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K R Hess

Publications and source records attributed to K R Hess.

At least 73 records · Page 4Linked to original sources
PubMed1995

Prognostic significance of p53 immunoreactivity in patients with glioma.

Abnormal p53 as revealed by immunostaining has been shown to be a predictor of poor outcome in a variety of malignant tumors. This study examines the relationship of p53 immunostaining and survival in 182 adult patients with gliomas. Tumor tissues obtained from patients with glioma within 4 months of initial diagnosis were investigated by immunohistochemical analysis for detection of p53 protein abnormalities using the monoclonal antibody PAb 1801. There were 122 patients with glioblastoma multiforme, 48 patients with anaplastic glioma, and 12 patients with low-grade glioma. Among these patients, 73 of those with glioblastoma multiforme, 35 with anaplastic glioma, and 6 with low-grade glioma had positive p53 immunoreactivity. Kaplan-Meier survival plots (log rank test) showed that the patients with anaplastic astrocytoma or low-grade glioma and p53-positive tumors had longer survival times compared to the patients with p53-negative tumors. No differences in survival were detected among the glioblastoma patients. Cox proportional hazards regression analysis, adjusted for age at diagnosis, showed that the p53 positivity was a significant predictor of longer survival (relative risk = 0.56; 95% confidence intervals = 0.35, 0.90; P = 0. 015) in anaplastic astrocytoma patients, but not in glioblastoma patients (relative risk = 1.03; 95% confidence intervals = 0.82, 1. 29; P = 0.80). These results suggest that anaplastic glioma patients with p53 protein alterations may have a better response to chemoradiation, possibly because the malignant cells cannot arrest in G1 to correct lethal damage induced by chemotherapy or radiotherapy.

Adult↗
PubMed1994

Effect of pregnancy on prognosis for young women with breast cancer.

Breast cancer in women under 30 years old carries a poor prognosis, for reasons that have not been identified. This study aimed to identify prognostic factors in this age group. Special attention was paid to the history of pregnancy. The clinical presentation and course of breast cancer was documented for 407 women, aged 20-29 years, who registered between 1978 and 1988 at one of nine cancer centres. Eligible patients had histologically confirmed local or regional invasive breast carcinoma, and received part or all of their initial therapy at the participating hospital. For patients whose breast cancers were diagnosed during pregnancy, the risk of dying from breast cancer was significantly greater than that of women who had never been pregnant (relative risk 3.26 [95% CI 1.81-5.87], p = 0.0004). Adjustment for number of axillary nodes affected and tumour diameter reduced the relative risk only slightly (2.83 [1.24-6.45], p = 0.023). For each 1-year increment in the time between the latest previous pregnancy and breast cancer diagnosis, the risk of dying decreased by 15% (relative risk 0.85, p = 0.011). Thus concurrent or recent previous pregnancy adversely affects survival of breast cancer in young women. The size of the effect is such that it probably contributes substantially to the poor prognosis of breast cancer in this age group as a whole.

Adult↗
PubMed1994

Assessing time-by-covariate interactions in proportional hazards regression models using cubic spline functions.

Proportional hazards (or Cox) regression is a popular method for modelling the effects of prognostic factors on survival. Use of cubic spline functions to model time-by-covariate interactions in Cox regression allows investigation of the shape of a possible covariate-time dependence without having to specify a specific functional form. Cubic spline functions allow one to graph such time-by-covariate interactions, to test formally for the proportional hazards assumption, and also to test for non-linearity of the time-by-covariate interaction. The functions can be fitted with existing software using relatively few parameters; the regression coefficients are estimated using standard maximum likelihood methods.

Epidemiologic Methods↗
PubMed1994

Primary adenocarcinoma of the duodenum: management and survival in 67 patients.

