Biomedical subjects

M Goormastic

Publications and source records attributed to M Goormastic.

At least 55 records · Page 3Linked to original sources

PubMed1997

Early results with partial left ventriculectomy.

OBJECTIVE: We sought to determine the role of partial left ventriculectomy in patients with dilated cardiomyopathy. METHODS: Since May 1996 we have performed partial left ventriculectomy in 53 patients, primarily (94%) in heart transplant candidates. The mean age of the patients was 53 years (range 17 to 72 years); 60% were in class IV and 40% in class III. Preoperatively, 51 patients were thought to have idiopathic dilated cardiomyopathy, one familial cardiomyopathy, and one valvular cardiomyopathy. As our experience accrued we increased the extent of left ventriculectomy and more complex mitral valve repairs. For two patients mitral valve replacement was performed. For 51 patients the anterior and posterior mitral valve leaflets were approximated (Alfieri repair); 47 patients also had ring posterior annuloplasty. In 27 patients (51%) one or both papillary muscles were divided, additional left ventricular wall was resected, and the papillary muscle heads were reimplanted. RESULTS: Echocardiography showed a significant decrease in left ventricular dimensions after resection (8.3 cm to 5.8 cm), reduction in mitral regurgitation (2.8+ to 0), and increase in forward ejection fraction (15.7% to 32.7%). Cardiac index did not increase significantly (2.2 to 2.4 L/min per square meter). Eight patients (15%) required a perioperative left ventricular assist device; one died and was the only perioperative mortality (1.9%). At 11 months, actuarial survival was 87% and freedom from relisting for transplantation was 72%. CONCLUSIONS: Improved selection criteria are necessary to avoid early failures, and much more follow-up and analyses of data are mandatory. However, the operation may become a biologic bridge, or even alternative, to transplantation.

Cardiomyopathy, Dilated↗

PubMed1997

G-CSF post-autologous progenitor cell transplantation: a randomized study of 5, 10, and 16 micrograms/kg/day.

G-CSF is routinely administered after autologous bone marrow or peripheral blood progenitor cell transplantation to enhance neutrophil engraftment. However, many different doses of G-CSF have been described with no clear consensus on the most cost-effective dose. We performed a prospective randomized trial examining the efficacy of three different doses of G-CSF post-autologous transplant (5, 10, or 16 micrograms/kg/day). Fifty-seven consecutive patients with breast cancer (n = 30), non-Hodgkin's lymphoma (n = 16), Hodgkin's disease (n = 6), multiple myeloma (n = 2), acute leukemia (n = 2), and testicular cancer (n = 1) were randomized, with 19 patients enrolled in each of the three treatment groups. All patients underwent a high-dose chemotherapy preparative regimen and received an autologous peripheral blood progenitor cell (PBPC) transplant (without bone marrow), with G-CSF beginning on day 0. There was no difference in time to neutrophil engraftment among the three treatment groups (mean 10.2 to 10.8 days). There is a trend towards earlier platelet engraftment in the patient group receiving 5 microgram/kg/day of G-CSF. The total cost of G-CSF by dose group was $2900, $4400, and $6500 per patient. We conclude that there was no advantage to the use of higher doses of G-CSF after autologous transplantation, and that lower doses are associated with lower costs.

Adult↗

PubMed1997

Durability of remission after ABMT for NHL: the importance of the 2-year evaluation point.

Few series describing the results of autologous bone marrow transplantation (ABMT) for the treatment of non-Hodgkin's lymphoma report mature follow-up. We retrospectively reviewed 110 adults with NHL treated with ABMT from 1988 to 1993. Overall survival and relapse-free survival were 50% and 35%, respectively. Estimated median relapse-free survival was 16 months. There was no statistically significant difference in relapse-free or overall survival by low, intermediate, and high-grade histologies, as defined by the International Working Formulation. The most powerful negative prognostic variable was an elevated LDH at the time of transplant (relapse-free survival 17% vs 42% for those with a normal LDH). Forty-seven patients were in complete remission 2 years after transplant. Extended follow-up revealed that 100% of patients with high-grade histologies remained in complete remission, whereas patients with intermediate-grade and low-grade histologies remained at risk of relapse with longer follow-up. Of 22 patients with diffuse large cell lymphoma (LCL) or immunoblastic (IBL) histologies, eight of eight with IBL remain in continued remission, while four of 14 with LCL relapsed 24-48 months after ABMT. We conclude that patients with high-grade histologic subtypes of NHL who are in complete remission 2 years after ABMT are likely to be cured. However, patients with intermediate and low-grade histologic subtypes are at continued risk of relapse and require appropriate clinical surveillance for at least 48 months after ABMT.

