Biomedical subjects

L D Fisher

Publications and source records attributed to L D Fisher.

At least 19 recordsLinked to original sources

PubMed1995

1995 Volvo Award in clinical sciences. Determinants of lumbar disc degeneration. A study relating lifetime exposures and magnetic resonance imaging findings in identical twins.

STUDY DESIGN: Retrospective cohort. OBJECTIVES: To investigate the effects of lifetime exposure to commonly suspected risk factors on disc degeneration using magnetic resonance imaging, and to estimate the effects of these suspected risk factors relative to age and familial aggregation, reflecting genetic and shared environmental influences. SUMMARY OF BACKGROUND DATA: Structural and biochemical changes associated with disc degeneration are suspected as the underlying conditions of many back-related symptoms. Little is known about the determinants of disc degeneration. METHODS: Based on lifetime discordance in suspected environmental risk factors for disc degeneration, 115 male identical twin pairs were selected. An in-depth interview was conducted of occupational and leisure time physical loading, driving, and smoking. Disc degeneration was evaluated using observational and digital magnetic resonance imaging assessment methods. RESULTS: Heavier lifetime occupational and leisure physical loading was associated with greater disc degeneration in the upper lumbar levels (P = 0.055 - 0.001), whereas sedentary work was associated with lesser degeneration (P = 0.006). These univariate associations did not reach statistical significance in the lower lumbar region. In multivariate analyses of the upper lumbar levels, the mean job code explained 7% of the variability in observational disc degeneration scores; the addition of age explained 16%, and familial aggregation improved the model such that 77% of the variability was explained. In the lower lumbar levels, leisure time physical loading entered the multivariate model, explaining 2% of the variability. Adding age explained 9%, and familial aggregation raised the variability in disc degeneration scores explained to 43%. CONCLUSIONS: The present study findings suggest that disc degeneration may be explained primarily by genetic influences and by unidentified factors, which may include complex, unpredictable interactions. The particular environmental factors studied, which have been among those most widely suspected of accelerating disc degeneration, had very modest effects.

Adult↗

PubMed1995

Long-term prognostic value of exercise testing in men and women from the Coronary Artery Surgery Study (CASS) registry.

Many prior studies involving a predominantly male population have demonstrated the importance of exercise test results in determining the outcome of patients with coronary artery disease. The prognostic significance of exercise testing in women is unknown. In our study, a total of 3,086 men and 747 women underwent maximal treadmill exercise testing, coronary angiography, and were prospectively followed for up to 16 years. They were divided into 3 groups (high, intermediate, and low risk) on the basis of exercise testing. Sixteen-year survival based on exercise test groups ranged from 38% to 61% in men and from 44% to 79% in women (p < 0.001). Among men, 12-year survival was enhanced by coronary artery bypass surgery versus medical therapy in the high-risk subgroup (69% vs 55%, respectively, p = 0.0025), but the 2 therapies were similar in the intermediate- and low-risk subgroups. Among women, neither medical nor surgical therapy resulted in improved 12-year survival rates in any of the 3 subgroups. These results suggest that exercise testing is helpful in assessing long-term survival in men and women. However, only exercise testing in men could identify a high-risk subset whose survival was enhanced by coronary artery bypass graft surgery.

Adult↗

PubMed1995

Observer variability in the assessment of disc degeneration on magnetic resonance images of the lumbar and thoracic spine.

STUDY DESIGN: Intraobserver and interobserver reproducibility study. OBJECTIVE: This study investigates the variability in the interpretation of degenerative disc findings using magnetic resonance imaging. SUMMARY OF BACKGROUND DATA: Magnetic resonance imaging has been used for years in clinical diagnostics, primarily to investigate disc herniation and spinal stenosis. Less attention has been paid to other disc findings and their assessment reliability. METHODS: Three independent readers evaluated magnetic resonance images of the lumbar and the lower and middle thoracic spines of 122 subjects by grading 12 aspects of the intervertebral discs and adjacent endplates using written definitions and example images. Images of 20 subjects were reevaluated for the assessment of intraobserver agreement. RESULTS: Agreement was highest in the lower lumbar and poorest in the middle thoracic spine. Intraobserver agreement was generally fair to excellent for almost all variables in the lumbar and lower thoracic spine (most intraclass correlation and kappa coefficients for these regions were above 0.70). Interobserver agreement was notably lower than intraobserver agreement, except for osteophytes and endplate defects in some regions. CONCLUSIONS: Intraobserver agreement in the evaluation of disc degeneration was at an acceptable level, in general, in the lumbar and lower thoracic spine. However, assessments were substantially more variable between readers, which limits comparisons of evaluations between different readers.

