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Mordechai R Kramer

Publications and source records attributed to Mordechai R Kramer.

At least 37 records · Page 2Linked to original sources
PubMed2005

Co-deposition of amyloidogenic immunoglobulin light and heavy chains in localized pulmonary amyloidosis.

Localized pulmonary amyloidosis is a rare condition whose pathogenesis is insufficiently understood. In the present study, we report a case of localized pulmonary amyloidosis associated with lung-restricted lymphoplasmacytoid lymphoma, monoclonal for immunoglobulin (Ig) G lambda (lambda). Biochemical microtechniques have been applied for extraction, purification, and characterization of amyloid proteins. Surprisingly, chemical analysis of these proteins revealed a not-previously-described case of combined deposits containing Ig fragments of gamma heavy chain (variable domain) and lambda light chain (constant domain). In view of the absence of circulating monoclonal Ig, this case supports the hypothesis that localized amyloid is formed by local plasmacytoid cells.

Aged↗
PubMed2005

Itraconazole prophylaxis in lung transplant recipients receiving tacrolimus (FK 506): efficacy and drug interaction.

BACKGROUND: Itraconazole is often given for fungal prophylaxis to lung transplant recipients after transplantation. The aim of this study was to determine the extent of interaction between tacrolimus and itraconazole in lung transplant recipients and the efficacy of itraconazole prophylaxis. METHODS: The study group included 40 lung transplant recipients followed for at least 12 months. All received prophylactic itraconazole, 200 mg twice a day, for the first 6 months after transplantation. Tacrolimus levels and dosage requirements were compared during and after itraconazole therapy. Rejection rate, fungal infection rate, and renal function were assessed. The mean cost per daily treatment of the itraconazole/tacrolimus combination and tacrolimus alone was calculated. RESULTS: The mean tacrolimus dose during itraconazole treatment was 3.26 +/- 2.1 mg/day compared with 5.74 +/- 2.9 mg/day after itraconazole was stopped (p < 0.0001) for a mean total daily dose elevation of tacrolimus of 76%. When the cost of itraconazole was taken into account, the average total daily cost of the combined treatment was US5.86 dollars less than the treatment with tacrolimus alone. No differences in the rejection or fungal infection rate, or in renal toxicity, were observed between the periods with and without itraconazole treatment, although less positive fungal isolates were identified during itraconazole therapy. CONCLUSION: Prophylaxis therapy with itraconazole is highly effective. Itraconazole reduces the dose of tacrolimus and therefore lowers the cost of therapy without causing an increase in rejection rate and with renal function preservation.

Antifungal Agents↗
PubMed2005

Breathing power of respiratory muscles in single-lung transplanted emphysematic patients.

Single-lung transplantation may induce asynchronous performance between the respiratory muscles of the chest. The objective of this study was to investigate the influence of a single transplanted lung on respiratory muscle mechanics. The force and power of the sternomastoid, external intercostal and external oblique muscles were evaluated throughout a range of respiratory maneuvers in emphysematic patients with a single transplanted lung and compared with that of healthy subjects. A significant differences was observed between the force, work and power of the muscles on the two sides of the chest in emphysematic patients (P<0.05). The control group demonstrated higher averaged maximal force, work and power. The total work done during either inspiration or expiration by the external intercostal and external oblique muscles on the side of the transplanted lung were higher compared with that of the native lung side and compared with the control group. The asynchrony between the lungs after single-lung transplant leads to asynchronous muscle force and work and lesser muscle strength compared to healthy subjects.

Biomechanical Phenomena↗
PubMed2005

Concomitant upper-lobe bullous emphysema, lower-lobe interstitial fibrosis and pulmonary hypertension in heavy smokers: report of eight cases and review of the literature.

INTRODUCTION: Smoking can cause a variety of pulmonary interstitial diseases. Pulmonary fibrosis has traditionally been considered a non-smoking-related disease. Recently, however, evidence of smoking-induced fibrosis has emerged. SUBJECTS AND METHODS: A group of eight patients from the pulmonary clinic in Rabin Medical Center with a combine presentation of fibrosis and emphysema was identified retrospectively. All patients underwent chest computed tomography and pulmonary function tests. One patient underwent lung-heart transplantation and a complete review of his lung pathology was obtained. Transbronchial biopsy was performed in 3 additional patients and echocardiography was performed to evaluate the pulmonary vasculature. RESULTS: Upper-lobe emphysema with bulluos changes was found in all patients. In addition, a basal interstitial process was recognized, ranging from ground glass opacities to severe pulmonary fibrosis, with honeycombing. The radiological findings matched the pathological results of combined emphysema and usual interstitial pneumonia. Pulmonary function tests were also in accord, showing severe hypoxemia with mild obstruction, normal-to-mildly reduced lung volumes and a severe decrease in diffusion capacity. Most of the patients had moderate-to-severe pulmonary hypertension as well as diffuse coronary artery disease. CONCLUSION: Our findings are in line with emerging evidence that the spectrum of interstitial damage caused by smoke includes not only Langerhans cell hystiocytosis, respiratory bronchiolitis or desquamative interstitial pneumonia but also advanced usual interstitial pneumonitis as well. We believe that in some patients smoking plays a destructive role by a variety of mechanisms and can cause emphysema, lung fibrosis as well as pulmonary vasculopathy and hypertension. Future studies are needed to define the genetics and pathophysiology of this uncommonly reported clinical syndrome.