BACKGROUND: Because of the rarity of primary adenocarcinoma of the duodenum, accumulation of natural history data has been difficult. As a result, debate continues over important treatment issues. METHODS: We did a retrospective review of 67 patients with nonampullary adenocarcinoma of the duodenum treated at the University of Texas M.D. Anderson Cancer Center between 1967 and 1991. Presenting symptoms and signs, diagnostic studies, operation performed, surgical pathology, and survival were analyzed. RESULTS: A primary duodenal tumor was demonstrated by upper gastrointestinal radiographs (UGI) in 37 of 42 patients (88%), esophagogastroduodenoscopy (EGD) in 49 of 55 (89%), and computerized tomograms (CT) in 21 of 42 (50%). A curative resection was performed in 36 of the 59 patients who underwent operation (61%); 27 had pancreaticoduodenectomies and nine had wide local excisions. Overall 5-year survival was 29%. The 5-year survival difference between resected and unresected patients was 54% versus 0%, respectively (p < 0.0001). No survival difference was noted between patients who underwent pancreaticoduodenectomy rather than wide local excision. Lymph node metastases were significantly related to the occurrence of distant metastases (p = 0.0034). The 5-year survival for patients with stage I or II tumors was 100% and 52%, respectively, compared to 45% and 0% for stage III and IV (p < 0.0001). CONCLUSIONS: Our data suggest that UGI and EGD are effective for diagnosing duodenal carcinoma. Survival is improved by curative resection and is not compromised by a wide local excision instead of a pancreaticoduodenectomy for lesions of the third and fourth portion. We recommend that adjuvant chemotherapy be considered for stage III disease, because distant failure is the predominant pattern of failure in this group.

Adenocarcinoma↗
PubMed1994

Influence of segmental arteries, extent, and atriofemoral bypass on postoperative paraplegia after thoracoabdominal aortic operations.

PURPOSE: The purpose of this article was to study the influence of either reattachment or oversewing of patient segmental intercostal or lumbar arteries, extent of aneurysm, and atriofemoral bypass on the incidence of postoperative paraplegia/paraparesis in patients at high risk with type I or II thoracoabdominal aneurysms. METHODS: Data were prospectively collected on 99 patients undergoing type I or II thoracoabdominal aneurysm repairs, including exact extent of repair and whether atriofemoral bypass ws used. Patency of intercostal arteries from T3 to T12 and lumbar arteries from L1 to L4 were checked by intraoperative inspection. If the arteries were patent, note was taken of whether they were reattached to the new aortic prosthesis. Postoperative neurologic motor function was graded daily for the first 5 days, and the worst score in the first 30 postoperative days (POD) was used for analysis. RESULTS: Ninety-five of 99 (96%) patients were 30-day survivors. By POD 30, 31 of 98 (32%) patients had had a neurologic deficit. There was no difference in the incidence of deficits according to whether lumbar or intercostal arteries were reattached, ignoring the effect of patency of the arteries. Of greater importance, however, was whether patent segmental arteries were oversewn at specific levels. Thus, for patients who had one or more arteries at T11, T12, or L1 oversewn (often because they could not be reattached), a deficit developed in 11 of 23 (48%) patients versus 20 of 75 (27%) patients who did not have patent arteries or had all patient arteries reattached (p = 0.05, odds ratio = 2.5). More specifically, if all arteries at this level were oversewn, a neurologic deficit developed in 63% of patients versus 23% if all their arteries were reattached (p = 0.01). Reattachment of patent arteries at individual levels from T7 to L4 showed a trend toward a lower risk of deficits but did not reach statistical significance. On multivariate analysis, atriofemoral bypass was associated with a lower risk of paralysis (p = 0.068), and significantly so when controlled for age (p = 0.0329, odds ratio 0.287). Subgrouping of extent type I thoracoabdominal aneurysms resulted in an incidence of paralysis of 14% (3/22) for subgroup A and 23% (5 of 22) for subgroup B compared with 43% (23 of 55) for type II thoracoabdominal aneurysms (type I [8 of 44 18%], versus type II [p = 0.0097]). CONCLUSION: Patients with no or few patent segmental arteries in the aortic segment being replaced have a lower risk of neurologic deficits, compared with those with patent arteries. Every effort should be made to reattach all arteries at T11, T12, and L1 and, when possible within the constraints of technical feasibility and time, also those from T7 to L4. Preoperative angiography or intraoperative hydrogen testing may better identify the arteries that need to be reattached. When feasible, atriofemoral bypass appears to be protective, particularly when sequential clamping and segmental repairs can be performed.

Adult↗
PubMed1994

Neurologic deficit in patients at high risk with thoracoabdominal aortic aneurysms: the role of cerebral spinal fluid drainage and distal aortic perfusion.