Adult↗

PubMed1995

Magnetic resonance imaging findings and their relationships in the thoracic and lumbar spine. Insights into the etiopathogenesis of spinal degeneration.

STUDY DESIGN: Descriptive epidemiologic study about magnetic resonance imaging findings in the spine. OBJECTIVES: To describe the prevalence of magnetic resonance imaging findings in a general population at spinal levels T6-S1, and to examine the relationships of these findings within each spinal level and between levels. SUMMARY OF BACKGROUND DATA: The prevalence of specific findings and the associations between findings and spinal levels can provide general insights into the etiopathogenesis of spinal degeneration. METHODS: Subjects consisted of 232 men from a population sample (mean age 49.3 years). Signal intensity, disc bulging, disc herniation, and endplate irregularities were among 11 findings assessed from magnetic resonance images. RESULTS: The disc signal intensities were assessed to be lowest in the lumbar and middle thoracic regions. Disc bulging and disc height narrowing were most common in the lower levels of both the thoracic and lumbar regions. All magnetic resonance imaging findings except herniations and endplate irregularities were clearly associated with age. Osteophytes were most highly associated with disc bulging in levels T6-L3, and with endplate irregularities in the lower lumbar levels. Disc herniations were not consistently associated with any other findings. The disc levels that most highly correlated are grouped as follows: T6-T10, T10-L4, and L4-S1. CONCLUSIONS: With the exception of endplate irregularities and herniations, the magnetic resonance imaging findings appeared to be associated with the same pathogenic process. The interaction of mechanical factors and spinal structures varies between spinal levels, and the degeneration common in the lower parts of the thoracic and lumbar spine could be an outcome of vulnerability for torsional forces. Some gross guidelines for grouping findings can be drawn from disc level correlations.

Adult↗

PubMed1995

A model for the study of wounds in normal elderly adults and patients with peripheral vascular disease or diabetes mellitus.

The purpose of the study was to test the hypothesis that significant delays in cutaneous wound healing could be demonstrated using standard wounds and high quality histological methods in patients with severe peripheral vascular disease (PVD) and/or diabetes mellitus (DM) compared to healthy elderly controls. Additionally, we proposed that standard wounds on the arms of elderly controls would heal more rapidly than comparable wounds on the legs. In order to test these hypotheses we developed and characterized a partial thickness wound model which could be used safely in human subjects. The study population consisted of 25 elderly normal volunteers, 17 patients with PVD, and 24 patients with DM. Standard wounds were created using a Simplate II bleeding-time device. A total of 309 wounds ranging in age from 1 to 25 days were determined to be suitable for analysis. A global index of wound maturity was developed based on selected epidermal and dermal events of repair which could be scored histologically. The superficial component (within 0.1 mm of the epidermis) and deep components of dermal wounds were analyzed separately. Simultaneously created arm and leg wounds were studied in 15 of the elderly controls. Transcutaneous partial pressure of oxygen (TcPO2) measurements were used to estimate the severity of cutaneous ischemia. Data analysis revealed that the most striking differences observed were in dermal events of repair. Control wounds were more mature than dermal wounds from patients with PVD (P < 0.05). A significant reduction in the number of neutrophils and macrophages (P < 0.05) was demonstrated in 7-day-old wounds of patients with PVD compared to controls. Patients with DM showed a similar trend of reduced wound maturity but it did not reach statistical significance. Wounds created in skin with TcPO2 > 20 were more mature than wounds with TcPO2 < or = 20 (P < 0.05) and arm wounds were more mature than leg wounds (P < 0.01). The most significant difference noted in this wound model was that the superficial compartment of dermal wounds was significantly more mature than the deep compartment (P < 0.001). Good agreement was observed between two independent scorers of wound histology and no complications were noted in either patients or controls when using this human wound model. We conclude that the model described allows evaluation of both epidermal and dermal events of repair with relative safety even in patients with PVD and DM.(ABSTRACT TRUNCATED AT 400 WORDS)

