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Biomedical subjects

Mordechai R Kramer

Publications and source records attributed to Mordechai R Kramer.

At least 19 recordsLinked to original sources
PubMed2006

Association of elevated levels of vascular endothelial growth factor in obstructive sleep apnea syndrome with patient age rather than with obstructive sleep apnea syndrome severity.

BACKGROUND: Although certain studies report high levels of vascular endothelial growth factor (VEGF) in obstructive sleep apnea syndrome (OSAS), the effect of systemic hypoxia on circulating VEGF remains controversial. OBJECTIVES: To study the association of serum VEGF and OSAS in a large group of patients. METHODS: One hundred patients with OSAS (mean age 58.1+/-12.4 years, mean body mass index 30.6+/-5.4 kg/m2) were tested for serum VEGF levels, and the findings were correlated with the severity of OSAS, as determined by the apnea-hypopnea index (AHI) on the basis of polysomnography and background data. RESULTS: The mean AHI was 40.0+/-21.2 (range 10-106). Mean minimal oxygen saturation was 80.6+/-11.7% (range 43-98%) and mean time of oxygen saturation under 90% was 50.0+/-75.0 min (range 0-300 min). The mean VEGF level was 445.2+/-289.8 pg/ml in the study group (vs. 280 pg/ml reported in normal controls). The mean platelet count was 233.8+/-64.4 10(3)/ml and the mean VEGF/platelet ratio was 1.95+/-1.40 pg/10(6). There was no association of VEGF or VEGF/platelets with the severity of OSAS. However, both factors showed a significant correlation with patient age (r=0.224, p=0.01 and r=0.425, p=0.01, respectively). Age was the only parameter to significantly predict VEGF and VEGF/platelets on multivariate analysis (R2=0.713, p=0.001 and R2=0.844, p=0.001, respectively). CONCLUSION: The elevation of serum VEGF in OSAS is not associated with the severity of the disease, but it is associated with patient age. VEGF might be involved in the long-term adaptive mechanism in OSAS, and its age-dependent increase might partly explain the reduced mortality in elderly OSAS patients.

Adult↗
PubMed2006

Right upper lobe 'window' in right main bronchus stenting.

Stent insertion for bronchial stenosis has become common practice in lung transplantation and advanced lung malignancy, and for external compression of the airways for other reasons. Right main bronchus stenting may require blocking the right upper lobe by the stent, placing the patient at risk of recurrent pneumonia and atelectasis. In this study, three patients after insertion of a metal stent to the right main bronchus are described. In all cases, the right upper lobe was covered by the stent, and a laser (Nd:YAG) procedure was used to open a 'window' in the stent toward the right upper lobe with a follow-up of 1 year. We conclude that stent insertion to the right main bronchus may be followed by a laser therapy to open a 'window' toward the right upper lobe.

Bronchi↗
PubMed2006

Inspiratory muscles experience fatigue faster than the calf muscles during treadmill marching.

The possibility that respiratory muscles may fatigue during extreme physical activity and thereby become a limiting factor leading to exhaustion is debated in the literature. The aim of this study was to determine whether treadmill marching exercise induces respiratory muscle fatigue, and to compare the extent and rate of respiratory muscle fatigue to those of the calf musculature. To identify muscle fatigue, surface electromyographic (EMG) signals of the inspiratory (sternomastoid, external intercostals), expiratory (rectus abdominis and external oblique) and calf (gastrocnemius lateralis) muscles were measured during a treadmill march of 2 km at a constant velocity of 8 km/h. The extent of fatigue was assessed by determining the increase in root-mean-square (RMS) of EMG over time, and the rate of fatigue was assessed from the slope of the EMG RMS versus time curve. Results indicated that (i) the inspiratory and calf muscles are the ones experiencing the most dominant fatigue during treadmill marching, (ii) the rate of fatigue of each muscle group was monotonic between the initial and terminal phases of exercise, and (iii) the inspiratory muscles fatigue significantly faster than the calf at the terminal phase of exercise, and are likely to fatigue faster during the initial exercise as well. Accordingly, this study supports the hypothesis that fatigue of the inspiratory muscles may be a limiting factor during exercise.

