- Email: [email protected]
Prognostic value of circulating levels of interleukin-6 in patients with congestive heart failure
The Journal of Heart and Lung Transplantation Volume 18, Number 1 235
EVALUATION OF A MENTORSHIP PROGRAMME TRANSPLANT PATIENTS J.J. Pennington, L. Wright The Toronto Hospital, Toronto, Ontario, CANADA
Abstracts
FOR
HEART
The Heart Transplant Mentor Programme (HTMP) was initiated in 1996, for patients listed for cardiac transplantation. The programme aims to augment patient education and social support, both of which have been correlated wifh improved patient and caregiver coping ability. More specifically, one of the main objectives of the HTMP is to provide patients and families with “information and support from a peer perspective”. In order to assess the effectiveness of this programme, a study was conducted comprising a series of semi-structured interviews (1.5-2.5 hours). Sixtythree per cent (10116) of the patients who had been mentored were interviewed. The participants were representative of the general adult heart transplant population on the basis of age, gender and race. In addition to open-ended inquiry, participants were asked to rate various aspects of the programe on a 5-point scale (l-poor to 5excellent). Furthermore, patients were asked to select descriptors, developed from the literature, of the HTMP and their individual mentors. Qualitative and quantitative analyses, based on scores and frequency of responses, indicated that participants found the information and support provided by their mentors positive (3.8 and 4.0 respectively). All participants attested to the value of a “peer perspective”. Although participants (7/10) reported differences in their pre- and posttransplantation ratings of tbe programme, variation in subject responses precluded statistical significance. Participant testimonials indicated that prc-transplant dissatisfaction was due to late or little mentor contact pre-operatively, whereas posttransplant dissatisfaction was generally attributed to difference in clinical course behveen mentor and patient. Participants most frequently described their mentor as a “friend” (lo/lo) and were most likely to discuss medical rather than psychosocial topics with their mentor. The reluctance to discuss psychosocial topics (l-3110) may be due to the population of predominantly middle-aged males or to a lack of commonalties (education, hobbies, etc.) between the mentee and mentor. Recommendations to increase patient satisfaction with the programme both prc- and post- transplant include earlier introduction of a mentor and the use of multiple mentors on the basis of demographics and clinical course.
236
237
DIAGNOSTIC VALUE OF STRUCTURED INTERVIEWS IN ASSESSING NONCOMPLIANCE WITH IMMUNOSUPPRESSIVE THERAPY IN HEART TRANSPLANT RECIPIENTS S. Dc Geest’, I. Dunbar-Jacob’, J. Vanhaecke’ ’ Catholic University ofLeuven, Leaven, Belgium; ’ University of Pittsburgh, Pittsburgh, PA, USA. Noncompliance with immunosuppressive therapy is a known risk factor for poor clinical outcome after transplantation. Interview data are perhaps the most common method of assessing compliance in clinical practice and in research studies. Yet considerable concerns exist about the accuracy of these data. We examined the reliability and diagnostic value of a structured patient interview to assess compliance with immunosuppressive therapy among 99 HTX patients whose compliance was also being monitored electronically. Patients (8% females) had a median age of 56 years (Ql=SO; Q3=62), and were minimum I year posttransplant (range: 1-6). The prevalence of noncompliance with immunosuppressive therapy was 15% based on electronic event monitoring data (EEM) and 8% of the patients were so judged by patient interview indicating that noncompliance is underreported by patient interview. A two by hvo table was constructed to calculate the diagnostic value of patient interview compared to a clinically validated gold standard baaed on EEM. The accuracy of the patient interview was calculated to be 85%, specificity was 95% and sensitivity was 27%. Thus, the interview identified a large portion of compliers but did not detect a significant number of noncompliers. The positive predictive value, indicating the probability that if a patient was classified as a noncomplier by patient intcwiew, that he/she is actually a noncomplier was 50%. The negative predictive value indicating the probability that if a patient was categorized as a complier, that he/she is actually a complier was 88%. These data suggest that patient interviews have limited value lo identify noncompliant patients both in clinical practice and in research settings restricting the possibility to target these patients for restorative compliance interventions and endangering reliability of research findings, respectively.
