PubMed Health⌕ Search

Biomedical subjects

P Sheiner

Publications and source records attributed to P Sheiner.

34 records · Page 2Linked to original sources
PubMed1994

Tuberculosis in liver transplant patients.

Tuberculosis has been increasing especially in urban areas and in immunosuppressed patients; however, the incidence and factors associated with tuberculosis in OLT patients are unknown. Five of 550 patients who underwent OLT at the Mount Sinai Medical Center during a 5-year period were noted to have tuberculosis. The mean age of the patients was 49.2 years; there were 3 males and 2 females and 3 were foreign born. One of 5 had a prior history of tuberculosis. Tuberculin skin tests performed before transplant revealed 1 positive and 2 anergic reactions. The preoperative chest x-ray revealed apical fibrosis in 2 patients and bilateral apical disease with a nodule in 1 patient. Tuberculosis developed from 2 to 57 months after surgery in 4/5 patients. One had miliary lesions of the peritoneum discovered at the time of OLT. One patient had recent contact with a patient with pulmonary tuberculosis. At presentation, fever was present in 4 of 5 patients, pulmonary lesions in 3 patients, meningitis in 2; during hospitalization, 1 had a liver abscess and disseminated intravascular coagulation and peripheral gangrene. Lymphocytosis was noted in the pleural (1), peritoneal (1), and cerebrospinal fluid (1). Acid-fast smears were positive in bronchoalveolar lavage fluid (1), peritoneal isolates (1), and liver biopsy (1). All patients had positive cultures for Mycobacterium tuberculosis. These isolates were all sensitive to isoniazid, streptomycin, rifampin, ethambutol, and pyrazinamide. Four of 5 patients were treated with isoniazid and rifampin, 2 received pyrazinamide, 2, amikacin, 2, ofloxacin, and 2, ethambutol. Three of 5 patients are doing well on antituberculous therapy and 2 expired with tuberculosis as the cause of death. In OLT patients with unexplained fever, tuberculosis including extrapulmonary and disseminated disease should be considered since the mortality rate is very high. Liver transplantation can be performed in the presence of active peritoneal tuberculosis with the use of judicious antituberculous therapy. The role of preventive therapy is controversial, though use in certain high risk patients is suggested.

Adult↗
PubMed1994

Obviation of prereperfusion rinsing and decrease in preservation/reperfusion injury in liver transplantation by portal blood flushing.

Liver allografts are traditionally rinsed with cold lactated Ringer's (LR) prereperfusion to clear K(+)-rich preservation solution from the hepatic vasculature. LR has been shown, however, to be injurious to the graft. By restoring portal blood flow without rinsing and discarding the initial blood traversing the liver (PB flush), we sought to eliminate rinsing without inducing hyperkalemia. Between August 1988 and December 1992, 481 OLTx were performed in 412 pts. Four rinsing methods were used sequentially: group 1 (157 pts)--low-flow-rate cold LR rinse (500 ml, 100 ml/min via standard i.v. tubing at 100 cm H2O [LFLR]) during lower caval anastomosis; Group 2 (120 pts)--LFLR as in group 1, at reperfusion, 500 ml PB flush via IVC catheter; group 3 (66 pts)--high-flow-rate LR rinse (500 ml, 1 L/min using large-bore tubing with 100 cm H2O rinsing pressure [HFLR]), PB flush as in group 2; Group 4 (62 pts)--no LR rinse; PB flush as in groups 2 and 3. Poor early graft function (PEGF) was defined as peak ALT or AST > 2500 U or PT > 16 sec (on POD 2); PEGF causing re-OLTx or death within 14 days was called primary nonfunction (PNF). Group 1 and Group 3 had high PEGF rates. Group 4 had significantly less PEGF than Group 1, with a trend toward a significant difference from Group 3. In Group 1, 3 pts. had intraoperative hyperkalemic cardiac arrest; this did not occur when PB flush was performed. PB flush without prior rinsing optimizes graft function without risk of hyperkalemia. LR rinse, alone or followed by PB flush, is unnecessary and may be deleterious.

Adolescent↗
PubMed1994

Comparison of short and long-term renal function in liver transplant patients receiving cyclosporin or FK 506.