Aged↗
PubMed2005

Gastrointestinal involvement of posttransplant lymphoproliferative disorder in lung transplant recipients: report of a case.

PURPOSE: Lymphoproliferative disorder is a well-recognized complication of lung transplantation. Risk factors include Epstein-Barr virus infection and immunosuppression. The gastrointestinal manifestations of post-transplant lymphoproliferative disorder in lung transplant recipients have not been fully characterized. METHODS: Case presentation and 16 previously reported cases of post-transplant lymphoproliferative disorder with gastrointestinal involvement are reviewed. RESULTS: Patient ages ranged from 25 to 65 (median, 52) years. Median time from lung transplantation to onset of posttransplant lymphoproliferative disorder was 36 (range, 1-109) months; 35 percent of cases (6/17) occurred within 18 months; Eighty-eight percent of patients (15/17) had positive Epstein-Barr virus serology before transplantation. In five patients (29 percent), the posttransplant lymphoproliferative disorder also involved sites other than the gastrointestinal tract. The most common gastrointestinal site of posttransplant lymphoproliferative disorder was the colon, followed by the small intestine and stomach. Clinical features included abdominal pain, nausea, and bloody diarrhea. Diagnosis was based on typical pathologic changes on gastrointestinal tract biopsy obtained mainly by colonoscopy. Treatment included a reduction in the immunosuppressive regimen in 15 of 17 cases (88 percent) and surgical resection in 10 (59 percent). One patient was untreated. Seven of 16 patients (44 percent) responded to treatment and 9 patients died. Median time from onset of posttransplant lymphoproliferative disorder to death was 70 (range, 10-85) days. CONCLUSIONS: Posttransplant lymphoproliferative disorder with gastrointestinal involvement is a unique entity that should be considered in all Epstein-Barr-Virus-positive lung transplant recipients who present with abdominal symptoms. Although immunosuppressive modulation and resection can lead to remission, the risk of death is 50 percent.

Aged↗
PubMed2005

The role of routine culture for tuberculosis during bronchoscopy in a nonendemic area: analysis of 300 cases and review of the literature.

BACKGROUND: Many centers routinely culture bronchoscopy samples for mycobacteria, even when tuberculosis (TB) is not strongly suspected. The value of this practice is poorly defined in areas with a low prevalence of TB. METHODS: A retrospective observational study was conducted in tertiary care, university-affiliated medical center and included 300 consecutive patients who underwent a bronchoscopy examination. The findings for acid-fast bacillus (AFB) staining and culture were reviewed, and data on demographic characteristics, presenting symptoms, old TB, autoimmune status, and chest x-ray results were collected from the files. RESULTS: The study included 175 men (58%) and 125 women, with a mean age of 62 +/- 25 years. Eight cultures (2.67%) grew mycobacteria: 4 (1.33%) Mycobacterium tuberculosis and 4 (1.33%) nontuberculous mycobacteria (NTM). Thus, the incidence of TB was 4 of 300 (1.33%) patients. There were no cases of positive AFB smear or culture in patients with atelectasis, pulmonary mass, or hemoptysis with normal chest x-ray. One of the 22 patients (5%) with diffuse pulmonary nodules had active TB as did 3 of the 134 patients (2.24%) with pulmonary infiltrates. All 4 patients with NTM had pulmonary infiltrates. The use of a cost-effective diagnostic strategy in our series, wherein testing would have been ruled out for patients without a clinical suspicion of TB and radiologic findings of a pulmonary mass (n = 107, 35.6%), would have saved the system US $5350. CONCLUSION: The findings highlight the importance of an effective strategy for routine TB cultures during bronchoscopy in patients from nonendemic areas in whom TB is not suspected, especially those with pulmonary mass.

Academic Medical Centers↗
PubMed2005

Recurrence of pulmonary veno-occlusive disease after heart-lung transplantation.