OR IMPROVING NUTRITIONAL PARAMEXRS AWAlTING LUNG TRANSPLANTATION N.L. Endres, D. L. Welter, B.L. Loren& MM. Cartwright, University of Wisconsin, Madison, Wisconsin Purpose: Patients awaiting lung transplantation experience pulmonay dysfunction during waiting periods of 12-24 months. status generally suffers as pulmonary disability increases and is
MAINTAINING FOR PATiENTS
RB.
Love.
progressive Nutritional
a factor that
91
may contribute to morbidity and mortality. Our lung transplant program works aggressively with pre-lung transplant patients to improve and or maintain adequate nutritional status. Our rationale is that without nutritional intervention, we expect the patients to lose weight due to deceased calorie intake, declining albumin, and in turn, have a increased morbidity. Methods: All patients have a nutritionaI assessment at time of evaluation and continuously throughout the waiting period. Nutritional assesment includes diet history, appropriate laboratory values (albumin, cholesterol, etc. and more recently pre-albumin) and weightmeight ratio, weight history and metabolic studies. If the patient bad a significant decline in appetite, weight or albumin nutrition intervention was started. Initially optimal po intake was encouraged which included calorie dense foods and small frequent meals. If the patient was unable to maintain weight or albumin, nutritional supplements (Ensure., Ensure Plus, Boost, Boost Plus, etc.) were started. Usually the cystic fibrosis patients started or increased Scandishake consumption. When the stable pretransplant patient continued to loose weight or have depressed albumin, a percutaneous gastrostomy tube (PEG) was placed for feeding. The product used for feeding varied by individual tolerance. Results: of our 61 patients studied, 17 patients had an albumin less than 3.5 mg/dl. Supplementation or PEG feeds were received by 12 of these patients. After the nutrition intervention the albumin increased a mean of 0.233 g/dl. Also, 24 patients were less than 90% of ideal body weight (Hamwi equation). Of these 24 patients, 21 received supplementation or PEG feedings the mean weight increase ~85 1.4 kg., or an increase of 2% of ideal body weight. Conclusion: Aggressive nutritional intervention can maintain or improve nutritional status of patients on list and contribute to best patient outcome.
236
RISK FACTOR ANALYSIS FOR INAPPROPRIATE GROWTH AFTER PEDIATRIC HEART TRANSPLANTATION(HTX) T. Flaspohler , K. Bando, R. Caldwell, R. Darragh, T. Sharp, Y. Okada, M. Turrentine, H-J. Park, J. Brown, Indiana University, Ind. Objectives: Although HTX is recognized as a valuable modality for end-stage heart failure in pediatric patients, decreased growth may result. ihe purpose of this study was to examine growth rates of weight (W) and height (H) after HTX and analyze risk factors for decreased growth. Methods: Pediatric HTX survivors (n=44 since 1989) were analyzed. The age and gender of HTX patients, doses of immune-suppressive agents (prednisone, cyclosporin, and imuran) as well as the severity and frequency ofrejection episodes were reviewed to assess risks for growth retardation. Results: Although weight gain is relatively normal in both boys and girls, gain in H was significantly reduced (Table). w m HN Ratio m 51532 1.15~0.32 44k28 Preop Boys 52+34 53c27 0.9850.33 Girls 23+5 0.6620.34 46220 Boys 5 Y* 48k31 33+19 0.7520.44 Girls Decreased H relative to W is more prominent among boys than girls but this difference is not statistically significant Risks for decreased H/W include older age at HTX (p=O.O09), frequency of rejection w.04) and severity of rejection (p=O.O6). Although the maintenance doses of prednisone were not correlated with decreased growth, there was a significant correlation between total steroid pulse doses and decreased growth of both H and W (p
239
PROGNOSTIC VALUE OF CIRCULATING LEVELS OF INTERLEUKIN-6 IN PATIENTS WITH CONGESTIVE HEART FAILURE. E. Roig, F. Perez -Villa, J. Gnis, C. Par&, M. Azqueta, X. Filella, M. Hew G. Sanz. Hospital Clinic. Barcelona. Spain. To assess the prognostic value of increased serum cytokines, plasma renin activity(PRA), aldosterone, atrial natriuretic peptide (ANP), norepinephriie (N), interleukind (IL-6), interleukin-1B (IL-LB), tumor necrosis factor (TNF), ejection fraction (EF), end-diastolic (EDL) and end-systolic (ESL) left ventricular lengths were assessed in 87 patients (Pts) with congestive heart failure (CHF), (mean age 57f9 years). Mean EF of the studied population was 24f6% and the EDL and ESL were 70f7 and 59f8 mm, respectively. Coronary artery disease was present in 32 Pts (37%) while the remaining 55(63%) had idiopathic dilated cardiomyopathy.
