Biomedical subjects

L W Stevenson

Publications and source records attributed to L W Stevenson.

137 records · Page 8Linked to original sources

PubMedDate not supplied

Quality of life in patients with advanced heart failure.

Although evaluation of the treatment of congestive heart failure is usually based on objective clinical outcomes, patient self-assessment is increasingly recognized as an important component of evaluation. A study was designed to measure the quality of life of 134 patients with symptoms of advanced heart failure who were being evaluated for possible heart transplantation. The patients' quality of life was assessed using a mix of subjective and objective measures, including functional status, physical symptoms, emotional state, and psychosocial adaptation. There was no significant relationship between patients' cardiac ejection fraction and any quality-of-life measures; however, the results of a 6-minute walking test, New York Heart Association classification, and self-reported functional status were all significantly correlated with psychosocial adjustment. Self-reported functional status, depression, and hostility accounted for 43% of the variance in total psychosocial adjustment to illness. These findings support the inclusion of quality of life as an outcome measure in any evaluation of treatment efficacy and suggest that interventions to improve the quality of life of patients with advanced heart failure need to be targeted at reducing depression and hostility and increasing daily activity levels.

Activities of Daily Living↗

PubMedDate not supplied

Tailored therapy before transplantation for treatment of advanced heart failure: effective use of vasodilators and diuretics.

Because of the limited supply of donor hearts, many candidates for heart transplantation must remain on waiting lists for several months. Although most such patients are considered to be refractory to standard therapy with vasodilators, diuretics, and digoxin, many will respond to a more intensive approach specifically tailored to hemodynamic goals in advanced heart failure. In this article the principles, design, and benefits of tailored therapy are reviewed. In addition, six common ideas about the management of advanced heart failure, derived from other patient populations, are shown to be myths. These myths are (1) that a low ejection fraction precludes good hemodynamics, exercise capacity, and survival; (2) that high ventricular filling pressures are necessary to maintain cardiac output in patients with chronic dilated heart failure; (3) that vasodilators in chronic advanced heart failure act primarily to increase ejection fraction and total stroke volume; (4) that hemodynamics measured during drug titration do not predict long-term benefit; (5) that the interval risk of deterioration and death without transplantation increases with time from evaluation; and (6) that for patients with low ejection fractions, heart transplantation is always better than medical therapy.

Diuretics↗

PubMedDate not supplied

Randomized study of high dose oral cyclosporine therapy for mild acute cardiac rejection.

Mild acute rejection progresses to moderate rejection in approximately one third of the cases. Standard rejection therapy would then be instituted with the attendant risk of infection and other side effects. We randomized 40 episodes of mild acute rejection (20 episodes in each group) to receive no additional therapy or to have the oral cyclosporine dose increased for 7 to 10 days with repeat endomyocardial biopsy performed. In the group with no additional therapy 30% progressed to moderate rejection, whereas in the group with increased doses of oral cyclosporine, 10% progressed to moderate rejection (p = 0.10). As the purpose of our study was to assess the efficacy of increased cyclosporine levels for preventing progression from mild to moderate rejection, the treated group was redefined according to whether the cyclosporine level increased by greater than or equal to 50% during the study. In this treated group average cyclosporine levels increased from 169 +/- 78 to 413 +/- 267 ng/ml. Progression to moderate rejection occurred in one of 21 cases (5%) compared with seven of 19 cases (37%) in the group without an increase in cyclosporine level (p less than 0.05). The transient increase in cyclosporine levels was well tolerated. This study demonstrates that the use of high dose oral cyclosporine to treat mild acute rejection is well tolerated and may reduce progression to moderate rejection when a significant increase in cyclosporine level is achieved.

Acute Disease↗

PubMedDate not supplied

Heart transplantation in a Jehovah's Witness.

Heart transplantation has been successfully performed without blood products in a 45-year-old Jehovah's Witness. Management of this patient is described. The medical, ethical, and religious issues involved in the decision to offer transplantation and to accept it are discussed.

Blood Transfusion, Autologous↗

PubMedDate not supplied

Urgent priority transplantation: when should it be done?