Adult↗
PubMed2006

Intravitreal voriconazole for the treatment of endogenous Aspergillus endophthalmitis.

OBJECTIVE: To describe the first use of intravitreal voriconazole in a human eye for the treatment of Aspergillus endophthalmitis. DESIGN: Interventional case report. PATIENT: A 22-year-old woman receiving immunosuppressive agents 5 weeks after lung transplantation who presented with blurred vision and redness in the right eye. INTERVENTIONS: Intravitreal injection of voriconazole (100 microg/0.1 ml) with pars plana vitrectomy, given after isolation of A. terreus in the vitreous sample. Previous treatment modalities, including vitrectomy with repeated intravitreal amphotericin B and systemic voriconazole, failed to prevent deterioration. MAIN OUTCOME MEASURES: Visual acuity (VA) and ocular inflammation. RESULTS: Significant improvement was observed in VA (to 6/15) and in ocular inflammatory reaction. The patient recovered with no evidence of systemic fungal infection. CONCLUSION: Intravitreal voriconazole may be used as an adjunct to systemic treatment in patients with Aspergillus endophthalmitis. Further clinical studies are needed to determine how often this approach can safely treat this condition.

Adult↗
PubMed2006

Mechanics of respiratory muscles in single-lung transplant recipients.

BACKGROUND: Emphysema and pulmonary fibrosis force the patients to breathe at an abnormal lung volume, which alters the lengths of the respiratory muscles and thereby their work capability is reduced. After single-lung transplantation, muscle function is restored on the side of the transplant but it may be asymmetric to that on the side of the native diseased lung. OBJECTIVE: Investigating the hypothesis that single-lung transplantation induces mechanical asymmetry of the respiratory muscles on the two sides. METHODS: Simultaneously noninvasive measurements of inspiratory and expiratory mouth pressure, airflow rate and electromyography signals from the sternomastoid, external intercostal, rectus abdominis and external oblique muscles were acquired during different breathing maneuvers. The study group included 10 single-lung transplant recipients (5 with pulmonary fibrosis and 5 with emphysema) and 10 healthy controls. RESULTS: Analysis of the finding shows a significant lower global strength of the respiratory muscles of single-lung transplant recipients compared to that of healthy subjects. No significant difference in the EMG signals of respiratory muscles was found either between the different groups or between the sides of the transplant and the native lung in the patient groups. Both single-lung transplant recipients and healthy subjects demonstrated high EMG activity of the inspiratory muscles during inspiration at different breathing efforts. CONCLUSION: Patients after single-lung transplantation have lower respiratory muscle strength than healthy subjects, but apparently normal electrical activity. The lower global respiratory muscle strength emphasizes the importance of their rehabilitation before and after single-lung transplantation.

Adult↗
PubMed2006

Development of malignancy following lung transplantation.

BACKGROUND: A substantial excess risk of certain malignancies has been demonstrated after organ transplantation. Immunosuppressive treatment to prevent allograft rejection is probably the main cause. METHODS: We reviewed retrospectively all medical records of the 121 patients that underwent lung and heart-lung transplantation from 1992 until December 2004. We compared our results to the International Society for Heart and Lung Transplantation (ISHLT) registry data and previous reports concerning lung transplantation. RESULTS: 102 of the 121 patients survived for 3 months to 12 years. Malignancies developed in 16 patients, as follows: lymphoproliferative disorder in 3, Kaposi's sarcoma in 3, other nonmelanoma skin cancers in 7, urinary bladder transitional cel carcinoma in 3, and colon cancer in 1. Patients with malignancy were older at transplantation than those without (mean +/- SD, 54.1+/-7.8 vs. 49.5+/-14.2 years; P=0.03). Fourteen had smoked in the past. Four died of bronchiolitis obliterans. In comparison with the ISHLT, we observed more skin cancer and transitional cell carcinoma (12.8% vs. 0.7% and 3.8% vs. 0.03%, respectively) and a similar frequency of posttransplant lymphoproliferative disease. CONCLUSIONS: We conclude that malignancy is a common complication after lung transplantation. In Israel, which is sunny most of the year, skin cancers and transitional cell carcinoma of bladder are more common. Modification of the immunosuppression late posttransplantation may reduce the risk of cancer. Patients should also be counseled to avoid sun exposure and ensure adequate hydration.

