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Biomedical subjects

S M Levine

Publications and source records attributed to S M Levine.

At least 55 records · Page 3Linked to original sources
PubMed1993

Possible case of procainamide-induced intrahepatic cholestatic jaundice.

OBJECTIVE: To describe a possible case of procainamide-induced intrahepatic cholestatic jaundice that was recognized six weeks after the initiation of procainamide therapy and to summarize the five previously reported cases. CASE SUMMARY: A 77-year-old woman with a history of hypertension, insulin-dependent diabetes mellitus, temporal arteritis, and Wolff-Parkinson-White syndrome who had taken procainamide for six weeks presented to the hospital with disorientation and acute renal and hepatic dysfunction. In addition to disorientation, scleral icterus, and diffuse maculopapular rash, her physical examination was generally normal. There was no evidence of fever, nausea, vomiting, lymphadenopathy, or eosinophilia. Her liver enzyme concentrations increased significantly from baseline (beginning of procainamide therapy). Her N-acetylprocainamide (NAPA) concentration was elevated to 52 mg/L upon admission. Procainamide was discontinued and her NAPA concentration returned to within normal limits in two days. Diagnostic tests were performed to rule out active hepatitis, vasculitis, and liver malignancies. After procainamide was discontinued and prednisone treatment was started, she became more oriented and her liver enzyme concentrations slowly improved. DISCUSSION: Only five cases of procainamide-induced liver abnormalities have been previously reported; these included granulomatous hepatitis and intrahepatic cholestasis. The mechanism for liver dysfunction is not known; however, it is proposed to be a delayed hypersensitivity reaction. Clinical hallmarks of hypersensitivity include fever, eosinophilia, rash, and lymphadenopathy; nausea and vomiting also may be present. Of the five reported cases, all experienced fever and only one experienced pruritus. No patients had eosinophilia or lymphadenopathy. Because of the temporal increase in liver enzyme concentrations after six weeks of procainamide therapy, we believe that this case represents another possible procainamide-induced hypersensitivity reaction. CONCLUSIONS: Procainamide-induced liver dysfunction can occur from one day to six weeks after initiation of the drug and may subside one day to several weeks after discontinuation of therapy. Symptoms may include nausea, vomiting, rash, and fever. Liver enzyme concentrations are abnormal. It is important to recognize the possibility of such a reaction early so that procainamide therapy can be discontinued promptly to avoid further liver damage.

Aged↗
PubMed1993

Graft position and pulmonary function after single lung transplantation for obstructive lung disease.

Single lung transplantation (SLT) has become a therapeutic option for the treatment of end-stage obstructive lung disease. Between January 1989 and June 1990, there were 14 patients with end-stage obstructive lung disease who underwent SLT. Eleven of these patients were surviving at 1 year following transplantation. Three of the patients had received left-sided SLT, and eight had received right-sided SLT. In the patients receiving left-sided SLT, the native right lung radiographically appeared to compress the left lung graft. In the patients receiving right-sided SLT, the native left lung did not appear to compress the right lung graft. We hypothesized that right SLT may provide a functional advantage over left SLT for patients with obstructive lung disease. We compared pulmonary function test results before and after transplantation (approximately 3 and 12 months) and compared quantitative ventilation-perfusion lung scan results between the patients with left SLT and those with right SLT. Additionally, we compared graded-exercise test results at 3 and 12 months after transplant between the two groups. Our data revealed no statistical difference in pulmonary function test results or graded-exercise test results between the two groups, although patients undergoing right SLT showed greater increases in FEV1 and forced vital capacity than those undergoing left SLT. Quantitative ventilation and perfusion were greater to the graft in patients receiving right-sided SLT than in patients receiving left-sided SLT, most likely due to the larger size of the right lung. We conclude that there is no functional difference between patients undergoing left or right SLT for end-stage obstructive lung disease.

Adult↗
PubMed1992

Resistive breathing activates the glutathione redox cycle and impairs performance of rat diaphragm.