92 Abstracts
The Journal of Heart and Lung Transplantation January 1999
New York Heart Association functional class (NYHA FC) III-IV was present in 24 pts.During followup(l4i9 months), 19 pfs had new events: 7 pts died, one underwent a heart transplantation and 11 were readmitted because of new episodes of heart failure. By multiple regression analysis the variables associated with new events were: F Sienificance F variables 49.7 0.0001 NYHA FC III-IV 47;7 0.0001 IL-6 (pg/ml) ANP (fmol/ml) 0.004 a,7 IL-18 (pg/ml) 0.01 7,5 5,06 0.02 N (Pg/mO PRA (ng/dl.h) 0.03 4.4 By stepwise regression analysis, IL-6 (p=O.OOOS) and NYHA FC III-IV (p=O.O2) were identified as independent predictors of prognosis. In conclusion, Pts with CHF: I/ Serum IL-6 was identified as the first independent predictor of new evenfs during follow-up. 2/ Serom IL-6 was better predictor of prognosis than IL16, TNF and plasma neurohormones.
240 PATIENT OUTCOME AND COSTS FOLLOWING AN ACUTE HEART FAILURE (I-IF) MANAGEMENT PROGRAM IN AN EMERGENCY DEPARTMENT (ED) OBSERVATION UNIT (OU) W. F. Peacock, Nancy M. Albert, The Cleveland Clinic Foundation, Cleveland, Ohio, USA. Aggressive outpatient HF management decreaseshospital admission rates, inpatient length of stay (LOS), and cost. Purpose: To evaluate the impact of an aggressive I-IF management protocol in an ED & OU setting. Methods: An acute HF protocol, designed by physicians and nurses from cardiology and emergency medicine, consisted of clinical pathways including aggressive diagnosis, diuretic & vasodilator therapies, patient education, nutritional consults, heart failure physician specialist consultation, t quality improvement monitoring. Outcome data was collected 10 months prior to 5 months after program implementation. Remlts: Compared to pre-protocol, there was a 7% (p-0.015) increase in HF admissions to the OU. Despite the increased census,hospital admissions decreased by 9% (67 % pre to 58% post program, W.008). If hospitalized from the OU, there was a trend of decreasing mean LOS (Inclusive of OU LOS) by 23% [-0.82 days] (P--08), and median LOS by 40% [-1.5 days] (p--O. 15). If admitted from the OU to the hospital, there was a trend for patients requiring a billable procedure post-program, 25% pre vs. 36% post (P=O.40), suggesting a higher level of acuity. Total costs saving for 5 months = $37,217, due to admission avoidance. Annualized costs savings projected: $89,321 (note: ED census = 1.4% HF). Per casecosts: ED discharge = unchanged; OU = increased $8 1; if hospit+ii from OU = increased $587. Conclusions: Implementation of an aggressive ED I-IF program decreaseshospitalization rates, hospital LOS, and cost.
241
~~‘BSoBI,AS
AN INDEPENDENT
RISK
FACTOR
GM Mullon, K. Me4hmiq CE. Iawkas, B.A Fimni, J.C. Mcrda, LqrolaUniversily-systernq~-Rolgmn,--
IN HEART J.A Robson.
