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Biomedical subjects

L D Sharples

Publications and source records attributed to L D Sharples.

At least 37 records · Page 2Linked to original sources
PubMed1999

Transmyocardial laser revascularisation in patients with refractory angina: a randomised controlled trial.

BACKGROUND: Transmyocardial laser revascularisation (TMLR) is used to treat patients with refractory angina due to severe coronary artery disease, not suitable for conventional revascularisation. We aimed in a randomised controlled trial to assess the effectiveness of TMLR compared with medical management. METHODS: 188 patients with refractory angina were randomly assigned TMLR plus normal medication or medical management alone. At 3 months, 6 months, and 12 months after surgery (TMLR) or initial assessment (medical management) we assessed exercise capacity with the treadmill test and the 12 min walk. FINDINGS: Mean treadmill exercise time, adjusted for baseline values, was 40 s (95% CI -15 to 94) longer in the TMLR group than in the medical-management group at 12 months (p=0.152). Mean 12 min walk distance was 33 m (-7 to 74) further in TMLR patients than medical-management patients (p=0.108) at 12 months. The differences were not significant or clinically important. Perioperative mortality was 5%. Survival at 12 months was 89% (83-96) in the TMLR group and 96% (92-100) in the medical-management group (p=0.14). Canadian Cardiovascular Society score for angina had decreased by at least two classes in 25% of TMLR and 4% of medical-management patients at 12 months (p<0.001). INTERPRETATION: Our findings show that the adoption of TMLR cannot be advocated. Further research may be appropriate to assess any potential benefit for sicker patients.

Angina Pectoris↗
PubMed1999

The transmyocardial laser revascularization international registry report.

AIMS: This report aimed to provide an analysis of the data submitted from Europe and Asia on transmyocardial laser revascularization. METHODS AND RESULTS: Prospective data was recorded on 967 patients with intractable angina not amenable to conventional revascularization in 21 European and Asian centres performing transmyocardial laser revascularization using the PLC Medical Systems CO2 laser. Patient characteristics, operative details and early complications following transmyocardial laser revascularization were recorded. The in-hospital death rate was 9.7% (95% confidence interval 7.8% to 11.6%). Other early complications were consistent with similar cardiothoracic surgical procedures. There was a decrease of two or more Canadian Cardiovascular Score angina classes in 47.3%, 45.4% and 34.0% of survivors at 3, 6 and 12 months follow-up, respectively (P=0.001 for each). Treadmill exercise time increased by 42 s at 3 months (P=0.008), 1 min 43 s at 6 months (P<0.001) and 1 min 50 s at 12 months (P<0.001) against pre-operative times of 6 min. CONCLUSION: Uncontrolled registry data suggest that transmyocardial laser revascularization may lead to a decrease in angina and improved exercise tolerance. It does, however, have a risk of peri-operative morbidity and mortality. Definitive results from randomized controlled trials are awaited.

Adult↗
PubMed1999

Prospective study of health related quality of life before and after coronary artery bypass grafting: outcome at five years.

OBJECTIVE: To determine the long term health related quality of life of coronary artery bypass graft patients, to look at changes between one and five years after surgery, and to examine the ability of preoperative variables to predict longer term outcome. DESIGN: Nottingham health profile (NHP) was used to assess patients at five years compared to results obtained at one year. PATIENTS: 100 male patients aged < 60 years at time of surgery; 77 had three vessel disease and 84 received three or more saphenous vein grafts. RESULTS: In comparing the five year results with those at one year, lower mean scores, indicating slight improvements, were seen in the NHP dimensions of pain, sleep, social isolation, and emotional reactions, whereas signs of deterioration were noted in the physical mobility and energy scores. Chest pain was experienced by 34 of 84 patients at five years compared with 17 of 89 patients at one year. The proportion of patients who were unrestricted in their activities ranged from 61-70% at five years compared with 82-88% at one year. Absence of dyspnoea before surgery, indicating relatively good left ventricular function, was a predictor of good outcome at both one and five years. CONCLUSIONS: Evidence of deterioration in physical function is compatible with expected decline in graft patency; specific rather than generic measures were most sensitive to this change.

Adult↗
PubMed1998

Late complications following permanent pacemaker implantation or elective unit replacement.