Adult↗
PubMed2006

Two successful lung transplantations from a dialysis-dependent donor.

The shortage of organs for lung transplantation has led to the growing use of "marginal" donors. Although patients on hemodialysis are still excluded as lung transplant donors because of the possible effects of renal failure on the lungs, recent data suggest that they may be suitable in selected cases. This article describes the successful transplantation of two lungs from a single donor who had been receiving long-term hemodialysis treatment. In the absence of other causes of pulmonary diseases, such as smoking or lung infection, lungs from dialysis-dependent patients may be acceptable for lung transplantation.

Female↗
PubMed2006

Echocardiography versus right-sided heart catheterization among lung transplantation candidates.

BACKGROUND: Right-heart-catheterization and transthoracic echocardiography are routine tests to measure pulmonary artery systolic pressure among lung transplantation candidates. Echocardiography may be as accurate as right-heart-catheterization, without the inherent risks of an invasive test. METHODS: We examined the correlation between pulmonary pressures estimated by echocardiography versus right-heart-catheterization among lung transplantation candidates and their correlation to measurements during lung transplantation. Our cohort included all lung transplantation candidates during 1997 through 2004 who initially underwent pulmonary pressure evaluation by right-heart-catheterization and echocardiography, as well as measurements during lung transplantation. RESULTS: Of the 106 candidates, evaluation by transthoracic echocardiography was possible in 79 (74.5%). Median pulmonary systolic pressures by right-heart-catheterization was 44.0 [33.2-50.0] mm Hg and by echocardiography 40.0 [32.5-51.5] mm Hg (r = 0.80, p < 0.0001). In 14 (17.7%) patients the difference between the 2 methods was > 20 mm Hg. The median time interval between echocardiography and right-heart-catheterization was 65 [40-155] days. The median value of pulmonary systolic pressure measured during lung transplantation in 44 (70.1%) of 62 patients was 39.5 [31.0-50.0] mm Hg. The time interval right-heart-catheterization-to-lung transplantation was 143 [87-339] days and echocardiography-to-lung transplantation 229 [130-367] days. The correlation between measurements during lung transplantation and initial measurements by right-heart-catheterization and echocardiography were r = 0.50 and r = 0.31, respectively, with corresponding p values of p = 0.001 and p = 0.07. CONCLUSIONS: For lung transplantation candidates and a suitable transthoracic echocardiography estimate of pulmonary systolic pressure, the need for right-heart catheterization, with its inherent risks for complications, may be foregone. The weak correlation between the initial and intraoperative measurements, probably stemming from the significant time interval, suggests that serial measurements may be needed.

Cardiac Catheterization↗
PubMed2006

Lamivudine prophylaxis for hepatitis B virus infection after lung transplantation.

