Biomedical subjects
Publications and source records attributed to M R Kramer.
In rare cases the use of cyclosporin in transplant patients can cause myopathic changes. We describe two patients, the recipients of lung transplants, who developed severe reversible rhabdomyolysis associated with cyclosporin drug-drug interaction.
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Flying may expose passengers to hypoxic conditions, which may induce hypoxemia, particularly in those with chronic heart and/or lung disease. Onset of dyspnea, wheezing, chest pain, cyanosis and right heart failure can lead to urgent need for oxygen during flight. The hypoxia inhalation test (HIT) provides a safe and simple means of identifying those who may develop hypoxemia during flight. We report our experience with 48 self-reporting patients who underwent HIT prior to pre-planned air travel. They inhaled for 15-minute periods a reduced oxygen concentration (F1O2 15%) under normobaric conditions, during which O2 saturation was monitored by pulse oximeter; electrocardiogram, blood pressure and symptoms were also monitored. O2 saturation of < 85% (PaO2 50 mm Hg) was considered a positive test. In the 8 cases (17%) with a positive test, 5 had chronic obstructive pulmonary disease and 3 had cardiovascular and/or combined heart-lung disease. We calculated predicted O2 partial pressure in altitude (PaO2ALT) and compared it to actual results in the 8 patients with a positive HIT. In 5, use of the predicted formula would have under-diagnosed the hypoxemia that developed during the HIT. Thus, the results of the HIT changed treatment strategy in these patients. We recommend that patients with positive tests use O2 (2LPM or 4LPM) during flight. HIT is practical and of potential benefit in the objective assessment of patients with various degrees of heart, lung or combined heart-lung disease. Clinicians should be aware of the relative risk of hypoxia during flight in such patients, and of the value of HIT in identifying them, leading to increase in its use.
Brachytherapy is especially suitable for palliative treatment of endobronchial tumors adjacent to internal organs that might be damaged by intensive external beam radiation, but are easily accessed with a flexible bronchoscope. This treatment is mostly palliative. 30 patients underwent such palliative high-dose endobronchial brachytherapy to alleviate malignant airway obstruction. With the aid of a flexible fiberoptic bronchoscope an endobronchial catheter was inserted adjacent to the tumor and treatment delivered using a 192Ir remote afterloader for 5-10 min, in 2 or 3 sessions. There was symptomatic improvement in 26 (86%) and objective improvement in 27 (90%). 1 patient died of hemoptysis.
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The usual haemodynamic response to fibreoptic bronchoscopy is an increase in heart rate and blood pressure. We therefore compared, in a prospective, randomised, double-blind study, the effect of two doses of oral clonidine premedication (150 microg or 300 microg) with placebo (control group) on the haemodynamic alterations in 62 patients who underwent elective fibreoptic bronchoscopy. Significant increases in blood pressure and heart rate were observed during fibreoptic bronchoscopy only in the control group. Clonidine 150 microg blunted the haemodynamic response to fibreoptic bronchoscopy (p < 0.05). Significant decreases in systolic blood pressure (< 90 mmHg) were observed in all patients premedicated with 300 microg clonidine. Throughout the study nine patients (75%) in the 300 microg clonidine group were treated at least once for hypotension. Compared with the control group, time to awakening was significantly longer only in patients premedicated with 300 microg clonidine. In conclusion, premedication with 150 microg oral clonidine attenuates haemodynamic responses to fibreoptic bronchoscopy, without causing excessive haemodynamic depression and sedation. These data encourage the administration of clonidine as premedication in patients undergoing fibreoptic bronchoscopy, particularly in those with, or at risk for, coronary artery disease.