OBJECTIVE: To determine the rate of late complications following first implantation or elective unit replacement of a permanent pacemaker system. DESIGN: Analysis of pacemaker data and complications prospectively acquired on a computerised database. Complications were studied over an 11 year period from January 1984 to December 1994. SETTING: Tertiary referral cardiothoracic centre. PATIENTS: Records of 2621 patients were analysed retrospectively. MAIN OUTCOME MEASURES: Complications requiring repeat procedures occurring more than six weeks after pacemaker implantation or elective unit replacement. RESULTS: The overall rate of late complications was significantly lower after first implantation of a permanent pacemaker (34 cases, complication rate 1.4%, 95% confidence interval 0.9% to 1.9%) than after elective unit replacement (16 cases, complication rate 6.5% (3.3% to 9.7%). There were 20 cases of erosion, 18 infections, five electrode problems, and seven miscellaneous problems. Complications were more common with inexperienced operators (18.9% (6.0% to 31.8%)) than with experienced operators (0.9% (0.3% to 1.5%). CONCLUSIONS: The incidence of late complications following pacemaker implantation is low and compares favourably with early complication rates. The majority are caused by erosion and infection. Patients who have undergone elective unit replacement are at particular risk.

Adult↗
PubMed1998

Bronchiolitis obliterans syndrome: incidence, natural history, prognosis, and risk factors.

BACKGROUND: In lung transplantation, obliterative bronchiolitis is the major factor limiting long-term survival. Bronchiolitis obliterans syndrome (BOS), defined as staged decline in pulmonary function has proved a reproducible and sensitive marker of obliterative bronchiolitis. METHODS: The incidence of, and risk factors for, BOS were investigated in 230 lung transplant recipients who underwent transplantation from April 1984 to December 1995 and who survived at least 3 months after operation. Progression and prognosis was investigated in the 109 cases with development of BOS. RESULTS: Actuarial BOS-free probability at 5 years was 36%. Post-BOS onset survival was 51% at 3 years. BOS onset conferred increased risk of death (hazard ratio [HR], 5.96; 95% confidence interval [CI], 3.61, 9.83). Donor and recipient characteristics such as sex, age, underlying disease, type of transplant, and graft ischemic time did not affect BOS onset, progression, or prognosis. Cytomegalovirus serologic status and early acute rejection were risk factors for BOS onset in multivariate modeling. In univariate analysis, other risk factors were lung infection, cytomegalovirus episodes, organizing pneumonia, and human leukocyte antigen mismatch. Later transplantation era (1991 to 1995) was associated with decreased risk of BOS (HR, 0.64; 95% CI, 0.44, 0.92). Acute rejection affected post-BOS progression (HR, 1.28/episode; 95% CI, 1.12, 1.45) and survival (HR, 1.20/episode; 95% CI, 1.05, 1.37). Post-BOS lung infection was an independent prognostic factor (HR, 1.12/episode; 95% CI, 1.01, 1.24). BOS onset in the later half of the series (1992 to 1997) was associated with decreased risk of progression (HR, 0.52; 95% CI, 0.33, 0.82). CONCLUSIONS: This study confirms that BOS is a major problem in lung transplantation, with a high incidence, rapid progression, and poor survival. It affects all modes of lung transplantation, regardless of sex, age, or underlying diagnosis. Acute rejection is a major prognostic factor. Lung infections after BOS onset worsen survival rates.

Actuarial Analysis↗
PubMed1997

Cost implications of mitral valve replacement versus repair in mitral regurgitation.