BACKGROUND: Several reports have shown the efficacy of prophylactic lamivudine treatment for hepatitis B virus (HBV) infection in liver and renal transplantations. No data are available, however, after lung transplantation. We report our experience with prophylactic lamivudine treatment in lung transplant recipients with HBV infection or when the donor was HBc antibody positive. METHODS: All our 120 lung transplant recipients and their donors were routinely screened for HBV markers. All recipients who tested positive for hepatitis B surface antigen and negative for HBV-DNA, or had organs from donors who tested positive for hepatitis B core antibody, were treated prophylactically with lamivudine for 12 months after lung transplantation. Patients whose liver functions became abnormal during follow-up were tested for HBV serology and HBV-DNA. RESULTS: Eleven of 120 lung transplant recipients (9.2%) were treated with prophylaxis lamivudine. Four recipients were hepatitis B surface antigen positive, and 7 recipients received organs from donors positive for HBc antibodies. Median follow-up after treatment was 24 months. All patients had normal alanine transaminase and undetectable levels of HBV-DNA before treatment. No side effects of lamivudine therapy were reported by any of the patients. Reactivation with alanine transaminase elevation and high HBV-DNA levels occurred in 2 patients. Both of them were recipients positive for hepatitis B surface antigen. In the first patient, lamivudine-resistant strain was detected and adefovir dipivoxil was started. In the other, reactivation developed 2 months after the end of lamivudine treatment. Lamivudine treatment was resumed, with rapid normalization of the HBV-DNA. CONCLUSIONS: Use of lamivudine is considered safe for suppressing HBV infection after lung transplantation.

Adolescent↗
PubMed2006

Increased thromboembolic events after lung transplantation.

BACKGROUND: Lung transplantation is a good therapeutic option for end-stage lung disease. Data on thromboembolic complications following lung transplantation are scarce. STUDY OBJECTIVES: To evaluate the incidence of thromboembolic events following lung transplantation, and to determine their possible association with hypercoagulable state. DESIGN: Retrospective study in a single, tertiary-care, university-affiliated referral center. SUBJECTS AND METHOD: The records of 70 patients who underwent lung transplantation in our institution between September 1997 and September 2003 were reviewed for thromboembolic complications. Parameters pertaining to risk of thrombophilia were measured in the patients with thromboembolic complications. RESULTS: Thromboembolic complications developed in 6 of the 70 patients (8.6%) at 4 to 24 months after transplantation: deep vein thrombosis (DVT) in 2 patients, pulmonary embolism (PE) in 1 patient, both DVT and PE in 1 patient, and retinal vein thrombosis in 2 patients. The fibrinogen level was elevated in all six patients, and factor VIII, IX, and/or XI levels were elevated in five patients. Heterozygosity for 5 10-methylene tetrahydrofolate reductase was documented in two patients, and mutation for factor II or factor V-Leiden mutation was found in one patient. Levels of protein C and protein S and activated protein C resistance were within normal range in all patients. Four patients had mildly elevated levels of at least one antiphospholipid antibody; none had a positive lupus anticoagulant test result. Overall, all patients demonstrated abnormalities on hypercoagulability tests. CONCLUSIONS: Thromboembolic complications occur at a high rate (8.6%) in lung transplant recipients and are associated with abnormalities in hypercoagulability. The cause remains unclear. Our results should prompt a high index of suspicion for these potentially fatal complications, which would lead to early diagnosis and successful treatment.

Adolescent↗
PubMed2006

Pulmonary Mycobacterium kansasii infection in Israel, 1999-2004: clinical features, drug susceptibility, and outcome.

BACKGROUND: Mycobacterium kansasii infection is one of the most common causes of nontuberculous mycobacterial lung disease in world. However, little is known about its background characteristics or drug sensitivity in nonendemic areas. DESIGN: We assessed the clinical features, radiologic findings, and drug sensitivity associated with M kansasii infection in Israel. METHODS: Patients with a culture-positive diagnosis of M kansasii infection between April 1999 and April 2004 were identified from a clinic database of tuberculosis centers. Mycobacterial cultures were performed with standard methods. Data on patient background and clinical features were collected from the medical files. RESULTS: Mean age (+/- SD) of the 56 patients was 58 +/- 18 years, and 64% were men; 59% had associated lung disease. Fifteen percent were receiving immunosuppressive medications. None had HIV infection. Systemic comorbid diseases were noted in 27%. The most common clinical presentations were chest pain, cough, hemoptysis, fever, and night sweats. Cavitation was noted only in 54%. Older patients had more noncavitary disease than younger patients (p = 0.01, r = 0.35). Lower-lobe predominance was very rare (4%). None of the patients presented with pleural effusion or lymphadenopathy. Only seven patients (11%) underwent bronchoscopy for diagnosis. M kansasii isolates showed the highest sensitivity to rifampin, ethambutol, clarithromycin, and ofloxacin, and the highest resistance to ciprofloxacin and capreomycin. The mean duration of treatment was 21 +/- 7.2 months. There were no disease-related deaths. CONCLUSIONS: M kansasii disease in Israel has no association with HIV, more systemic comorbid diseases and associated lung disease, and fewer cavitations. Following appropriate treatment, patients with M kansasii disease have an excellent prognosis.