Pulmonary veno-occlusive disease, a rare cause of pulmonary hypertension, is characterized by extensive and diffuse occlusion of pulmonary veins by fibrous tissue. Although the diagnosis can be suspected by the presence of the classic clinical triad of severe pulmonary arterial hypertension, radiographic evidence of pulmonary hypertension and edema, and normal pulmonary artery occlusion pressure, the definitive diagnosis is histopathologic. The prognosis of pulmonary veno-occlusive disease is poor with most described patients dying within 2 years of diagnosis. Although anti-coagulation, oxygen, and vasodilator therapies are effective temporarily, the definitive treatment is lung transplantation. We describe the recurrence of pulmonary veno-occlusive disease at 3 months after heart-lung transplantation in a 26-year-old man. Recurrence after transplantation for this disease has not been reported previously, and lung transplantation was thought to be definitive treatment. With this 1st report of early recurrence of pulmonary veno-occlusive disease after heart-lung transplantation, we believe that extrapulmonary factors may play a role in the pathogenesis of this rare disease.

Adult↗
PubMed2005

Long-term azithromycin use for treatment of bronchiolitis obliterans syndrome in lung transplant recipients.

Short-term improvement in lung function was observed in 5 of 6 lung transplant recipients with bronchiolitis obliterans syndrome (BOS) who were treated with oral azithromycin. We assessed the long-term effect (mean duration 10 months) of treatment with oral azithromycin in 11 lung transplant recipients with BOS. Mean forced expiratory volume in 1 second (FEV1) was 40 +/- 9% at initiation of azithromycin treatment, 39 +/- 10% after 1 month, 39 +/- 12% after 4 months, 38 +/- 10% after 7 months and 38 +/- 10% after 10 months, respectively (statistically non-significant for all data). We conclude that long-term administration with oral azithromycin does not reverse BOS in lung transplant recipients, but may slow progression of the disease.

Administration, Oral↗
PubMed2005

Pregnancy outcome in patients with pulmonary arterial hypertension receiving prostacyclin therapy.

BACKGROUND: Pregnancy is contraindicated in cases of pulmonary hypertension, a highly morbid disease affecting young women of childbearing age. CASES: We describe the pregnancies of 3 patients with pulmonary arterial hypertension (idiopathic, Eisenmenger syndrome, and related to systemic lupus erythematosus). They received epoprostenol and low-molecular-weight heparin throughout pregnancy. The patient with Eisenmenger syndrome started epoprostenol in gestational week 16. Cesarean delivery under general anesthesia was performed at 28-33 weeks of gestation; early delivery was necessary in the patient with Eisenmenger syndrome because of fetal growth restriction. All deliveries were uneventful, and birth weights were 1,700, 1,500, and 795 g. There were no postpartum complications. CONCLUSION: Pregnancy in women with pulmonary hypertension should still be considered high risk for both mother and child, but stable patients on epoprostenol may successfully complete pregnancy.

Adult↗
PubMed2005

Use of sirolimus and low-dose calcineurin inhibitor in lung transplant recipients with renal impairment: results of a controlled pilot study.

BACKGROUND: Renal failure induced by calcineurin-inhibitor agents is a common complication of lung transplantation. Sirolimus, a macrolide immunosuppressant with a distinct mechanism of action, may prevent renal failure but was found to have a high infectious and toxicity rate in the only relevant study conducted so far. The aim of the present prospective pilot study was to assess the benefit of sirolimus combined with low-dose calcineurin inhibitors in this patient population. METHODS: Sixteen lung transplant recipients with post-transplantation renal dysfunction were allocated to receive the standard immunosuppression regimen or a combination sirolimus/low-dose calcineurin-inhibitor regimen. Target trough levels of sirolimus were 4 to 8 ng/mL. Tacrolimus was tapered down to target trough levels of 4 to 8 ng/mL and cyclosporine to 80 to 120 ng/mL. Duration of follow-up was 18 months. RESULTS: At the end of follow-up, the sirolimus group showed a significant improvement in creatinine clearance (42.6 mL/min vs. 32.5 mL/min, P= 0.05), whereas the control group showed a significant reduction (32.3 mL/min vs. 40.3 mL/min, P= 0.02). The difference between the groups was statistically significant (P < 0.0001). Acute rejection episodes occurred in 2 patients in the sirolimus group and 1 patient in the control group (P= NS). Pneumonia developed in 6 study patients and 4 controls; all responded to antibiotics. CONCLUSION: Sirolimus combined with low-dose calcineurin inhibitors appears to be a safe and effective alternative immunosuppressive therapy to sirolimus alone in lung transplant recipients with renal failure. Graft function is preserved, and infection and drug toxicity rates are low.