PURPOSE: This prospective study evaluated the possible prevention of postoperative neurologic deficit in patients at high risk with thoracoabdominal aortic aneurysms (TAAA), types I and II, by use of perioperative cerebrospinal fluid drainage and distal aortic perfusion. METHODS: Between September 18, 1992, and August 8, 1993, 45 consecutive patients underwent TAAA repair (14 type I, 31 type II). Thirty-six were men and nine were women. The median age was 63 years (range 28 to 88). Twenty-four of 45 patients (53%) had dissection and 17 of 45 (38%) had prior proximal aortic replacement. All patients underwent perioperative cerebrospinal fluid drainage and distal aortic perfusion. Median aortic clamping time was 42 minutes. Thirty-five of 45 patients (78%) underwent intercostal artery reattachment. RESULTS: The 30-day survival rate was 96% (43 of 45 patients). Early neurologic deficit occurred in two of 45 patients (4%), and late neurologic deficit also occurred in two of 45 patients (4%). We compared the neurologic deficit of our current group of 45 patients with the data of a previously unpublished study of 112 patients also from this center. Total neurologic deficit for the current group was four of 45 (9%) versus the previous group of 35 of 112 (31%) with a p value of 0.0034 (Pearson chi-square test). Neurologic deficit for patients with type I TAAA was 0 of 14 (0%) versus 15 of 73 (21%) (p = 0.062); for patients with type II TAAA 4 of 31 (13%) versus 20 of 39 (51%) (p = 0.0008). In patients with aortic dissection, neurologic deficit was 3 of 24 (12%) versus 9 of 32 (28%) (p = 0.0304); no dissection was 1 of 21 (5%) versus 26 of 80 (32%) (p = 0.011). For aortic clamp times less than 45 minutes, neurologic deficit was 1 of 24 (4%) versus 14 of 68 (21%) (p = 0.061); for aortic clamp times equal to or greater than 45 minutes, neurologic deficit was 3 of 21 (14%) versus 21 of 44 (48%) (p = 0.0090). CONCLUSION: Neurologic deficit in patients treated for types I and II TAAA was reduced significantly by perioperative cerebral spinal fluid drainage and distal aortic perfusion.

Adult↗
PubMed1994

High doses of purified influenza A virus hemagglutinin significantly augment serum and nasal secretion antibody responses in healthy young adults.

The reactogenicity and immunogenicity of purified influenza virus hemagglutinin (HA) vaccines administered intramuscularly were evaluated in two placebo-controlled clinical trials. A total of 139 healthy young adults were randomized to receive increasing doses of monovalent influenza A/Taiwan/1/86 (H1N1) virus HA (range, 0 to 405 micrograms per dose [study 1]). An additional 139 subjects were given increasing doses of a trivalent HA vaccine containing equal amounts of A/H1N1 virus, A/Shanghai/16/89 (H3N2) virus, and influenza B/Yamagata/16/88 virus HA (range, 0 to 135 micrograms of HA per strain, 0 to 405 micrograms per dose) or a standard dose of commercial influenza vaccine (study 2). Increasing doses of HA were associated with increasing frequencies of symptoms at the vaccination site early after vaccination, but all doses were well tolerated. Occurrence of systemic symptoms was unrelated to dose. Increasing the dose of HA resulted in increasingly higher postimmunization levels of serum hemagglutination inhibiting and neutralizing antibody levels versus influenza A/H1N1 virus in study 1 (P < 0.05); these enhanced responses persisted for up to 6 months. Nasal secretory immunoglobulin A and G antibody responses were assessed 2 weeks after immunization with monovalent H1N1 virus HA; the frequencies of significant responses also increased in a dose-related fashion. Similar increases in serum antibody levels were noted for both A/H1N1 and A/H3N2 viruses in study 2. These data provide a basis for proceeding with the evaluation of high doses of purified HA in the elderly.

Adolescent↗
PubMed1994

Unknown primary carcinoma: natural history and prognostic factors in 657 consecutive patients.

