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Tsur E, Blumenfeld P, Rottenberg Y, Nechushtan H, Arnon J, Wald O, Izhar U, Pfeffer R, Krakow A, Wygoda M, Popovtzer A, Michaeli TF. Outcomes of extracranial stereotactic body radiation therapy for induced oligometastatic non-small cell lung cancer on novel systemic therapy. Transl Lung Cancer Res 2024; 13:465-474. [PMID: 38601442 PMCID: PMC11002507 DOI: 10.21037/tlcr-23-802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 01/26/2024] [Indexed: 04/12/2024]
Abstract
Background Stereotactic body radiation therapy (SBRT) is often delivered in patients with oligometastatic disease (OMD). However, the specific subset of patients with polymetastatic non-small cell lung cancer (NSCLC) on novel systemic therapies who develop induced oligopersistant disease (OpersisD) or oligoprogressive disease (OprogD), as defined by the European Organisation for Research and Treatment of Cancer (EORTC) OMD classification, has not been well described. This study explores the outcomes of patients treated with this strategy. Methods Patients with stage IV NSCLC being treated with osimertinib or immune checkpoint inhibitors (ICIs) who received extracranial SBRT for OpersisD or OprogD were identified in our retrospective analysis. Outcomes reported include progression-free survival (PFS), time to change of systemic treatment (TTCST), overall survival (OS), local control (LC) and treatment-related toxicity. Results Forty-nine patients received SBRT for OpersisD (34.7%) or OprogD (65.3%) at a median of 5.8 and 15.3 months after start of systemic therapy, respectively. 55.1% received concurrent osimertinib and 44.9% received ICI. Seventy-seven extracranial lesions were treated with various fractionation schemas. At a median of 18.8 months follow-up from first SBRT, LC was achieved in 92.2% of total lesions treated (71). The 1-year OS was 91.7% for OpersisD and 83.3% for OprogD. OpersisD compared to OprogD had a longer median PFS (18.3 vs. 6.1 months) and longer median TTCST (23.6 vs. 13.5 months), median OS was not reached for either cohort. On multivariate analysis, patients treated with osimertinib had shorter PFS (HR: 2.20; 95% CI: 1.01-4.82; P=0.048) and shorter TTCST (HR: 2.83; 95% CI: 1.09-7.33; P=0.032). One patient (2%) experienced grade 3 pneumonitis after SBRT, and no grade 4-5 toxicities were reported with SBRT treatment. Conclusions This study indicates that SBRT for OpersisD or OprogD in Stage IV NSCLC patients on osimertinib or ICIs is safe, very well tolerated, and may prolong the time before needing a shift in systemic therapy. Further prospective research is needed to validate and expand upon these findings.
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Affiliation(s)
- Eyal Tsur
- Department of Military Medicine, “Tzameret”, and Medical Corps, Israel Defense Forces, Ramat Gan, Israel
- Department of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Philip Blumenfeld
- Department of Radiation Oncology, Sharett Institute of Oncology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yakir Rottenberg
- Department of Medical Oncology, Sharett Institute of Oncology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hovav Nechushtan
- Department of Medical Oncology, Sharett Institute of Oncology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Johnathan Arnon
- Department of Medical Oncology, Sharett Institute of Oncology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ori Wald
- Department of Cardiothoracic Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Uzi Izhar
- Department of Cardiothoracic Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Raphael Pfeffer
- Department of Radiation Oncology, Sharett Institute of Oncology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aron Krakow
- Department of Developmental Biology and Cancer Research Institute for Medical Research Israel-Canada, Hebrew University Medical School, Jerusalem, Israel
| | - Marc Wygoda
- Department of Radiation Oncology, Sharett Institute of Oncology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aron Popovtzer
- Department of Radiation Oncology, Sharett Institute of Oncology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tal Falick Michaeli
- Department of Radiation Oncology, Sharett Institute of Oncology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Developmental Biology and Cancer Research Institute for Medical Research Israel-Canada, Hebrew University Medical School, Jerusalem, Israel