Free radical activation and lipid peroxidation have been described in skeletal muscle during strenuous exercise. We hypothesized that oxygen radicals could also be formed in the diaphragm muscle during strenuous resistive breathing and that these radicals might affect diaphragm function. Seven control and 12 experimental male Sprague-Dawley rats were studied. Six experimental animals were subjected to resistive breathing (RB) alone and six animals received 15 min of mechanical ventilatory support (MV) after the resistive breathing period. Inspiratory resistance was adjusted to maintain airway opening pressure at 70% maximum in both groups until exhaustion. Diaphragm samples were obtained for analysis of thiobarbituric acid-reactive substances (TBAR), reduced glutathione (GSH), and glutathione disulfide (GSSG). In vitro isometric contraction times, twitch (Pt) tension and maximum tetanic (Po) tension, force-frequency curves, fatigue index, and recovery index were measured. In RB and MV compared with controls, there were significant decreases in Pt and Po. Diaphragm TBAR concentrations were increased in MV compared with controls or RB. GSSG-to-total glutathione ratio was increased in RB and MV compared with controls. Production of free radicals during RB and MV may represent an important mechanism of diaphragmatic injury that could contribute to the decline in contractility.

Airway Resistance↗
PubMed1992

Ventilation-perfusion inequalities during graft rejection in patients undergoing single lung transplantation for primary pulmonary hypertension.

We report herein data on single lung transplant (SLT) recipients with primary pulmonary hypertension (PPH). One patient did well following surgery but died on the 30th postoperative day due to cytomegalovirus pneumonia. The remaining two patients initially did well with unlimited exercise tolerance following transplantation, but then developed marked dyspnea on exertion and hypoxemia on postoperative days 144 and 120, respectively. Pulmonary function testing showed marked deterioration of function and transbronchial lung biopsy specimens revealed acute graft rejection in one patient and evidence of chronic graft rejection in the second patient. Quantitative ventilation-perfusion lung scanning demonstrated a marked decrease in ventilation to the transplanted lung in both cases associated with only a mild decrease in perfusion. This V/Q mismatch resulted in markedly decreased arterial oxygen saturations, widened alveolar-arterial oxygen gradients, and clinically debilitating dyspnea. We conclude that rejection may result in significant V/Q mismatch and hypoxemia in PPH patients undergoing SLT, which may limit the use of this specific type of surgery for PPH.

Female↗
PubMed1992

The technique of fiberoptic bronchoscopy. Diagnostic and therapeutic uses in intubated, ventilated patients.

Fiberoptic bronchoscopy has a variety of applications in the intensive care unit. This procedure, which can be done at the patient's bedside, can be used to clear excess secretions; check the position of, or replace, an endotracheal tube; identify areas of active bleeding; diagnose opportunistic infections; and evaluate obstructive airway lesions. Before the bronchoscope is inserted, antisialagogues, anxiolytics, and topical anesthetics are administered along with supplemental oxygen. In intubated, ventilated patients, a fiberoptic bronchoscope may be passed through a swivel adapter to prevent loss of the delivered oxygen and tidal volume. Cardiac arrhythmias and hypoxemia are among the most common complications.

Airway Obstruction↗
PubMed1992

The technique of bronchoalveolar lavage. A guide to sampling the terminal airways and alveolar space.

Bronchoalveolar lavage (BAL) provides a means of recovering cells and biochemical substances directly from the alveoli in patients with numerous pulmonary diseases. It is also useful in diagnosing opportunistic infections in immunocompromised patients. Upper airway contamination of BAL specimens is the chief liability. In diffuse lung disease, the bronchoscope is usually positioned in the middle lobe; when focal lung disease is present, the bronchoscope is placed in the area of greatest roentgenographic involvement. Sterile saline is instilled and recovered for analysis. Most side effects are related to endoscopic technique, location and extent of lavaged lung area, and the volume and temperature of instilled fluid.

Bronchoalveolar Lavage Fluid↗
PubMed1992

Single lung transplantation. Factors in postoperative cytomegalovirus infection.

Thirty-one single lung transplantations were performed between March 17, 1988, and November 1, 1990. Postoperative infection, especially with cytomegalovirus, has been the major cause of morbidity and mortality. Eighteen of the 31 patients were receiving prednisone before transplantation. Every patient was prepared preoperatively with oral cyclosporine 5 mg/kg and azathioprine (Imuran) 2 mg/kg. Every patient received methylprednisolone for 3 days postoperatively, followed by prednisone 1.0 mg/kg/day, oral cyclosporine, and azathioprine. Ten patients additionally had cytolytic therapy with OKT3 and 12 with antilymphocyte globulin. Nine patients had no cytolytic therapy. Cytolytic therapy was chronologic, not randomized. Postoperative infection occurred in 20 patients, 13 of whom had cytomegalovirus infection. Preoperative use of prednisone did not correlate with postoperative infection, cytomegalovirus, or death. Postoperative infection occurred in 17 of 22 patients with cytolytic therapy compared with three of nine without cytolytic therapy (p = 0.035). Cytomegalovirus infection occurred in 13 of 22 with cytolytic therapy and in none of the nine without cytolytic agents (p = 0.003). Therefore preoperative prednisone does not appear to be a contraindication to single lung transplantation. Cytolytic therapy with either OKT3 or antilymphocyte globulin increases the prevalence of postoperative infection with cytomegalovirus and should not be used in patients undergoing lung transplantation.