PURPOSE: To evaluate the natural history, validate previous observations, and identify prognostic factors in patients with unknown primary carcinoma (UPC). PATIENTS AND METHODS: Nine hundred twenty-seven consecutive patients referred to the M.D. Anderson Cancer Center with a preliminary diagnosis of UPC were prospectively identified. A standardized evaluation narrowed the study population to 657 patients with UPC. All data were recorded and computerized for storage, retrieval, and analysis. The primary end point for the study was survival, which was calculated from the first day of patient registration. Survival curves were estimated using the Kaplan-Meier method and compared using the Cox-Mantel log-rank test. To identify important prognostic factors, univariate and multivariate analyses were conducted. RESULTS: The demographics of the UPC patient population mirrored those of the general population of patients referred to our cancer center except for an excess of men among the UPC patients. Most patients had histologic or cytologic evidence of adenocarcinoma and had more than one organ site metastatically involved. Univariate and multivariate analyses identified numerous important prognostic factors with a significant influence on survival, including sex, number of organ sites involved, specific organ sites involved, and pathologic subtypes. CONCLUSION: This study validated previously identified important prognostic factors for survival in UPC. Additional variables that had an impact on survival were identified and the complex interaction of the factors was explored. As patient numbers increase, this database will be able to provide further analyses of patient subsets and potentially relate specific clinical features to the evolving molecular and biochemical understanding of these malignancies.

Adenocarcinoma↗
PubMed1994

Prognostic significance of bromodeoxyuridine labeling in primary and recurrent glioblastoma multiforme.

To evaluate the prognostic significance of bromodeoxyuridine (BUdR) labeling index (LI) and to estimate tumor proliferative potential, BUdR LI was examined in 98 patients having a primary diagnosis of glioblastoma multiforme (GBM); 55 underwent infusion of 200 mg/m2 of BUdR at the time of the primary resection and 49 underwent infusion at the time of the second resection. The tumors of six patients were labeled at both operations. The tumor specimens were stained with hematoxylin and eosin for histopathology and by immunohistochemical methods to determine the ratio of labeled to unlabeled cells, i.e., BUdR LI. The median BUdR LIs for the primary and recurrent GBM were significantly different at 6.8 and 2.6%, respectively (P < 0.0001). However, there was no significant association between BUdR LI at the first or second operation and survival (log rank, P = 0.12; Cox regression analysis, P = 0.91; log rank, P = 0.55; Cox regression analysis, P = 0.17, respectively). Patients who underwent a second operation within 10 months of the first operation had a lower BUdR LI than did patients with a longer interval between procedures (P = 0.078; Spearman rank correlation, 0.26). The aggressive biological behavior of GBM is dependent on complex cellular kinetics, not simply on the number of cells within the S phase of the cell cycle. Caution should be used when determining prognosis with BUdR LI in GBM.

Adult↗
PubMed1993

Effects of low dose transdermal scopolamine on heart rate variability in acute myocardial infarction.

OBJECTIVES: We hypothesized that by enhancing parasympathetic activity, low dose transdermal scopolamine would increase heart rate variability after myocardial infarction. BACKGROUND: Low heart rate variability is associated with increased mortality after acute myocardial infarction. METHODS: Conventional time domain heart rate variability was measured from 24-h Holter recordings of 61 consecutive male patients (mean age 58 +/- 10 years, left ventricular ejection fraction 44.7 +/- 15.5%) 6 days (median) after acute myocardial infarction. Patients were then randomly assigned to wear one patch of transdermal scopolamine or a matching placebo patch for 24 h, during which their 24-h heart rate variability was remeasured. RESULTS: Compared with placebo, transdermal scopolamine caused a significant increase in time domain measures of 24-h heart rate variability by 26% to 35% above baseline. Transdermal scopolamine was well tolerated. CONCLUSIONS: Low dose transdermal scopolamine safely increases cardiac parasympathetic activity and short-term heart rate variability after acute myocardial infarction. Whether the effect of transdermal scopolamine on heart rate variability is a reasonable surrogate for improvement of long-term morbidity and mortality requires an appropriate designed investigation.

Administration, Cutaneous↗
PubMed1993

Impact of adjuvant mitotane on the clinical course of patients with adrenocortical cancer.

