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Biomedical subjects

P C Adams

Publications and source records attributed to P C Adams.

At least 73 records · Page 4Linked to original sources
PubMed1996

Alcoholism in hereditary hemochromatosis revisited: prevalence and clinical consequences among homozygous siblings.

The relationship between alcoholism and hereditary hemochromatosis remains controversial. Previous studies have included patients with alcoholic siderosis rather than hereditary hemochromatosis. In this retrospective study, the clinical features, iron status, alcohol history, liver histology, and long-term survival were reviewed in 105 homozygotes for hemochromatosis using rigid diagnostic criteria including an HLA identical sibling with iron overload. Heavy alcohol consumption (>80 g ethanol/day) was found in 15 percent of hemochromatosis patients. Histological features of alcoholic liver disease (Mallory's hyaline bodies, pericentral fibrosis, polymorphonuclear infiltrate, and fatty infiltration) were uncommon in hemochromatosis. Hemochromatosis patients with heavy alcohol consumption had a higher prevalence of cirrhosis than hemochromatosis patients without heavy alcohol consumption. Hepatic iron concentration and hepatic iron index did not significantly differ between these two hemochromatosis groups. Long-term survival was significantly reduced in patients with heavy alcohol consumption (mean follow-up, 9.22 years). This suggests that chronic alcohol consumption has an additive hepatotoxic effect despite the paucity of histological features of alcoholic liver disease.

Alcoholism↗
PubMed1996

Outpatient cardiac catheterisation.

Cardiac catheterisation is increasingly performed in an outpatient setting. The majority of series of outpatient cardiac catheterisation are in laboratories with immediate access to cardiovascular surgery. However, some units may be sited more distantly, although still generally close to a hospital. Compared to an inpatient procedure, outpatient cardiac catheterisation increases bed availability and there are considerable financial rewards with suggested savings of 11-54% of inpatient costs. Most patients are satisfied with an outpatient procedure and, although a quarter may have unanswered questions afterwards, this level may not differ from that found with inpatients. No study has been large enough to detect differences in the major complication rate which occur infrequently in whichever setting, and there is considerable variation between studies in the incidence of minor complications after outpatient procedures. In the only study which randomised all eligible patients to an inpatient (189 patients) or outpatient (192 patients) procedure, seven outpatients (3.6%) suffered bleeding or developed haematomas at the site of percutaneous femoral artery puncture towards the end of the mobilisation period and one patient was syncopal. These events were thought to be a direct result of the procedure being carried out in the outpatient setting. The proportion of patients considered eligible for outpatient cardiac catheterisation varies widely between different series from 20% to more than 80%. Whereas some of this variation may result from the implementation of different exclusion criteria for patients with potentially severe disease, the differences are so large that it is likely that different populations were studied. Unplanned admission rates varied from less than 1% to nearly 19%. With the currently available data no absolute guidelines can be derived to exclude all patients at risk of complications, but the American College of Cardiology/American Heart Association (ACC/AHA) task force recently published guidelines which identified low risk patients suitable for outpatient procedures. These guidelines have been used to select patients for investigation in two mobile units in the USA, and only 0.9% required urgent transfer for clinical instability, and 0.6% developed major complications. However, most patients did not need referral to a tertiary centre for additional procedures and there may be less scope for selecting patients within the ACC/AHA guidelines in the UK compared with the USA.

Ambulatory Care↗
PubMed1996

The effect of arthritis on the quality of life in hereditary hemochromatosis.

OBJECTIVE: To assess clinical factors affecting the quality of life in patients with hereditary hemochromatosis. METHODS: Fifty consecutive patients with hereditary hemochromatosis completed a self-administered survey (Medical Outcome Survey, MOS-SF36). The effects of cirrhosis, diabetes, and arthritis on physical, social, and general health variables were assessed in 8 subscales including physical, social, emotional, and general health. RESULTS: Multiple linear regression models demonstrated that arthritic patients had impairments in more subcategories (physical functioning, pain and general health perception) than cirrhotic (vitality) and diabetic patients. A multivariate analysis of variance model suggested that arthritis is the strongest single factor affecting quality of life (p = 0.0516). CONCLUSION: Although cirrhosis is the major factor affecting survival, arthritis is a prominent clinical factor affecting quality of life in hemochromatosis.