Aged↗
PubMed2005

Is routine coronary angiography and revascularization indicated among patients undergoing evaluation for lung transplantation?

OBJECTIVES: To review coronary artery disease (CAD) prevalence among lung transplantation (LTx) candidates, the time interval from coronary angiography (CA) to LTx/death, and post-revascularization outcomes. BACKGROUND: CA is advised for LTx candidates because significant CAD is a contraindication for LTx. METHODS: We monitored all LTx candidates from 1997 who underwent CA. Significant CAD was defined as stenosis > or = 70% in diameter. RESULTS: Of 118 candidates > 40 years old (68.3% men; median age, 58 years; 25 to 75th interquartiles, 53 to 61 years), 59 patients underwent LTx, 56 patients were eligible for LTx, and 3 patients were excluded due to CAD. Significant CAD was detected in 21 patients (17.8%), nonsignificant CAD was found in 21 patients (17.8%), and no CAD was found in 76 patients (64.4%), without significant differences in the demographic/clinical profile among patients with or without significant CAD. Among 21 patients with significant CAD, 12 patients (57.1%) underwent successful percutaneous coronary intervention (PCI), 1 patient had failed to respond to PCI, and 8 patients (38.1%) had no intervention. After PCI, one patient had periprocedural infarction, one patient had stent thrombosis, and one patient had symptomatic restenosis. The median time interval CA to LTx/death/last visit among the 115 candidates was 166 days (interquartiles, 48 to 410 days). Death occurred before LTx in 30 patients (53.5%) during a follow-up of 312 days (interquartiles, 46 to 664 days) and after LTx in 14 patients (23.7%) during a follow-up of 142 days (interquartiles, 73 to 304 days), without any difference in outcome based on severity of CAD in the two groups (p = 0.7 and p = 0.6, respectively). CONCLUSIONS: CAD prevalence among LTx candidates is low and cannot be accurately predicted by risk factors. Revascularization may be associated with complications, and the time interval between revascularization and LTx may be long. Conversely, certain patients with significant CAD underwent LTx without complications. The practice of routine CA and revascularization prior to LTx should be reconsidered, and perhaps reserved for selected patients with high-risk features.

Cohort Studies↗
PubMed2005

Accuracy of virtual bronchoscopy for grading tracheobronchial stenosis: correlation with pulmonary function test and fiberoptic bronchoscopy.

STUDY OBJECTIVES: To compare the accuracy of virtual bronchoscopy (VB) with fiberoptic bronchoscopy (FOB) and pulmonary function testing (PFT) for the assessment of tracheal stenosis and bronchial anastomotic stenosis. DESIGN: Prospective case series. SETTING: Pulmonary institute of major tertiary university-affiliated center. PATIENTS: The study group included 10 lung transplant recipients and 13 patients with central airway stenosis. INTERVENTIONS: All patients underwent PFT, VB, and FOB. All cases were graded by each modality on a scale of 1 to 3, and the findings were compared between modalities. RESULTS: Mean +/- SD stenosis score was 2.0 +/- 0.79 for PFT, 1.62 +/- 0.73 for FOB, and 1.82 +/- 0.77 for VB. A statistically significant correlation was found between VB and FOB scores (p < 0.0001, r = 0.76) and between VB scores and PFT (p = 0.03, r = 0.45). There was no correlation between PFT and FOB. CONCLUSIONS: VB grading of tracheobronchial stenosis is well correlated with PFT. VB may be used to evaluate patients with known tracheobronchial stenosis after treatment and thereby reduce the frequency of repeated invasive FOB performed for that purpose. The correlation of VB with PFT may improve the reliability of this approach.

Adult↗
PubMed2005

Diagnostic value of CYFRA 21-1, CEA, CA 19-9, CA 15-3, and CA 125 assays in pleural effusions: analysis of 116 cases and review of the literature.

