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Biomedical subjects

M R Kramer

Publications and source records attributed to M R Kramer.

At least 91 records · Page 5Linked to original sources
PubMed1994

Nocardiosis in 30 patients with advanced human immunodeficiency virus infection: clinical features and outcome.

A total of 30 patients (aged 6-56 years) with nocardiosis and infection due to human immunodeficiency virus type 1 (HIV-1) were identified in our institution between January 1985 and June 1989. Eighteen patients had an AIDS-defining illness before or concurrently with nocardiosis. The mean CD4 lymphocyte count was 109/mm3. Pulmonary nocardiosis in 21 patients, extra-pulmonary nocardiosis in 8, and pulmonary and extrapulmonary nocardiosis in 1 patient was diagnosed. Chest radiographs showed alveolar patterns of infiltrates in 14 patients, reticulonodular patterns in 2, mixed alveolar and reticulonodular patterns in 6, cavitation in 4, and pleural effusion in 3. Of 27 patients treated, the conditions of 22 improved, but the extensive disease in 5 progressed. For 14 patients, recurrence was rapid after their treatment was discontinued. Nocardiosis caused or contributed to the death of 19 patients; in six patients, there was no evidence of nocardial infection at death. Nocardiosis can be a fatal complication of advanced HIV-1 disease. Delayed diagnosis, extensive disease, and early discontinuation of treatment were associated with poor outcome.

AIDS-Related Opportunistic Infections↗
PubMed1993

Infectious complications in heart-lung transplantation. Analysis of 200 episodes.

BACKGROUND: Infection remains an important cause of morbidity and mortality in heart-lung transplant recipients. This study was designed to assess the frequency, type, and timing of infection in heart-lung transplant recipients. METHODS: A retrospective analysis of 200 episodes of serious infections occurring in 73 heart-lung recipients at Stanford (Calif) University Medical Center between 1981 and 1990. RESULTS: Bacterial infections accounted for half of all infections, with the highest incidence in the first month after transplantation. Fungal infections (14%) were also common in the first month. Cytomegalovirus was the most common viral agent (15%), occurring primarily in the second month after transplantation. Other viruses (herpes simplex, adenovirus, and respiratory syncytial virus) accounted for a further 15% of total infections. Pneumocystis carinii infections were common 4 to 6 months after transplantation, and Nocardia typically infected recipients later than 1 year after transplantation. There was no significant difference in incidence of infections between patients receiving triple (cyclosporine, prednisone, immuran) or double (cyclosporine and prednisone) immunosuppression therapy. Mortality due to infection accounted for 40% of all deaths. CONCLUSIONS: Knowledge of the incidence and timing of infection should help in the prevention, early detection, and initiation of therapy in these patients.

Cause of Death↗
PubMed1993

Acute gastric dilatation causing respiratory failure and "tension pneumothorax" in an elderly women with a diaphragmatic hernia.

The occurrence of respiratory failure as a result of a large diaphragmatic hernia is a well-described entity in infants with congenital hernias. On reviewing the literature, the authors did not find a similar clinical presentation in the adult population. They report the case of an elderly patient with a large hiatus hernia who developed recurrent episodes of life-threatening respiratory failure and hemodynamic compromise due to recurrent gastric dilatation. Decompression with nasogastric suction resulted in dramatic and immediate relief of the respiratory distress. One should keep in mind the possibility of intrathoracic gastric dilatation as a cause of acute respiratory insufficiency in patients with hiatal hernia.

Acute Disease↗
PubMed1993

Radiation-induced pulmonary veno-occlusive disease.

Late occurrence of radiation-induced pulmonary pneumonitis and fibrosis is well documented. We report an unusual case of radiation induced veno-occlusive disease (VOD) occurring six years following mantle irradiation for Hodgkin's lymphoma. The patient developed severe pulmonary hypertension and cor pulmonale. A left lung transplantation was performed successfully and pathologic examination of the explanted lung showed severe changes compatible with VOD. In the absence of exposure to alternate therapeutic or toxic agents that may cause VOD, it is likely that radiation caused damage to the venular endothelium and caused progressive obliteration of the pulmonary vessels. Review of the literature reveals only a few similar reports of VOD mostly following radiation for bone marrow transplantation. We conclude that previous irradiation (even several years earlier) should be considered as a possible cause of pulmonary VOD.

Adult↗
PubMed1993

Continuous therapy with intravenous prostacyclin for primary pulmonary hypertension: a bridge to heart-lung transplantation.

Primary pulmonary hypertension (PPH) continues to be a major problem. Vasodilator therapy has been of variable success in selected patients. Recently, with the introduction of prostacyclin (Prostaglandin I2, epoprostenon) as a potent vasodilator, several reports have shown a positive effect in primary pulmonary hypertension. We report here two patients with PPH who responded favorably to continuous intravenous therapy with prostacyclin. Both patients responded with a reduction in pulmonary vascular resistance, increase in cardiac output and dramatic improvement of right heart failure. Although therapy with prostacyclin is extremely expensive it may be used as a bridge to heart-lung transplantation in patients with end-stage PPH who do not respond adequately to alternative therapy.

Adult↗
PubMed1992

[Brachytherapy: endobronchial irradiation for primary and secondary bronchial tumors].

Intrabronchial obstruction is one of the serious complications of primary and secondary lung tumors. Brachytherapy (intraluminal irradiation) aims at palliation and opening airway obstruction. Of our first 10 patients, 4 had primary and 6 metastatic pulmonary lesions. Brachytherapy was administered through the fiberoptic bronchoscope under topical anesthesia from a 192iridium source delivered with an afterload system. In 3 patients laser therapy was used initially. In 6 complete opening of the airway was achieved, and in 3 others partial opening. In all patients there was symptomatic relief without significant side-effects. We conclude that endobronchial brachytherapy is a safe, useful procedure for palliation of malignant endobronchial obstruction.

