01). These data demonstrate that LA, especially directed against donor class I HLA antigens following corneal transplantation in high risk patients, are associated with immune graft rejection and can be an indicator of allograft rejection.

Antilymphocyte Serum↗
PubMed1995

Patient-reported symptoms associated with graft reactions in high-risk patients in the collaborative corneal transplantation studies. Collaborative Corneal Transplantation Studies Research Group.

The Collaborative Corneal Transplantation Studies (CCTS) were designed to evaluate the effect of donor-recipient histocompatibility matching and cross-matching on the survival of corneal transplants in high-risk patients. We now report on the role of symptoms in the detection of corneal allograft reactions in the CCTS and on the relationship between symptom reporting and graft survival. The 456 patients transplanted in the CCTS were followed for a minimum of 2 years or until graft failure. The follow-up protocol included 11 scheduled examinations in the first year, four examinations during the second year, and examinations every 6 months thereafter. Interim examinations were performed in response to patient-reported symptoms. At every examination, patients were asked specifically if they had redness, sensitivity to light, loss of vision, or pain (RSVP). Of the 456 patients transplanted, 62% had at least one graft reaction. Patients diagnosed with reactions at scheduled visits in the first postoperative year were 2.5 times more likely to report symptoms than those without reactions. Reports of red eye and vision loss were strongly associated with allograft reaction. However, these symptoms were neither highly sensitive nor specific for reaction (sensitivity = 46%, specificity = 70% at 6 months). The severity of reaction influenced the reporting of symptoms: 69% of patients with severe reactions reported symptoms versus 48% of patients with mild reactions (p < 0.001). The only patient characteristic associated with reliable symptom reporting was age, with younger patients with reactions being more likely to report symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

Strabismus in the Marfan syndrome.

We studied 573 patients with the Marfan syndrome for the presence of ocular misalignment, refractive errors, and amblyopia. A total of 110 patients (19.2%) had strabismus. Of 573 patients, exotropia occurred in 67 (11.7%), esotropia in 12 (2.1%), vertical deviations in eight (1.4%), and primary inferior oblique muscle overaction in three (0.5%). Of 67 patients with exotropia, 18 had anisometropia and 39 had amblyopia. Of the 12 patients with esotropia, four had amblyopia and none had anisometropia. Exotropia and esotropia are more common in patients with the Marfan syndrome than in the general population of the United States (P < .001 for exotropia and .05 < P < .10 for esotropia). Abnormal afferent visual inputs to cortical centers caused by ectopia lentis, craniofacial abnormalities, and mechanical and genetic factors may all contribute to the higher prevalence of strabismus in this disease.

Adolescent↗