Long-term renal function was compared in 49 liver recipients [25 patients received cyclosporin (CyA) and 24 patients received FK 506] followed for a period of 1 year. Creatinine (CR) and glomerular filtration rate (GFR) pretransplantation (pre-Tx) and at 1, 3, 5, and 12 months post-Tx were recorded, as well as incidences of hyperkalemia, post-Tx hypertension, and insulin-dependent diabetes mellitus (IDDM) in the two groups. At 1 year post-Tx, the mean Cr had risen from baseline by 56% and 60% in the FK and CyA groups, respectively; the mean GFR had dropped by 32% in FK patients and by 27% in CyA patients. Acute nephrotoxicity occurred in 7/25 CyA patients (2/7 required dialysis) and 9/26 FK patients (7/9 required dialysis; 2/7 were switched to CyA). None remained on dialysis at 3 months. Renal insufficiency persisted at 1 year in 7/16 patients with early toxicity (CyA, 4; FK, 3) and in 3 of the remaining 36 pts (P < 0.001). Hyperkalemia occurred in 4/25 CyA, and in 12/24 FK patients (P < 0.025), post-Tx hypertension occurred in 15 CyA, and 7 FK patients (P < 0.05), and IDDM occurred in 4 CyA and 7 FK patients (P = ns). FK 506 and CyA, thus, exerted similar chronic renal effects. Although acute renal insufficiency improved upon dose reduction, renal impairment was permanent in some cases.

Creatinine↗
PubMed1994

Neurologic complications of orthotopic liver transplantation.

Neurologic complications are frequent after liver transplantation and are the cause of significant morbidity and mortality. A substantial proportion of the neurologic complications encountered after transplant is iatrogenic--the consequence of the harsh therapeutic interventions required to maintain function of the transplanted liver. The preoperative condition of the patient is also a major determinant of the incidence and impact of neurologic complications, as is the occurrence of poor early graft function or of repeated rejection episodes that require augmented immunosuppression. By recognizing the early signs of drug-related neurotoxicity, it is often possible to preempt the development of more severe trouble. Careful perioperative fluid management, specifically related to sodium and glucose levels, may reduce the risk of CPM. As effective treatment modalities have emerged, an aggressive approach to the diagnosis of central nervous system infection has assumed increased importance. With persistent attention to the details of basic patient care as well as to the specific neurologic diagnosis, and with a commitment to intensive rehabilitation therapy, the large majority of patients who suffer neurologic complications after transplant can ultimately return to a productive life.

Cerebrovascular Disorders↗
PubMedDate not supplied

Methylphenidate in post liver transplant patients.

Methylphenidate (Ritalin, manufacturer: Ciba/Geigy) has been shown effective for the treatment of depression in various medically ill populations, but to our knowledge its use in organ transplant patients has not been described. The authors retrospectively reviewed clinical records of the first eight inpatients who received methylphenidate for treatment of depressive and/or cognitive symptoms in the post liver transplant period at Mount Sinai Medical Center. Target symptoms included psychomotor and cognitive slowing as well as lack of motivation for recovery, poor rehabilitation effort, social withdrawal, and apathy. A positive response was noted in seven patients, and in one patient the response was equivocal. Side effects noted were increased blood pressure (N = 2) and subjective restlessness/agitation (N = 3). Methylphenidate appears to be an effective, rapidly acting agent in this setting at dosages of 10-20 mg/day, with minimal side effects. Methylphenidate may have a significant role in the care of an ever-increasing population of organ transplant recipients with multiple medical problems and associated disabilities.

Adult↗
PubMedDate not supplied

Aggressive surgical management of fibrolamellar hepatocellular carcinoma.

Fibrolamellar hepatocellular carcinoma (FLHC) is recognized as a distinct clinicopathologic variant of hepatocellular carcinoma. Ten consecutive patients with FLHC undergoing operative management at our institution were reviewed. At the initial presentation seven patients had stage II disease (pT2N0M0), whereas three patients were in stage III (pT2N0M0 or pT3N0M0). Initial procedures included formal right or left hepatectomy in four patients, right or left trisegmentectomy in two patients, left lateral segmentectomy or nonanatomic resection in three patients, and in one patient considered for liver transplantation, only exploration with biopsy of positive nodes was performed. Four stage II patients required a second procedure for resection of recurrent disease from 8 months to 6 years after the initial resection and one patient required a third procedure after 13 years. Reoperations included hepatic re-resection, resection of extrahepatic disease, and liver transplantation. Overall 5- and 10-year Kaplan-Meier survival was 70%. There were no deaths among stage II patients (follow-up 96 to 180 months). All stage III patients (i.e., lymph node involvement, vascular invasion, or multiple tumors) died within 5 years. Patients with stage II disease had better survival than patients with stage III disease (P = 0.011, log-rank test). Aggressive treatment of FLHC including reoperation and liver transplantation is justified, especially in patients with stage II disease.

Adult↗