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Biomedical subjects

Mordechai R Kramer

Publications and source records attributed to Mordechai R Kramer.

At least 55 records · Page 3Linked to original sources
PubMed2005

An association between oxygen desaturation and D-dimer in patients with obstructive sleep apnea syndrome.

D-dimer, a degradation product of fibrin, is being increasingly used as a marker and prognostic factor in various thrombotic diseases. Previous reports have shown that obstructive sleep apnea is associated with platelet activation and hypercoagulability. The aim of the study was to assess the potential role of the plasma D-dimer test in patients with obstructive sleep apnea. We designed a prospective group comparison study in a tertiary-care, university-affiliated medical center. One hundred and three patients of mean age 57 years (range 50-76 years) with symptoms suggestive of obstructive sleep apnea were included. Polysomnography was performed in all cases, and blood was collected for plasma D-dimer measurement by MiniQuant turbidmetric assay. The demographic and polysomnograph data were compared between patients with normal and high (> 250 ng/ml) D-dimer levels. The group with higher D-dimer values had lower mean minimal oxygen saturation (72.1 +/- 16.4 vs. 81.7 +/- 11.6%, p = 0.008) and a longer mean period of oxygen saturation below 90% (84.1 +/- 86.2 vs. 38.5 +/- 70.8 minutes, p = 0.032). There was no correlation of respiratory disturbance index and sleep architecture with D-dimer values. We concluded that sleep apnea syndrome is associated with fibrinolytic activity. Oxygen desaturation seems to be one of the mediatory factors in the putative connection between obstructive sleep apnea and hypercoagulability state.

Aged↗
PubMed2004

Progressive multifocal leukoencephalopathy in transplant recipients.

Progressive multifocal leukoencephalopathy (PML) is a demyelinating infection caused by the JC virus. It is an emerging disease in transplant recipients; however, it remains poorly defined. Twenty-four cases of PML reported in the literature in transplant recipients were reviewed. Of the 24 cases, nine occurred in renal, six in bone marrow, four in liver, three in heart and two in lung transplant recipients. Median time to onset was 17 months; 71% occurred within 24 months of transplantation. PML tended to occur later in the kidney recipients (P=0.04). Seventy-five percent had subacute presentation; hemiparesis (50%), apathy (46%) and confusion (38%) were the most frequently presented features. Treatment included reduction of immunosuppression and chemotherapy, mainly cidofovir. Death occurred within 2.5 months of the onset of symptoms in 17 patients (71%). PML is a unique entity that should be considered in any transplant recipient with neurological symptoms. The outcome is usually fatal, although regression has been reported.

Adult↗
PubMed2004

Successful steroid withdrawal in lung transplant recipients: result of a pilot study.

OBJECTIVE: Corticosteroids play a key role in immunosuppression after transplantation. However, because chronic steroid treatment may cause significant morbidity and mortality, steroid-free immunosuppression remains a desirable goal. To the best of our knowledge, there are no reports on successful steroid withdrawal (SW) in lung transplant recipients. METHODS: The study group included 35 patients who underwent heart-lung, double-lung or single-lung transplantation. Criteria for initiation of SW were stable pulmonary function tests and absence of clinical or bronchoscopic evidence of acute or chronic rejection in the last 6 months. Pulmonary function, blood pressure and metabolic parameters were compared between the patients who underwent SW and those who did not. RESULTS: Eight patients (23%) underwent SW. Median follow-up was 19 months (range 11-23 months). Compared to the non-withdrawal group, the withdrawal group was older (60+/-6 vs. 52+/-13 years, P=0.01, r=0.49), had higher rates of emphysema (88% vs. 18%, P=0.01) and use of a cyclosporine-based regimen (62% vs. 26%, P=0.0001), and had longer time from transplantation to the withdrawal attempt (70+/-13 vs. 29+/-26 months, P=0.0002). The SW group showed no adverse effects in graft function and no deterioration on pulmonary function tests. SW had a beneficial metabolic effect, with a decrease in mean cholesterol level from 229+/-45 to 194+/-25 mg/dl (P=0.02) and no significant change in weight, systolic blood pressure or glucose level. In the non-withdrawal group, mean cholesterol levels increased from 175+/-34 to 209+/-57 mg/dl (P=0.0005), weight increased from 72+/-15 to 80+/-14 kg (P=0.0001), and systolic blood pressure increased from 125+/-15 to 139+/-16 mmHg (P=0.001); glucose levels did not change. There was a significant correlation between total cholesterol level and weight in both groups (P=0.0006, r=-0.56 and P=0.01, r=-0.46, respectively). CONCLUSIONS: Late SW is safe in stable patients after lung transplantation. There was no evidence of rejection or a deterioration in pulmonary function. Lipid profile improvement and blood pressure stabilization accompanied the termination of steroid therapy.