Aged↗

PubMed1995

Significance of silent myocardial ischemia during exercise testing in women: report from the Coronary Artery Surgery Study.

To evaluate the significance of silent myocardial ischemia during exercise testing in women compared to men, we analyzed the data on 1087 women and 3834 men who underwent exercise testing and coronary angiography from the Coronary Artery Surgery Study (CASS) registry. The patients were divided into three groups on the basis of the results of exercise testing: group 1, silent ischemia (253 women, 853 men); group 2, symptomatic ischemia (156 women, 1250 men); and group 3, no ischemia (678 women, 1731 men). The survival rate at 12 years for women was 80% for group 1, 75% for group 2, and 86% for group 3 (p = 0.0022); the survival rate for men was 69% for group 1, 69% for group 2, and 76% for group 3 (p < 0.001). In both men and women with silent ischemia, the 12-year survival rate was related to the severity of coronary artery disease (CAD) and ranged from 79% for women with one-vessel CAD to 46% for men with three-vessel CAD. Survival at 12 years was enhanced by coronary artery bypass graft surgery as compared to medical treatment in patients with silent ischemia and three-vessel CAD for men (61% vs 46%, respectively, p = 0.0014) but not for women (45% vs 50%, respectively, p = 0.98). These data suggest that silent ischemia in women and men adversely affects survival rate and that men may gain more benefit from coronary artery bypass graft surgery than women when three-vessel CAD is present.

Cardiac Catheterization↗

PubMed1995

Myocardial infarction in young adults: angiographic characterization, risk factors and prognosis (Coronary Artery Surgery Study Registry).

OBJECTIVES: This study examined the angiographic characteristics, coronary risk factors and prognosis in young men and women with a history of myocardial infarction compared with that in older patients. BACKGROUND: There are few data regarding myocardial infarction in young adults. It is undetermined whether the development of myocardial infarction at a young age represents a form of coronary heart disease with an adverse prognosis. METHODS: Of the 8,839 patients with a history of myocardial infarction in the Coronary Artery Surgery Study (CASS), there were 294 men < or = 35 years old and 210 women < or = 45 years old. Coronary anatomy, baseline characteristics and prognosis were compared in younger and older patients. RESULTS: Young men and women more often had angiographically normal coronary arteries, nonobstructive disease < 70% stenosis and single-vessel disease than older patients (p < 0.0001). Current smoking was more frequent in young patients (p < 0.0001). Hypertension and diabetes were more frequent in both older men and women, whereas a positive family history of premature coronary disease was significantly more prevalent only in young men. The survival rate at 7 years was improved for young men compared with that in older men (84% vs. 75%, p = 0.0094) and for young women compared with that in older women (90% vs. 77%, p = 0.0004). When multivariate analysis was applied to the data, the survival advantage for young patients remained after adjustment. CONCLUSIONS: Young patients with a myocardial infarction have a favorable prognosis compared with that in older patients.

Adult↗

PubMed1995

Similarities in degenerative findings on magnetic resonance images of the lumbar spines of identical twins.

Although the etiology of most degenerative changes in the lumbar spine is unclear, genetic factors may play an important role. To investigate this link, we reviewed magnetic resonance images of the lumbar spines of identical twins to assess the degree of similarities in degenerative findings in the discs. Observers who were blinded to twinship evaluated sagittal T1-weighted and T2-weighted magnetic resonance images of the lumbar spines of forty male identical twins (twenty pairs) with respect to changes in the end plates, desiccation of the discs, bulging or herniated discs, and decrease in the height of the disc space. Similarities between co-twins were significantly greater than would be expected by chance. Whereas smoking status and age explained 0 to 15 per cent of the variability in the various degenerative findings in the discs, 26 to 72 per cent of the variability was explained with the addition of a variable representing co-twin status. These findings are compatible with a marked genetic influence and warrant further investigation.

