Days In Control Patients Research Articles

Feasibility and Safety of Active Physiotherapy in the Intensive Care Unit for Intubated Patients with Malignancy.

Physiotherapy leads to improvements in critically ill patients who receive mechanical ventilation. However, cancer patients have not been included in previous studies on this subject. This study explored the feasibility and safety of physiotherapy in the intensive care unit for patients with malignancy. Observational prospective single-centre study, comparing cancer and control patients. All consecutive patients admitted to the intensive care unit who needed invasive mechanical ventilation for more than 2 days with no contraindication to physiotherapy were included in the study. The main outcome was the proportion of physiotherapy sessions at the prescribed level in each group. A total of 60 patients were included within 1 year. A total of 576 days were screened for physiotherapy sessions and 367 physiotherapy-days were analysed (137 days for control patients and 230 days for cancer patients). The ratio of physiotherapy sessions performed/prescribed did not differ between groups: 0.78 (0.47-1) in the control group vs 0.69 (0.6-1) in the cancer group (odds ratio 1.18 (IC95% 0.74-1.89); p = 0.23). A sensitivity analysis including patient effect as random variable confirmed those results (odds ratio 1.16 (0.56-2.38), p = 0.69). Adverse events occurred with the same frequency in cancer patients and non-cancer patients. Physiotherapy in cancer patients who require intubation is feasible and safe. However, only two-thirds of prescribed physiotherapy sessions were performed. Studies are warranted to explore the barriers to physiotherapy in the intensive care unit setting.

High-dose intravenous vitamin C decreases rates of mechanical ventilation and cardiac arrest in severe COVID-19

Intravenous vitamin C (IV-VitC) has been suggested as a treatment for severe sepsis and acute respiratory distress syndrome; however, there are limited studies evaluating its use in severe COVID-19. Efficacy and safety of high-dose IV-VitC (HDIVC) in patients with severe COVID-19 were evaluated. This observational cohort was conducted at a single-center, 530 bed, community teaching hospital and took place from March 2020 through July 2020. Inverse probability treatment weighting (IPTW) was utilized to compare outcomes in patients with severe COVID-19 treated with and without HDIVC. Patients were enrolled if they were older than 18 years of age and were hospitalized secondary to severe COVID-19 infection, indicated by an oxygenation index < 300. Primary study outcomes included mortality, mechanical ventilation, intensive care unit (ICU) admission, and cardiac arrest. From a total of 100 patients enrolled, 25 patients were in the HDIVC group and 75 patients in the control group. The average time to death was significantly longer for HDIVC patients (P = 0.0139), with an average of 22.9 days versus 13.7 days for control patients. Patients who received HDIVC also had significantly lower rates of mechanical ventilation (52.93% vs. 73.14%; ORIPTW = 0.27; P = 0.0499) and cardiac arrest (2.46% vs. 9.06%; ORIPTW = 0.23; P = 0.0439). HDIVC may be an effective treatment in decreasing the rates of mechanical ventilation and cardiac arrest in hospitalized patients with severe COVID-19. A longer hospital stay and prolonged time to death may suggest that HDIVC may protect against clinical deterioration in severe COVID-19.

Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: A matched case-control study.