Aged↗
PubMed2004

Role of siroliumus, a novel immunosuppressive drug in heart and lung transplantation.

Lung and heart transplantation has become an accepted therapeutic option for patients with end-stage disease. However, the calcineurin-inhibitor-based immunosuppression often causes renal impairment. Therefore, sirolimus, a novel immunosuppressive agent, may serve as an alternative or complementary agent to calcineurin inhibitors. The aim of this review was to summarize the role of sirolimus in lung and heart transplantation. Although only a few, small studies have been conducted so far, the drug's mechanisms of action and low-toxicity profile make it a highly promising option.

Drug Monitoring↗
PubMed2004

Prognostic value of a new quantitative D-dimer test in critically ill patients 24 and 48 h following admission to the intensive care unit.

A D-dimer assay may predict mortality in medical critically ill patients, although no consensus on the clinical utility of this diagnostic test has been reached. A prospective single-center study was designed to evaluate whether D-dimer levels, as measured by a new, rapid assay, correlate with poor outcome in critically ill patients. A total of 95 blood samples were collected from medical and surgical adult patients 24 and 48 h following admission to the intensive care unit (ICU). D-dimer was assayed by the Miniquant quantitative test and correlated to the ICU length of stay, the hospital length of stay, the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Simplified Acute Physiology Score (SAPS) 24 and 48 h following admission to the ICU, organ system failure index and hospital mortality. The 24-h D-dimer level correlated with the 48 h APACHE II and SAPS scores (r = 0.41, P = 0.01; and r = 0.39, P = 0.01, respectively). The 48-h D-dimer level correlated with the APACHE II and SAPS scores at 48 h and with the organ system failure index (number of organ failure) (r = 0.54, P = 0.0008; r = 0.60, P = 0.0001; and r = 0.37, P = 0.02, respectively). Neither the 24-h nor the 48-h D-dimer levels were predictive of in-hospital mortality in a multivariate model. We conclude that this simple and new laboratory test may serve as an additional tool to predict the clinical severity of patients admitted to the ICU.

APACHE↗
PubMed2004

[Lung and heart-lung transplantation in Rabin medical center: early experience with 70 cases].

Lung transplantation is a relatively new field in solid organ transplantation. We present our early experience with the first 70 cases at the Rabin Medical Center during the years 1997-2003. Forty seven patients underwent single lung, eight double lung and eight heart-lung transplantations. The patients treated included 49 men and 21 women aged 5-66 years. There were 26 cases with emphysema COPD. 30 patients with pulmonary fibrosis. 5 patients with pulmonary hypertension/Eisenmenger and 9 patients with cystic fibrosis and bronchiectasis. Although early results (1997-1999) showed 1 and 3 year survival of only 50%, in the last 3 years (2000-2003), survival reached 84% and 82% at 1 and 3 years respectively. Improvement in the success rate is due to better patient selection, new immunosuppressive regimen and, most importantly, excellent teamwork. We conclude that lung transplantation is a viable option for selected patients with end-stage lung disease.