Adult↗

PubMed1995

Graft-rejection and toxicity following bone marrow transplantation in relation to busulfan pharmacokinetics.

We have determined the relationships between busulfan average concentration at steady-state and (1) rejection of graft, and (2) regimen-related toxicity, and have evaluated the dependence of busulfan clearance/F on body size and age. Patients received 16-30 mg/kg of busulfan followed by cyclophosphamide in doses of 120, 150, 174, or 200 mg/kg or 8 g/m2 in preparation for autologous, syngeneic or allogeneic grafts varying in compatibility from HLA-matched siblings to HLA-partially-matched unrelated donors. In a multivariate Cox time-to-rejection analysis, only busulfan concentration remained a significant determinant of rejection, P = 0.0154. An average concentration of busulfan at steady-state of at least 200 ng/ml was needed to avoid rejection of a matched-sibling graft, while 600 ng/ml was needed to avoid rejection of HLA-partially-matched related or HLA-matched unrelated donor grafts. The toxicity of the cytoreductive regimen correlated with busulfan average concentration at steady-state (rs = 0.717). Busulfan clearance/F expressed relative to body weight, ideal body weight or surface area declined with age during the first decade of life. Over the entire span of age, the coefficient of variation in clearance/F for all ages was similar when clearance/F was expressed in absolute terms (ml/min) and when adjusted for body surface area; the coefficient of variation was greater for clearance/F when expressed relative to total or ideal body weight. We conclude that busulfan concentration in plasma is an important determinant of graft survival and regimen-related toxicity, and that the variability of busulfan pharmacokinetics with age precludes the use of a fixed dose for all ages and indications.

Adolescent↗

PubMed1994

Marrow transplantation for patients in accelerated phase of chronic myeloid leukemia.

The records were reviewed of 58 patients receiving transplants in Seattle with unmanipulated marrow from HLA-identical siblings during the accelerated phase (AP) of chronic myeloid leukemia. Variables examined for association with survival and relapse included the interval from diagnosis to transplant, the reasons for categorization as AP, age, regimen, and cytomegalovirus serology. Four patients relapsed. The 4-year probabilities of survival, relapse-free survival, nonrelapse mortality, and relapse were 0.49, 0.43, 0.51, and 0.12, respectively. After completion of the stepwise multivariate analysis, age less than 38 years and categorization as AP solely on the basis of chromosomal abnormalities emerged as being independently significantly associated with improved survival. The 4-year probability of survival for the 16 patients categorized as AP because of chromosomal abnormalities and receiving transplant less than 1 year from diagnosis was 0.74. The low probability of relapse in these patients suggests that more aggressive preparative regimens are not indicated for patients receiving transplants in AP because of the increased risk of transplant-related mortality.

Acute Disease↗

PubMed1994

Marrow transplantation for chronic myeloid leukemia: a randomized study comparing cyclophosphamide and total body irradiation with busulfan and cyclophosphamide.

A prospective randomized study was conducted comparing two conditioning regimens for the treatment of patients with chronic myeloid leukemia in chronic phase by marrow transplantation from HLA identical siblings. Sixty-nine patients received 60 mg/kg of cyclophosphamide on each of 2 successive days followed by 6 fractions of total body irradiation each of 2.0 Gy (CY-TBI), and 73 patients received 16 mg/kg of busulfan delivered over 4 days followed by 60 mg/kg CY on each of 2 successive days (BU-CY). There was no significant difference between the CY-TBI and the BU-CY groups in the 3-year probabilities of survival (0.80 for both), relapse (0.13 for both), or event-free survival (CY-TBI, 0.68; BU-CY, 0.71) or in speed of engraftment or incidence of venocclusive disease of the liver. The 4-year probabilities of survival and event-free survival for patients transplanted within 1 year of diagnosis were 0.86 and 0.72, respectively, for each group. Significantly more patients in the CY-TBI group experienced major creatinine elevations. There was significantly more acute graft-versus-host disease in the CY-TBI group. Fever days, positive blood cultures, hospitalizations, and inpatient hospital days were significantly more common in the CY-TBI group than in the BU-CY group. In conclusion, the BU-CY regimen was better tolerated than, and associated with survival and relapse probabilities that compare favorably with, the CY-TBI regimen.