Levels of tumor markers in pleural effusions may help to establish the diagnosis of pleural malignancy, but the precise diagnostic value of each marker remains unclear. The aim of this study was to assess the diagnostic value of five common pleural fluid tumor markers, carcinoembryonic antigen (CEA), cytokeratin fragment (CYFRA) 21-1, cancer antigen (CA) 15-3, CA 19-9, and CA 125, and to review the literature from the past 15 years. Pleural fluid samples were collected prospectively from 116 patients and assayed for CEA, CYFRA 21-1, CA 15-3, CA 19-9, and CA 125 levels. A MEDLINE search of the English-language literature from the past 15 years was also done. Effusions were classified as benign or malignant on the basis of their definitive pathologic or cytologic diagnoses. The levels of all pleural tumor markers were statistically significantly higher in the malignant group than in the benign group. The marker with the highest accuracy was CEA (85.3%); CA 15-3, CYFRA 21-1, and CA 19-9 had similar accuracies (75.2%, 72.4%, and 71.5%, respectively), and CA 125 had the lowest accuracy (40.5%). On univariate analysis, tumor-marker combinations did not result in a greater accuracy than that of CEA alone. On multivariate logistic regression, CA 15-3 and CYFRA 21-1 were significant predictors of malignancy. Among the nine reports in the literature comparing 11 different tumor markers, CEA, CA 15-3, and CYFRA 21-1 yielded the best results. We conclude that pleural fluid analysis should include CEA for the diagnosis of malignancy. CA 15-3 and CYFRA 21-1 may serve as alternative options.

Adult↗
PubMed2005

Initial experience with a mechanical ventilation weaning unit.

BACKGROUND: While increasing numbers of patients require prolonged mechanical ventilation, resources for weaning are either limited (ICU beds) or inadequate (general wards). OBJECTIVES: To report on our initial experience over a 7 month period with an eight-bed mechanical ventilation weaning unit. METHODS: Sixty-nine patients requiring MV for > 10 days were admitted to the unit (nurse:patient ratio 1:4). Data collected included reason for MV, duration of hospital stay, and MVWU course. Outcome results (successful weaning and mortality) were compared to those in historic controls (patients ventilated in the general wards over a 4 month period prior to the MVWU; n = 100). RESULTS: The mean age of the patients was 68 +/- 16.6 years and hospital stay prior to MVWU admission 28.6 +/- 24.2 days (range 10-72). The main reasons for MV included acute exacerbation of chronic obstructive pulmonary disease (31%) and recent pneumonia (28%). Mean MVWU stay was 13.5 +/- 15.7 days (range 1-72 days). Thirty-four patients (49%) underwent tracheostomy. Fourteen patients required admission to the ICU due to deterioration in their status. Twenty-nine patients (42%) were successfully weaned and discharged to the wards. A further 20 patients were transferred to the chronic ventilation unit of a regional geriatric rehabilitation hospital, where 5 were subsequently weaned and 15 required prolonged ventilation. Compared to controls (matched for age and reason for mechanical ventilation), more MVWU patients underwent successful weaning (49% vs. 12%, P < 0.001) and their mortality rate (n = 12) was significantly lower (17% vs. 88%, P < 0.001). CONCLUSION: The higher level of care possible in a MVWU may result in a significantly improved rate of weaning and lower mortality. The assessment of long-term outcome in patients discharged to pulmonary rehabilitation centers requires further investigation.

Aged↗
PubMed2005

[Pulmonary hypertension--classification and treatment: new guidelines].

Pulmonary arterial hypertension is a severe pulmonary vascular disease characterized by elevated pulmonary vascular resistance and low cardiac output. Prior to prostacyclin therapy, it was a fatal disease with a median survival of 3 years. In recent years, the understanding and treatment of the disease have significantly improved patient outcome. The new therapeutic guidelines are based on the finding that vasoconstriction and vascular remodeling correlated with endothelial dysfunction, endothelin overexpression and diminished prostacyclin and nitric oxide synthesis. This article outlines the new classification and the current therapeutic guidelines accepted in the world presenting the role of prostacyclins, endothelin antagonist, phosphodiesterase V inhibitor, and the potential value of combination therapies.

Drug Therapy, Combination↗
PubMed2005

[Bronchiectasis--an orphan disease? Diagnosis and treatment in the 21st century].

Bronchiectasis has been termed an "orphan disease" since its decline in the developed world but it is still common in developing countries and in lower socioeconomic classes. Recurrent respiratory infections, under treatment with antibiotics and poor immunization rates are the main causes for the relatively high prevalence in these populations. Today the disease is not often adequately diagnosed nor treated. Airways dilatation, poor clearance of secretions and recurrent infections are the basis of the disease that is characterized by chronic productive purulent cough and recurrent exacerbations. The disease can be localized or diffuse, primary or secondary to other systemic disease. High resolution CT is the examination of choice for diagnosis. Lack of sufficient randomized control trials makes it difficult to establish guidelines. Nevertheless, partial information favors the use of prolonged antibiotic treatment, mucolytic agents and inhaled corticosteroids. Treatment should be tailored to the individual patient guided by the clinical picture while bronchodilators, bronchopulmonary hygiene and physical therapy are optional. Surgical resection is recommended for symptomatic localized bronchiectatic disease while lung transplantation should be reserved, as a last resort, for end-stage bilateral disease.

Bronchiectasis↗