Pharyngolaryngeal and oesophagogastric cancers present with swallowing symptoms and as such, their clinical evaluation traverses boundaries between different specialties. We studied the incidence and significance of interspecialty cancer referrals (ICRs), that is, pharyngolaryngeal cancers first evaluated by gastroenterology and oesophagogastric cancers first evaluated by otolaryngology. A subset analysis of our Integrated Aerodigestive Partnership's audit dataset, of all ICR patients, and an equal number of controls matched for age, sex and cancer subsite. Information about patient age and presenting symptoms was recorded. The relationship between symptoms and ICR risk was examined with binary logistic regression. Referral-to-diagnosis latency was compared between ICR and control patients with unpaired Student's t test. Cox regression was used to identify independent predictors of overall survival. Of 1130 patients with pharyngolaryngeal and oesophagogastric cancers between 2008 and 2018, 60 diagnoses (5.3%) were preceded by an ICR. Referral-to-diagnosis latency increased from 43±50days for control patients to 115±140days for ICR patients (P<.0001). Dysphagia significantly increased the risk of an ICR (odds ratio 3.34; 95% CI 1.30-8.56), and presence ofclassic gastroesophagealreflux symptoms (heartburn or regurgitation; OR 0.25; 95% CI 0.08-0.83) and "distal" symptoms (nausea/vomiting, abdominal pain or dyspepsia; OR 0.23; 95% CI 0.08-068) significantly reduced the risk. Eleven pharyngolaryngeal cancers (of 26; 42%) were missed by gastroenterology, and eight (of 34; 24%) oesophageal cancers were missed by otolaryngology. An ICR was an independent adverse prognostic risk factor on multivariable analysis (hazard ratio 1.76; 95% CI 1.11-2.73; P<.02; log-rank test). Two systemic root causes were poor visualisation of pharynx and larynx by per-oraloesophago-gastro-duodenoscopy (OGD) for pharyngolaryngeal cancers, and poor sensitivity (62.5%) of barium swallow when it was used to 'evaluate' oesophageal mucosa. An interspecialty cancer referral occurs in a significant proportion of patients with foregut cancers. It almost triples the time to cancer diagnosis and is associated with a high incidence of missed cancers and diminished patient survival. It is a complex phenomenon, and its reduction requires an integrated approach between primary and secondary care, and within secondary care, to optimise referral pathways and ensure appropriate and expeditious specialist evaluation.

Implementation of an enhanced recovery program framework in medical oncology.

66 Background: Enhanced recovery programs (ERPs) apply multi-modal approaches to manage symptoms, decrease complications, and reduce length of stay (LOS). Widely adopted in surgical settings, there is limited evidence of their implementation in non-surgical patient cohorts. An ERP was implemented in a medical oncology population at a National Cancer Institute-designated comprehensive cancer center. The aim of this quality improvement initiative was to evaluate the implementation of an enhanced recovery framework and determine feasibility in medical oncology. Methods: Enhanced recovery in medical oncology (ERMO) was implemented using Plan, Do, Study, Act methodology. Implementation included introduction of integrative medicine, opioid sparing alternatives, fluid and nutrition management, and functional mobility. Outcome measures included symptom distress as measured by the Edmonton Symptom Assessment Scale (ESAS), return to intended oncologic therapy (RIOT), LOS, and opioid use, evaluated from January 2017 through April 2018. Results: A total of 50 patients were evaluated during the program implementation, and compared with 49 control patients retrospectively reviewed prior to ERMO implementation. Average LOS for ERMO patients was 7.3 days compared to 5.5 days for the control group. Time to RIOT averaged 18.9 days for control patients (n = 30) versus 20.8 days for ERMO patients (n = 17). Nineteen patients (38%) had a reduction in morphine equivalent daily dose (MEDD) from admission to discharge, with an average MEDD of 328.47 milligrams per patient. Conclusions: ERMO as a framework is feasible. The patient reported outcomes such as ESAS and RIOT, and barriers to implementation, including participant engagement and patient pain management perceptions, should be evaluated in the context of larger clinical trials.

Why Not Life and Limb? Vasopressor Use in Intensive Care Unit Patients the Cause of Acute Limb Ischemia.