Analysis of Variance↗
PubMed1995

Cortical blindness during left internal mammary angiography.

Two cases of transient cortical blindness during coronary and graft angiography are described. In both cases, the onset of blindness was immediately preceded by manipulation of a guidewire in the left subclavian artery during attempts to selectively engage the internal mammary artery. Vertebral angiography was performed in the first patient and the appearances were compatible with multiple emboli in the posterior circulation. This patient was anticoagulated with intravenous heparin. His vision recovered within 72 h, but a mild visual agnosia persisted and it was only after nearly 3 weeks that all neurological deficits had resolved. The second patient recovered fully within 15 min. We postulate that emboli occurring as a result of manipulation of the guidewire close to the origin of the left vertebral artery was the cause of the cortical blindness in both these patients, although vasospasm as a contributory factor cannot be excluded. With an increasing need for investigation of patients after coronary artery bypass grafting, angiographers should be aware that selective internal mammary graft angiography may carry a higher than normal risk of neurological complications. The use of a guidewire to manipulate the catheter in the subclavian artery may increase this risk.

Angiography↗
PubMed1995

Employment after liver transplantation.

The objective of this study was to study the factors affecting employment after liver transplantation. The employment status and health status of 203 adult liver transplant recipients was assessed retrospectively in a survey comprising an employment questionnaire, the Sickness Impact Profile (SID), and the Medical Outcomes Survey (MOS). The patient population consisted of all surviving adult patients who had undergone liver transplantation between 1982 and 1992 at our institution and who had survived a minimum of 9 months. Fifty-seven percent of the recipients were employed and 43% of the recipients were unemployed. Eighteen percent of the recipients considered themselves not well enough to work. Other reasons cited for not working in the unemployed patients were early retirement (8%), return to school (3%), family reasons (3%), no work available (3%), and chose not to work (3%). Patient age, duration of disability before transplantation, and type of job before transplantation significantly affected posttransplantation employment status. Health status measurements predicting employment were ambulation, home management, physical functioning, and pain. Older recipients and those who were continuously out of the workforce for several years before transplantation were the least likely to return to gainful employment after liver transplantation. These findings have implications for assessing the success of liver transplantation and the implementation of strategies to fully rehabilitate patients after liver grafting.

Adolescent↗
PubMed1995

Use of OKT3 monoclonal antibody as induction therapy for control of rejection in liver transplantation.

This report details a single center's experience with OKT3 induction immunosuppression for liver transplantation. One hundred ninety-nine consecutive, unselected adult liver recipients received OKT3 therapy for 9-10 days combined with low-dose steroids and azathioprine. Cyclosporine was begun to overlap with the last few days of OKT3 therapy. The average dose of OKT3 was 45 mg. Fifty-two patients (26.1%) experienced 57 episodes of acute rejection. The median time of onset of rejection was 18 days after grafting. Seventy-eight percent of the rejection episodes were steroid-sensitive. Recurrent rejection was uncommon and the need for OKT3 retreatment was infrequent. One year actuarial graft and patient survival was 79.7% and 82.3% respectively. Based on this evidence, it appears that OKT3 prophylaxis provides good control of acute rejection with a very low incidence of recurrent rejection.

Acute Disease↗
PubMed1995

Non-HLA-linked hemochromatosis in a Chinese woman.

A 55 year-old Chinese woman is described with severe iron overload similar in degree and distribution to that seen in hereditary hemochromatosis in the Caucasian population. Autopsy findings confirmed severe iron overload in the liver, pancreas, skin, heart, and endocrine organs. Hepatic iron concentration was 482 mumol/g with a hepatic iron index of 8.8. There was no history of thalassemia, transfusions, or alcohol abuse. Pedigree analysis revealed two HLA identical brothers that had no clinical or biochemical evidence of iron overload. This case is an unusual example of severe iron overload in a non-Caucasian kindred and may represent a non-HLA-linked form of iron overload.