Adult↗
PubMed2006

Is routine chest radiography after transbronchial biopsy necessary?: A prospective study of 350 cases.

BACKGROUND AND STUDY OBJECTIVE: Pneumothorax following flexible bronchoscopy (FB) with transbronchial biopsy (TBB) occurs in 1 to 6% of cases. Routine chest radiography (CXR) following TBB is therefore requested by most pulmonologists in an attempt to detect complications, particularly pneumothorax. The objective of this study was to determine if routine CXR after bronchoscopy and TBB is necessary. PATIENTS AND METHOD: The study group included 350 consecutive patients who underwent FB with TBB at our institution between December 2001 and January 2004. Routine CXR was performed up to 2 h after the procedure in all cases. Additionally, the following information was recorded in all patients: sex, age, immune status, indication for bronchoscopy, total number of biopsies done, segment sampled, pulse oxygen saturation, and development of symptoms suggestive of pneumothorax. RESULTS: Pneumothorax was diagnosed radiologically in 10 patients (2.9%). Seven patients had symptoms strongly suggestive of pneumothorax prior to CXR, including four patients with large (> 10%) pneumothorax. The other three patients were asymptomatic, with only minimal pneumothorax (</= 10%), which resolved completely 24 to 48 h later. CONCLUSIONS: We conclude that routine CXR after bronchoscopy with TBB is necessary only in patients with symptoms suggestive of pneumothorax. In asymptomatic patients, pneumothorax is rare and usually small, so routine CXR is not necessary in this category of patients.

Adult↗
PubMed2006

Pulmonary arterial hypertension associated with autoimmune disease: a single medical center experience.

BACKGROUND: New drugs have significantly improved the prognosis and quality of life of patients with pulmonary arterial hypertension. However, PAH associated with autoimmune disease, particularly progressive sclerosis, remains a very serious problem. OBJECTIVES: To evaluate whether the course of the disease and survival is significantly different in patients with PAH related to autoimmune disease as compared to other patients with PAH and to determine the prognostic factors in these patients. METHODS: We retrospectively compared 24 patients with PAH associated with autoimmune disease to 42 patients with other causes of PAH. We focused on the clinical and hemodynamic parameters and on the outcome. RESULTS: The early mortality rate was slightly higher in patients with PAH associated with autoimmune disease (13% after the first year, 25% after the fifth year). The prognostic factor was a shorter distance on the 6 minute walking distance test (r = 0.2, P= 0.01). CONCLUSIONS: The early detection of PAH associated with autoimmune disease should encourage earlier and more aggressive treatment than in idiopathic PAH.

Adult↗
PubMed2006

Lung transplantation in patients with cystic fibrosis: the Israeli experience.