Adolescent↗

PubMed1994

Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration.

We carried out a systematic overview using individual patient data from the seven randomised trials that have compared a strategy of initial coronary artery bypass graft (CABG) surgery with one of initial medical therapy to assess the effects on mortality in patients with stable coronary heart disease (stable angina not severe enough to necessitate surgery on grounds of symptoms alone, or myocardial infarction). 1324 patients were assigned CABG surgery and 1325 medical management between 1972 and 1984. The proportion of patients in the medical treatment group who had undergone CABG surgery was 25% at 5 years, 33% at 7 years, and 41% at 10 years: 93.7% of patients assigned to the surgery group underwent CABG surgery. The CABG group had significantly lower mortality than the medical treatment group at 5 years (10.2 vs 15.8%; odds ratio 0.61 [95% CI 0.48-0.77], p = 0.0001), 7 years (15.8 vs 21.7%; 0.68 [0.56-0.83], p < 0.001), and 10 years (26.4 vs 30.5%; 0.83 [0.70-0.98]; p = 0.03). The risk reduction was greater in patients with left main artery disease than in those with disease in three vessels or one or two vessels (odds ratios at 5 years 0.32, 0.58, and 0.77, respectively). Although relative risk reductions in subgroups defined by other baseline characteristics were similar, the absolute benefits of CABG surgery were most pronounced in patients in the highest risk categories. This effect was most evident when several prognostically important clinical and angiographic risk factors were integrated to stratify patients by risk levels and the extension of survival at 10 years was examined (change in survival -1.1 [SE 3.1] months in low-risk group, 5.0 [4.2] months in moderate-risk group, and 8.8 [5.4] months in high-risk group; p for trend < 0.003). A strategy of initial CABG surgery is associated with lower mortality than one of medical management with delayed surgery if necessary, especially in high-risk and medium-risk patients with stable coronary heart disease. In low-risk patients, the limited data show a non-significant trend towards greater mortality with CABG.

Adult↗

PubMed1994

Benefits of lipid-lowering therapy in men with elevated apolipoprotein B are not confined to those with very high low density lipoprotein cholesterol.