Adolescent↗
PubMed2004

Unexplained severe pulmonary hypertension in the elderly: report on 14 patients.

BACKGROUND: Unexplained pulmonary hypertension is assumed to occur mainly in young adults. OBJECTIVE: To describe the features of the disease in older patients and compare them to those in PHT patients of all ages. METHODS: We conducted a retrospective evaluation of the files of patients over 65 years of age in whom UPHT was diagnosed between 1987 and 1999 at two PHT centers serving a population of 4 million. Patients were followed for survival until March 2003. Clinical variables of the study patients were compared with those in PHT patients of all ages. RESULTS: The study group included 14 patients, 10 females and four males, with a mean age of 70.5 +/- 6.7 years. The calculated mean annual incidence of UPHT for the study population was one new case per year per million persons. Seven patients (50%) had systemic hypertension. The mean interval from onset of symptoms to diagnosis was 8.3 months. At diagnosis, 64% of patients had functional capacity of III-IV according to the New York Heart Association classification, and 43% had right heart failure. Mean systolic pulmonary artery pressure was 80 +/- 21 mmHg, peripheral vascular resistance 11.7 +/- 7 mmHg/L/min, cardiac index 2.16 +/- 0.81, and mean right atrial pressure 10.5 +/- 5.9 mmHg. Median survival time was 43 months; survival rates for 1 year, 3 years and 5 years were 92.6%, 50% and 40%, respectively. Compared to data from the U.S. National Institute of Health Registry, UPHT in older patients is more common in females, but the incidence as well as clinical, hemodynamic and survival parameters are similar to those in PHT patients at any age. CONCLUSIONS: UPHT occurs in the elderly more frequently than previously thought, with similar features in PHT patients of all ages. The coexistence of systemic and pulmonary hypertension warrants further investigation.

Aged↗
PubMed2003

Late-onset chylothorax after heart-lung transplantation.

Chylothorax has rarely been reported after heart and lung transplantation. We describe a case of a bilateral chylothorax that occurred in a 53-year-old man 4 months after heart-lung transplantation and review the three additional reports in the literature of chylothorax after heart transplantation. Chyle drainage may cause compromise of the transplant patient. The good nutritional status of our recipient, however, allowed conservative therapy with chest tube drainage and enteral low-fat diet, without the need for surgical intervention. We concluded that chylothorax can presents late after lung transplantation and that conservative treatment should be considered in patients with good nutritional status.

Chylothorax↗
PubMed2003

Late postoperative pleural effusion following lung transplantation: characteristics and clinical implications.

OBJECTIVE: Pleural effusions are extremely common in the early postoperative period after lung transplantation (LTX). It occurs in all transplant recipients, and like pleural fluid following other cardiothoracic surgery is bloody, exudative and neutrophil predominant. There was no information, however, on the characteristics of the late (14-45 days) postoperative pleural fluid after LTX. The purpose of this study was to describe the characteristics and the clinical implications of late postoperative pleural effusion after LTX. METHODS: Thirty-five patients underwent TX between May 1997 and May 2001. Seven patients (20%) developed late postoperative pleural effusion. Thoracentesis were performed in these patients and the white blood cell counts, cell differential as well as biochemical parameters were determined. RESULTS: The median time for late pleural effusion appearance was 23 days (range, 14-34 days) after TX. The pleural effusions were medium in size (700 ml, range, 100-1300), exudative in all the patients and had lymphocyte predominance. No evidence of fluid recurrence or clinical deterioration was noted in these patients. CONCLUSION: Late-onset exudative lymphocytic pleural effusion after LTX is not uncommon. When there is no evidence of rejection or infection, it usually has a benign, favorable outcome.

Adult↗
PubMed2003

Progressive multifocal leukoencephalopathy in a lung transplant recipient.