Adult↗

PubMed1997

Platelet transfusion requirements during autologous peripheral blood progenitor cell transplantation correlate with the pretransplant platelet count.

The use of primed peripheral blood progenitor cells (PBPC) has improved platelet engraftment following autologous bone marrow/PBPC transplantation (ABMT). The thrombocytopenia associated with ABMT generally lasts 14-18 days, and is associated with variable platelet transfusion requirements. Little, if any, data exist examining prognostic parameters for platelet transfusion requirements during autologous transplantation. We retrospectively examined 286 consecutive patients undergoing autologous transplantation from 1 January 1994 to 1 June 1996 with respect to platelet engraftment and platelet transfusion requirements. One hundred and fifty four patients were transplanted for breast cancer (54%), 72 for non-Hodgkin's lymphoma (25%), 35 for Hodgkin's disease (12%), 13 for acute leukemia (5%), eight for myeloma (3%), and four for other malignancy (1%). The median age was 44. All patients received cytokine priming, usually with G-CSF, for the procurement of PBPC. The median number of CD34+ cells collected was 4.3 x 10(6)/kg. All patients received a chemotherapeutic preparative regimen and all received an autologous transplant using PBPC alone. The median time to a platelet count of 20 x 10(9)/l was 13 days. Patients beginning the transplant with a less than normal platelet count (less than 150 x 10(9)/l) engrafted in 17 days, and received a median number of seven platelet transfusions, as compared with platelet engraftment of 12 days, and four platelet transfusions, for patients beginning the transplant with a normal platelet count (P = 0.001). Both groups of patients received an equivalent dose of CD34+ cells. We conclude that thrombocytopenia at the initiation of autologous transplantation is associated with increased platelet transfusion requirements, independent of the dose of CD34+ cells infused.

Adult↗

PubMed1997

Progressive disease after ABMT for Hodgkin's disease.

A major limitation of ABMT for relapsed/refractory Hodgkin's disease is disease recurrence post-transplantation. We retrospectively reviewed 68 patients undergoing ABMT from January 1987 to June 1993. All received a uniform preparatory regimen (CBV). The median patient age was 30; 75% received prior radiation therapy and all patients received prior chemotherapy. Thirty-one percent presented at the time of transplantation with tumor masses larger than 10 cm. Sixty-two percent received autologous marrow alone and 38% PBPC with or without autologous bone marrow. Overall and progression-free survival are 43 and 36% at 5 years. Median follow-up for survivors is 59 months. Multivariate analysis revealed that tumor bulk was the most powerful poor prognostic factor for both survival and progression-free survival. Those transplanted with non-bulky tumors had an overall survival and progression-free survival of 52 and 44%, respectively, compared to those transplanted with bulky tumors who had an overall survival and progression-free survival of 22 and 16% (P = 0.03 and P = 0.04, respectively). Twenty-seven patients have relapsed. Four relapsed more than 2 years after ABMT. Four of the 27 patients who have relapsed remain alive, two without evidence of disease. The time after transplant to relapse was prognostically important, with no patients who relapsed within 6 months of ABMT still being alive, compared with 25% of patients who relapsed 7 or more months after ABMT who are still alive. We conclude that salvage therapy for relapse after ABMT is appropriate, as some patients may achieve prolonged survival. The time from transplant to relapse is an important survival predictor.

Adult↗

PubMed1997

Validity of four models for predicting outcome in critically ill acute renal failure patients.

