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J Verter

Publications and source records attributed to J Verter.

At least 37 records · Page 2Linked to original sources
PubMed1996

Early-onset sepsis in very low birth weight neonates: a report from the National Institute of Child Health and Human Development Neonatal Research Network.

OBJECTIVE: Early-onset sepsis (occurring within 72 hours of birth) is included in the differential diagnosis of most very low birth weight (VLBW) neonates. To determine the current incidence of early-onset sepsis, risk factors for disease, and the impact of early-onset sepsis on subsequent hospital course, we studied a cohort of 7861 VLBW neonates (401 to 1500 gm) admitted to the 12 National Institute of Child Health and Human Development (NICHD) Neonatal Research Network centers during a 32-month period (1991-1993). METHODS: The NICHD Neonatal Research Network maintains a prospectively collected registry on all VLBW neonates born or cared for at participating centers. Data from this registry were analyzed retrospectively. RESULTS: Blood culture-proven early-onset sepsis was uncommon, occurring in only 1.9% of VLBW neonates. Group B streptococcus was the most frequent pathogen associated with early-onset sepsis (31%), followed by Escherichia coli (16%) and Haemophilus influenzae (12%). Decreasing gestational age was associated with increased rates of infection. Antibiotic therapy for suspected sepsis is frequently initiated at birth in VLBW neonates. Almost half of the infants in this cohort were considered to have clinical sepsis and continued to receive antibiotics for 5 or more days, despite a negative blood culture result in 98% of cases. These findings underscore the difficulty of ruling out sepsis in the symptomatic immature neonate and the special concern for culture-negative clinical sepsis in the face of maternal antibiotic use. Neonates with early-onset sepsis were significantly more likely to have subsequent comorbidities, including severe intraventricular hemorrhage, patent ductus arteriosus, and prolonged assisted ventilation. Although 26% of VLBW neonates with early-onset sepsis died, only 4% of the 950 deaths that occurred in the first 72 hours of life were attributed to infection. For those infants discharged alive, early-onset sepsis was associated with a significantly prolonged hospital stay (86 vs 69 days; p <0.02). CONCLUSIONS: Early-onset sepsis remains an important but uncommon problem among VLBW preterm infants. Improved diagnostic strategies are needed to enable the clinician to distinguish between the infected and the uninfected VLBW neonate with symptoms and to target continued antibiotic therapy to those who are truly infected.

Age of Onset↗
PubMed1996

Interlaboratory variability of bilirubin measurements.

During an 8-month study, 14 laboratories used automated analytical systems to measure total bilirubin concentrations in lyophilized bovine specimens containing 38, 169, and 253 micromol/L bilirubin (2.2, 9.9, and 14.8 mg/dL, respectively). The measured mean +/- SD (n, range) were: 39 +/- 7 micromol/L (n = 90, 31-53) [2.3 +/- 0.4 mg/dL (1.8-3.1)]; 176 +/- 29 micromol/L (n = 89, 146-222) [10.3 +/- 1.7 mg/dL (8.5-13.0)]; and 260 +/- 43 micromol/L (n = 103, 208-316) [15.2 +/- 2.5 mg/dL (12.1-18.5)]. In comparison with target values, measurements were consistently lower at 4, higher at 6, and within +/- 4% at 4 laboratories for each of the three concentrations. The measured values for each concentration remained fairly constant during the study at each laboratory. We conclude that bilirubin measurements differed significantly from the established target values at most of the participating laboratories.

Animals↗
PubMed1994

Prophylaxis for stress-related gastric hemorrhage in the medical intensive care unit. A randomized, controlled, single-blind study.