BACKGROUND: Adrenocortical carcinoma is a rare and aggressive disease with a poor prognosis. Adjuvant mitotane administration has been suggested as a strategy that might improve the outcome of patients with localized disease. METHODS: The authors analyzed the clinical outcome of patients with localized or regional adrenocortical cancer. The study included 19 patients who were registered at M.D. Anderson Cancer Center during a 3-year period and who had localized or regional disease at the time of surgery. Of these, eight patients received mitotane postoperatively and continued the drug until their last contact or recurrence (Group A, adjuvant); five patients began taking mitotane after surgery but discontinued it after 2-12 months for reasons unrelated to the disease (Group P, postoperative); and six patients did not receive mitotane (Group N, no mitotane). All patients have been followed for at least 12 months. RESULTS: The treatment groups differed significantly in their time to recurrence; the disease-free interval was shortest in Group A (P = 0.0055, by log-rank test). There was no statistical difference in survival among the groups, but the profile remained unfavorable for Group A. The 2-year survival rate was 100% for Groups N and P but only 43% for Group A. Of the potentially confounding factors, gender, age, steroid hypersecretion, and tumor size, none had any influence on recurrence or survival rates. CONCLUSIONS: These findings do not support the conclusion that adjuvant mitotane is beneficial in patients with localized or regional adrenocortical cancer. Neither the disease-free interval nor survival was improved by the drug. The authors suggest that alternative therapeutic strategies be explored for the management of these patients.

Adrenal Cortex Neoplasms↗
PubMed1993

Conventional heart rate variability analysis of ambulatory electrocardiographic recordings fails to predict imminent ventricular fibrillation.

OBJECTIVES: The purpose of this report was to study heart rate variability in Holter recordings of patients who experienced ventricular fibrillation during the recording. BACKGROUND: Decreased heart rate variability is recognized as a long-term predictor of overall and arrhythmic death after myocardial infarction. It was therefore postulated that heart rate variability would be lowest when measured immediately before ventricular fibrillation. METHODS: Conventional indexes of heart rate variability were calculated from Holter recordings of 24 patients with structural heart disease who had ventricular fibrillation during monitoring. The control group consisted of 19 patients with coronary artery disease, of comparable age and left ventricular ejection fraction, who had nonsustained ventricular tachycardia but no ventricular fibrillation. RESULTS: Heart rate variability did not differ between the two groups, and no consistent trends in heart rate variability were observed before ventricular fibrillation occurred. CONCLUSIONS: Although conventional heart rate variability is an independent long-term predictor of adverse outcome after myocardial infarction, its clinical utility as a short-term predictor of life-threatening arrhythmias remains to be elucidated.

Adult↗
PubMed1993

Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients.

We have retrospectively evaluated our results after aortic surgery in adults using deep hypothermia with circulatory arrest to determine the patient predictors of early death and postoperative stroke by logistic regression analysis. Of the 656 patients operated on between July 7, 1979, and January 30, 1991, 43% (n = 283) were female, the median age of the patients was 64 years (range 10 to 88 years), 12% (n = 77) had acute dissection, 26% (n = 173) had previously undergone either cardiac or ascending aortic operations, and 13% (n = 85) had a history of cerebrovascular disease. Eighty-four patients underwent elephant trunk procedures. The median circulatory arrest time was 31 minutes (range 7 to 120 minutes). The univariable predictors of transient or permanent stroke, defined as clinical evidence of neurologic injury, either global or hemiparetic, which occurred in 44 patients (7%), were as follows (p < 0.05): increased age; a history of cerebrovascular disease; circulatory arrest time (7 to 29 minutes = 12/298 [4%], 30 to 44 minutes = 15/201 [7.5%], 45 to 59 minutes 9/84 [10.7%], 60 to 120 minutes 7/48 [14.6%]; cardiopulmonary bypass time; and concurrent descending thoracic aorta repair. The multivariably determined predictors were as follows (p < 0.05): a history of cerebrovascular disease; previous aortic surgery distal to the left subclavian artery; and cardiopulmonary bypass time. A history of aortic valve incompetence, however, was associated with a lower risk of stroke (adjusted odds ratio 0.42, p = 0.015). The multivariably determined predictors for increased risk of early death (p < 0.05), which occurred in 66 (10%) patients, were as follows: increased age; Marfan syndrome; concurrent distal aortic aneurysm; previous ascending aortic operation; cardiopulmonary bypass time; cardiac complications; renal complications; and stroke. In this study, the occurrence of stroke was observed to increase after 40 minutes of circulatory arrest; furthermore, the mortality rate increased markedly after 65 minutes of circulatory arrest. Thus the "safe" period for strokes not developing appeared to be limited to approximately 40 minutes. We conclude that deep hypothermia with circulatory arrest is a safe technique for the repair of complex aortic problems provided both the circulatory arrest and the cardiopulmonary bypass times are not excessive. In addition, the clinical characteristics of the patients are important determinants of stroke and death.