OBJECTIVE: Several mathematical models are used to predict the survival of patients in renal failure and have become standards. Few of these models have been sufficiently validated, however, and their applicability at other institutions has been established. DESIGN: We attempted to validate four models used to predict mortality in the setting of acute renal failure (Lohr, Bullock, Cioffi, APACHE II) with a registry of 512 ICU patients who received acute dialysis at our institution between 1988 and 1992. Using mortality as an endpoint, we applied each model as described by the original authors and compared the predicted results against the actual outcomes recorded in the registry. RESULTS: The Lohr Model is based on five risk factors thought to predict mortality or survival. Although we found these five factors were strongly associated with mortality (p < 0.001), more than 20% of the highest-risk group survived. The Bullock Model predicted only 20% of the mortality of our data. For the Cioffi Model, the original study found a clear discrimination score (survivors: 1.76, non-survivors: -0.423); however, we found no significant difference in the score discriminating survivors and non-survivors (survivors: 0.70, non-survivors: 0.71, p = 0.96). APACHE II is a risk model consisting of a premorbid assessment of chronic health and 12 physiologic variables taken during ICU admission. We applied APACHE II to both our cardiac and non-cardiac patients, and found that this score did not discriminate between survivors and non-survivors (p values ranged from 0.37 to 0.62) in acute renal failure in either case: the original APACHE II system was not applied to cardiac surgery patients. CONCLUSIONS: We conclude that models with good performance in their institutions of origin may not be valid in other institutions. Before using a predictive model, validity testing at the specific institution should be undertaken.

APACHE↗

PubMed1997

Does distance between home and transplantation center adversely affect patient outcomes after heart transplantation?

BACKGROUND: The emergence of heart transplantation referral centers, in an era of cost-conscious managed care programs, frequently leads to long-distance patient consultation and care. The purpose of this project was to review one center's experience regarding the effect of long distances from home to transplantation hospital on outcomes. METHODS: Three hundred twelve adult, noninternational, transplant recipients surviving at least 3 months were assessed for 10 events: rejection episodes, number of endomyocardial biopsies, emergency department visits, hospital admissions, return to full-time work or school, infections, coronary allograft vasculopathy, malignancies, retransplantation, and death. Presence of a locally involved physician was also determined. Distance from the transplantation center was analyzed in three discrete groups: 0 to 150 miles (n = 207), 151 to 300 miles (n = 69), and >300 miles (n = 36). RESULTS: There were no differences among the groups in mean length of follow-up (40.6, 36.9, 39.0 months, p = 0.27) or number of biopsies (20.5 +/- 0.16, 18.3 +/- 1.1, 18.0 +/- 1.1, p = 0.07). As the distance increased from the transplantation center, there was no greater incidence of adverse outcomes. Cellular rejection was the same among the groups (45%, 45%, 36%, p = 0.58). Likewise, emergency department visits and hospital admissions also did not vary: (9.7%, 5.8%, 8.3%, p = 0.61) and (22.2%, 13.0%, 16.7%, p = 0.23, respectively). There were no differences in the incidence of coronary vasculopathy (9.2%, 11.6%, 13.9%, p = 0.63). More importantly, the three groups did not differ in death/retransplantation rates (3-year survival, 84.5, 94.0 and 86.9, p = 0.14). Patients cared for by a local physician in addition to their transplant cardiologist had better survival rates than patients without a local physician (3-year survival rate, 90.7 vs 72.6, p = 0.0008). CONCLUSIONS: Long-distance management of heart transplant recipients is successful and is not associated with an increase in adverse outcomes. By itself, distance should not represent a contraindication to transplantation. Patients should be encouraged to maintain contact with a local physician, in addition to the regularly scheduled visits at the transplantation center.

Adolescent↗

PubMed1996

Determinants of chronic renal allograft rejection in cyclosporine-treated recipients.