Asian People↗
PubMed1995

Screening blood donors for hereditary hemochromatosis: decision analysis model based on a 30-year database.

BACKGROUND & AIMS: The high prevalence, morbidity, premature death, and benefit of early diagnosis and treatment make hemochromatosis a prime target for screening in the white population. Decision analysis techniques were used to compare the outcome, utility, and incremental cost savings of a plan to screen voluntary blood donors for hemochromatosis. METHODS: The screening strategy includes sequential testing of serum unsaturated iron-binding capacity, serum transferrin saturation, serum ferritin, and either hepatic iron index or venesections to measure exchangeable body iron. Estimates of prevalence, asymptomatic intervals, probabilities of life-threatening clinical complications, symptom-specific life expectancy, and sensitivity and specificity of screening tests are based on our database of 170 hemochromatosis homozygotes and the published literature. RESULTS: The screening strategy led to an incremental increase in utility of 0.84 quality-adjusted life days with an incremental cost savings of $3.19 per blood donor screened. When the potential of identifying asymptomatic homozygous siblings was included, these values increased to 1.18 quality-adjusted life days and $12.57 per person screened. Screening remained a dominant strategy given a prevalence of hemochromatosis of > 0.0026 or an initial screening test cost of < $8. CONCLUSIONS: Screening blood donors for hemochromatosis has the potential to improve overall societal health status and decrease third-party payer health care costs over the long-term.

Adolescent↗
PubMed1995

Patients undergoing coronary artery bypass graft surgery are at high risk of impaired glucose tolerance and diabetes mellitus during the first postoperative year.

This study demonstrates that patients who have undergone coronary artery bypass graft (CABG) surgery have a high prevalence of abnormal glucose tolerance 3 months and 1 year later. Although only 6% were known to have diabetes mellitus (DM) preoperatively, a further 4% were classified DM at two oral glucose tolerance tests (OGTTs) over the subsequent year and a further 18% were classified as having impaired glucose tolerance (IGT) at 12 months. Reproducibility of the 120-minute plasma glucose level in the 75-g OGTT was estimated from a repeat test performed within 10 days. The coefficient of variation (CV) of 120-minute glucose was between 14% and 18%. The observed changes in class of glucose tolerance observed at OGTTs repeated 6 and 12 months after surgery differed from the predicted changes based purely on the estimated variability of 120-minute glucose measurement. There was evidence of regression to the mean for the IGT group. However, there was also evidence of deteriorating glucose tolerance in some subjects. Between 4% and 9% of those with IGT 3 months after CABG surgery developed DM by 12 months, and 26 (13%) of those with initially normal glucose tolerance (NGT) developed IGT. Insulin and glucose responses in the OGTT and estimates of insulin resistance and beta-cell function from fasting samples show that insulin resistance was the principal abnormality in IGT subjects, whereas in DM subjects, both insulin resistance and beta-cell dysfunction contributed. Analysis of preoperative patient characteristics showed that the presence of either a systolic blood pressure of 140 mm Hg or body mass index (BMI) of more than 25 kg/m2 identified 51% of the subjects who would at 1 year after surgery include all those who would be classified DM and 67% of those who would have IGT. Further analyses including insulin levels identified groups at particularly high risk of DM, but no combination of readily available preoperative measures identified all those destined to be classified IGT.

Blood Glucose↗
PubMed1995

Comparison of Nottingham Health Profile (NHP) scores with exercise duration and measures of ischaemia during treadmill exercise testing in patients with coronary artery disease.