OBJECTIVE: To investigate the effect of ventilation with 100% oxygen on lung injury associated with surgery involving cardiopulmonary bypass (CPB). DESIGN: A prospective randomized study. SETTING: University hospital. PARTICIPANTS: Thirty patients undergoing coronary artery bypass graft surgery with CPB. INTERVENTIONS: Patients were randomized to receive 100% oxygen (Oxygen group) or 50% oxygen (Air group) throughout surgery. During CPB, patients' lungs in the Air group were flushed with air and in the Oxygen group with 100% oxygen. MEASUREMENTS AND MAIN RESULTS: Lung injury was evaluated by arterial oxygen tension-inspired oxygen concentration (PaO2-FIO2) ratio and cytokine levels (tumor necrosis factor-alpha and interleukin-8) in blood and bronchoalveolar lavage fluid measured before and after CPB. The lowest PaO2-FIO2 value was observed after 40 minutes following the completion of CPB in both groups. PaO2-FIO2 values 6 hours after CPB were not different from baseline in the Air group but remained lower (359+/-63 mmHg and 298+/-78 mmHg; p = 0.013) in the Oxygen group. Blood cytokine levels rose during surgery in both groups. Bronchoalveolar lavage levels of interleukin-8 did not change, whereas tumor necrosis factor-alpha increased only in the Oxygen group (p = 0.035). CONCLUSIONS: A significant decrease of oxygenation was observed in the early post-CPB period in both groups of patients, with delay in recovery in patients treated with 100% oxygen. A larger increase of the proinflammatory cytokines was found in patients treated with 100% oxygen. High oxygen concentrations during surgery with CPB should be used only when specifically required.
Pulmonary calcification is a common asymptomatic finding, usually discovered on routine chest X-ray or at autopsy. Pulmonary calcifications are caused mainly by two mechanisms: the dystrophic form and the metastatic form (1). Despite the different aetiologies, the pulmonary function and clinical manifestations are quite similar in both forms. We present a review of the clinical and radiology findings of the different aspects of pulmonary calcifications according to its pathogenesis and its anatomic distribution: parenchymal, lymphe node and pleural.
Bronchoscopy is a procedure that is likely to provoke anxiety as the patient is surrounded by monitoring and bronchoscopy equipment, and care is administered by strangers who perform intimate, invasive, and sometimes, painful procedures. Sedation is needed, therefore, to allay anxiety and reduce stress, improve patient comfort and co-operation, provide amnesia and facilitate the bronchoscopic procedure. In this review we try to summarize the current knowledge on currently used sedation protocols with special reference to the commonly used pharmacological agents. We believe sedation should be used routinely in fiberoptic bronchoscopy in order to achieve a safe and pleasant procedure for both the patient and the pulmonologist.
BACKGROUND: Chemical pleurodesis is an effective treatment for malignant pleural effusion and pneumothorax. This mode of therapy is, however, less widely accepted in the treatment of patients with refractory benign or undiagnosed pleural effusion. STUDY OBJECTIVES: To analyze the outcome of talc slurry pleurodesis in patients with nonmalignant pleural effusions. DESIGN: Retrospective and partly prospective analysis of clinical outcome. SETTING: Hadassah University Hospital, Jerusalem, Israel. PATIENTS AND PARTICIPANTS: Between 1992 and 1997, we treated 16 patients with nonmalignant pleural effusion using talc slurry pleurodesis. The cause of effusion was congestive heart failure in 6 patients, liver cirrhosis in 4 patients, yellow nail syndrome in 1 patient, systemic lupus erythematosus in 1 patient, chylothorax in 1 patient, and undiagnosed in 3 patients. INTERVENTIONS: Nine patients were hospitalized, and seven patients received treatment in a day-care setting. Follow-up ranged from 2 months to 3 years. RESULTS: Complete success was observed in 12 cases (75%), partial success in 3 cases (19%), and pleurodesis was ineffectual in 1 case (6%). There were no significant complications after the procedure in any of our patients. A review of the English-language medical literature revealed an additional 110 reported cases of nonmalignant pleural effusion that were treated with chemical pleurodesis. Of these cases, talc was used in 65% with a success rate of nearly 100%. CONCLUSIONS: Chemical pleurodesis, and specifically talc slurry, is an effective treatment for recurrent benign or undiagnosed pleural effusion. This procedure is safe and easily performed and, in selected cases, can be performed in an outpatient day-care setting.
