Withdrawing life-sustaining treatment from people with severe disabilities who request it: equal protection considerations.
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Biomedical subjects
Publications and source records attributed to D Coleman.
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Among 347 AIDS patients seen at St Mary's Hospital, London between 1983 and 1989, cytomegalovirus (CMV) disease was observed in 75 (22%). Of these, 58 (77%) had CMV retinitis, 26 (35%) CMV colitis, and 12 (16%) had CMV infection diagnosed at other sites. Relapse occurred in 71%. A favourable response to the use of ganciclovir as induction therapy for CMV retinitis was observed in 92%. Relapse of CMV retinitis occurred in 54% at a median time of 97 days. Neutropenia was the most frequent and serious side-effect of ganciclovir, 76% patients having neutrophil counts less than 1.0 x 10(9)/l and 48% less than 0.5 x 10(9)/l at some stage of therapy. Thrombocytopenia was also common, and platelet counts of less than 50 x 10(9)/l occurred in 43% patients on ganciclovir. The concurrent use of zidovudine made the development of severe neutropenia and thrombocytopenia more likely. Median survival following the diagnosis of CMV disease increased from 5-8 months between 1984 and 1987, to over 12 months in 1988. Patients with CMV colitis had a worse prognosis than patients with CMV retinitis, with median survival of 4.5 and 7 months respectively. In conclusion, CMV is an important opportunist infection in AIDS and both the disease and its treatment cause considerable morbidity. Hence, it is important to develop more effective and less toxic forms of therapy for CMV infection.
The limitations of case review as a means of identifying errors in death certificates among breast cancer patients in a non-randomised trial of screening are illustrated by the findings of this large study. Records of 928 out of 990 deaths were available for review but were very variable in quality. Definite errors were found in 1%, errors were suspected in a further 5% and uncertainty about the cause of death, despite review, was recorded for 27%. The overall bias in reporting breast cancer deaths was less than 1%. It was concluded that the certified underlying cause of death without review provides an adequate endpoint for evaluating breast cancer screening programmes in the UK.
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A pneumatically powered artificial heart, constructed primarily from a polyurethane, was implanted in the chest of a calf and supported the calf for more than 6 months. The heart, which was designed to fit in the chest of a 90 kilogram calf, was able to suppor the animal when it weighed 180 kilograms. During the first 105 days the calf remained strong and healthy. The animal grew progressively weaker after day 106, and by day 160 right heart failure became apparent. The principal cause of the right heart failure was an obstructive growth between the right atrium and the right ventricle. An attempt to correct the problem on day 184 with an artificial heart resulted in the animal's death.
This report summarizes the surface changes seen in artificial hearts implanted in calves for periods up to four months. Fabrication defects as well as degradation resulting from wear are identified. SEM evaluation of the blood contacting surface as well as the surface of the diaphragm associated with the drive mechanisms has revealed potential problems with current heart designs and methods of fabrication. Materials evaluation of implanted hearts is crucial for a clinically useful system to evolve.
Two methods of preparing sensitivity disks were compared for their effect on disk stability at 25 and 37 C. One method consisted of applying a solution of the antibiotic to blank disks by the conventional procedure; the second method consisted of applying the antibiotic to the disks as a suspension of crystals. Of the four beta-lactam antibiotics that were studied, disks made with suspended crystals were substantially more stable than corresponding disks made by the conventional method. The increased stability is related to the greater chemical stability of the antibiotics in the crystalline versus the amorphous state.
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Between January 1973 and February 1975, 77 adults with acute nonlymphoblastic leukemia were treated with a combination of daunorubicin, cytosine arabinoside, 6-thioguanine, prednisone, and vincristine in university-affiliated and private institutions. After 31 patients were treated (regimen 1) the doses of all drugs were significantly increased (regimen 2). Regimes 1 and 2 yielded CR rates of 59% (17 of 29 patients) and 70% (32 of 46 patients) respectively. With regimens 2 the mean number of courses and the median number of days to CR decreased from 3 to 1.4 and from 46 to 29 respectively. Failure to achieve CR was due to persistent leukemia during regimen 1 and fatal infections during regimen 2. With regimen 2 ten of 20 patients (50%) greater than 50 years had CR compared to 22 of 26 patients (85%) less than 50 years. CR rates were similar in community and university institutions.