OBJECTIVE: To determine the efficacy and safety of cimetidine and sucralfate prophylaxis for stress-related gastrointestinal hemorrhage in patients admitted to a medical intensive care unit. SETTING: Medical intensive care unit of a nonprofit, university-affiliated teaching hospital. PATIENTS: 300 patients admitted to the medical intensive care unit during a 10-month period. DESIGN: Randomized, controlled, single-blind clinical trial. INTERVENTION: Patients were assigned to receive no prophylaxis (control), 1 g sucralfate given orally every 6 hours, or continuous intravenous cimetidine titrated to maintain gastric pH at 4.0, intervention was maintained until the occurrence of clinically severe hemorrhage, onset of drug-related complications, death, or discharge from the medical intensive care unit. OUTCOME MEASURES: The primary outcome measure was the incidence of clinically severe hemorrhage from endoscopically verified stress-related gastritis. Other outcome measures were transfusion requirements, duration of medical intensive care unit stay, incidence of nosocomial pneumonia, adverse drug reactions, and death. RESULTS: 100 patients were randomly assigned to each treatment. The three groups were similar with regard to demographic characteristics, intensive care unit admission diagnoses, and APACHE II scores. Stress-related hemorrhage was seen in 6% of control participants and in 5% of those receiving sucralfate or cimetidine (relative risk compared with control, 0.83 for each group; 95% CI, 0.26 to 2.64; P = 0.75). No statistically significant differences were found for transfusion requirements, duration of medical intensive care unit stay, and mortality rates among the three groups. Nosocomial pneumonia was diagnosed in 6%, 12%, and 13% of controls, sucralfate recipients, and cimetidine recipients, respectively (sucralfate: relative risk, 2.0 [CI, 0.79 to 5.01], P = 0.14; cimetidine: relative risk, 2.2 [CI, 0.88 to 5.33], P = 0.09). Prophylaxis caused no definite adverse drug reactions. CONCLUSIONS: The observed effects of cimetidine and sucralfate on the incidence and severity of hemorrhage from stress-related gastritis were not significant when compared with no treatment. Routine prophylaxis with these agents for patients entering the medical intensive care unit does not seem warranted.

Adult↗
PubMed1994

Bilirubin production in healthy term infants as measured by carbon monoxide in breath.

To describe total bilirubin production in healthy term infants, we measured the end-tidal breath CO, corrected for ambient CO (ETCOc), with an automated sampler and electrochemical (EC) CO instrument. For infants of mothers with a negative Coombs' test, the ETCOc was 1.3 +/- 0.7 microL/L (n = 397) and the serum bilirubin on day 3 postpartum was 73 +/- 35 mg/L (n = 381). In contrast, the ETCOc for infants with ABO or Rh incompatibility, a positive direct Coombs' test, and bilirubin > 130 mg/L (n = 9) was significantly higher, 1.8 +/- 0.8 microL/L, than for those who had a positive Coombs' test result but whose bilirubin was < or = 130 mg/L (n = 12), 1.0 +/- 0.5 microL/L (P < 0.05). At 2 to 8 h postpartum seven term babies from mothers with insulin-dependent diabetes had ETCOc of 1.8 +/- 0.7 microL/L, significantly higher than that in the other term infants [1.3 +/- 0.7 microL/L (n = 390), P < 0.04]. Their bilirubin concentration at 72 +/- 12 h was also higher: 121 +/- 45 mg/L (n = 7) vs 73 +/- 34 mg/L (n = 374; P = 0.03). We conclude that ETCOc measurements may be helpful in understanding the mechanisms of jaundice in healthy term infants in a variety of conditions.

Asian↗
PubMed1993

Data monitoring in the cardiac arrhythmia suppression trial.