We analyzed the development of chronic rejection in 511 kidney-only renal transplants in 507 patients between July 1987 and November 1994. A database was established for recipients > or = 18 years old who received cyclosporine-based immunosuppression and demonstrated graft survival for a minimum of 12 months. The 347 recipients of cadaver transplants (67.9%) and 164 recipients of live donor transplants (32.1%) were followed for 12 to 102 months (mean 51 months). Chronic rejection was diagnosed in 124 transplants (24%), with a mean time to diagnosis of 23+/-18 months (range 3-92). Risk factors were identified in a multivariate analysis using the Cox model. The impact of the timing and severity of rejection episodes was analyzed in a univariate model. The presence of chronic rejection resulted in decreased (P=0.0001) 5-year graft survival for both cadaver graft (83.7% vs. 58.2%) and live donor graft (93.2% vs. 53.1%) recipients. Significant variables for the development of chronic rejection included an acute rejection episode (P=0.0001), a black recipient (P=0.0006), donor age > or = 50 years (P=0.006), and a serum creatinine level >2.0 mg/dl by 6 months after transplantation. Severity of rejection measured by peak serum creatinine or posttreatment return to baseline was not related to chronic rejection. However, acute rejection episodes lasting for more that 5 days (P=0.03) or occurring after 6 months (P=0.001) did influence time to chronic rejection. In addition, mismatching for donor-recipient race was a significant (P=0.008) risk factor for recipients of cadaver grafts. We conclude that acute rejection is the most significant risk factor for chronic rejection, and the long-term fate of grafts may be determined as early as the first 6 months. Racial matching of donor-recipient pairs may be useful to minimize chronic rejection risk. Future advances that diminish the incidence and severity of acute rejection may have the greatest impact on long-term survival.

Acute Disease↗

PubMed1996

The dilemma of diagnosing coronary calcification: angiography versus intravascular ultrasound.

OBJECTIVES: We sought to determine whether careful examination of angiograms in conjunction with other clinical information could reliably detect, quantitate and localize target lesion calcification before a coronary intervention. BACKGROUND: The presence, extent and location of calcium in coronary artery lesions are important determinants of outcome after coronary intervention. Intravascular ultrasound is proposed as a superior technique for identifying patients with coronary artery calcification. However, the precise role of this costly and invasive method has not yet been established. METHODS: Target lesion calcification was assessed in 183 patients (155 men; mean [+/-SD] age 58 +/- 10 years) by angiography and intravascular ultrasound before a planned percutaneous coronary intervention. RESULTS: Ultrasound detected calcium in 138 patients (>90 degrees in 56, 91 degrees to 180 degrees in 52, 181 degrees to 270 degrees in 22 and > 270 degrees in 8), whereas angiography showed calcification in 63 (1+ in 32, 2+ in 27 and 3+ in 4). The two techniques agreed in 92 patients and disagreed in 91. Sensitivity and specificity of angiography were 40% and 82%, respectively. The arc of calcium by ultrasound was greater in patients with angiographically visible calcification (175 degrees +/- 85 degrees vs. 108 degrees +/- 71 degrees, p=0.0001). The depth of calcification by ultrasound was superficial in 61 patients (44%), deep in 68 (49%) and mixed in 8 (7%). The sensitivity of angiography in identifying superficial calcium was 35%. Of 120 patients without angiographically visible calcium at the target lesion site, 83 showed calcium by ultrasound. The only predictor of ultrasound calcium in these 120 patients was angiographic calcification elsewhere in the coronary tree (p=0.0001). The probability of any calcium and superficial >90 degrees calcium were 60% and 12%, respectively, in the 90 patients without angiographic calcifications anywhere in the coronary tree. CONCLUSIONS: Despite poor sensitivity, angiography may help identify patients requiring intravascular ultrasound. When it is angiographically visible, the arc of calcium is likely to be large and superficial. Angiographic calcification at a remote site is a predictor of angiographically undetected target lesion calcium. Patients without angiographic calcification in the coronary tree may not need routine ultrasound examination, as the likelihood of >90 degrees superficial calcium is low.

Aged↗

PubMed1996

Dichotomous pattern of coronary atherosclerosis 1 to 9 years after transplantation: insights from systematic intravascular ultrasound imaging.