A cross-sectional study of patients with stable coronary artery disease was performed to compare perceived health status with the results of a treadmill exercise test. One hundred and twenty one patients, mean age 55.07 years, 106 male, who had all suffered a myocardial infarction under the age of 56 years, up to 9 years earlier were studied. Perceived health status was assessed using the Nottingham Health Profile, part 1 of which assesses six dimensions of normal living, and part 2 seven areas of daily life. Nottingham Health Profile scores were higher (worse perceived health status) in patients with poor treadmill exercise capacity within all dimensions of part 1 (energy, pain, physical mobility P < 0.001, emotional reactions, sleep P < 0.01, social isolation P < 0.05) and most of those within part 2 (care of home, taking holidays P < 0.001, hobbies P < 0.01, relationships at home, sex life P < 0.05). The perceived health status of patients without a history of angina is significantly better than those with angina (pain, physical mobility P < 0.001, energy, emotional reactions, social isolation P < 0.01, sleep P < 0.05, within part 1, taking holidays P < 0.01, care of the home, social life, sex life, hobbies P < 0.05, within part 2). Thus, patients with a poor perceived health status, also have poorer results using more conventional clinical measures of coronary artery disease. The Nottingham Health Profile may be a useful adjunct in patient assessment.

Activities of Daily Living↗
PubMed1995

Assessing the impact of blood sample type on the estimated prevalence of impaired glucose tolerance and diabetes mellitus in epidemiological surveys.

In a prospective study of 353 patients who had undergone coronary artery bypass graft surgery a 75 g oral glucose tolerance test was performed at 3 months and 12 months after surgery. Venous whole blood glucose and venous plasma glucose samples were assayed on a bench-top analyser. The World Health Organization diagnostic criteria for impaired glucose tolerance and diabetes mellitus were applied to venous whole blood glucose and venous plasma glucose measurements. The difference between the plasma and whole blood concentration of glucose was 0.79-0.86 mmol l-1 at a plasma glucose of 7.8 mmol l-1 and 1.22-1.24 mmol l-1 at a plasma glucose of 11.1 mmol l-1 (compared to 1.1 mmol l-1 by World Health Organization criteria at both cut-points). Despite this, in our subject population with a high prevalence of impaired glucose tolerance (20.3% at 3 months, 15.3% at 12 months) and diabetes mellitus (10.1% at 3 months and 12 months), there was no significant difference in the proportion classified impaired glucose tolerance or having diabetes mellitus using venous whole blood glucose compared to venous plasma glucose. We conclude that despite the minor anomaly between WHO diagnostic criteria based on venous whole blood glucose and venous plasma glucose measurements, these criteria are robust and give broadly comparable population prevalence of diabetes mellitus and impaired glucose tolerance irrespective of blood sample choice.

Autoanalysis↗
PubMed1995

Rescue thrombolysis: alteplase as adjuvant treatment after streptokinase in acute myocardial infarction.

BACKGROUND: In acute myocardial infarction patients who do not reperfuse their infarct arteries shortly after thrombolytic treatment have a high morbidity and mortality. Management of this high risk group remains problematic, especially in centres without access to interventional cardiology. Additional thrombolytic treatment may result in reperfusion and improved left ventricular function. METHODS: Failure of reperfusion was assessed non-invasively as less than 25% reduction of ST elevation in the electrocardiographic lead with maximum ST shift on a pretreatment electrocardiogram. 37 patients with acute myocardial infarction who showed electrocardiographic evidence of failed reperfusion 30 minutes after 1.5 MU streptokinase over 60 minutes were randomly allocated to receive either alteplase (tissue type plasminogen activator (rt-PA) 100 mg over three hours) (19 patients) or placebo (18 patients). 43 patients with electrocardiographic evidence of reperfusion after streptokinase acted as controls. Outcome was assessed from the Selvester Q wave score of a predischarge electrocardiogram and a nuclear gated scan for left ventricular ejection fraction 4-6 weeks after discharge. RESULTS: Among patients in whom ST segment elevation was not reduced after streptokinase, alteplase treatment resulted in a significantly smaller electrocardiographic infarct size (14% (8%) v 20% (9%), P = 0.03) and improved left ventricular ejection fraction (44 (10%) v 34% (16%), P = 0.04) compared with placebo. This benefit was confined to patients who failed fibrinogenolysis after streptokinase (fibrinogen > 1 g/l). In patients in whom ST segment elevation was reduced after streptokinase, infarct size and left ventricular ejection fraction were not significantly different from those in patients treated with additional alteplase. CONCLUSION: Patients without electrocardiographic evidence of reperfusion after streptokinase may benefit from further thrombolysis with alteplase.