The success of heart transplantation has created longer waiting lists of candidates, some of whom require transplantation urgently. Decisions must be made regarding which patients require urgent transplantation and how many donor hearts should be committed to urgent transplantation. To determine whether some patients who are considered refractory to medical therapy may be stabilized for elective transplantation, 40 patients transferred for urgent transplantation underwent intensive vasodilator and diuretic therapy, and outcomes were determined. To examine the impact of urgent transplantation on survival, we then determined the survival for urgent priority candidates in the western region. Discharge of the patients who were receiving oral dosages of vasodilators and diuretics was possible for 32 of 40 patients (80%), with a 6-month actuarial survival of 75% on medical therapy, despite an initial ejection fraction of 0.15 +/- 0.04, a cardiac index of 1.9 +/- 0.6 L/min/m2, and a pulmonary wedge pressure of 30 +/- 8 mm Hg. Of 11 patients discharged to await regular priority transplantation, one died suddenly, one died postoperatively, and the others went home 14 +/- 4 days after transplantation. The eight patients unable to be discharged after transfer had lower initial mean arterial pressures and serum sodium levels. Of 59 urgent priority patients from the five western region programs, 50 patients underwent transplantation after 33 +/- 41 days. Subsequent 1-month survival was 88% and overall survival 80%, compared with 97% and 90% in 137 regular priority patients, with a 4.5 times greater risk of early mortality in the urgent group (p = 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Emergencies↗

PubMedDate not supplied

Report of the consensus conference on candidate selection for Heart Transplantation-1993.

BACKGROUND: Despite several task forces and numerous reviews, criteria for candidate selection for heart transplantation are not uniform. METHODS AND RESULTS: This report summarizes results compiled from a survey that was reviewed at a consensus conference held before the meeting of the International Society of Heart and Lung Transplantation in 1993 in Boca Raton, Florida. The meeting was attended by representatives of 52 programs from the United States, Canada, England, and Australia. The unique feature of this report is that is represents a review of the actual practice of patient selection at some of the largest and most experienced centers in the field. Key areas of the selection process including medical and surgical alternatives to transplantation, the composition of the transplant work-up, specific inclusion criteria as well as specific psychosocial factors and specific disease etiologies and co-morbidities that might represent contraindications were extensively reviewed. In addition, the standard follow-up for a patient on an active waiting list, and criteria to remove patients from the active waiting list are described. This survey provides information and insight regarding current areas of consensus as well as disagreement regarding candidate selection for heart transplantation. CONCLUSIONS: These differences may be important when considering outcomes and possible strategies in the use of resources.

Data Collection↗

PubMedDate not supplied

Extended comparison of quality of life between stable heart failure patients and heart transplant recipients.

Heart failure has been associated with poor quality of life, which can improve after heart transplantation. Long-term quality-of-life comparisons between patients with heart failure stabilized with medical therapy and heart transplant recipients have not been performed. We assessed quality of life at the time of heart transplantation evaluation and again after 41 months in 12 patients with advanced heart failure stabilized with medical therapy and in 19 patients who had gone on to undergo heart transplantation. Quality of life was measured by three questionnaires. Both groups had similar quality-of-life and clinical features during the transplantation evaluation. Over time, feelings of anxiety and depression, psychologic adaptation, and perceived functional capability improved in the transplant recipients. However, transplant recipients reported more weakness after surgery; this was the major symptom that limited activities. At follow-up 41 months later, we found no significant differences in quality-of-life changes over time between patients stabilized with medical therapy and heart transplant recipients. Overall quality of life for patients who remain stable while receiving medical therapy may not be significantly different from patients who have undergone transplantation.

Aged↗

PubMedDate not supplied

Antibodies to the T-cell receptor (CD3) induce LFA-1/Mac-1-dependent mononuclear cell adhesion to human arterial endothelium.