OBJECTIVES: Do the benefits of intensive lipid-lowering therapy extend to patients with only borderline or moderately elevated levels of low density lipoprotein (LDL) cholesterol? BACKGROUND: The merits of the present LDL cholesterol treatment goal of < or = 100 mg/dl need to be clarified for patients without high levels of LDL cholesterol, particularly for those patients previously classified as having only borderline high (130 to 159 mg/dl) or desirable (101 to 130 mg/dl) levels. METHODS: Disease change and clinical events were examined in LDL cholesterol subgroups in the Familial Atherosclerosis Treatment Study (FATS) trial, a randomized, blinded, quantitative arteriographic comparison of one conventional and two intensive lipid-lowering strategies in men with coronary artery disease, a positive family history and apolipoprotein B > or = 125 mg/dl. The primary end point, disease change per patient, was measured as the mean change in severity of stenosis (delta %SProx) among nine standard proximal segments. RESULTS: Of the 120 patients completing the 30-month protocol, 60 had a baseline LDL cholesterol < 90th percentile (mean LDL cholesterol 152 mg/dl) and 60 > 90th percentile (mean LDL cholesterol 221 mg/dl). Thirty-one patients had levels < 160 mg/dl (mean LDL cholesterol 134 mg/dl) and 89 > 160 mg/dl (mean LDL cholesterol 205 mg/dl). Patients with LDL cholesterol < 90th percentile benefited angiographically from therapy (delta %SProx = -1.5% diameter stenosis [regression] during intensive therapy vs. +2.3% diameter stenosis [progression] during conventional therapy, p < 0.01), as did patients with LDL cholesterol < 160 mg/dl (delta %SProx = -4.2% vs. +3.3% diameter stenosis, p = 0.0001). By comparison, angiographic benefit was less pronounced among those entering with very high LDL cholesterol (delta %SProx = -0.2% vs. +1.9% diameter stenosis, p = 0.07) or with LDL cholesterol > or = 160 mg/dl (delta %SProx = +0.2% vs. +1.6% diameter stenosis, p = 0.13). Intensive therapy resulted in a statistically significant reduction in clinical events only in the subgroup with baseline LDL cholesterol < 90th percentile (2 of 42 vs. 8 of 29 patients initially enrolled, p = 0.01) and a trend toward fewer events in patients with LDL cholesterol < 160 mg/dl (2 of 20 vs. 6 of 15 patients, p = 0.05). No such difference was seen in the higher LDL cholesterol subgroups. CONCLUSIONS: Treatment benefit in the FATS trial was not confined to patients with very high levels of LDL cholesterol and was in fact particularly evident in those patients with levels < 160 mg/dl. Such patients should be considered more likely, not less, to benefit from intensive lipid-lowering therapy.

Adult↗

PubMed1994

Simulation as a design tool for phase I/II clinical trials: an example from bone marrow transplantation.

We discuss the design and analysis of a proposed phase I/II clinical trial in bone marrow transplantation whereby dose modifications that decrease the risk of one complication increase the risk of another. Trials of this type are carried out to determine whether a dose can be found that balances the risks of each complication. Three different scenarios describing potential relationships between each risk and the treatment dose are postulated. The scenarios encompass both favorable situations in which several acceptable doses exist and unfavorable situations in which no acceptable dose exists. The operating characteristics of three sequentially developed trial designs were examined by simulation under each dose-response scenario. The first design was derived from seemingly reasonable rules, but simulations showed that performance fell far short of what was desired, thus motivating modifications. Subsequent designs showed improved performance characteristics compared to the original design. Without close examination of the operating characteristics, the original design would have been implemented, leading to high risk of an erroneous conclusion.

Bone Marrow Transplantation↗

PubMed1994

Femoropopliteal bypass with externally supported knitted Dacron grafts: a follow-up of 200 grafts for one to twelve years.

PURPOSE: This article reports our experience with externally supported, preclotted knitted Dacron grafts in femoropopliteal bypass. METHODS: This is a retrospective analysis of a consecutive series of 154 patients who received 200 grafts (175 above knee and 25 below knee). Follow-up extended to 12 years (mean 59 1/2 months). RESULTS: Primary patency rates for the entire series were 75%, 70%, and 47% at 3, 5, and 10 years, respectively. Above-knee grafts had 76%, 71%, and 50% rates and 3, 5, and 10 years, respectively. Below-knee grafts had 65% and 57% at 3 and 5 years, respectively. Limb-salvage rates were 87%, 79%, and 73% at 3, 5, and 10 years, respectively, for the 57 limbs operated on because of critical ischemia. The most significant predictor of graft failure was poor runoff as determined by preoperative arteriography. The effect of poor runoff was most pronounced in the first 3 months. CONCLUSION: Externally supported, preclotted knitted Dacron grafts provide encouraging primary patency rates for above-knee femoropopliteal bypass. Poor leg vessel runoff is a major determinant of early graft failure.

Adult↗

PubMed1994

Prevalence and epidemiologic correlates of human T cell lymphotropic virus infection among intravenous drug users.