Actuarial Analysis↗
PubMed1993

Experience with 1509 patients undergoing thoracoabdominal aortic operations.

PURPOSE: The purpose of this study was to retrospectively identify variables associated with early death and postoperative complications in patients undergoing thoracoabdominal aortic operations. METHODS: The data on 1509 patients who underwent 1679 thoracoabdominal aortic repairs between 1960 and 1991 were retrospectively reviewed. The median age was 66 years (range 1.5 years to 86 years), and aortic dissection was present in 276 (18%) patients. The extent of the first repair performed included 378 (25%) type I (proximal descending to upper abdominal aorta), 442 (29%) type II (proximal descending aorta to below the renal arteries), 343 (23%) type III (distal descending and abdominal aorta), and 346 (23%) type IV (most of the abdominal aorta). The median total aortic clamp time was 43 minutes. RESULTS: The 30-day survival rate was 92% (1386/1509) for the 30-year period. On multivariate analysis the preoperative and operative variables associated with death included (p < 0.05) increasing age, preoperative creatinine level, concurrent proximal aortic aneurysms, coronary artery disease, chronic lung disease, and total aortic clamp time. When the postoperative variables were also included in the stepwise logistic regression model, then in addition, cardiac complications, stroke, kidney failure, and gastrointestinal hemorrhage became significant (p < 0.05). The overall incidence of paraplegia or paraparesis was 16% (234/1509). By use of stepwise logistic regression analysis, the significant predictors (p < 0.05) of paraplegia or paraparesis developing were total aortic clamp time, extent of aorta repaired, aortic rupture, patient age, proximal aortic aneurysm, and history of renal dysfunction. Kidney failure (postoperative creatinine level > 3 mg/dl or dialysis) occurred in 18% (269/1509) of patients; dialysis was required in 9% (136/1509). Gastrointestinal complications manifested in 7% (101/1509) of patients. CONCLUSION: Although the survival rate has improved, paraplegia/paraparesis and kidney failure continue to be vexing problems that require further research.

Adolescent↗
PubMed1992

Composite valve graft replacement of the proximal aorta: comparison of techniques in 348 patients.

Composite valve graft replacement of the ascending aorta is being increasingly used, although it is not clear which technique, the Bentall, Cabrol, or button, is the best method for coronary artery ostial reattachment. We retrospectively analyzed our results with respect to these three techniques in 348 consecutive patients operated on between September 17, 1979, and January 29, 1991. Variables included aortic arch replacement in 88 patients (25%), need for deep hypothermia and circulatory arrest in 119 (34%), aortic dissection in 131 (38%), acute dissection in 34 (9.8%), reoperation in 79 (23%), and insertion of St. Jude prostheses in 270 (78%). The 30-day survival rate was 91% (316/348), the in-hospital survival rate was 90% (312/348), and the 30-day incidence of postoperative new transient (n = 6) and permanent (n = 6) stroke was 3% (12/348). The 30-day survival rates for each method were as follows: Cabrol, 92% (144/157); button, 91% (39/43); and Bentall, 91% (125/137). On stepwise multivariate logistic regression analysis with control for operative date and independent prognostic factors, operative technique was not an independent determinant of early mortality or stroke. On late follow-up, the Kaplan-Meier 5-year survival rate was 71% with no significant difference between the groups (3-year survival: Cabrol, 76%; Bentall, 79%; and button, 81%; p = 0.28). The 3-year freedom from reoperation was 95% (Cabrol, 97%; Bentall, 91%; and button, 100%; p = 0.17). We conclude that for patients undergoing reoperation or complicated repairs or when tension on the ostial anastomoses may occur, the Cabrol technique is preferable. If feasible, however, the button technique has better long-term results for both survival and rate of reoperation. An alternative technique is to use an interposition graft to reattach the left coronary artery and excise an aortic button for the right coronary artery reattachment. This has the advantages of technical ease in reattaching the left coronary artery, good results for reattachment of the right coronary artery, minimal tension on the anastomoses, and visualization of all anastomoses.

Adolescent↗