OBJECTIVE: This report discusses practical aspects of data monitoring in a clinical trial which stopped ahead of schedule due to adverse findings. DESIGN: A review of the considerations and decisions made by the data-monitoring committee of the Cardiac Arrhythmia Suppression Trial (CAST), a randomized, double-blind clinical trial. PATIENTS: CAST consisted of men and women with a recent myocardial infarction, asymptomatic or minimally symptomatic ventricular arrhythmias, and reduced left ventricular ejection fraction. INTERVENTIONS: In CAST, 3 antiarrhythmic agents, encainide, flecainide, and moricizine, were compared against placebo. MAIN OUTCOME MEASURES: The main outcome measures in CAST were arrhythmic death and total mortality. RESULTS: CAST found the 3 agents to be harmful. Encainide and flecainide were stopped first. Subsequently, moricizine was discontinued ahead of schedule. CONCLUSIONS: The complexity of the study design and a midcourse protocol modification raise several data-monitoring issues not previously discussed. These include how to handle apparently dramatic yet unexpected results, the need for flexibility in modifying study design and goals, and the conflict between existing study data and both conventional wisdom and medical practice.

Anti-Arrhythmia Agents↗
PubMed1993

Psychosocial predictors of mortality in the Cardiac Arrhythmia Suppression Trial-1 (CAST-1).

Psychosocial variables predict the recurrence of clinical events in symptomatic patients, controlling for measures of disease severity. The Cardiac Arrhythmia Suppression Trial-1, a pharmacologic test of the arrhythmia suppression and mortality hypothesis among postmyocardial infarction patients, allowed a prospective test of the relationship of distress, perceived support, social interaction, life stress, and other variables, to mortality, adjusting statistically for ejection fraction, arrhythmia rates, and other known risk factors for coronary heart disease. Results indicated that the treatment medications, encainide and flecainide, were powerful predictors of mortality. Although the psychosocial variables were significant as univariate predictors, these variables were not significant as predictors in a multivariate model that included drug treatment. When the data analysis was restricted to patients randomized to placebo, thereby eliminating the antiarrhythmic drug effect, the level of perceived social support was a significant multivariate predictor of mortality, adjusting for measures of disease severity. The adjusted hazards ratio for a 1-point decrease in the perceived support score is equal to 1.46, based on the multivariate model.

Arrhythmias, Cardiac↗
PubMed1993

Thrombolytic therapy for unstable angina.

Thrombolytic therapy for unstable angina has not gained acceptance as a primary treatment for unstable angina (UA) despite the evidence showing a reduction in mortality when these agents are given for myocardial infarction. The purpose of this review is to examine the clinical value of thrombolytic therapy for UA. The multiple lines of evidence supporting intracoronary thrombus formation as a key mechanism in the pathogenesis of UA are reviewed. Studies examining the effect of thrombolytic therapy on angiographic endpoints have shown little effect on the extent of luminal narrowing, but do reveal a decrease in angiographically detected thrombus. Twelve randomized, controlled trials of thrombolytic agents in 611 UA patients with predefined clinical endpoints have been published. These trials varied widely in design and adjunctive therapy both in treated and control grops. Review of these trials show a tendency to fewer clinical events such as death, infarction, and need for revascularization in treated patients, with a corresponding increase in bleeding complications. Clinical efficacy of thrombolytic therapy cannot be excluded by the available data, perhaps in part because of insufficient numbers of patients treated. Determination of the net clinical value of thrombolytic therapy must await larger and more definitive trials.

Angina, Unstable↗
PubMed1991

Randomizing responders. Cardiac Arrhythmia Suppression Trial (CAST) investigators.

Three clinical trial designs for use in testing the effect of long-term drug therapy on an outcome are considered: empiric (randomization to one of several specified and fixed therapies); randomization followed by dose-adjustment of the drug; and dose adjustment followed by randomization of responders. It is shown that the latter, though some information may be lost and bias may be introduced, can be more efficient because of the reduction of noise. These results are illustrated using information gathered by the Cardiac Arrhythmia Pilot Study (CAPS) and Cardiac Arrhythmia Suppression Trial (CAST), the former being a pilot study using the second design, and the latter a large clinical trial adopting the third design. For CAST, the efficiency (represented by ratio of sample sizes) is 0.78 relative to the empiric design, and 0.6 relative to the design incorporating randomization followed by dose adjustment.