Progressive multifocal leukoencephalopathy (PML) is a sub-acute, demyelinating disease of the brain caused by a human polyomavirus. We describe a patient with the onset of PML 7 months after lung transplantation. The patient was treated with immunosuppressive modulation and cidofovir, a new anti-viral therapy for PML, with stabilization of the symptoms. We also review the 4 additional reports in the literature of PML after heart and lung transplantation. Progressive multifocal leukoencephalopathy may become more prevalent as the population of heart and lung transplantation recipients increases.

Humans↗
PubMed2003

High dose rate brachytherapy for nonmalignant airway obstruction: new treatment option.

STUDY OBJECTIVES: High dose rate (HDR) endobronchial brachytherapy is widely used as a palliative treatment for symptomatic airway obstruction by primary or secondary malignant tumors. We report on a successful use of HDR brachytherapy in patients with nonmalignant airway obstruction. DESIGN: Case series PATIENTS: Six patients received HDR brachytherapy for airway obstruction caused by granulation tissue around a metal stent placed for restoration of the airway patency for nonmalignant causes. In four patients, brachytherapy was performed following recurrent occlusion of the airway by granulation tissue formation; in two patients, it was done as a prophylactic procedure. INTERVENTION: HDR brachytherapy catheters were passed through the metal stents under direct fluoroscopic guidance. Simulation and computerized treatment planning were done, and a single dose of 10 Gy was administered using a brachytherapy remote afterloader with a (192)Ir source. The dose was prescribed to a distance of 1 cm from the center of the source, with a margin of 1 cm from the proximal and distal ends of the stent. RESULTS: At a median follow-up of 15 months, moderate granulation tissue formation was observed in only one patient; in four others, it was categorized as minimal, 5 to 30 months from the procedure. Restoration of the lumen was complete in four patients, near complete in one patient, and partial in one patient. In one patient, previously treated by external radiotherapy, local tissue necrosis was evident. CONCLUSION: HDR brachytherapy can be used safely for nonmalignant airway obstruction. Further studies including more patients and longer follow-up are needed.

Adult↗
PubMed2002

Advanced non-small cell lung cancer: induction chemotherapy and chemoradiation before operation.

BACKGROUND: Induction chemotherapy before operation is beneficial for patients with advanced locoregional non-small cell lung cancer. However, no optimal regimen has been established. This study assesses feasibility, response, resectability, and survival of chemotherapy followed by chemoradiation before operation in patients with non-small cell lung cancer. METHODS: Fifty-seven stage IIIA and selected IIIB patients with non-small cell lung cancer received 2/3 cycles of cisplatin and oral etoposide, followed in 3/4 weeks by chemoradiation with daily cisplatin before each radiation fraction. Patients achieving a resectable status underwent operation. RESULTS: Response to induction treatment was documented in 73%; 69% achieved a resectable status and 53% underwent operation. Median survival was 16 months. The 1-, 2-, and 3-year survival rates were 65%, 35% and 22%, respectively. There was no difference in survival between stage IIIA and IIIB disease. Myelotoxicity was moderate to severe (grade III/IV in 61% of patients). Three patients died of late complications of pneumonectomy. CONCLUSIONS: Our presurgery chemotherapy and chemoradiation protocol yields high response and resectability rates, with moderate to severe myelotoxicity. Pneumonectomy is associated with a relatively high rate of late complications.

Adult↗
PubMed2002

Functional evaluation in patients with chronic obstructive pulmonary disease: pulmonary function test versus cardiopulmonary exercise test.