IicarttmqW&on(HT)harkcomeamutinepmccdurrforendstage ofkalthilm. EwathKughcdcIlHTarndidare~verycarerul eval~oCCpsiollpllypticatsansdcdedwit6relsdvecoatraiDdicntions(e.g. obesity) ifthe cardiac condition is life threatening. Howcvcr,
the outcome in such ~ridrrocipientrmaynotbeoptimalandthuswewantedNreviewthe crermMioa behwn the recipient weight and HT outcome. in w institution Wehadaoalyed27Opathtaatcw&,whowrrc~ be~0~1March1,1984toJune30,1993. Thap&catswcrcdivi&dintothree giwpsbnaadontheirbodytightat(bctitnaoftbeti~biopay. GnwpIcwi~cdof63liT~recigiclllswoi%ing~-lO%ofideobodywciweightand
inGroupUwae106pstieatsweiehinebshucsn-l~to+109Cdidealbody wdgbtan6inGmplllwem62patic&wighiag
>+lO%ofi&alWyWgl&
Group I 43.6zt16.9
Age 6-d
Gender @ht&hale)** ~iwi*@wj ~~w~~w~ Mean BP CmmHg) Cardiac Index flhidtd)
oneyeorsalvival’ Fivcycarwvival** CONCLUSIONS:
10153 loot127 54 (86%) 55.W5.0 0.64f1.16 107fl5 2.7110.65 57 (90%) 42 (67%)
Group II
Group III
46.7i13.7 17/89
49.3f11.6 37164 268f274 61(61%) 43.5ti8.7 0.65f1.23 lO6f14 2.86fo.67 76 (76%) 53 (48%)
177lt251
74 (7O%) 41.3ti4.6 0.55i1.10 107*13 2.79fo.69 93 (88%) 80 (75%)
had worse Perhapsthe over time. Further study on the reasons
The above data indicate
~MntboughlessofthemwereuNOSstaNsIpreHT. Clint’ dates to obesity complications for this difference is necwwy.
that heavier
patients
*p
**p
242
PUBLIC AND PROFESSIONAL ATTITUDES TOWARD XEN~TRANSPLANTI~N AND OTHER 0Pn0~S TO INCREASE ORGAN AVAILABILITY Alao R. Hull, MD, National Kidney Foundation, New York, NY The purpose of the sNdy was to assess the perceptions and altitudes Americans have of the concept of Xenotransplantation and compare the attractiveness of this option to other concepts for increasing the availability of organs for traosplantation. The study analyzed the attihldes of 1,677 General Consumers, Transplant Candidates, Transplant Recipients, Transplant Surgeons and Physicians and Primary Care Physicians. Eight consumer focus groups and telephone interviews were conducted with randomly selected individuals across the United States from each of these groups behveen June 30, 1997 and December 3 1, 1997. The key issues measured included: Perceptions and knowledge of organ donation in general, Reaction to Xenotraosplaotation, Reaction to alternatives for increasing organ availability, Donor stahls, Demographic profiles of key subgroups. Nearly all have heard of Xenotransplantation. Concerns about Xenotransplantation focused on organ compatibility, disease transfer and tramplant outcomes. Xenotransplantation is seen as one of the most viable options for increasing availability of donor organs, along with implied consent. The majority feel that Xenotransplaotation research should continue with the government paying for the research and the physicians regulating it. The clergy can have a significant impact on the public’s altitude toward organ donation and transplantation with 21% saying clergy would make them more willingly accept xenotransplantation. The study found little differences in attitudes among groups. Transplant surgeon and physician attitudes often mirror those of the primary care physicians and the general public, but with greater intensity. Transplant recipients are not surprisingly the most supportive.
243
OF POTENTIAL HEART AND HEARTLUNG PATIENTS TO XENOTRANSPLANTATION? T. Long. I. Wray. N. Banner. Harcfield Hospital. Harefield. M~ddlescs. U.K The views of potential heart and he&-lung transplant recqxents about xenotransplantation arc unclear. stud& in renal patients have shown contradictory results. This exploratory survey of the patients on the wailing list for heart or heart-lung transplantation at this institution investigated the following issues: patients’ decision mating in relation 10 tnnsplantation. attitudes toward xenotransplanmtioo, the source and level of their knowledge about xenotransplantation and the perceived costs and benefits. The patients’ views about animal experimentation and killing animals for human benefit were also survcycd using a specifically dcsipcd attitude questionnaire.One hundredand onepatientswere sent a questionnaire of whom 60 (60%) responded. Results indicated that pients use a sponraneous decision-making style in response to transplantation. This was contrary to the view that patients make considered decisions based on information gained from knowledgeable sources. The majority of respondents (54%) were unsure about xenouansplantation. The patients indicated that they had little or no information about xenotransplantation. and lhac which thcv had was from non-medical soorccs. Twentv one patients (36%) indicated that availability of organs was the main perceived benefit. and 12 patients that ethical and moral issues (20%) the main perceived cost. Overall, patients were in agreement with animal experimentation and killing animals for human bcncfit. It is concluded thal potential heart and heati-lung recipients at this institution are currently uncertainaboutxeaotransplanmtion. whilst this maytx due to their lack of information. it may also reflect coocems regarding moral and ethical issues WHAT ARE THE ATTITUDES