Background: Acute limb ischemia (ALI) of the upper extremity is a rare yet severe condition in intensive care unit (ICU) patients that generally leads to amputation. The aim of this study is to determine risk factors for development of upper extremity limb ischemia in ICU patients requiring vasopressor support. Methods: This is a retrospective study conducted from 2010 to 2015. Patients who received vasopressors during ICU admission were considered for the study. Patients were identified via Current Procedural Terminology (CPT) billing codes. ALI patients were matched to control patients based on diagnosis and Acute Physiology and Chronic Health Evaluation II score. Days on pressors, number of pressors, total doses, and level of ischemia were recorded. Primary end point was doses, types, and days on vasopressors. Secondary end point was level of ALI. Results: Patients in the ALI group were more likely to be started on a higher number of different types of pressors (2.6 vs 1.3 pressors). ALI patients received pressors for 8.5 days compared with 1.6 days in control patients, and received 12.8 doses compared with 3.0 doses in control patients. In addition, vasopressors with alpha-adrenergic activity were more likely to be used in the ALI group. Level of ischemia was not linked to any of the tested variables. Conclusion: Patients admitted to the ICU are more likely to sustain an acute ischemic event of an upper extremity with more vasopressor usage. Patients who received alpha-adrenergic activating vasopressors were more likely to sustain limb ischemia. When discoloration of an extremity is detected, patients should receive counteractive treatments in an effort to salvage the extremity and prevent function loss.

Survival and cost-effectiveness of sorafenib therapy in advanced hepatocellular carcinoma: An analysis of the SEER-Medicare database.

Sorafenib is associated with improved survival in elderly patients with advanced HCC; however, it is not cost-effective among those with hepatic decompensation. (Hepatology 2017;65:122-133).

4:06 PM, Abstract No. 220 - Mesenteric angiography for GI bleeding in patients with left ventricular assist devices (LVAD): a single institution experience

To follow outcomes of patients on anticoagulation with LVADs necessitating mesenteric angiography for GI bleeding compared with a control group. A retrospective study was conducted on 48 patients on anticoagulation presenting to our department with GI bleeding over a seven year period - 24 consecutive patients with LVAD (21 male, 3 female) and 24 consecutive control patients without LVAD (9 male, 15 female). Chi-square analysis for discrete variables (t-test for continuous variables) and multi-variate analysis were used for statistical evaluation. Mean ages were 62.1 ± 9.6 and 74.5 ± 11.3 years in LVAD and control patients, respectively. No statistically significant difference was observed in hemodynamic instability, hemoglobin or INR at presentation, or in hemoglobin nadir. Six embolizations were performed in LVAD patients; 2 had positive angiograms (8.3%) and the remainder underwent empiric embolization based on preprocedure localization. Of the 8 embolizations performed in control patients, all 8 had positive angiograms (33.3%) (p = 0.032). Clinical success with embolization was achieved in 2 of 6 LVAD patients (33.3%) and 7 of 8 control patients (87.5%) (p = 0.036). 7 LVAD patients (29.2%) and 1 control patient (4.5%) had repeat angiography within 14 days (p = 0.020). 7 LVAD patients (29.2%) and 4 control patients (18.2%) required post-procedural endoscopic or operative intervention for definitive therapy (p = 0.302). Average admission length was 28.4 days versus 12.6 days in control patients (p = 0.009). In-hospital mortality was 16.7% versus 4.2% (p = 0.032) and 1 year mortality was 33.3% versus 9.1% (p = 0.080) in LVAD and control patients, respectively. Patients with LVADs presenting with GI bleeding have lower rates of positive angiograms yielding fewer successful embolizations. There is a higher rate of clinical failure, with more frequent need for subsequent endoscopic or surgical intervention for definitive therapy. LVAD patients additionally suffer a greater in-hospital and 1-year mortality rate.

Perioperative immunonutrition in patients undergoing liver transplantation: A randomized double‐blind trial