Contraindications↗
PubMed1991

Cardiopulmonary exercise responses after single lung transplantation for severe obstructive lung disease.

The purpose of this study was to characterize cardiovascular and ventilatory responses to exercise in single lung transplantation (SLT) recipients with nonseptic, severe obstructive lung disease (SLT-OB). We also investigated whether the hyperinflated native lung in SLT-OB recipients could limit normal increases in tidal volume by mechanically constraining the transplanted lung, resulting in ventilation-perfusion imbalance in the lung graft. Data from six SLT-OB recipients (five women, one man) and six age-matched SLT recipients (two women, four men) with severe interstitial lung disease (SLT-IN) were compared. Resting arterial O2 and CO2 tensions were normal and comparable between the SLT groups. Spirometry results were reduced but comparable between SLT groups. Total lung capacity was significantly larger in patients with SLT-OB than in patients with SLT-IN. Diffusion capacity was not different between SLT groups when differences in alveolar volume were accounted for. Quantitative perfusion to the lung graft was comparable between the SLT groups, but quantitative ventilation was greater in patients with SLT-OB than in patients with SLT-IN. Maximum exercise capacity following SLT-OB was decreased, but was comparable to that of SLT-IN recipients. None of the SLT-OB recipients reached predicted maximum minute ventilation and only one experienced mild arterial O2 desaturation, suggesting peripheral muscle abnormalities from corticosteroid use and deconditioning as limiting factors rather than a ventilatory limitation. Tidal volumes at end exercise in the SLT-OB recipients were normal. Our quantitative lung scan and exercise testing data suggest that ventilation-perfusion imbalance and resulting gas exchange abnormalities from lung graft constraint and compression do not occur at rest or with exercise after SLT for obstructive lung disease.

Anaerobic Threshold↗
PubMed1991

Single lung transplantation. Alternative indications and technique.

Twenty-two patients have undergone 23 single lung transplants between March 1980 and April 1990 at the University of Texas Health Science Center at San Antonio. The actuarial survival rate is 77.27% at 12 months and 72.73% at 24 months. There have been no instances of bronchial dehiscence or stenosis, even though 13 of the patients were on a program of preoperative prednisone, every patient had high-dose perioperative methylprednisolone, and omental wraps were not used on any bronchial anastomosis. Of particular interest is the fact that three patients had primary pulmonary hypertension, three had secondary pulmonary hypertension, and 10 patients had chronic obstructive pulmonary disease, due in five cases to an alpha 1-antitrypsin deficiency. Each of these entities was previously thought to contraindicate single lung transplantation. Donor selection was based on an oxygen tension/inspired oxygen concentration ratio greater than 300, donor/recipient chest circumference within 3 inches, clear chest x-ray film, negative sputum Gram stain, and less than 6-hour estimated ischemic time. Harvest technique included donor prostaglandin E1 500 micrograms, topical slush, and pulmonoplegia with cold Euro-Collins solution. The heart and lung were separated in situ rather than the heart lung block being removed. A telescoping bronchial anastomosis was performed with 4-0 Prolene (not absorbable) sutures. We conclude that single lung transplantation has evolved into a simple operation, necessitating meticulous preoperative and postoperative care, which can be performed on a wide spectrum of critically ill patients with an acceptable mortality rate.

Adult↗
PubMed1990

Single lung transplantation for primary pulmonary hypertension.

Single lung transplantation has become a therapeutic option for end-stage interstitial lung disease and obstructive lung disease. Our group recently extended this treatment to three patients with primary pulmonary hypertension. All patients had marked decreases in pulmonary artery pressures and pulmonary vascular resistance and increases in cardiac output following single lung transplantation. Spirometry, lung volumes, and diffusion capacity were not different in comparison to preoperative studies. Quantitative ventilation-perfusion scans revealed the majority of perfusion distributed to the transplanted lung, with ventilation approximately equally divided between the native and the transplanted lung. Despite ventilation-perfusion imbalance, there was no resting hypoxemia and there was no arterial oxygen desaturation with exercise. One patient expired on the 30th postoperative day due to cytomegalovirus infection of the lungs. In the remaining two patients, maximum exercise capacity following transplantation was near normal in one recipient and reduced in the second recipient. Of note, there was no evidence of ventilatory limitation or impaired oxygenation during exercise in these two recipients. Although an exaggerated exercise ventilatory response was present, this did not limit exercise performance. This report supports the use of single lung transplantation for the treatment of primary pulmonary hypertension.