Adult↗
PubMed1992

Trimethoprim-sulfamethoxazole prophylaxis for Pneumocystis carinii infections in heart-lung and lung transplantation--how effective and for how long?

Pneumocystis carinii pneumonia (PCP) is a common clinical problem in the setting of organ transplantation, particularly in heart-lung and lung allograft recipients. Without prophylactic measurements, the incidence of P carinii pneumonia can reach up to 88% of heart-lung transplant recipients. We conducted a retrospective analysis of the Stanford heart-lung and lung transplant experience in order to assess the efficacy of the prophylactic therapy and to try to define the duration of therapy necessary for prevention. During a 9-year period 82 heart-lung and 13 single-lung transplants were performed. Of the patients not on prophylaxis therapy 27% (13 patients) developed P carinii infection as compared with 0% of patients on trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis. The incidence of PCP infection peaked between 3 and 6 months posttransplantation. No case of infection was observed before the 7th week posttransplant. PCP was more common following induction immunosuppression with OKT3 as compared with RATG (P less than 0.05). All cases of infections later than one year posttransplant were associated with recent increase in the immunosuppression regimen with high-dose corticosteroids for treatment of acute or chronic (obliterative bronchiolitis) rejection. Although our study is retrospective and based on various immunosuppressive and diagnostic technique periods, it seems that TMP-SMX is highly effective in preventing PCP infections in heart-lung and lung transplant recipients. Twelve months of therapy is probably a sufficient length of therapy if immunosuppressive therapy is stable. However, whenever augmentation in the immunosuppression regimen is indicated, prophylactic therapy should promptly be restarted.

Adrenal Cortex Hormones↗
PubMed1991

Sudden unexpected death in persons less than 40 years of age.

This study retrospectively assesses the underlying causes of sudden unexpected death and the occurrence of prodromal symptoms in 162 subjects (aged 9 to 39 years) over a 10-year period (1976 to 1985). Underlying cardiac diseases accounted for sudden death in 73% and noncardiac causes in 15% of subjects. In 12% of subjects, the causes were unidentifiable. Myocarditis (22%), hypertrophic cardiomyopathy (22%) and conduction system abnormalities (13%) were the major causes in 32 subjects aged less than 20 years. Major causes of 46 deaths in subjects 20 to 29 years were atherosclerotic coronary artery disease (24%), myocarditis (22%) and hypertrophic cardiomyopathy (13%). The largest number of deaths in 84 subjects aged greater than or equal to 30 years was attributed to coronary artery disease (58%), followed by myocarditis (11%). Among noncardiac causes of sudden death, intracranial hemorrhage was the most frequent (5%), followed by infectious disease (4%). Prodromal symptoms were reported by 54% of subjects; most frequent were chest pain (25%) in subjects aged greater than or equal to 20 years, and dizziness (16%) in those aged less than 20. Sudden death, which occurred during routine daily activity in 49% and during sleep in 23% of subjects, was related to physical exercise in 23% and emotional upset in 6%. Sudden unexpected death in the young is still an unresolved medical problem. The early recognition of prodromal symptoms could be crucial in the prevention of sudden death, specifically when exercise-related.

Adult↗
PubMed1991

Effects of pulmonary restriction on hypercapnic responses of heart-lung transplant recipients.

Previous studies of hypercapnic ventilatory responses (HCVR) in human heart-lung transplant recipients (HLTX) have yielded conflicting results. We compared the HCVR of restricted transplant recipients (HLTX-R) to recipients with normal pulmonary function (HLTX-N), and normal controls (C). HLTX-R exhibited limited tidal volume responses, whereas their frequency responses were essentially identical to those of other subjects. Accordingly, HCVR of HLTX-R (1.45 +/- 0.59 l.min-1.Torr CO2(-1)) were significantly depressed compared with both HLTX-N and C (2.90 +/- 0.55 vs 3.05 +/- 1.23, respectively) (P less than 0.02). Despite undoubtedly greater ventilatory impedances, airway (mouth) occlusion pressure responses (Pm0.1) during hypercarbia of HLTX-R (0.46 +/- 0.28 cmH2O) were similar to those of C (0.43 +/- 0.20) and paradoxically blunted compared with HLTX-N (0.83 +/- 0.36) (P less than 0.02). We conclude that pulmonary reflexes are superfluous for maintenance of HCVR in HLTX with normal respiratory mechanics, whereas the presence of moderate restriction results in profound depression of CO2 responses among these subjects.

Adult↗
PubMed1991

Ulcerative tracheobronchitis after lung transplantation. A new form of invasive aspergillosis.

Invasive aspergillosis is frequently a fatal disease in the setting of immunosuppression, including organ transplant recipients. The fungus usually affects lung parenchyma and may disseminate from there. We have recently noted tracheobronchitis in six patients with heart-lung and lung transplants, three of whom had deep mucosal ulceration and histologic evidence of invasive aspergillosis. This apparently new form of invasive disease is initially limited to the anastomosis site and large airways. Ulceration, necrosis, cartilage invasion, and formation of a pseudomembrane are the pathologic features. In two patients subsequent disseminated aspergillosis occurred with a fatal outcome. In the two single-lung recipients, disease was limited to the transplanted side emphasizing the importance of abnormal local defense mechanisms in the airways of lung transplant recipients. Routine bronchoscopic examination of the airways is important in early detection of this complication. Oral therapy with the new, antifungal agent itraconazole was successful in five of the six patients, with fatal relapse in one. A classification of the various forms of saprophytic, allergic, and invasive forms of aspergillus tracheobronchitis, to include this new entity, is proposed.

Adult↗