Intravenous drug users (IVDUs) in Seattle (n = 213) were studied to identify the prevalence and predominant types of and risk factors for human T cell lymphotropic virus (HTLV) infection. Detailed questionnaires, serologic screening, and polymerase chain reaction analysis (for a subset) were used. Evidence of HTLV infection was found in 16.5%, of which 89% were HTLV-II. HTLV infection was significantly associated with nonwhite race, older age, more years of intravenous drug use, prior use of heroin, history of gonorrhea, history of any sexually transmitted disease, hepatitis B virus infection, and antibody to herpes simplex virus type 2 (HSV-2). By stepwise logistic regression analysis, associations persisted with race, age, hepatitis B markers, and HSV-2. Thus, the strong association of HTLV with hepatitis B, a marker for injection behavior, and the independent association with HSV-2 infection, a sexually transmitted pathogen, suggest similarities in the epidemiology of HTLV and human immunodeficiency virus infections in IVDUs.

Adult↗

PubMed1994

Long-term survival of medically treated patients in the Coronary Artery Surgery Study (CASS) Registry.

BACKGROUND: This study describes the impact of clinical, angiographic, and demographic characteristics on the long-term survival of Coronary Artery Surgery Study (CASS) patients while they were under medical treatment. Revascularization rates for the population are also provided. METHODS AND RESULTS: All CASS patients who had not received heart surgery before enrollment (23,467 patients) were included in this survival analysis while they were under medical treatment or surveillance. Follow-up time ranged from 0 to 17 years (median, 12 years). Long-term vital status is known for 95.8% of these patients. Log-rank tests, Kaplan-Meier survival curves, and Cox proportional-hazards regression are used to describe and assess the impact of patient characteristics on survival. Characteristics that had a significant impact on survival, in order of observed explanatory power, are age, number of diseased vessels, congestive heart failure score, smoking history, ejection fraction, sex, presence of left main coronary artery disease, presence of diabetes, left ventricular wall motion score, presence of other illnesses, history of myocardial infarction, and presence of left main equivalent disease. Overall, 12-year survival for patients with zero-, one-, two- and three-vessel disease is 88%, 74%, 59%, and 40%, respectively. Twelve-year survival for patients with at least one diseased vessel and ejection fractions in the ranges of 50% to 100%, 35% to 49%, and 0% to 34% is 73%, 54%, and 21%, respectively. High myocardial jeopardy, high anginal class, and two or three proximal diseased vessels characterize the profile of patients most likely to have received surgical treatment during follow-up. CONCLUSIONS: These results contribute to the understanding of the natural history of coronary artery disease and are also of historical interest. The poor survival of patients with three-vessel disease and low ejection fractions continues to emphasize the importance of considering revascularization for these patients.

Angioplasty, Balloon, Coronary↗

PubMed1994

Changing use of intensive care for HIV-infected patients with Pneumocystis carinii pneumonia.

Clinicians' approach to acute respiratory failure from Pneumocystis carinii pneumonia (PCP) is hypothesized to have gone through three phases: aggressive management due to an absence of data on prognosis (1981-84), withholding of intensive care based on a few small studies showing high case fatality (1985-87), and an increase in intensive care to an intermediate level (1988 forward). Unfortunately, studies of survival from acute respiratory failure among such patients have been small and have been limited to patients in the intensive care unit. To determine whether this three-phase scenario has empirical support, we performed a retrospective chart review of all patients with human immunodeficiency virus (HIV) infection and PCP at a university-affiliated municipal hospital from 1983 to 1990. We identified 180 patients, representing 218 episodes of PCP. The previously hypothesized relationship between intensive care and year of diagnosis was confirmed: intubation rates were 30% before 1985, 0% in 1987, and 12% after 1988 (p = 0.03). Among all patients, the percentage dying in the hospital without intensive care had the opposite relationship with year of diagnosis, increasing from 0% in 1984 to 21% in 1987 and then declining to 0% in 1990 (p = 0.001). Overall mortality from an episode of PCP was 25% and did not change significantly over time. Disease severity also did not change significantly over time. In summary, the significant swings in the use of intensive care for HIV-infected patients with PCP suggest that judgments about the futility of intensive care were strongly influenced by incorrect perceptions of survival.

AIDS-Related Opportunistic Infections↗