The pulmonary function test (PFT) alone may be inadequate for predicting work-related exercise capacity in patients who file workers' compensation claims for respiratory limitation and compensation. Two hundred sixteen ambulatory patients with chronic obstructive pulmonary disease (forced expiratory volume in 1 second = 54.1 +/- 16.8% predicted) were administered the PFT and cardiopulmonary exercise test, and the results were analyzed by categorical statistical comparison, based on standard medical impairment classifications. Sixty-five patients (30.1%) were similarly classified by the two methods. Of the remaining patients, 132 (61.1%) were found to be less impaired according to the cardiopulmonary exercise test than according to the PFT, and 19 (8.8%) were more impaired according to the PFT. The results favor the use of the cardiopulmonary exercise test for the routine evaluation of respiratory impairment in patients with chronic obstructive pulmonary disease, particularly for patients with mild or moderate impairment revealed by the PFT. The large discrepancy between the two procedures emphasizes the need for a novel approach.

Aged↗
PubMed2002

The relationship between left ventricular function assessed by multigated radionuclide test and cardiopulmonary exercise test in patients with ischemic heart disease.

STUDY OBJECTIVES: To compare the oxygen pulse curve (O(2)P-C) as measured during cardiopulmonary exercise testing (CPET) with left ventricular (LV) ejection fraction (LVEF) rest-exercise response as measured by multigated equilibrium (99m)Tc radionuclide cineangiography (MUGA) in patients with different degrees of ischemic heart disease (IHD). PATIENTS: Forty-six patients (39 men and 7 women; mean plus minus 1 SD age, 59.2 plus minus 11 years) with IHD, with no hypertrophic, valvular, or pericardial disease. METHODS: A supine bicycle ergometer with increments of 25 W every 2 min was used for MUGA, and an electronically braked cycle ergometer was used for upright symptoms-limited CPET. Exercise was increased by 10 to 20 W/min until the target heart rate (HR) was reached (similar peak HR for both studies). MEASUREMENTS AND RESULTS: The O(2)P-C was scored on a 10-point scale as follows: type A, normal curve (10 points); type B, normal-shaped curve with low values (8 points); type C, low and flat curve (5 points); type D, descending curve (3 points). Findings for the MUGA study were classified into four groups by the degree of ischemic response: group 1 (control), normal diastolic function (n = 10), LVEF > 55%, LVEF during exercise minus LVEF at rest [DeltaLVEF] greater-than-or-equal 5%; group 2, mild ischemia (n = 10), LVEF > 55%, < 0 DeltaLVEF < 5%, diastolic dysfunction at exercise (prominent "A" waves); group 3, LV dysfunction (n = 9), LVEF < or = 35% at rest; and group 4, significant ischemia (n = 17), LVEF > 55%, DeltaLVEF < 0, diastolic dysfunction. A highly significant relationship between the O(2)P-C score and the MUGA grouping was observed by Fisher's Exact Test and Pearson's linear regression line (p < 0.001; R = - 0.89). CONCLUSIONS: Exercise-responded O(2)P-C might serve as a good noninvasive, physiologically based, parameter to distinguish between IHD patients with normal and impaired LV function.

Adult↗
PubMed2002

Value of a negative aeroallergen skin-prick test result in the diagnosis of asthma in young adults: correlative study with methacholine challenge testing.

BACKGROUND: None of the existing tests for the diagnosis of asthma are considered to be definitive. Certain circumstances require prompt diagnosis, and a test able to predict the absence of asthma would be very useful. OBJECTIVE: To evaluate the contribution of a skin-prick test (SPT) to the diagnostic workup of subjects with suspected asthma. PATIENTS AND METHODS: The study included three groups of subjects aged 18 to 24 years: group A, asthmatic patients (n = 175); group B, control subjects (n = 100); and group C, subjects with suspected asthma (n = 150) with normal spirometry findings and a negative exercise challenge test result. All underwent an SPT to a battery of common aeroallergens, and group C underwent a methacholine challenge test (MCT) in addition. The sensitivity, specificity, positive predictive value, and negative predictive values (NPV) of the SPT were calculated using provocative concentrations of methacholine causing a 20% fall in FEV(1) (PC(20)) of < 4 mg/mL and < 8 mg/mL as diagnostic cutoff values for asthma in the MCT. Bayes' formula was used to determine posttest probabilities of having asthma, both for positive and negative SPT results. RESULTS: A positive SPT result to at least one allergen was found in 95.5%, 54%, and 69% of patients in the three groups, respectively. The sensitivity, specificity, and NPV of the SPT were 90.7%, 52.0%, and 84.8%, respectively, with a cutoff value of PC(20) < 8 mg/mL. The lower cutoff, PC(20) < 4 mg/mL, increased the sensitivity and NPV to 98.2% and 97.8%, respectively. A negative SPT result decreased the probability of having asthma by 10-fold to 20-fold in subjects whose pretest probability was low to moderate. CONCLUSIONS: Incorporating an SPT into the workup of subjects with suspected asthma can reduce the cost of this process significantly. The SPT may be used as a simple, fast, safe, inexpensive, and reliable method to predict the absence of asthma in young adults.