Anti-Arrhythmia Agents↗
PubMed1989

Classification of deaths after myocardial infarction as arrhythmic or nonarrhythmic (the Cardiac Arrhythmia Pilot Study).

The Cardiac Arrhythmia Pilot Study (CAPS) was a randomized, double-blind trial of antiarrhythmic drugs (encainide, flecainide, moricizine, imipramine and placebo) in 502 patients with at least 10 ventricular premature complexes/hour, 6 to 60 days after acute myocardial infarction. CAPS tested the feasibility of performing a larger study to determine if suppression of ventricular ectopic activity after acute myocardial infarction could improve survival. Patients in CAPS were followed for 1 year. All death or cardiac arrest events were evaluated by at least 2 investigators using a classification scheme that characterized the underlying mechanism as cardiac arrhythmic, cardiac nonarrhythmic or noncardiac. Forty-five patients (9%) died or had cardiac arrest during the 1-year follow-up, 29 (64%) within 1 hour from the onset of symptoms and 16 greater than 1 hour from the onset of symptoms. Twenty-three deaths (51%) were classified as arrhythmic, 19 (42%) as nonarrhythmic and 3 (7%) as noncardiac. Acute myocardial ischemia or infarction was associated with the death/cardiac arrest event in 16 patients (36%), 8 in the arrhythmic death group. Discrepancies in classification among reviewers were particularly common in patients with long-standing symptoms of congestive heart failure, in whom it was frequently difficult to identify the precise moment of the onset of symptoms in the death/cardiac arrest event. Using only the temporal relation of symptoms to categorize deaths or cardiac arrests, the mechanism of 12 (27%) of the 45 patients was in disagreement with the classification based on the Events Committee review. Classification of death as sudden or nonsudden is not equivalent to the classification of death as arrhythmic or nonarrhythmic.

Anti-Arrhythmia Agents↗
PubMed1987

Serum lipids and lipoproteins after myocardial infarction: associations with cardiovascular mortality and experience in the Aspirin Myocardial Infarction Study.

Serum cholesterol and triglyceride levels were measured at baseline in 4021 men and 503 women (myocardial infarction survivors) participating in the Aspirin Myocardial Infarction Study (AMIS). A cohort of participants (1824 men and 226 women) had, in addition, a determination of high-density lipoprotein (HDL) cholesterol and an estimate of low-density lipoprotein (LDL) cholesterol. In comparison with values obtained for normal Americans by the Lipid Research Clinics Prevalence Study Group, AMIS participants had higher serum cholesterol, higher serum triglyceride, higher LDL cholesterol, and lower HDL cholesterol levels. These values were the most disparate in the women and younger men. The serum total cholesterol, the ratio of LDL to HDL cholesterol, and the serum triglyceride level were significantly related (p less than 0.05) to the 3-year cardiovascular mortality rate for men less than 55 years of age (univariate relationships). For men older than 55 years, these relationships were not statistically significant. After adjustment for multiple risk factors, serum cholesterol and the ratio of LDL to HDL cholesterol remained significant risk factors for cardiovascular death and the combined incidence of cardiovascular death or nonfatal myocardial infarction in men less than age 55 years.

Adult↗
PubMed1984

The prognostic significance of proteinuria: the Framingham study.

Despite considerable clinical experience with proteinuria, its prognostic meaning in the ambulatory general population is poorly documented. From a 16-year study of 5209 men and women in the Framingham cohort it is evident that proteinuria, even in casual urine specimens, carries substantial risk with the mortality rate increased threefold. Proteinuria was three times as common in hypertensive persons and also occurred to excess in diabetic patients and in persons with cardiac enlargement. In the absence of these factors, proteinuria was so uncommon that its risk could not be accurately assessed. Among persons with these associated risk factors, those with proteinuria have higher death rates than those without proteinuria. In men, overall mortality and cardiovascular mortality rates remained significantly increased even when other contributors to risk were taken into account. Proteinuria in the ambulatory general population is not a benign condition and carries a serious prognosis. It appears to reflect widespread vascular damage.