OBJECTIVE: The aim of this study was to evaluate the extent and distribution of coronary atherosclerosis after transplantation. BACKGROUND: Transplant coronary artery disease is an important cause of death after cardiac transplantation. Unlike coronary angiography, intravascular ultrasound is a sensitive tool for detection and quantitation of this disease. METHODS: We performed intravascular ultrasound imaging in 132 (106 men, 50 +/- 10 years) patients, 1 to 9 years after transplantation using a 30-MHz ultrasound catheter. RESULTS: All three coronary arteries were visualized in 49, two in 62 and one in 21 patients. Of the 1,188 coronary artery segments, 706 were imaged (74% proximal, 64% mid- and 40% distal). At least one site with atherosclerosis (intimal thickness > or = to 0.5 mm) was found in 83% of patients. Atherosclerosis was noted in 64% of proximal, 43% of mid- and 26% of distal segments. Disease was diffuse in 48% and focal in 52%, circumferential in 66% and noncircumferential in 34%. Focal atherosclerosis was more common in proximal (59%) than mid- (48%) and distal segments (27%) (p=0.001). Noncircumferential plaques were more common in the proximal (42%) than mid- (28%) and distal segments (12%) (p=0.001). This pattern of focal and noncircumferential disease proximally, diffuse and circumferential disease distally, was observed irrespective of the time from transplantation. CONCLUSION: Atherosclerosis was detected in more than 80% of patients, with proximal segments most frequently involved. Diffuse and circumferential atherosclerosis was more common in mid- and distal segments. However, focal and noncircumferential involvement was more frequent proximally, a similar pattern to native atherosclerosis. These findings suggest that transplant coronary artery disease has a dual etiology based on the dichotomous pattern of atherosclerosis seen by intravascular ultrasound.

Chi-Square Distribution↗

PubMed1996

Does successful bridging with the implantable left ventricular assist device affect cardiac transplantation outcome?

OBJECTIVES: We sought to determine whether cardiac transplant recipients who required a bridge to transplantation with an implantable left ventricular assist device had a different outcome than patients who underwent transplantation without such a bridge. METHODS: A retrospective study of 256 cardiac transplants from 1992 to 1996 included 53 patients who received the HeartMate left ventricular assist device and 203 patients who had no left ventricular assist device support. RESULTS: Left ventricular assist device transplants increased from 8% of all transplants in 1992 (n = 63) to 32% in 1995 (n = 65) and 43% in 1996 (n = 14 year to date). Patients with and without left ventricular assist device had similar age and sex distributions. Left ventricular assist device recipients were larger (body surface area 1.96 vs 1.86 m2, p = 0.004). They were more likely to have ischemic cardiomyopathy (70% vs 45%, p = 0.001) and type O blood group (51% vs 34%, p = 0.06). All patients with left ventricular assist device and 42% of those without had undergone previous cardiac operations by the time of transplantation (mean number per patient 1.5 vs 0.3, p < 0.001). More patients in the left ventricular assist device group had anti-HLA antibodies before transplantation (T-cell panel reactive antibody level > 10% in 66% of left ventricular assist device group vs 15% of control group, p < 0.0001). Waiting time was longer for the left ventricular assist device than for patients in status I without a left ventricular assist device (median 88 vs 37 days, p = 0.002). There was no difference in length of posttransplantation hospital stay (median 15 days for each) or operative mortality (3.8% vs 4.4%). Mean follow-up averaged 22 months. No significant difference was found in Kaplan-Meier survival estimates. One-year survival was 94% in the left ventricular assist device group and 88% in the control group (difference not significant). Comparison of posttransplantation events showed no significant difference in actuarial rates of cytomegalovirus infection (20% vs 17%) or vascular rejection (15% vs 12%) at 1 year of follow-up. Similar percentages of patients were free from cellular rejection at 1 year of follow-up (12% vs 22%, p = 0.36). CONCLUSIONS: Left ventricular assist device support intensified the donor shortage by including recipients who otherwise would not have survived to transplantation. Bridging affected transplant demographics, favoring patients who are larger, have ischemic cardiomyopathy, have had multiple blood transfusions and complex cardiac operations, and are HLA sensitized. Successfully bridged patients wait longer for a transplant than do UNOS status I patients without such a bridge, but they have similar posttransplantation hospital stay, operative mortality, and survival to those of patients not requiring left ventricular assist device support.