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Peretz A, Loyfer N, Piyanzin S, Ochana BL, Neiman D, Magenheim J, Klochendler A, Drawshy Z, Fox-Fisher I, Fridlich O, Moss J, Cohen D, Zemmour H, Cann G, Bredno J, Venn O, Avni B, Alekberli T, Samet Y, Korach A, Wald O, Yutkin V, Izhar U, Pillar N, Grompe M, Fridlender Z, Rokach A, Planer D, Landesberg G, Glaser B, Shemer R, Kaplan T, Dor Y. The DNA methylome of human vascular endothelium and its use in liquid biopsies. Med 2023; 4:263-281.e4. [PMID: 37060900 DOI: 10.1016/j.medj.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 02/17/2023] [Accepted: 03/17/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND Vascular endothelial cells (VECs) are an essential component of each tissue, contribute to multiple pathologies, and are targeted by important drugs. Yet, there is a shortage of biomarkers to assess VEC turnover. METHODS To develop DNA methylation-based liquid biopsies for VECs, we determined the methylome of VECs isolated from freshly dissociated human tissues. FINDINGS A comparison with a human cell-type methylome atlas yielded thousands of loci that are uniquely unmethylated in VECs. These sites are typically gene enhancers, often residing adjacent to VEC-specific genes. We also identified hundreds of genomic loci that are differentially methylated in organotypic VECs, indicating that VECs feeding specific organs are distinct cell types with a stable epigenetic identity. We established universal and lung-specific VEC markers and evaluated their presence in circulating cell-free DNA (cfDNA). Nearly 2.5% of cfDNA in the plasma of healthy individuals originates from VECs. Sepsis, graft versus host disease, and cardiac catheterization are associated with elevated levels of VEC-derived cfDNA, indicative of vascular damage. Lung-specific VEC cfDNA is selectively elevated in patients with chronic obstructive pulmonary disease (COPD) or lung cancer, revealing tissue-specific vascular turnover. CONCLUSIONS VEC cfDNA biomarkers inform vascular dynamics in health and disease, potentially contributing to early diagnosis and monitoring of pathologies, and assessment of drug activity. FUNDING This work was supported by the Beutler Research Program, Helmsley Charitable Trust, JDRF, Grail and the DON Foundation (to Y.D.). Y.D holds the Walter & Greta Stiel Chair in heart studies. B.G., R.S., J.M., D.N., T.K., and Y.D. filed patents on cfDNA analysis.
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Affiliation(s)
- Ayelet Peretz
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Netanel Loyfer
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sheina Piyanzin
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Bracha Lea Ochana
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Daniel Neiman
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Judith Magenheim
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Agnes Klochendler
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Zeina Drawshy
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilana Fox-Fisher
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ori Fridlich
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joshua Moss
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Daniel Cohen
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hai Zemmour
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gordon Cann
- GRAIL, LLC, a subsidiary of Illumina, LLC, Menlo Park, CA, USA
| | - Joerg Bredno
- GRAIL, LLC, a subsidiary of Illumina, LLC, Menlo Park, CA, USA
| | - Oliver Venn
- GRAIL, LLC, a subsidiary of Illumina, LLC, Menlo Park, CA, USA
| | - Batia Avni
- Department of Bone Marrow Transplantation and Immunotherapy, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tural Alekberli
- Department of Anesthesiology and Critical Care Management, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yaacov Samet
- Department of Vascular Surgery, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Amit Korach
- Department of Cardiothoracic Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ori Wald
- Department of Cardiothoracic Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Vladimir Yutkin
- Department of Urology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Uzi Izhar
- Department of Cardiothoracic Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Nir Pillar
- Department of Pathology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Markus Grompe
- Pape Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR, USA
| | - Zvi Fridlender
- Institute of Pulmonary Medicine, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ariel Rokach
- Pulmonary Institute, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Planer
- Department of Cardiology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Giora Landesberg
- Department of Anesthesiology and Critical Care Management, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Benjamin Glaser
- Department of Endocrinology and Metabolism, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ruth Shemer
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tommy Kaplan
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yuval Dor
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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Alfi O, Yakirevitch A, Wald O, Wandel O, Izhar U, Oiknine-Djian E, Nevo Y, Elgavish S, Dagan E, Madgar O, Feinmesser G, Pikarsky E, Bronstein M, Vorontsov O, Jonas W, Ives J, Walter J, Zakay-Rones Z, Oberbaum M, Panet A, Wolf DG. Human Nasal and Lung Tissues Infected Ex Vivo with SARS-CoV-2 Provide Insights into Differential Tissue-Specific and Virus-Specific Innate Immune Responses in the Upper and Lower Respiratory Tract. J Virol 2021; 95:e0013021. [PMID: 33893170 PMCID: PMC8223920 DOI: 10.1128/jvi.00130-21] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/20/2021] [Indexed: 12/25/2022] Open