Preliminary work suggested that perioperative immunonutrition (IMN) enriched in n-3 fatty acids, arginine, and nucleotides may improve preoperative nutritional status, enhance postoperative recovery, and reduce postoperative infectious complications in patients undergoing liver transplantation (LT). The current study examined these outcomes in a double-blind, randomized, controlled trial. Patients wait-listed for LT (n = 120) were randomized to either supplemental (0.6 L/d) oral IMN or an isocaloric control (CON). Enteral IMN or CON was resumed postoperatively and continued for at least 5 days. The change in total body protein (TBP) measured by neutron activation from study entry until immediately prior to LT was the primary endpoint and TBP measurements were repeated 10, 30, 90, 180, and 360 days after LT. Infectious complications were recorded for the first 30 postoperative days. Nineteen patients died or were delisted prior to LT. Fifty-two IMN and 49 CON patients received supplemental nutrition for a median (range) 56 (0-480) and 65 (0-348) days, respectively. Preoperative changes in TBP were not significant (IMN: 0.06 ± 0.15 [SEM]; CON: 0.12 ± 0.10 kg). Compared to baseline, a 0.7 ± 0.2 kg loss of TBP was seen in both groups at 30 days after LT (P < 0.0001) and, at 360 days, TBP had not increased significantly (IMN: 0.08 ± 0.19 kg; CON: 0.26 ± 0.23 kg). Infectious complications occurred in 31 (60%) IMN and 28 (57%) CON patients (P = 0.84). The median (range) postoperative hospital stay was 10 (5-105) days for IMN and 10 (6-27) days for CON patients (P = 0.68). In patients undergoing LT, perioperative IMN did not provide significant benefits in terms of preoperative nutritional status or postoperative outcome.

Apoyo con Cariño: A Pilot Randomized Controlled Trial of a Patient Navigator Intervention to Improve Palliative Care Outcomes for Latinos With Serious Illness

ContextLatinos experience significant health disparities at the end of life compared with non-Latinos. ObjectivesTo determine the feasibility of a patient navigator intervention to improve palliative care outcomes for Latino adults with serious illness. MethodsThis was a pilot randomized controlled trial that included 64 Latino adults with life-limiting illness randomized to an intervention or a control group. All participants received a packet of linguistically matched materials on palliative care. In addition, intervention participants received up to five home visits from the bilingual, bicultural patient navigator. Visits focused on addressing barriers to palliative care through education, activation, and culturally tailored messaging. Outcomes included feasibility and advance care planning rates, documentation of pain management discussions in the medical record, and hospice utilization. ResultsOf the 32 patients randomized to the intervention arm, 81% had at least one home visit (range 1–5) with the patient navigator. Overall, advance care planning was higher in the intervention group (47% [n = 15] vs. 25% [n = 8], P = 0.06), and 79% of intervention participants had a discussion about pain management documented in their medical record vs. 54% of control patients (P = 0.05). Hospice enrollment between the two groups (n = 18 decedents) was similar (n = 7 intervention vs. n = 6 control); length of stay in the intervention group was 36.4 ± 51.6 vs. 19.7 ± 33.6 days for control patients (P = 0.39). ConclusionA culturally tailored patient navigator intervention was feasible and suggests improved palliative care outcomes for Latinos facing advanced medical illness, justifying a fully powered randomized controlled trial.

Cost-effectiveness of the artificial liver support system MARS in patients with acute-on-chronic liver failure

For patients with an acute exacerbation of chronic liver failure (ACLF), the molecular adsorbent recirculating system (MARS) can result in a prolongation of life, but data on costs and cost-effectiveness are lacking. A health economic evaluation of a prospective controlled cohort trial in patients with ACLF not eligible for liver transplantation with 3 years follow-up and consecutive modelling of long-term costs, outcomes and cost-effectiveness was conducted. Costs were calculated from the perspective of the German health-care system. One hundred and forty-nine patients with ACLF were included of which 67 (44.9%) were treated with MARS and 82 (55.1%) assigned to the control group. Mean survival was 692 days in MARS-treated patients (33% survival after 3 years) and 453 days in control patients (15% after 3 years, logrank P = 0.022). MARS patients gained 0.66 [95% confidence interval (CI): -0.12 to 1.46] life years (LYs), determined by the bootstrap method. The mean cost difference was 19.835 euro (95% CI: 13.308-25.429) with 35639 euro for MARS-treated patients and 15804 euro for controls. Incremental costs per LY gained were 29.985 euro (95% CI: 9.441-321.761) and 43.040 euro (95% CI: 13.551-461.856) per quality-adjusted LY gained. There is an acceptable cost-effectiveness of MARS, compared with other medical technologies presently reimbursed. Randomized controlled trials with sufficient sample size are necessary before a final recommendation for MARS can be given.