Adult↗

PubMed1996

Cadaveric kidney transplantation under prophylactic polyclonal antibody immunosuppression with anti-lymphoblast globulin versus anti-thymocyte globulin.

OBJECTIVES: This retrospective study was undertaken to evaluate and compare the clinical and immunologic outcomes following prophylactic induction treatment with Minnesota anti-lymphoblast globulin (MALG) and Upjohn anti-thymocyte globulin (ATGAM) in cadaver renal transplantation. METHODS: From 1990 to 1994, 63 patients with renal transplants from cadavers received MALG and 77 patients received ATGAM for induction treatment. Most pretransplant parameters were equivalent in both groups. There was no significant difference in the total dose and mean duration of MALG/ATGAM administration. The post-transplant outcome in these groups was compared. RESULTS: There was no difference between the MALG and ATGAM groups with respect to the overall number of rejection episodes, median days to rejection, or the number of steroid-resistant rejection episodes. However, MALG-treated patients experienced a greater number of rejections in the first 60 days postoperatively (P = 0.06). There was no difference in the nadir serum creatinine level in the first 20 postoperative days in the two groups; however, it took fewer days to reach the nadir in the ATGAM group (P = 0.03). The incidence of delayed graft function was higher in the MALG group than in the ATGAM group (38% versus 31%) but not statistically significant. Graft survival at 12 and 24 months was comparable in both groups. However, patient survival was superior at 12 and 24 months in ATGAM-treated transplant recipients (P = 0.03). The mean serum creatinine at 6, 12, and 24 months was similar in both the MALG and ATGAM groups. The mean fall and recovery of CD3, CD4, and CD8 T-lymphocyte subsets while on MALG/ATGAM were similar in both groups. The incidence of infectious complications was greater in the MALG group. CONCLUSIONS: MALG and ATGAM have comparable clinical immunosuppressive effects. Patients receiving ATGAM experienced fewer rejections in the first 2 months, fewer infections, and better survival.

Antilymphocyte Serum↗

PubMed1996

Long-term results with single pediatric donor kidney transplants in adult recipients.

PURPOSE: We investigated whether transplantation of single pediatric donor kidneys into adults leads to an increased incidence of functional allograft impairment and complications, as previously reported. MATERIALS AND METHODS: To evaluate long-term functional outcome using single pediatric donor kidneys 60 adults (study group) who underwent transplantation between March 1973 and December 1988 using single pediatric donor kidneys 6 years old or younger (mean donor age plus or minus standard deviation 41.1 +/- 17.9 months) were compared to 58 matched adults (control group) who underwent transplantation with adult kidneys (mean donor age 29.7 +/- 10.8 years). The groups were identical for era of transplantation, recipient age, sex and followup (82 versus 83 months). RESULTS: There was no difference in patient survival between the study and control groups (p = 0.26). In the study group there were an increased requirement for early dialysis (45 versus 24%, p = 0.02), a higher incidence of proteinuria (greater than 0.8 gm./24 hours, 67 versus 48%, p = 0.04) and a higher incidence of rejection within the first 6 months (80 versus 64%, p = 0.05). There was also an increased incidence of graft failure from acute rejection in the study group. Early differences in serum creatinine levels in the 2 groups dissipated after 3 months. Renal allograft histopathology revealed no significant difference in the incidence of focal segmental glomerulosclerosis in the study versus control groups after transplantation (22.9 versus 13.3%, p = 0.70). However, focal segmental glomerulosclerosis manifested sooner after transplantation in study than control patients (mean 37 versus 82 months). After transplantation proteinuria developed in study patients with focal segmental glomerulosclerosis at a mean of 4.6 months compared to 31.8 months in controls with post-transplant focal segmental glomerulosclerosis. Graft survival in the study group was superior when cyclosporine was given rather than conventional noncyclosporine based immunosuppression. Five-year graft survival rates were 48 versus 44% for cyclosporine treated and 33 versus 44% for conventionally treated study versus control patients. CONCLUSIONS: These data suggest that with cyclosporine immunosuppression transplanting single pediatric kidneys into adults yields the same long-term functional graft outcome as adult donor kidneys.