EVALUATION OF A MENTORSHIP PROGRAMME TRANSPLANT PATIENTS J.J. Pennington, L. Wright The Toronto Hospital, Toronto, Ontario, CANADA
Abstracts
FOR
HEART
The Heart Transplant Mentor Programme (HTMP) was initiated in 1996, for patients listed for cardiac transplantation. The programme aims to augment patient education and social support, both of which have been correlated wifh improved patient and caregiver coping ability. More specifically, one of the main objectives of the HTMP is to provide patients and families with “information and support from a peer perspective”. In order to assess the effectiveness of this programme, a study was conducted comprising a series of semi-structured interviews (1.5-2.5 hours). Sixtythree per cent (10116) of the patients who had been mentored were interviewed. The participants were representative of the general adult heart transplant population on the basis of age, gender and race. In addition to open-ended inquiry, participants were asked to rate various aspects of the programe on a 5-point scale (l-poor to 5excellent). Furthermore, patients were asked to select descriptors, developed from the literature, of the HTMP and their individual mentors. Qualitative and quantitative analyses, based on scores and frequency of responses, indicated that participants found the information and support provided by their mentors positive (3.8 and 4.0 respectively). All participants attested to the value of a “peer perspective”. Although participants (7/10) reported differences in their pre- and posttransplantation ratings of tbe programme, variation in subject responses precluded statistical significance. Participant testimonials indicated that prc-transplant dissatisfaction was due to late or little mentor contact pre-operatively, whereas posttransplant dissatisfaction was generally attributed to difference in clinical course behveen mentor and patient. Participants most frequently described their mentor as a “friend” (lo/lo) and were most likely to discuss medical rather than psychosocial topics with their mentor. The reluctance to discuss psychosocial topics (l-3110) may be due to the population of predominantly middle-aged males or to a lack of commonalties (education, hobbies, etc.) between the mentee and mentor. Recommendations to increase patient satisfaction with the programme both prc- and post- transplant include earlier introduction of a mentor and the use of multiple mentors on the basis of demographics and clinical course.
236
237
DIAGNOSTIC VALUE OF STRUCTURED INTERVIEWS IN ASSESSING NONCOMPLIANCE WITH IMMUNOSUPPRESSIVE THERAPY IN HEART TRANSPLANT RECIPIENTS S. Dc Geest’, I. Dunbar-Jacob’, J. Vanhaecke’ ’ Catholic University ofLeuven, Leaven, Belgium; ’ University of Pittsburgh, Pittsburgh, PA, USA. Noncompliance with immunosuppressive therapy is a known risk factor for poor clinical outcome after transplantation. Interview data are perhaps the most common method of assessing compliance in clinical practice and in research studies. Yet considerable concerns exist about the accuracy of these data. We examined the reliability and diagnostic value of a structured patient interview to assess compliance with immunosuppressive therapy among 99 HTX patients whose compliance was also being monitored electronically. Patients (8% females) had a median age of 56 years (Ql=SO; Q3=62), and were minimum I year posttransplant (range: 1-6). The prevalence of noncompliance with immunosuppressive therapy was 15% based on electronic event monitoring data (EEM) and 8% of the patients were so judged by patient interview indicating that noncompliance is underreported by patient interview. A two by hvo table was constructed to calculate the diagnostic value of patient interview compared to a clinically validated gold standard baaed on EEM. The accuracy of the patient interview was calculated to be 85%, specificity was 95% and sensitivity was 27%. Thus, the interview identified a large portion of compliers but did not detect a significant number of noncompliers. The positive predictive value, indicating the probability that if a patient was classified as a noncomplier by patient intcwiew, that he/she is actually a noncomplier was 50%. The negative predictive value indicating the probability that if a patient was categorized as a complier, that he/she is actually a complier was 88%. These data suggest that patient interviews have limited value lo identify noncompliant patients both in clinical practice and in research settings restricting the possibility to target these patients for restorative compliance interventions and endangering reliability of research findings, respectively.
OR IMPROVING NUTRITIONAL PARAMEXRS AWAlTING LUNG TRANSPLANTATION N.L. Endres, D. L. Welter, B.L. Loren& MM. Cartwright, University of Wisconsin, Madison, Wisconsin Purpose: Patients awaiting lung transplantation experience pulmonay dysfunction during waiting periods of 12-24 months. status generally suffers as pulmonary disability increases and is
MAINTAINING FOR PATiENTS
RB.