Risk factors and incidence of postoperative delirium in elderly patients after elective and emergency surgery

: This study evaluated the incidence of postoperative delirium (POD) in elderly patients undergoing general surgery, the risk factors associated with POD, and its impact on hospital stay and mortality. : Patients aged over 65 years who had emergency or elective operations were eligible for this case-control study. Risk factors significantly associated with POD using univariable analysis were entered into multivariable analysis, to establish those independently associated with POD. : A total of 351 patients (357 admissions) were enrolled in the study. The incidence of POD was 13.2 per cent (17.9 per cent for emergency operations). Independent variables associated with POD were: age above 75 years, co-morbidity, preoperative cognitive impairment, psychopathological symptoms and abnormal glycaemic control. Median length of hospital stay was 21 (range 1-75) days for patients with POD versus 8 (range 1-79) days for control patients (P < 0.001). The hospital mortality rate was 19 and 8.4 per cent respectively (P = 0.021). : The incidence of POD is high in elderly patients for both emergency and elective surgery, leading to an increase in hospital stay and perioperative mortality. To minimize POD, associated risk factors of co-morbidity, cognitive impairment, psychopathology and abnormal glycaemic control must be identified and treated.

Prospective Randomized Evaluation of Periureteral Botulinum Toxin Type A Injection for Ureteral Stent Pain Reduction

The use of ureteral stents for ureteral obstruction and after ureteroscopy can result in substantial deterioration in patient quality of life due to pain, frequency and urgency. We postulated that many stent related symptoms may be related to detrusor muscle spasm in and around the intramural ureter, and evaluated the effect of botulinum toxin type A (Botox) in patients with indwelling stents after ureteroscopy. A total of 51 patients between December 2007 and March 2009 were enrolled in an institutional review board approved, prospective, randomized, single-blind study comparing botulinum toxin type A injection at a concentration of 10 U/ml to 3 locations around the ureteral orifice (30) vs no injection after unilateral ureteral stent insertion (21). Pain and urinary symptoms after stent placement were evaluated through the Ureteral Stent Symptom Questionnaire, which was completed on postoperative day 7. In addition, patients were required to maintain a log of narcotic use after stent placement until removal. The Wilcoxon rank sum and Fisher exact tests were used for nonparametric and categorical data, respectively, with p <or=0.05 considered significant. No complications or adverse events occurred in this study. There was a significant decrease in the reported postoperative pain score between the botulinum toxin type A and control group at 3.4 vs 6.0 (p = 0.02). Postoperative narcotic use was also significantly less in the botulinum toxin type A group at 7.7 pills during an average of 2.7 days vs 24.7 in an average of 7.0 days in control patients (p = 0.03). With respect to postoperative lower urinary tract symptoms there was no significant difference between cohorts using the individual index scores within the Ureteral Stent Symptom Questionnaire. Stent related emergency room visits were reported by 1 patient treated in the botulinum toxin type A group vs 2 in the control group. Periureteral botulinum toxin type A injection improves ureteral stent tolerability by significantly decreasing postoperative pain and narcotic requirements. Improvement in irritative symptoms was not observed.