Adult↗

PubMed1996

Early infectious complications in autologous bone marrow transplantation: a review of 219 patients.

The objective of this study was to define the incidence, type and timing of early infectious complications, occurring within the first 30 days, in autologous bone marrow transplant (autoBMT) recipients over a 45-month period, and in addition to assess the effects of growth factors and primed peripheral blood progenitor cells on the rate of infectious complications. The paper describes a retrospective and observational study, carried out at the bone marrow transplantation unit at a tertiary referral center. The subjects were two hundred and nineteen patients who underwent autologous bone marrow transplantation for a variety of indications from April 1989 to December 1992. The median duration of neutropenia after autologous bone marrow transplantation was 12 days. There was a direct correlation between the duration of neutropenia and the incidence of infectious complications. The overall incidence of infections and isolated febrile episodes was 35%. Septicemia occurred in 7.8% of patients, pneumonia in 2.7%, skin infection in 1.8%, other infections in 2.7% and isolated febrile episodes in 20.1%. Viridans streptococci were the most common cause of septicemia. Invasive fungal infections occurred in only 2.3% of patients. There were no documented viral infections. The use of growth factors and primed peripheral blood progenitor cells was associated with a shorter duration of neutropenia; a decrease in the overall incidence of infections, particularly septicemia and fungal infections; a shorter length of stay in the hospital and a lower mortality rate in the first 30 days after transplantation. We found a lower incidence of bacterial and fungal infections compared to previous studies. The critical factor associated with the occurrence of any early infection was the duration of neutropenia, which was significantly shortened by the use of growth factors and peripheral blood progenitor cells. Septicemia was uncommon in our population and viridans streptococci were the most common bloodstream isolates.

Adolescent↗

PubMed1996

Risk modeling in acute renal failure requiring dialysis: the introduction of a new model.

Predicting patient outcome in acute renal failure has become increasingly important as technology advances and ethical questions arise concerning life supporting therapies. We propose a new model which uses mortality as an endpoint and may be applied to the acute renal failure patient in the ICU setting who requires dialysis. This model is based on our ICU acute renal failure registry and has been prospectively validated for our institution. Our registry for the purposes of developing this model consists of data from 512 ICU patients requiring acute dialysis from 1988 until 1992. The model was developed by testing a variety of potential risk factors for mortality in a univariate analysis (Student's t-test and Chi square), and those factors found to be significant (p < 0.05) were subsequently tested in a multivariate fashion. The factors found significant included male gender, respiratory failure requiring intubation, hematologic dysfunction (platelet count < 50,000, leukocyte count < 2,500, or bleeding diathesis), bilirubin < 2.0 mg/dl, the absence of surgery, serum creatinine on the first dialysis treatment day, an increasing number of failed organ systems, and an increased BUN from the time of admission. Weights are assigned to each variable based on the odds ratio, and a score is generated with a range of 0 to 20. The initial data for the registry demonstrates good fit using the Hosmer and Lemeshow goodness-of-fit table. The model is next validated in 88 patients from 1993 through February 1994, then prospectively tested in 35 additional patients using a standard data collection form, and the model continues to demonstrate good fit. Although this model has been prospectively validated at our institution, this model or any such predictive model should be used with caution if not independently validated at any institution which proposes its use.

Acute Kidney Injury↗

PubMed1995

Hemodynamic and physiologic changes during support with an implantable left ventricular assist device.