Love.
progressive Nutritional
a factor that
91
may contribute to morbidity and mortality. Our lung transplant program works aggressively with pre-lung transplant patients to improve and or maintain adequate nutritional status. Our rationale is that without nutritional intervention, we expect the patients to lose weight due to deceased calorie intake, declining albumin, and in turn, have a increased morbidity. Methods: All patients have a nutritionaI assessment at time of evaluation and continuously throughout the waiting period. Nutritional assesment includes diet history, appropriate laboratory values (albumin, cholesterol, etc. and more recently pre-albumin) and weightmeight ratio, weight history and metabolic studies. If the patient bad a significant decline in appetite, weight or albumin nutrition intervention was started. Initially optimal po intake was encouraged which included calorie dense foods and small frequent meals. If the patient was unable to maintain weight or albumin, nutritional supplements (Ensure., Ensure Plus, Boost, Boost Plus, etc.) were started. Usually the cystic fibrosis patients started or increased Scandishake consumption. When the stable pretransplant patient continued to loose weight or have depressed albumin, a percutaneous gastrostomy tube (PEG) was placed for feeding. The product used for feeding varied by individual tolerance. Results: of our 61 patients studied, 17 patients had an albumin less than 3.5 mg/dl. Supplementation or PEG feeds were received by 12 of these patients. After the nutrition intervention the albumin increased a mean of 0.233 g/dl. Also, 24 patients were less than 90% of ideal body weight (Hamwi equation). Of these 24 patients, 21 received supplementation or PEG feedings the mean weight increase ~85 1.4 kg., or an increase of 2% of ideal body weight. Conclusion: Aggressive nutritional intervention can maintain or improve nutritional status of patients on list and contribute to best patient outcome.
236
RISK FACTOR ANALYSIS FOR INAPPROPRIATE GROWTH AFTER PEDIATRIC HEART TRANSPLANTATION(HTX) T. Flaspohler , K. Bando, R. Caldwell, R. Darragh, T. Sharp, Y. Okada, M. Turrentine, H-J. Park, J. Brown, Indiana University, Ind. Objectives: Although HTX is recognized as a valuable modality for end-stage heart failure in pediatric patients, decreased growth may result. ihe purpose of this study was to examine growth rates of weight (W) and height (H) after HTX and analyze risk factors for decreased growth. Methods: Pediatric HTX survivors (n=44 since 1989) were analyzed. The age and gender of HTX patients, doses of immune-suppressive agents (prednisone, cyclosporin, and imuran) as well as the severity and frequency ofrejection episodes were reviewed to assess risks for growth retardation. Results: Although weight gain is relatively normal in both boys and girls, gain in H was significantly reduced (Table). w m HN Ratio m 51532 1.15~0.32 44k28 Preop Boys 52+34 53c27 0.9850.33 Girls 23+5 0.6620.34 46220 Boys 5 Y* 48k31 33+19 0.7520.44 Girls Decreased H relative to W is more prominent among boys than girls but this difference is not statistically significant Risks for decreased H/W include older age at HTX (p=O.O09), frequency of rejection w.04) and severity of rejection (p=O.O6). Although the maintenance doses of prednisone were not correlated with decreased growth, there was a significant correlation between total steroid pulse doses and decreased growth of both H and W (p
239
PROGNOSTIC VALUE OF CIRCULATING LEVELS OF INTERLEUKIN-6 IN PATIENTS WITH CONGESTIVE HEART FAILURE. E. Roig, F. Perez -Villa, J. Gnis, C. Par&, M. Azqueta, X. Filella, M. Hew G. Sanz. Hospital Clinic. Barcelona. Spain. To assess the prognostic value of increased serum cytokines, plasma renin activity(PRA), aldosterone, atrial natriuretic peptide (ANP), norepinephriie (N), interleukind (IL-6), interleukin-1B (IL-LB), tumor necrosis factor (TNF), ejection fraction (EF), end-diastolic (EDL) and end-systolic (ESL) left ventricular lengths were assessed in 87 patients (Pts) with congestive heart failure (CHF), (mean age 57f9 years). Mean EF of the studied population was 24f6% and the EDL and ESL were 70f7 and 59f8 mm, respectively. Coronary artery disease was present in 32 Pts (37%) while the remaining 55(63%) had idiopathic dilated cardiomyopathy.
