Of 347 endomyocardial biopsies performed on 49 patients, 47 specimens demonstrated histologic evidence of acute rejection. In this study, acute rejection was characterized by the presence of interstitial edema with pyrinophilic lymphocytes, with or without myonecrosis. Simultaneous immune activation of peripheral blood lymphocytes occurred with 33 biopsy specimens positive for acute rejection (Table 1). Thus, the morphologic evaluation of lymphocytes demonstrated a 70 percent sensitivity in detecting an episode of acute cardiac rejection. The predictive value of a positive test (positive immune activation of lymphocytes) was 39 percent. Significant differences in absolute numbers of total lymphocytes, T-cell subsets (helper cells, cytotoxic-suppressor cells, cytotoxic cells, resetting T cells, mitogenic T cells) and helper/suppressor ratios analyzed via a Students t test revealed no consistent, statistically significant differences in absolute numbers of the above-described cell populations. During acute cardiac rejection, the helper/ suppressor ratio was variable, with high, low, and normal values noted. Read the rest of this entry »

Immunologic Monitoring of the Cardiac Transplant PatientAcute cardiac rejection may be difficult to diagnose in orthotopic cardiac transplant patients. The endomyocardial biopsy is the current gold standard for detection of acute rejection. This study examined the feasibility of morphologic evaluation of peripheral blood lymphocytes to provide a sensitive indicator of acute cardiac rejection.
Material and Methods
Peripheral blood lymphocytes of 49 orthotopic cardiac transplant patients were repeatedly examined over three years. Immunosuppressive therapy for these patients included preoperative antithymocyte globulin, followed by an intraoperative dose of methylpred-nisone and antithymocyte globulin. The postoperative regimen consisted of individualized doses of horse or rabbit antithymocyte globulin, cyclosporine A, prednisone and azathioprine. Rejection episodes were treated with methylprednisone; refractory acute rejection was rarely treated with the mouse monoclonal antibody OKT3. Read the rest of this entry »

Prospective Trial of Supranormal Values of Survivors as Therapeutic Goals in High-Risk Surgical Patients: ConclusionBlood pressure, heart rate, hematocrit, CVI? ECG, urine output, and blood gases are conventional measurements that are well recognized descriptors of acute crises as well as the end stages of circulatory failure. Although these variables should be monitored and corrected if abnormal, they are neither sensitive nor accurate descriptors of circulatory decompensation in the perioperative period. However, the use of PA catheters in surgical patients is considered to be highly controversial because of the lack of adequately controlled clinical trials. Recently, Robin has called attention to the fact that use of PA catheters has assumed epidemic proportions without clinical trials establishing improved outcome from their use. Moreover, hospitals and third-party payers view PA catheterization in the surgical patient as a potentially morbid and unnecessary expense. Read the rest of this entry »

The cardiac output, Do2 and Vo2 values were higher in the protocol patients than in the control patients, while the other monitored variables were not appreciably different, indicating that there was reasonable compliance with the protocol. The higher Cl and Do2 values are consistent with the concept that this pattern represents compensatory increases in circulatory function needed to meet the increased metabolic requirements reflected by Vo2. The present study suggests that this augmented circulatory response represents appropriate goals of therapy for the critically ill noncardiac surgical patient. However, the protocol, defined by median values of survivors may be overly aggressive for elderly patients with limited capacity for physiologic compensation and it may be unattainable or ineffective for overwhelming lethal disease. Read the rest of this entry »

Prospective Trial of Supranormal Values of Survivors as Therapeutic Goals in High-Risk Surgical Patients: Catheter ComplicationsComplications were observed less frequently in patients treated by the protocol in both series (Table 8). Both the proportion of patients who had complications and the average number of complications per patient were lowest in the PA-protocol group (p<0.05). There was a higher incidence of patients with multiple complications in the control group of both series. There were 17 patients (57 percent) in the CVP group who in the opinion of the primary service developed indications for PA catheterization for management in the postoperative period; seven (29 percent) of these patients subsequently died. Read the rest of this entry »

Outcome Data
Table 6 summarizes the outcome data of the control and protocol groups of the first series which had sufficient numbers of patients to stratify into clinical subgroups. There were 168 operations on 151 control patients, 57 (38 percent) of whom died and 108 operations on 101 protocol patients, 21 (21 percent) of whom died (p<0.05). The data of each subgroup are listed in Table 6 and in general show improved mortality in protocol patients in subgroups with sufficient numbers. In series 1, seven of the 67 protocol patients with normal preoperative values dfed; three of these patients had delayed insertion of their PA catheters that averaged 56 h after the end of their operation. Five patients had overwhelming medical problems: one patient had massive intraoperative blood loss associated with delayed transfusion. Read the rest of this entry »

Prospective Trial of Supranormal Values of Survivors as Therapeutic Goals in High-Risk Surgical Patients: ResultsStatistical Methods
Comparisons of mortality and morbidity figures were done using chi square analysis with Yates’ correction for small cell size where applicable. Hemodynamic data comparisons within groups and between groups were analyzed using either paired or unpaired Student’s t test and ANO\A with Newman-Keuls’ test for significance of individual comparisons. All p values were obtained using two-tailed tests. Read the rest of this entry »

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