To evaluate hemodynamic effectiveness and physiologic changes on the HeartMate 1000 IP left ventricular assist device (Thermo Cardiosystems, Inc., Woburn, Mass.), we studied 25 patients undergoing bridge to heart transplantation (35 to 63 years old, mean 50 years). All were receiving inotropic agents before left ventricular assist device implantation, 21 (84%) were supported with a balloon pump, and 7 (28%) were supported by extracorporeal membrane oxygenation. Six patients died, primarily of right ventricular dysfunction and multiple organ failure. Nineteen (76%) were rehabilitated, received a donor heart, and were discharged (100% survival after transplantation). Pretransplantation duration of support averaged 76 days (22 to 153 days). No thromboembolic events occurred in more than 1500 patient-days of support with only antiplatelet medications. Significant hemodynamic improvement was measured (before implantation to before explantation) in cardiac index (1.7 +/- 0.3 to 3.1 +/- 0.8 L/min per square meter; p < 0.001), left atrial pressure (23.7 +/- 7 to 9 +/- 7.5 mm Hg; p < 0.001), pulmonary artery pressure, pulmonary vascular resistance, and right ventricular volumes and ejection fraction. Both creatinine and blood urea nitrogen levels were significantly higher before implantation in patients who died while receiving support. Renal and liver function returned to normal before transplantation. We conclude that support with the HeartMate device improved hemodynamic and subsystem function before transplantation. Long-term support with the HeartMate device has a low risk of thromboemboli and makes a clinical trial of a portable HeartMate device a realistic alternative to medical therapy.

Adult↗

PubMed1995

Restenosis after experimental angioplasty. Intimal, medial, and adventitial changes associated with constrictive remodeling.

Predicting and preventing arterial restenosis after angioplasty has failed despite considerable research into mechanisms and techniques. We examined the roles of chronic constriction, neointimal-medial growth, and adventitial changes in restenosis in atherosclerotic rabbits. Angioplasty was performed on femoral artery lesions 4 weeks after lesion induction by air drying and cholesterol-supplemented diet. Angiographic and histological evaluation was conducted 3 to 4 weeks after angioplasty. The angiographic minimum luminal diameter (MLD) increased from 1.31 +/- 0.21 to 1.73 +/- 0.41 mm after angioplasty. Loss in MLD by 3 to 4 weeks was 0.95 +/- 0.64 mm. Initial gain and late loss correlated (P = .008). Late residual stenosis, defined histologically as the difference between the luminal areas of a proximal reference site and lesion site normalized by the luminal area of the reference site, was 52 +/- 32%. Histological indices of chronic constriction, neointimal-medial growth, and adventitial growth were defined on the basis of the areas of these arterial wall layers at the lesion site relative to the reference site. Another parameter defined as the ratio of adventitial area to the area of intima+media at the lesion site allowed evaluation of the relative importance of these layers. Surprisingly, late residual stenosis correlated with chronic constriction (P = .0003) but not with neointimal-medial growth or adventitial growth. The ratio of adventitial area to the area of intima+media at the lesion site also correlated with chronic constriction (P = .01). These findings suggest that factors related to arterial remodeling rather than neointimal-medial growth may dominate the response to angioplasty.

Angiography↗

PubMed1995

Survival after ABO-incompatible allogeneic bone marrow transplant after a preparative regimen of busulfan and cyclophosphamide.

The use of an ABO-incompatible donor for BMT after total body irradiation (TBI) has no adverse effect on engraftment, incidence of GVHD or survival when donor erythrocytes and plasma are depleted from the infused marrow. The outcome of ABO-incompatible BMT following a non-TBI-containing preparative regimen has not been as well studied. We therefore performed a retrospective review of consecutive patients undergoing allogeneic BMT for myeloid leukemia after treatment with high-dose busulfan and cyclophosphamide (BUCY) between January 1984 and January 1993. Of the 199 evaluable patients, 100 had AML or myelodysplastic syndrome, 30 of which were ABO-incompatible, and 99 had CML, 35 of which were ABO-incompatible. All patients undergoing transplant received erythrocyte and plasma-depleted marrow but 14 major ABO-incompatible patients also underwent plasma exchange before transplant. T cell-depletion and purging techniques were not employed. All records were reviewed for prognostic factors including patient age, sex, diagnosis, remission status at the time of transplant, and incidence and severity of acute and chronic GVHD. Compatible and incompatible patients with myeloid leukemia did not differ with respect to age, sex, remission status of disease at the time of transplant or incidence of GVHD.(ABSTRACT TRUNCATED AT 250 WORDS)

ABO Blood-Group System↗