Adult↗
PubMed1989

Prognosis of patients with AIDS requiring intensive care.

The Acute Physiology and Chronic Health Evaluation (APACHE) II classification, a measure of severity of illness in patients requiring intensive care, was devised before the rapid expansion of the acquired immunodeficiency syndrome (AIDS) epidemic. To determine the applicability of the APACHE II system to AIDS, we related observed in-hospital death rates to those predicted by APACHE II in 83 patients with AIDS. In a control group of patients without AIDS (n = 166) mean predicted and observed death rates (34.1 vs 31.3 percent) were similar. For the AIDS group overall observed mortality (63.9 percent) was significantly greater than that predicted by APACHE II (45.8 percent). The subgroup with Pneumocystis pneumonia requiring mechanical ventilation (n = 37) had an observed mortality (86.5 percent) that significantly exceeded the predicted value (44.3 percent), whereas all other AIDS patients (n = 46) showed similar predicted and observed death rates (47.0 vs 45.7 percent). APACHE II prediction of death rate also matched observed mortality in mechanically ventilated patients without Pneumocystis infection. The discrepancy between predicted and observed mortality in patients with Pneumocystis pneumonia requiring mechanical ventilation is most likely due to the lack of an APACHE II diagnostic category that accurately reflects the severity of this disease. A new diagnostic category that provides accurate outcome prediction in this patient group would form a basis for evaluation of new therapeutic interventions.

Acquired Immunodeficiency Syndrome↗
PubMed1989

Ciguatera fish poisoning.

Cases of ciguatera fish poisoning no longer are confined to endemic areas. This makes awareness of this entity important. The diagnosis usually is made by the presence of gastrointestinal symptoms, nausea, vomiting, and diarrhea, and of neurological symptoms such as paresthesias, paresis, and pruritus. The detection of ciguatoxin in the ingested fish by any of the available bioassays, will confirm the diagnosis. The treatment of this food poisoning is supportive, although intravenous mannitol is reported to be safe and effective. The prognosis is good and complete recovery is to be expected. However, relapses can occur, especially on re-exposure to the toxin.

Adult↗
PubMed1988

Adult visual system plasticity.

The functional area of optometry assumes plasticity of the neurological input to the visual system. This paper reviews the literature which investigates adult visual system plasticity. Literature on development of the visual system, as well as adult central nervous system plasticity, provides additional inferences. A discussion is presented suggesting that there exists a multiplicity of sensitivity periods within the visual system.

Animals↗
PubMed1984

Wirsungorrhagia or hemoductal pancreatitis: report of a case and review of the literature.

An unusual case of gastrointestinal hemorrhage due to rupture of the splenic artery into the pancreatic duct in a patient with chronic pancreatitis is described. The diagnosis was suspected by observing blood coming from the papilla of Vater during duodenoscopy and corroborated by findings seen on splenic arteriography. Previously reported cases are reviewed. An etiology is discussed and a classification suggested. This obscure cause of gastrointestinal bleeding should be suspected when the more common causes of bleeding have been satisfactorily ruled out.

Adult↗
PubMed1983

Toothpick perforation of the duodenum.

An 82-year-old man developed gastrointestinal hemorrhage and polymicrobial sepsis from toothpick perforation of the duodenal bulb. We removed the toothpick endoscopically.

Aged↗
PubMed1983

Pregnancy and inflammatory bowel disease: a review of the literature.

This review encompasses fertility with inflammatory bowel disease, risk of inheritance, effects of inflammatory bowel disease on pregnancy, effects of pregnancy on inflammatory bowel disease, effects of treatment on the mother and child, and pregnancy after proctocolectomy with ileostomy. Fertility is minimally, if at all, compromised. The fetus is likely to survive despite disease activity. Inactive disease favors a normal pregnancy. Active disease may worsen during the first trimester or the puerperium. Close medical supervision allows therapy to be instituted promptly. Patients with Crohn's disease who have medically induced remissions may fare less well than those who have undergone a successful operation. Previous surgery does not preclude vaginal delivery. Sulfasalazine and corticosteroids may be used. Patients with extensive fistulas may require cesarean section. There are few reasons to consider therapeutic abortion.

Colitis, Ulcerative↗