Monoclonal antibodies to the CD3 determinant on T lymphocytes have been used extensively as immunosuppressive agents. The T-cell receptor forms a complex with CD3 so that antibodies to CD3 mimic T-cell receptor cross-linking by human leukocyte antigens. Both CD3 and T-cell receptor cross-linking have been associated with lymphocyte activation and expression of the LFA-1 adhesion ligand, which leads to adhesion to intercellular adhesion molecule 1 immobilized on artificial surfaces. We sought to determine if anti-CD3 antibodies would increase adhesion of heart transplant recipient peripheral blood mononuclear cells to confluent human aortic endothelial cells by a similar mechanism. Peripheral blood mononuclear cells were incubated for 30 minutes with monoclonal CD3 or CD3 + CD18 antibody, before a 15-minute incubation with unstimulated human aortic endothelial cells. Mononuclear cell adhesion doubled after anti-CD3 antibody preincubation from 15.1 +/- 2.1 to 29.3 +/- 6.7 cells/high-power field (p = 0.002). This increase was abolished by coincubation with anti-CD18 (7.1 +/- 3 cells/high-power field; p = 0.0002). The major increase was the result of increased lymphocyte adhesion (3.4 +/- 0.6 to 14.8 +/- 6.7 cells/high-power field; p = 0.02); however, monocyte adhesion also increased from 11.7 +/- 1.5 to 14.5 +/- 1.6 cells/high-power field (p = 0.04). Anti-CD18 antibodies markedly reduced binding of both cell types. Cross-linking of the T-cell receptor by antibodies to CD3 causes acute adhesion of mononuclear cells (particularly lymphocytes) to arterial endothelium. Increased adhesion is mediated through CD18 (LFA-1/Mac-1).

Antibodies, Monoclonal↗

PubMedDate not supplied

Orthotopic heart transplantation and concurrent coronary bypass.

Lack of donor organ availability is an increasing problem in heart transplantation. Methods to safely increase the donor pool are desperately needed. We report four cases of coronary artery bypass during orthotopic heart transplantation for donor hearts with normal ventricular function and subclinical coronary artery disease. An aggressive approach toward utilizing hearts from older donors with normal ventricular function may expand the donor pool and decrease the waiting period, with its attendant death, for patients awaiting heart transplantation.

Aged↗

PubMedDate not supplied

Does short-course induction with OKT3 improve outcome after heart transplantation? A randomized trial.

OKT3 is often used routinely for induction immunotherapy or selectively to avoid acute cyclosporine nephrotoxicity in heart transplant recipients at high risk for immediate postoperative kidney failure. It has not been shown in a randomized trial to be useful in patients at low risk for early kidney failure. We randomized 30 patients with a serum creatinine level of less than 1.4 mg/dl before heart transplantation to be treated with triple-drug immunotherapy with cyclosporine, which was started before surgery, (group 1) or to be treated with OKT3 for 4 to 6 days after surgery with oral cyclosporine, which was started between days 2 and 4, after renal function had stabilized (group 2). Follow-up for 6 months revealed no significant differences in the total number of rejection episodes, total number of infections, or in the serum creatinine level. Four patients in group 1 and five patients in group 2 have had no rejection. OKT3 showed a trend to delay time to first rejection (p = 0.10), as has been reported for the 14-day induction course of OKT3. A short course of OKT3 induction in heart transplant recipients at low risk for immediate postoperative kidney failure prolongs the time to first rejection for most patients but does not appear to reduce the total incidence of rejection in the first 6 months after heart transplantation.

Creatinine↗

PubMedDate not supplied

Corticosteroid weaning late after heart transplantation: relation to HLA-DR mismatching and long-term metabolic benefits.

BACKGROUND: To avoid the long-term side effects of corticosteroids, corticosteroid-free immunosuppression has been introduced immediately or late (more than 6 months) after heart transplantation. Late corticosteroid weaning may have a higher success rate as patients are selected on the basis of rejection history. Previous reports of HLA-DR mismatching and the long-term metabolic benefits with respect to corticosteroid weaning have been equivocal. METHODS: One hundred and one eligible heart transplant recipients receiving triple-drug immunosuppression 6 months from heart transplantation were weaned from prednisone by decreasing the daily prednisone dose by 1 mg each month. Moderate rejection episodes were recorded and after conclusion of the study, HLA-DR mismatching of recipient and donor was reviewed. Serum cholesterol level, body weight, and number of patients receiving blood pressure medications were recorded before and 1 year after corticosteroid weaning. RESULTS: Successful weaning from corticosteroids was achieved in 82% of patients. Of 31 patients with zero or one HLA-DR mismatch, 30 (97%) were successfully weaned. For those patients more than 1 year after discontinuation of corticosteroids, 67 had more weight loss and a lower serum cholesterol level than 15 patients who were unsuccessful at corticosteroid weaning and dependent on corticosteroids. CONCLUSIONS: Heart transplant recipients can safely be weaned from corticosteroids late after heart transplantation with zero or one HLA-DR mismatch conferring a higher success rate. The long-term metabolic benefits of corticosteroid weaning include a reduction in weight and serum cholesterol.

Body Weight↗