92 Abstracts
The Journal of Heart and Lung Transplantation January 1999
New York Heart Association functional class (NYHA FC) III-IV was present in 24 pts.During followup(l4i9 months), 19 pfs had new events: 7 pts died, one underwent a heart transplantation and 11 were readmitted because of new episodes of heart failure. By multiple regression analysis the variables associated with new events were: F Sienificance F variables 49.7 0.0001 NYHA FC III-IV 47;7 0.0001 IL-6 (pg/ml) ANP (fmol/ml) 0.004 a,7 IL-18 (pg/ml) 0.01 7,5 5,06 0.02 N (Pg/mO PRA (ng/dl.h) 0.03 4.4 By stepwise regression analysis, IL-6 (p=O.OOOS) and NYHA FC III-IV (p=O.O2) were identified as independent predictors of prognosis. In conclusion, Pts with CHF: I/ Serum IL-6 was identified as the first independent predictor of new evenfs during follow-up. 2/ Serom IL-6 was better predictor of prognosis than IL16, TNF and plasma neurohormones.
240 PATIENT OUTCOME AND COSTS FOLLOWING AN ACUTE HEART FAILURE (I-IF) MANAGEMENT PROGRAM IN AN EMERGENCY DEPARTMENT (ED) OBSERVATION UNIT (OU) W. F. Peacock, Nancy M. Albert, The Cleveland Clinic Foundation, Cleveland, Ohio, USA. Aggressive outpatient HF management decreaseshospital admission rates, inpatient length of stay (LOS), and cost. Purpose: To evaluate the impact of an aggressive I-IF management protocol in an ED & OU setting. Methods: An acute HF protocol, designed by physicians and nurses from cardiology and emergency medicine, consisted of clinical pathways including aggressive diagnosis, diuretic & vasodilator therapies, patient education, nutritional consults, heart failure physician specialist consultation, t quality improvement monitoring. Outcome data was collected 10 months prior to 5 months after program implementation. Remlts: Compared to pre-protocol, there was a 7% (p-0.015) increase in HF admissions to the OU. Despite the increased census,hospital admissions decreased by 9% (67 % pre to 58% post program, W.008). If hospitalized from the OU, there was a trend of decreasing mean LOS (Inclusive of OU LOS) by 23% [-0.82 days] (P--08), and median LOS by 40% [-1.5 days] (p--O. 15). If admitted from the OU to the hospital, there was a trend for patients requiring a billable procedure post-program, 25% pre vs. 36% post (P=O.40), suggesting a higher level of acuity. Total costs saving for 5 months = $37,217, due to admission avoidance. Annualized costs savings projected: $89,321 (note: ED census = 1.4% HF). Per casecosts: ED discharge = unchanged; OU = increased $8 1; if hospit+ii from OU = increased $587. Conclusions: Implementation of an aggressive ED I-IF program decreaseshospitalization rates, hospital LOS, and cost.
241
~~‘BSoBI,AS
AN INDEPENDENT
RISK
FACTOR
GM Mullon, K. Me4hmiq CE. Iawkas, B.A Fimni, J.C. Mcrda, LqrolaUniversily-systernq~-Rolgmn,--
IN HEART J.A Robson.