BACKGROUND: Lung transplantation is a well-established therapeutic option for end-stage lung disease in cystic fibrosis. Although it confers a clear survival advantage, outcome differs among centers according to local experience, patient selection, transplantation procedure, and postoperative care. OBJECTIVES: To evaluate the national Israeli experience with lung transplantation in patients with CF. METHODS: We reviewed the medical charts of all CF patients who underwent lung transplantation between January 1996 and June 2005 at the two Israeli centers that perform this procedure. RESULTS: Eighteen transplantations were performed in 17 patients. Mean patient age at transplantation was 25.3 +/- 9.1 years, and mean duration of follow-up in survivors (n=14) was 37.2 months (range 1-113 months). The actuarial survival rate was 88% at 1 year and 74% at 5 years. Pulmonary function, expressed as percent of predicted normal forced expiratory volume in 1 sec, improved from 22.4 +/- 8.1% to 76 +/- 16.8% at one year after transplantation. Bronchiolitis obliterans syndrome was diagnosed in 5 patients (29%), of whom 2 died and 2 are currently candidates for retransplantation. Median time to onset of BOS was 34.2 months (range 17-64 months). CONCLUSION: In Israel, the early and intermediate-term results of lung transplantation for cystic fibrosis are encouraging. BOS remains a major complication that threatens long-term outcome.

Actuarial Analysis↗
PubMed2006

Assessment of functional capacity in patients with chronic obstructive pulmonary disease: correlation between cardiopulmonary exercise, 6 minute walk and 15 step exercise oximetry test.

BACKGROUND: Different exercise tests are used to evaluate the functional capacity in chronic obstructive pulmonary disease. The cardiopulmonary exercise test is considered the gold standard, but the 6 minute walk and the 15 step exercise oximetry test are considerably less expensive. OBJECTIVES: To determine whether reliable data could be obtained at lower cost. METHODS: The study sample consisted of 50 patients with mild to severe stable COPD. All underwent pulmonary function test and the cardiopulmonary exercise test, 6 minute walk and 15 step exercise oximetry test as part of their regular follow-up visit. Functional capacity was graded according to each test separately and the functional capacities obtained were correlated. RESULTS: The results showed that most of the patients had severe COPD according to pulmonary function tests (mean forced expiratory volume in the first second 46.3 +/- 19.9% of predicted value). There was a good correlation between the cardiopulmonary exercise test and the 6 minute walk functional capacity classes (r = 0.44, P = 0.0013). We did not find such correlation between the 15 step exercise oximetry test and the cardiopulmonary exercise test (r = 0.07, P = 0.64). CONCLUSIONS: The study shows that the 6 minute walk is a reliable and accurate test in the evaluation of functional capacity in COPD patients.

Adult↗
PubMed2006

Endobronchial stent for malignant airway obstructions.

BACKGROUND: Endobronchial stents are used to treat symptomatic patients with benign or malignant airway obstructions. OBJECTIVES: To evaluate the safety and outcome of airway stent insertion for the treatment of malignant tracheobronchial narrowing. METHODS: The files of all patients with malignant disease who underwent airway stent insertion in our outpatient clinic from June 1995 to August 2004 were reviewed for background data, type of disease, symptoms, treatment, complications and outcome. RESULTS: Airway stents were used in 34 patients, including 2 who required 2 stents at different locations, and one who required 2 adjacent stents (total, 37 stents). Ages ranged from 36 to 85 years (median 68). Primary lung cancer was noted in 35% of the patients and metastatic disease in 65%. Presenting signs and symptoms included dyspnea (82%), cough (11.7%), hemoptysis (9%), pneumonia (5.9%), and atelectasis (3%). The lesions were located in the left mainstem bronchus (31%), trachea (26%), right mainstem bronchus (26%), subglottis (14.3%), and bronchus intermedius (2.9%). Conscious sedation alone was utilized in 73% of the patients, allowing for early discharge. Eighteen patients (50%) received brachytherapy to the area of obstruction. Complications included stent migration (one patient) and severe or minimal bleeding (one patient each). Ninety-four percent of the patients reported significant relief of their dyspnea. Three of the four patients who had been mechanically ventilated before the procedure were weaned after stent insertion. Median survival from the time of stent placement was 6 months (range 0.25-105 months). CONCLUSION: Stent placement can be safely performed in an outpatient setting with conscious sedation. It significantly relieves the patient's symptoms and may prolong survival.

Adult↗