BACKGROUND: Mitral valve repair and replacement (MVR) with preservation of the tendinous chordae [MVR(p)], may have better results than MVR with valve excision [MVR(e)]. It is not known whether the type of surgery affects in-hospital stay and cost. METHODS AND RESULTS: We reviewed all patients who had mitral valve surgery for regurgitation over 5 years from January 1991. Patients were considered in three groups; MVR(e), MVR(p), and Repair. Cost was calculated using operating room, intensive care unit, and ward expenses, not hospital charges. There were a total of 253 patients; 84 MVR(e), 42 MVR(p), and 127 Repair. Mean ages and preoperative New York Heart Association (NYHA) classes were similar in the three groups. There were more male patients in the Repair (62%) and MVR(p) (67%) groups than in the MVR(e) (44%) group (P<.05), and more patients with degenerative etiology in the Repair group (P<.01). A majority of MVR(e) were in atrial fibrillation (63%), while 59% of Repair were in sinus rhythm (P<.01). Of 9 patients who died in the hospital; four had MVR(e), 3 had MVR(p), and 2 had Repair. In univariate analyses, in-hospital stay increased with patient age >70 years (P<.01), preoperative atrial fibrillation (P<.05), and NYHA class III or IV (P<.01). The median and interquartile ranges for postoperative stay was 10 (8 to 13) days for MVR(e), 8 (7 to 11) days for MVR(p), and 8 (7 to 10) days for Repair (P<.01 versus MVR(e); multivariate analysis adjusting for age, rhythm, and NYHA class). Cost per patient was US $14469 for MVR(e), $13151 for MVR(p), and $11606 for Repair. CONCLUSIONS: Repair and MVR(p) may predict shorter in-hospital stay and reduced cost, although there are important differences in the group of patients who have MVR(e).

Aged↗
PubMed1997

Human leukocyte antigen compatibility in heart transplantation: evidence for a differential role of HLA matching on short- and medium-term patient survival.

BACKGROUND: Studies of the influence of human leukocyte antigen (HLA) matching on cardiac transplant outcome have proved inconclusive, mainly due to the lack of well-matched grafts. However, a growing number of studies report improved clinical course and patient survival in cases with increased HLA compatibility. Opelz et al. believe these benefits justify the introduction of prospective HLA-matching strategies. METHODS: We performed univariate and multivariate analyses to examine the short- and medium-term influence of HLA matching on 556 consecutive primary heart transplants performed at a single center between 1983 and 1994. Overall graft survival at 1, 3, and 5 years was 80%, 74%, and 67% respectively. Sixteen (2.9%) grafts failed within 5 days and were not considered in the analysis of the HLA matching and graft survival data. RESULTS: Complete HLA-A, -B, and -DR typing data were available on 477 transplant pairs. The results demonstrate a 12% 1-year survival advantage for 31 patients with zero to two HLA antigen mismatches compared with three to six mismatches. The influence of each individual locus was 6.1%, 8.4%, and 5.4% for zero HLA-A, -B, and -DR mismatches, respectively, compared with two mismatches. However, when outcome from 1 to 5 years was considered, analysis of the role of each locus revealed marked differences. HLAA-matched grafts (n=45) had a 24% lower survival rate compared with two-antigen-mismatched grafts (n=148; 88% [SE 3.1] vs. 64% [SE 8.2], respectively; P=0.009). Furthermore, 34% of HLA-A-matched grafts failed between 1 and 5 years, compared with only 5% of HLA-B-matched grafts (P=0.013). CONCLUSIONS: These data suggest that although HLA matching is effective at reducing acute graft loss, in the longer term, HLA-A matching may impair survival. HLA-A may serve as a restriction element for indirect presentation of allopeptides or tissue-specific minor histocompatibility antigens, facilitating chronic graft loss. Therefore, we advocate a differential role for HLA matching over two epochs. A blanket approach to prospective matching for heart transplants may be premature for optimal long-term survival.

Adolescent↗
PubMed1997

Bronchiolitis obliterans syndrome in heart-lung transplantation: surveillance biopsies.

Transbronchial biopsies (TBBs) are useful to diagnose acute rejection and infection in patients with lung transplants. The value of routine surveillance biopsies (S-TBBs) is not known, and such biopsies with a clinical indication are not without risk and are expensive. One hundred twenty-six 6-mo survivors of heart-lung transplantation (HLT) were studied to determine the effect of stopping S-TBBs on the development of bronchiolitis obliterans syndrome (BOS) and subsequent survival. Fifty-one received transplants while S-TBB was part of routine care (group A), and 75 received transplants after this practice was stopped (group B). There was no difference in patient characteristics. Group A had shorter graft ischemia (p < 0.01) and longer postoperative ventilation (p < 0.01). Maintenance immunosuppression was similar, but group A had more steroid pulses in the second 6 mo after HLT (p < 0.01). The number of patients free from any functional deterioration at 49 to 60 mo after HLT declined to 39% in group A and 64% in group B. The risk of developing BOS grade 1 in group A relative to group B was 1.63 (95% confidence intervals: 0.96-2.79, p = 0.07). Patient survival was similar in the two groups. A total of 86 TBBs were taken in the absence of any signs or symptoms and had low diagnostic yield. In summary, there was no increased incidence of BOS after stopping S-TBBs.