IicarttmqW&on(HT)harkcomeamutinepmccdurrforendstage ofkalthilm. EwathKughcdcIlHTarndidare~verycarerul eval~oCCpsiollpllypticatsansdcdedwit6relsdvecoatraiDdicntions(e.g. obesity) ifthe cardiac condition is life threatening. Howcvcr,
the outcome in such ~ridrrocipientrmaynotbeoptimalandthuswewantedNreviewthe crermMioa behwn the recipient weight and HT outcome. in w institution Wehadaoalyed27Opathtaatcw&,whowrrc~ be~0~1March1,1984toJune30,1993. Thap&catswcrcdivi&dintothree giwpsbnaadontheirbodytightat(bctitnaoftbeti~biopay. GnwpIcwi~cdof63liT~recigiclllswoi%ing~-lO%ofideobodywciweightand
inGroupUwae106pstieatsweiehinebshucsn-l~to+109Cdidealbody wdgbtan6inGmplllwem62patic&wighiag
>+lO%ofi&alWyWgl&
Group I 43.6zt16.9
Age 6-d
Gender @ht&hale)** ~iwi*@wj ~~w~~w~ Mean BP CmmHg) Cardiac Index flhidtd)
oneyeorsalvival’ Fivcycarwvival** CONCLUSIONS:
10153 loot127 54 (86%) 55.W5.0 0.64f1.16 107fl5 2.7110.65 57 (90%) 42 (67%)
Group II
Group III
46.7i13.7 17/89
49.3f11.6 37164 268f274 61(61%) 43.5ti8.7 0.65f1.23 lO6f14 2.86fo.67 76 (76%) 53 (48%)
177lt251
74 (7O%) 41.3ti4.6 0.55i1.10 107*13 2.79fo.69 93 (88%) 80 (75%)
had worse Perhapsthe over time. Further study on the reasons
The above data indicate
~MntboughlessofthemwereuNOSstaNsIpreHT. Clint’ dates to obesity complications for this difference is necwwy.
that heavier
patients
*p
**p
242
PUBLIC AND PROFESSIONAL ATTITUDES TOWARD XEN~TRANSPLANTI~N AND OTHER 0Pn0~S TO INCREASE ORGAN AVAILABILITY Alao R. Hull, MD, National Kidney Foundation, New York, NY The purpose of the sNdy was to assess the perceptions and altitudes Americans have of the concept of Xenotransplantation and compare the attractiveness of this option to other concepts for increasing the availability of organs for traosplantation. The study analyzed the attihldes of 1,677 General Consumers, Transplant Candidates, Transplant Recipients, Transplant Surgeons and Physicians and Primary Care Physicians. Eight consumer focus groups and telephone interviews were conducted with randomly selected individuals across the United States from each of these groups behveen June 30, 1997 and December 3 1, 1997. The key issues measured included: Perceptions and knowledge of organ donation in general, Reaction to Xenotraosplaotation, Reaction to alternatives for increasing organ availability, Donor stahls, Demographic profiles of key subgroups. Nearly all have heard of Xenotransplantation. Concerns about Xenotransplantation focused on organ compatibility, disease transfer and tramplant outcomes. Xenotransplantation is seen as one of the most viable options for increasing availability of donor organs, along with implied consent. The majority feel that Xenotransplaotation research should continue with the government paying for the research and the physicians regulating it. The clergy can have a significant impact on the public’s altitude toward organ donation and transplantation with 21% saying clergy would make them more willingly accept xenotransplantation. The study found little differences in attitudes among groups. Transplant surgeon and physician attitudes often mirror those of the primary care physicians and the general public, but with greater intensity. Transplant recipients are not surprisingly the most supportive.
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OF POTENTIAL HEART AND HEARTLUNG PATIENTS TO XENOTRANSPLANTATION? T. Long. I. Wray. N. Banner. Harcfield Hospital. Harefield. M~ddlescs. U.K The views of potential heart and he&-lung transplant recqxents about xenotransplantation arc unclear. stud& in renal patients have shown contradictory results. This exploratory survey of the patients on the wailing list for heart or heart-lung transplantation at this institution investigated the following issues: patients’ decision mating in relation 10 tnnsplantation. attitudes toward xenotransplanmtioo, the source and level of their knowledge about xenotransplantation and the perceived costs and benefits. The patients’ views about animal experimentation and killing animals for human benefit were also survcycd using a specifically dcsipcd attitude questionnaire.One hundredand onepatientswere sent a questionnaire of whom 60 (60%) responded. Results indicated that pients use a sponraneous decision-making style in response to transplantation. This was contrary to the view that patients make considered decisions based on information gained from knowledgeable sources. The majority of respondents (54%) were unsure about xenouansplantation. The patients indicated that they had little or no information about xenotransplantation. and lhac which thcv had was from non-medical soorccs. Twentv one patients (36%) indicated that availability of organs was the main perceived benefit. and 12 patients that ethical and moral issues (20%) the main perceived cost. Overall, patients were in agreement with animal experimentation and killing animals for human bcncfit. It is concluded thal potential heart and heati-lung recipients at this institution are currently uncertainaboutxeaotransplanmtion. whilst this maytx due to their lack of information. it may also reflect coocems regarding moral and ethical issues WHAT ARE THE ATTITUDES