Peritoneal carcinomatosis immunotherapy with the trifunctional anti-EpCAM x anti-CD3 antibody catumaxomab in patients with colon, gastric, or pancreatic cancer: Long-term results after a 2-year follow-up

3033 Background: Peritoneal carcinomatosis (PC) from gastrointestinal (GI) cancer is associated with a poor outcome. The trifunctional antibody catumaxomab may induce remission by redirecting T-lymphocytes and Fcγ-receptor I/III positive accessory cells to tumor cells. The aim of this study was to investigate the treatment of PC with intraperitoneal catumaxomab. Methods: Patients with epithelial cell adhesion molecule (EpCAM)-positive PC from GI cancer were enrolled in a multicenter phase I study and received four sequential intraperitoneal catumaxomab infusions on days 0, 3, 7, and 10 at increasing doses. Results: Twenty-four patients were enrolled. The maximum tolerated dose (MTD) was reached at 10, 20, 50, and 200 μg on days 0, 3, 7, and 10, respectively. The most common drug-related adverse events at the MTD were fever, vomiting, abdominal pain, skin toxicity, and nausea. Eleven of 17 evaluable patients (65%) were progression-free at final examination: one patient had a complete response and three patients had a partial response. EpCAM-positive cells in peritoneal lavage samples decreased in six of 10 evaluable patients. Patient survival was compared in a post hoc matched-pair analysis with PC patients treated with conventional intravenous chemotherapy. Median survival from the time of diagnosis of PC was 502 days in study patients versus 180 days in control patients (log-rank p = .0083). Conclusions: Intraperitoneal treatment with catumaxomab had an acceptable safety profile. Elimination of tumor cells from peritoneal lavage samples, delayed disease progression, and prolonged survival indicate that intraperitoneal catumaxomab is a promising option for the treatment of PC from GI cancer. [Table: see text]

Procalcitonin (PCT)-guided algorithm reduces length of antibiotic treatment in surgical intensive care patients with severe sepsis: results of a prospective randomized study

Adequate indication and duration of administration are central issues of modern antibiotic treatment in intensive care medicine. The biochemical variable procalcitonin (PCT) is known to indicate systemically relevant bacterial infections with high accuracy. In the present study, we aimed to investigate the clinical usefulness of PCT for guiding antibiotic treatment in surgical intensive care patients with severe sepsis. Patients were randomly assigned to a PCT-guided or a control group requiring antibiotic treatment. All patients received a calculated antibiotic regimen according to the presumed microbiological spectrum. In the PCT-guided group, antibiotic treatment was discontinued if clinical signs of infection improved and the PCT value was either <1 ng/ml or decreased to <35% of the initial concentration within three consecutive days. In the control group, antibiotic treatment was directed by empirical rules. The PCT-guided group (n = 14 patients) and the control group (n = 13 patients) did not differ in terms of biological variables, underlying diseases, and overall disease severity. PCT guidance led to a significant reduction of antibiotic treatment from 6.6 +/- 1.1 days (mean +/- SD) compared with 8.3 +/- 0.7 days in control patients (p < 0.001) along with a reduction of antibiotic treatment costs of 17.8% (p < 0.01) without any adverse effects on outcome. Monitoring of PCT is a helpful tool for guiding antibiotic treatment in surgical intensive care patients with severe sepsis. This may contribute to an optimized antibiotic regimen with beneficial effects on microbial resistances and costs in intensive care medicine.

Implementation of the Continuous AutoTransfusion System (C.A.T.S) in Open Abdominal Aortic Aneurysm Repair: An Observational Comparative Cohort Study

The use of the Continuous AutoTransfusion System (C.A.T.S; Fresenius Hemotechnology, Bad Homburg v.d.H., Germany), which conserves allogenic blood, is reported in 187 patients having abdominal aortic aneurysm repair during a 9-year period. Patients were allocated to C.A.T.S if a Haemovigilance technician was available. A mean of 685 mL of retrieved blood was reinfused in 101 patients receiving C.A.T.S; 61% required 2 U or less. All control patients required 3 U or more of allogenic blood. Allogenic transfusion in C.A.T.S patients decreased significantly (P < .0001). Mean intensive care unit stay was significantly reduced in C.A.T.S patients (P = .042). Mean postoperative hospital stay was 18 days for C.A.T.S group and 25 days in control patients (P = .014). The respective 30-day mortality was 12% versus 19% (P = .199). The C.A.T.S markedly reduced the amount of blood transfused, was associated with reduced intensive care unit and postoperative hospital stay, and was cost-effective.