Actuarial Analysis↗
PubMed1996

A model for analyzing the cost of main clinical events after cardiac transplantation.

Using information from the Papworth Hospital heart transplant service, a model was developed to link the main clinical events after cardiac transplantation to survival and costs. On the basis of the clinical and survival experience of 387 patients treated with triple-drug immunosuppression between 1986 and 1993, together with protocols for patient management, resource use, and costs, a 5-year Markov model with three time periods was used to simulate survival and estimate costs. The model accurately mirrors observed actuarial survival; 1- and 5-year survival rates were 81% and 65%, respectively. An average cost per patient of 26,000 pounds over 5 years (discounted at a rate of 6%) was estimated. The expense of routine care for patients accounts for the majority of the costs; a patient who remains well throughout the 5-year period would incur costs of 23,000 pounds. The sensitivity of the estimates to alternative assumptions is presented, and the way in which the model can be used to compare alternative future scenarios is explored.

Adolescent↗
PubMed1996

Development of bronchiolitis obliterans syndrome in recipients of heart-lung transplantation--early risk factors.

Given the internationally recognized definition of bronchiolitis obliterans syndrome (BOS) and longer follow up of heart-lung transplant recipients, it is possible to establish some of the major risk factors for development and progression of BOS. Between April 1984 and 31 December 1993, 157 patients underwent heart-lung transplantation; 126 survived at least six months after operation and so were at risk of developing BOS. The following early risk factors were assessed for development of BOS grade 1 (21-35% decline in FEV1) and progression from grade 1 to grade 2 (36-50% decline in FEV1): age, gender and underlying diagnosis of the recipient, evidence of acute rejection and cytomegalovirus (CMV) infection within 6 months of operation, peak FEV1 achieved, age and gender of the donor, cold ischemic time of the graft, and matching of CMV serological status and HLA antigens of donor and recipient. The number of acute rejection episodes observed remained the single most important determinant of development of BOS grade 1 (relative risk 1.17 (1.06, 1.29), P=0.002) and progression to BOS grade 2 (relative risk 1.58 (1.02, 2.46), P=0.03). No other factors were significantly related to development or progression of BOS, although both evidence of CMV infection and disease and the number of HLA mismatches increased the risk. Bronchiolitis obliterans syndrome is a major problem for medium-to-long-term survivors of cardiothoracic transplantation. Acute rejection early after transplantation is a sensitive prognostic indicator of subsequent functional decline and requires prompt attention.

Adolescent↗
PubMed1996

Excellent outcome of cardiac transplantation using domino donor hearts.

OBJECTIVE: Domino cardiac transplantation affords flexible and optimal organ utilization, provides hearts unaffected by brain death, allows prospective tissue matching, and subsequent transplantation with short allograft ischemic times. A retrospective review of our experience with domino cardiac transplantation has been made. METHODS: Seventy-two of 119 patients who underwent heart-lung transplantation from 1988 on served as domino cardiac donors (40 males, 32 females; mean age of 32 years; mean weight of 51 kg). The domino donor diagnoses were cystic fibrosis (n = 47), bronchiectasis (n = 9), primary pulmonary hypertension (n = 6), emphysema (n = 7), pulmonary fibrosis (n = 2) and Eisenmenger's syndrome (n = 1). Forty-seven domino hearts were transplanted at our institution and 25 were exported to other centres in the United Kingdom. The 72 domino cardiac recipients were 62 males and 10 females, mean age of 47 years, mean weight of 60 kg, with ischemic heart disease (n = 32), cardiomyopathy (n = 36) and other conditions (n = 4). RESULTS: There were four deaths (5.6%) at less than 30 days (2 from multiple organ failure, 1 from primary allograft failure and 1 from acute rejection). Actuarial survival estimates and 1 and 5 years were 77 +/- 5.2% nd 69 +/- 6.3%, respectively. This compared favourably with survival data obtained in 234 non-domino cardiac recipients. In the patients transplanted at Papworth, there was no difference in the incidence of rejection (0.6 +/- 0.05 versus 0.7 +/- 0.03 events per 100 patient days for the first 12 months) or in the freedom from graft atherosclerosis (74 +/- 3% versus 70 +/- 3% at 5 years) between the domino and non-domino groups. CONCLUSIONS: The use of domino hearts donated by recipients of heart-lung transplants is beneficial and is associated with an excellent early and longer-term outcome.