Drug Therapy, Combination↗
PubMed1995

Prospective study of patients aged 55 years or less with acute myocardial infarction between 1981 and 1985: outcome 7 years and beyond.

OBJECTIVE: To determine the long-term prognosis of patients after a myocardial infarction (MI) at a young age. DESIGN: Prospective cohort study of patients aged 55 years or less suffering a myocardial infarction. SETTING: A single coronary care unit admitting patients from the community. PATIENTS: 255 consecutive patients (210 men) aged 55 years or less admitted between 1981 and 1985 after acute MI. Twenty four patients died in hospital or within 3 months of infarction and 11 were lost to further follow up after discharge. Of the remaining patients, 150 (mean (SD) age 48 (5.7) years) able to exercise 3 weeks after infarction and who agreed to undergo coronary angiography were recruited to a study group and seen 18 months, and 3, 5, and 7 years after MI. In addition, a cross sectional analysis of survival was made to a median of 120 months. Seventy 3 month survivors (mean (SD) age 48 (5.8) years) were not recruited to the study group but were traced for late survival through their general practitioners and family health service associations to a median of 130 months. MAIN OUTCOME MEASURES: Survival in young patients after MI and the survival of 3 month survivors stratified by their ability to exercise and agreement to undergo angiography. The rate of coronary artery surgery (CAGB) and reinfarction during the first 7 years after index MI in patients recruited to the study group. RESULTS: Sixteen patients (6%) died in hospital and eight (3%) within 3 months of the index infarction. The 7 and 11 year survival rates in the whole cohort of 255 patients were 80% and 66% respectively using life table methods. Survival 7 years after MI, in patients recruited to the study group was better than in those not recruited (93% v 79%, P = 0.001), but thereafter mortality in the study group accelerated and there was no significant difference in survival 11 years after infarction (76% v 67%, P = 0.05). There was a trend towards higher mortality in patients with multivessel disease and severely impaired left ventricular function. During the first 7 years after MI, 38 of 150 patients in the study group underwent CABG and 19 suffered reinfarction, which was fatal in three. CONCLUSION: The medium-term prognosis of young survivors of MI is good, particularly in patients recruited to the study group. After 7 years there is an increase in mortality and the long-term prognosis is less favourable. This should be taken into account when planning future management and follow up of young patients after MI.

Adult↗
PubMed1995

Screening for hemochromatosis in children of homozygotes: prevalence and cost-effectiveness.

Although hereditary hemochromatosis is an autosomal recessive disease, most homozygotes are concerned with the genetic implications for their children. The optimal age for testing children and the cost implications of screening their children have not been clearly established. A clinical database consisting of 255 children from families with at least one homozygote is used to assess the prevalence of homozygotes among children of homozygous parents and to review the biochemical abnormalities and life-threatening symptoms in these young adults. Decision analysis is used to estimate the cost and utility of screening children of a homozygous parent. Eleven homozygotes were discovered among children of homozygotes. Only one male had a life-threatening event, cirrhosis. Decision analysis estimated cost saving of $12 per child screened ($ net present value) and a saving of 10 quality-adjusted days per child screened at age 10 years compared with not screening. If screening began at age 20 years, there is a cost saving of $65 per child screened. Sensitivity analysis showed that the major factors influencing cost savings were the cost of venesections, sensitivity and specificity of the screening tests, and prevalence of disease. Because the prevalence of hemochromatosis is higher in children of homozygotes than in the general population, screening with transferrin saturation and ferritin as early as age 10 years is recommended. Savings are augmented if the cost per venesection is eliminated by allowing hemochromatosis patients to become voluntary blood donors.

Adolescent↗