UNLABELLED: The objective of this study was to evaluate the role of quantitative perfusion lung scintigraphy (QPLS) in predicting the development of chronic rejection in patients who underwent single-lung transplantation. METHODS: Eighteen patients (15 men, 3 women; age range, 41-60 y; mean age, 54.6+/-6.0 y) who underwent single-lung transplantation for emphysema (n = 14) or pulmonary fibrosis (n = 4) were studied. Patients were evaluated using QPLS and pulmonary function tests before surgery and at 1-3 mo and 1-3 y after transplantation. Relative perfusion of the transplanted lung was calculated from standard perfusion lung scintigrams. Values for forced expiratory volume in the first second (FEV1) were obtained from lung function tests at the same time points. The maximal and minimal relative perfusion and FEV1 values in the early (1-3 mo) and late (1-3 y) follow-up periods were identified for each patient. Receiver operating curve (ROC) analysis was performed on all parameters. RESULTS: In total, 82 lung scans were performed (mean, 4.8+/-1.55 per patient) and 484 FEV1 test determinations were obtained (mean, 30.0+/-15.6 per patient) during a follow-up period ranging from 8 to 84 mo (mean, 39.6+/-19.3 mo). In 7 of the 18 patients, chronic rejection developed, whereas 11 patients had a favorable outcome. No significant difference was found in the number of complications (acute rejection and infection episodes) between patients with a favorable outcome and patients with chronic rejection, up to 1 y after transplantation. At 1-3 mo, minimal relative perfusion values were 67.1%+/-12.2% in the favorable outcome group and 50.8%+/-9.6% in the chronic rejection group (P = 0.02). Before surgery and at 1-3 y, minimal relative perfusion was not significantly different between the 2 groups. The difference in maximal relative perfusion at 1-3 y was marginally significant, with 76.5%+/-8.9% in the favorable group and 64.3%+/-15.0% in the chronic rejection group (P = 0.051). FEV1 values were not significantly different preoperatively and 1-3 mo after surgery between the chronic rejection and the favorable outcome groups. Late in the follow-up period (1-3 y), FEV1 values in the chronic rejection and favorable outcome groups were 35.6%+/-7.9% and 56.9%+/-13.6%, respectively (P = 0.002). ROC analysis of minimal relative perfusion at 1-3 mo identified a threshold of 57% under which the sensitivity and specificity for chronic rejection were 83% and 88%, respectively. Minimal FEV1 for the same period identified a threshold of 48% under which the sensitivity and the specificity were 80% and 67%, respectively. CONCLUSION: QPLS early after transplantation in our patients predicted the development of chronic rejection in patients with single-lung transplantation for emphysema and pulmonary fibrosis, whereas surgical complications, acute rejection, infection episodes, and lung function tests did not predict the outcome. This early prediction could not be obtained from lung function tests performed at the same time.
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Cutaneous T-cell lymphomas (CTCL) are diseases characterized by cutaneous infiltrates of malignant clonally expanded T cells. CTCL cells exhibit a cytokine profile consistent with T helper-2 type (TH2) cells. Eosinophilic pneumonias are individual syndromes characterized by eosinophilic pulmonary infiltrates and commonly peripheral blood eosinophilia. CTCL and chronic eosinophilic pneumonia are rare clinical entities. We report a patient with the association of CTCL and chronic eosinophilic pneumonia. To understand the mechanism leading to the eosinophilia, we examined the patient's cytokine profile. This was consistent with a high TH2 activity. Her interleukin (IL) 5, 6, and 10 levels were extremely high, while her IL-2 and interferon-gamma (IFN-gamma) levels (TH1 profile) were low. We believe that eosinophilic pneumonia in this patient is probably secondary to high TH2 cytokine levels induced by tumor cells. We suggest that eosinophilic pneumonia should be considered as a possible diagnosis in patients with CTCL who have respiratory complaints.