Actuarial Analysis↗
PubMed1996

Lung Transplantation in patients with systemic diseases: an eleven-year experience at Papworth Hospital.

BACKGROUND: The presence of a systemic disease has traditionally been considered a contraindication to lung transplantation. METHODS: We present a retrospective review of 19 patients undergoing lung transplantation for end-stage pulmonary disease associated with a systemic illness since 1984. There were 11 male and 8 female patients, aged from 23 to 59 years (median 43 years) with end-stage pulmonary involvement by sarcoidosis (11 patients), Langerhan's cell histiocytosis (three patients), systemic vasculitis (four patients: three with systemic lupus erythrematosis, one with Churg-Strauss), and common variable immunodeficiency (one patient). Ten patients received a heart-lung transplant, and eight patients received a single lung transplant. One patient underwent single lung transplantation after an earlier heart-lung transplant. RESULTS: The 30-day mortality was 5.3%. Nine patients died overall. Two of these had systemic lupus erythrematosis with anticardiolipin antibodies and died from complications of their underlying vasculitis. The mean 1- and 2-year actuarial survivals for all patients were 71% (standard error +/- 10.8%) and 64% (standard error +/- 11.9%), respectively. All patients surviving longer than 3 months achieved an improvement in functional status to New York Heart Association class I or II, and a significant increase occurred in mean forced expiratory volume in 1 second and forced vital capacity. Disease recurrence without clinical significance occurred in two patients with sarcoidosis. Of the nine patients who died, seven had autopsies and none showed evidence of disease recurrence in the lungs. CONCLUSIONS: Patients with systemic diseases can be considered for lung transplantation and each case should be judged on its individual merits. However, patients with systemic lupus erythrematosis (particularly when associated with anticardiolipin antibodies) should probably not be offered lung transplantation because they are likely to develop further complications of their underlying vasculitis.

Actuarial Analysis↗
PubMed1996

Measurement of health-related quality of life before and after heart-lung transplantation.

BACKGROUND: The measurement of the quality of the outcome of treatment as viewed by patients is becoming increasingly recognized as an important aspect of decision making in all health services. This major study, which set out to measure the health-related quality of life outcomes of heart and lung transplantation, developed from the experience gained in the United Kingdom and United States studies of the cost and benefits of heart transplantation in the 1980s. METHODS: The design was prospective with a cohort of patients completing a variety of generic and specific health-related quality of life questionnaires at intervals before and after heart and lung transplantation. The sample size was not prescribed; one of the aims of the project was to test the feasibility of introducing routine monitoring of health-related quality of life outcomes as an integral part of a developing transplant service. RESULTS: Before the operation, there was evidence of deterioration over time in all dimensions of the Nottingham Health Profile. In comparing Profile scores at less than 3 months before with those at 3 to 6 months after transplantation, statistically significant improvements were evident (p < 0.001). Mean scores at intervals up to 2 years after transplantation showed little change over time and compared well with those from a general population sample. Hospital Anxiety and Depression Scale scores were reduced significantly (p < 0.01) by 1 year after heart and lung transplantation. In the pretransplantation period, at least 90% of 101 patients had some level of restriction in home and leisure activities, reducing to between 2% and 24% at 1 year after transplantation. Similarly, 79 patients (78%) had chest pain, and 101 (100%) were breathless before transplantation, reducing to 54% and 39%, respectively, at 1 year after surgery; by which time, for 8 of 10 patients, the problem was occasional. CONCLUSIONS: Highly significant improvements were observed in the physical, social, and emotional dimensions of health-related quality of life of patients after heart-lung transplantation. The advantages and feasibility of combining generic and condition-specific questionnaires are shown together with the need to develop new measures with greater sensitivity to the smaller peaks and troughs of recovery.

Activities of Daily Living↗