Adolescent↗
PubMed2002

Significance of a plasma D-dimer test in patients with primary pulmonary hypertension.

BACKGROUND: D-dimer, a degradation product of fibrin, has been increasingly used as a marker or prognostic factor in various thrombotic diseases. OBJECTIVE: To assess the significance of a d-dimer test in patients with primary pulmonary hypertension (PPH). PATIENTS AND METHODS: Fourteen patients with PPH (12 women and 2 men) aged 25 to 68 years (mean +/- SD age, 50 +/- 14 years) entered the study. Plasma d-dimer was determined by Miniquant assay (Biopool International; Venture, CA) 3 +/- 5 months after the disease onset, and patients were followed up for 1 year. We compared the d-dimer levels to the demographic, clinical, and hemodynamic data of the patients. RESULTS: D-dimer levels were positively correlated with New York Heart Association classification (r = 0.59, p = 0.01) and pulmonary artery pressure (r = 0.43, p = 0.03) and were negatively correlated with oxygen saturation (r = - 0.45, p = 0.03) and 6-min walk distance (r = - 0.49, p = 0.04). One-year survival was also negatively correlated with d-dimer (point-biserial r = - 0.71, p = 0.004), with a higher d-dimer value associated with poorer survival. No significant correlations were found between d-dimer values and sex, age, diffusing capacity of the lung for carbon monoxide, or cardiac index. CONCLUSION: D-dimer levels may have a role in the evaluation of patients with PPH. This simple, noninvasive test may be helpful for identifying patients who are at a higher risk for severe disease.

Adult↗
PubMed2002

Continuous intravenous epoprostenol in pulmonary hypertension: the Israel experience.

BACKGROUND: Primary idiopathic pulmonary hypertension is a rapidly progressive disease with a median survival of less than 3 years. Recently its prognosis was shown to dramatically improve with the use of epoprostenol, an arachidonic acid metabolite produced by the vascular endothelium, which increases the cardiac output and decreases the pulmonary vascular resistance and pulmonary arterial pressure. This drug enhances the quality of life, increases survival and delays or eliminates the need for transplantation. OBJECTIVE: To review the experience of Israel hospitals with the use of epoprostenol. METHODS: The study group comprised 13 patients, 5 men and 8 women, with an age range of 3-53 years. All patients suffered from arterial pulmonary hypertension. Epoprostenol was administered through a central line in an increased dose during the first 3 months, after which the dose was adjusted according to the clinical syndrome and the hemodynamic parameters. RESULTS: After 3 months the mean dose was 10 ng/kg/min and the pulmonary artery pressure decreased from 7 to 38%. After one year, the PAP decreased at a slower rate. Two cases required transplantation, three patients died, and seven continued taking the drug (one of whom discontinued). Four episodes of septicemia were observed. Today 10 patients are alive and well and 7 continue to take epoprostenol. CONCLUSION: We found that epoprostenol improves survival, quality of life and hemodynamic parameters, with minimum side effects.

Adolescent↗