Adult↗
PubMed1984

Timing, mechanism and clinical setting of witnessed deaths in postmyocardial infarction patients.

The temporal distribution and mechanism of death were studied in a large multicenter secondary prevention trial (Aspirin Myocardial Infarction Study) in which acute witnessed death represented 72% (270 of 376) of the deaths due to arteriosclerotic heart disease. Instantaneous deaths represented 28.9% (78 of 270) of the acute witnessed deaths; 45.2% (122 of 270) occurred in the first hour after the onset of symptoms and were defined as sudden deaths. In the subsequent 23 hours, an additional 113 deaths (41.8%) occurred and were defined as intermediate deaths; 29 late deaths (10.7%) occurred after 24 hours. Cardiac arrhythmia was the mechanism of death in 83% (194 of 235) of deaths within 24 hours. Univariate analysis of baseline clinical and electrocardiographic characteristics indicates that a history of congestive heart failure, cardiomegaly, angina pectoris, multiple myocardial infarctions and therapy with digitalis and nitroglycerin were more common in those who died than in survivors, regardless of the timing of death.

Arrhythmias, Cardiac↗
PubMed1983

Manifestations of coronary disease predisposing to stroke. The Framingham study.

Coronary heart disease (CHD) was examined as a precursor of stroke based on 24 years of biennial examinations, during which time 344 strokes occurred. Routine ECGs, chest roentgenograms, and BP levels were obtained, CHD and cardiac failure status were evaluated at each examination, and risk of stroke was ascertained. The five major CHD risk factors jointly were actually as predictive of stroke as CHD. The dominant stroke risk factors were hypertension, clinical manifestations of CHD, cardiac failure, atrial fibrillation, and ECG and roentgenographic evidence of a compromised coronary circulation. Coronary heart disease almost tripled the risk of a stroke, and cardiac failure was associated with more than a fivefold increased risk. Angina pectoris carried half the risk of myocardial infarction. Coronary disease and cardiac failure added to the risk of stroke associated with hypertension. Coronary heart disease increased stroke risk in the absence of hypertension or cardiac failure, but risk was greatly augmented when these coexisted.

Adult↗
PubMed1983

Current status of risk factors for stroke.

Prevention of stroke is the key to reduction of morbidity and mortality from stroke and requires correction of the precursors of stroke in susceptible individuals, the single most important measure being vigorous and sustained control of hypertension. Current studies provide important clues to pathogenesis and thereby provide strategies for prevention.

Adult↗
PubMed1978

Disproportionate ventricular septal thickening in the developing normal human heart.

A disproportionately thickened ventricular septum containing numerous disorganized cardiac muscle cells is the most characteristic anatomic feature of hypertrophic cardiomyopathy. Since information concerning ventricular wall thicknesses and cellular arrangement in the developing heart may be pertinent to understanding the genesis of hypertrophic cardiomyopathy, morphologic observations were made in 151 normal human embryos, fetuses and term infants. Disproportionate ventricular septal thickening (septal-free wall ratio greater than or equal to 1.3) was present in 94% of embryos and young fetuses; in over one-third disproportionate thickening was particularly pronounced (septal-free ratio greater than or equal to 2.0). Disproportionate septal thickening was also present in 65% of older fetuses, but in only 12% of infants over two weeks of age. Septal-free wall ratio decreased in a curvilinear fashion with increasing age and apporixmated unity in the newborn. This phenomenon occurred because, while both ventricular septal and left ventricular free wall thicknesses increased directly with age, free wall thickness increased at a greater rate than septal thickness, particularly after birth. Marked cellular disorganization in the septum was not a feature of the hearts studied.

Female↗