Organ transplantation is currently the standard therapy for patients with end-stage organ dysfunction. The immunosuppression caused by this therapy increases the rate of infection, particularly in the lungs. Early diagnosis is extremely important and fibre-optic bronchoscopy is a helpful tool in reaching diagnosis. Knowing the timing of various pathogens following transplantation, and the radiological picture as well as the prophylactic regimen, is helpful when specific pathogens are suspected. Bronchoscopy with bronchoalveolar lavage and transbronchial biopsies are particularly helpful in diagnosis of bacterial cytomegalovirus (CMV) and pneumocytosis carinii pneumocytosis, and is considered a safe procedure. Open lung biopsy is reserved for those who have negative bronchoscopy with a reasonable prognosis.
Neurofibromatosis has been known to involve blood vessels throughout the body. Pulmonary involvement with interstitial fibrosing alveolitis has been described but no case of pulmonary vascular involvement has been reported to date. A 51 year old patient with cutaneous neurofibromatosis is described who presented with severe pulmonary hypertension and radiographic, scintigraphic, and angiographic evidence of chronic thromboembolic pulmonary hypertension. Severe intimal fibrosis consistent with vascular involvement with neurofibromatosis was found on endarterectomy with no evidence of pulmonary thromboembolism. Neurofibromatosis of pulmonary arteries should be considered as a possible cause of pulmonary hypertension.
BACKGROUND: The rates of morbidity and mortality associated with lung abscess are still significant despite the introduction of antibiotic treatments. The aim of this work was to identify the factors that predict a poor outcome for patients with lung abscess. METHODS: We retrospectively reviewed the records and the roentgenographic files of adult patients with lung abscess who were hospitalized from 1980 to 1996 at the Hadassah University Hospital, in Jerusalem, Israel. RESULTS: The study population comprised 75 patients, and the mean age was 52 years old (range, 12 to 89 years). The mean (+/- SD) hospitalization duration was 25.7+/-21.5 days (range, 5 to 94 days). Fifteen patients (20%) succumbed to the infection. The patients who died had more predisposing factors (+/-SD), such as pneumonia, neoplasm, and altered consciousness, than those who survived, respectively: 2.73+/-1.4 vs 1.9+/-1.3 (p < 0.03). The patients with anemia on admission (hemoglobin levels of < 10 g/dL) had a higher mortality rate than those with higher hemoglobin levels, respectively: 58.3 vs 12.9% (p = 0.0008). A higher mortality rate was also associated with infection by Pseudomonas aeruginosa (83%), Staphylococcus aureus (50%), and Klebsiella pneumoniae (44%). The patients who died had larger abscess volumes (+/-SD) than those who survived (233+/-99 vs 157+/-33 mL), although it did not reach statistical significance. The diameter of the abscess correlated with the hospitalization time (r = 0.5; p < 0.001). CONCLUSION: High rates of morbidity and mortality are associated with lung abscess despite appropriate antibiotic therapy and better supportive care. In patients with several predisposing factors, such as a large abscess size and a right-lower-lobe location, the prognosis was worse. The patients infected with S aureus, K pneumoniae, and particularly P aeruginosa had an ominous prognosis. As the prognosis for lung abscess has not improved sufficiently since the introduction of antibiotics, other modalities should be considered for patients with poor prognostic signs.
A 63-year-old woman with metastatic breast cancer was referred to our bronchoscopy unit for outpatient laser resection of an endobronchial mass through fiberoptic bronchoscopy. The patient had no history of ischemic heart disease. During the procedure, the patient developed an ST-segment elevation and a complete atrioventricular block. IV nitroglycerin and morphine were effective in treating this episode. In this patient, we were able to demonstrate a focal spasm by postbronchoscopy coronary angiography.