Cardioplegic arrest with l-arginine improves myocardial protection: results of a prospective randomized clinical trial

Background. Blood cardioplegic arrest remains the method of choice for myocardial protection. l-arginine has been suggested to improve protection through an increase in nitric oxide production. Methods. A prospective, randomized, double-blinded clinical trial comparing standard blood cardioplegic solution to l-arginine-enriched solution (7.5 g/500 mL) enrolled 200 patients undergoing coronary artery bypass grafting. Clinical data and biochemical markers of ischemia were recorded. Warm blood cardioplegia (33°C) was administered in 74% of patients and cold blood (20°C) was used in 26% of patients. Both groups averaged three grafts per patient. Results. There were two (2%) deaths in both groups. There were four (4%) myocardial infarctions (MI) in the control group and six (6%) infarctions in the l-arginine group ( p = 0.5). For the 190 patients without MI, serum levels of troponin T averaged 0.40 ± 0.43, 0.38 ± 0.42, and 0.39 ± 0.50 μg/L in control patients compared with 0.28 ± 0.22, 0.24 ± 0.18, and 0.27 ± 0.20 μg/L in l-arginine patients, respectively, 12, 24 and 48 hours after coronary artery bypass grafting ( p = 0.03). The cardiac index averaged 2.7 ± 0.8 L · min −1 · m −2 in control patients and 2.9 ± 0.7 L · min −1 · m −2 in arginine patients immediately after surgery ( p = 0.09). Intensive care unit and hospital length of stay averaged 3.5 ± 5 days and 7.3 ± 6 days in control patients compared with 2.5 ± 3 days and 6.1 ± 4 days in arginine patients ( p = 0.09). Conclusions. l-arginine-supplemented blood cardioplegic solution is associated with reduced release of biochemical markers of myocardial damage, suggesting improved myocardial protection.

Inhibition of human vascular smooth muscle cell growth by heparin

We examined the inhibitory effect of heparin on vascular smooth muscle cell (VSMC) outgrowth from cultured coronary artery explants of primary atherosclerotic lesions and of undiseased regions from the same patients, compared with explant outgrowth from control patients (idiopathic cardiomyopathy) with no evidence of atherosclerosis. For undiseased tissue regardless of origin, heparin significantly delayed half-maximum percentage explant outgrowth time (mean difference from control treatment 2·1 [SE 0 8] days for atherosclerosis patients and 2 3 [10] days for control patients). For plaque tissue, heparin had no such effect. Thus the proliferative state of the cells involved in outgrowth may influence the activity of heparin.

Immunologic responses of graft recipients to antilymphocyte globulin: effect of prior treatment with aggregate-free gamma globulin.

The immunologic response of graft recipients to antilymphocyte globulin has been studied. The clearance from the serum of (125)I-labeled antilymphocyte globulin was studied in 15 graft recipients previously treated with antilymphocyte globulin and in 4 control patients not previously treated with antilymphocyte globulin. The mean serum half-life of antilymphocyte globulin was 7.2 days in control patients, 3.8 days in 13 renal graft recipients, and 22 hr in 2 heart graft recipients. All but one of the antilymphocyte globulin-treated patients had rapid clearance. Patients treated with equine antilymphocyte globulin had rapid clearance of rabbit and goat antilymphocyte globulin as well as horse antilymphocyte globulin. All patients with rapid clearance of antilymphocyte globulin had circulating antibodies to xenogeneic gamma globulin. Two patients with rapid clearance of antilymphocyte globulin had circulating complexes of antilymphocyte globulin. Five renal graft recipients were treated with aggregate-free equine gamma globulin before antilymphocyte globulin therapy in an attempt to induce tolerance to xenogeneic gamma globulin. In these five patients neither rapid clearance of antilymphocyte globulin nor significant titers of circulating antibody to xenogeneic gamma globulin developed. The induction of tolerance to xenogenic gamma globulin may benefit patients treated with antilymphocyte globulin.