Abstract
The nasal mucosa constitutes the primary entry site for respiratory viruses, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While the imbalanced innate immune response of end-stage coronavirus disease 2019 (COVID-19) has been extensively studied, the earliest stages of SARS-CoV-2 infection at the mucosal entry site have remained unexplored. Here, we employed SARS-CoV-2 and influenza virus infection in native multi-cell-type human nasal turbinate and lung tissues ex vivo, coupled with genome-wide transcriptional analysis, to investigate viral susceptibility and early patterns of local mucosal innate immune response in the authentic milieu of the human respiratory tract. SARS-CoV-2 productively infected the nasal turbinate tissues, predominantly targeting respiratory epithelial cells, with a rapid increase in tissue-associated viral subgenomic mRNA and secretion of infectious viral progeny. Importantly, SARS-CoV-2 infection triggered robust antiviral and inflammatory innate immune responses in the nasal mucosa. The upregulation of interferon-stimulated genes, cytokines, and chemokines, related to interferon signaling and immune-cell activation pathways, was broader than that triggered by influenza virus infection. Conversely, lung tissues exhibited a restricted innate immune response to SARS-CoV-2, with a conspicuous lack of type I and III interferon upregulation, contrasting with their vigorous innate immune response to influenza virus. Our findings reveal differential tissue-specific innate immune responses in the upper and lower respiratory tracts that are specific to SARS-CoV-2. The studies shed light on the role of the nasal mucosa in active viral transmission and immune defense, implying a window of opportunity for early interventions, whereas the restricted innate immune response in early-SARS-CoV-2-infected lung tissues could underlie the unique uncontrolled late-phase lung damage of advanced COVID-19. IMPORTANCE In order to reduce the late-phase morbidity and mortality of COVID-19, there is a need to better understand and target the earliest stages of SARS-CoV-2 infection in the human respiratory tract. Here, we have studied the initial steps of SARS-CoV-2 infection and the consequent innate immune responses within the natural multicellular complexity of human nasal mucosal and lung tissues. Comparing the global innate response patterns of nasal and lung tissues infected in parallel with SARS-CoV-2 and influenza virus, we found distinct virus-host interactions in the upper and lower respiratory tract, which could determine the outcome and unique pathogenesis of SARS-CoV-2 infection. Studies in the nasal mucosal infection model can be employed to assess the impact of viral evolutionary changes and evaluate new therapeutic and preventive measures against SARS-CoV-2 and other human respiratory pathogens.
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Affiliation(s)
- Or Alfi
- Clinical Virology Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Department of Biochemistry, IMRIC, The Hebrew University Faculty of Medicine, Jerusalem, Israel
- Lautenberg Center for General and Tumor Immunology, The Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Arkadi Yakirevitch
- Department of Otolaryngology—Head and Neck Surgery, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Wald
- Department of Cardiothoracic Surgery, Hadassah University Hospital, Jerusalem, Israel
| | - Ori Wandel
- Clinical Virology Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Uzi Izhar
- Department of Cardiothoracic Surgery, Hadassah University Hospital, Jerusalem, Israel
| | - Esther Oiknine-Djian
- Clinical Virology Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Yuval Nevo
- Bioinformatics Unit of the I-CORE Computation Center, The Hebrew University and Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Sharona Elgavish
- Bioinformatics Unit of the I-CORE Computation Center, The Hebrew University and Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Elad Dagan
- Department of Otolaryngology—Head and Neck Surgery, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ory Madgar
- Department of Otolaryngology—Head and Neck Surgery, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gilad Feinmesser
- Department of Otolaryngology—Head and Neck Surgery, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eli Pikarsky
- Lautenberg Center for General and Tumor Immunology, The Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Michal Bronstein
- Center for Genomic Technologies, Alexander Silberman Institute of Life Sciences, Hebrew University, Jerusalem, Israel
| | - Olesya Vorontsov
- Clinical Virology Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Department of Biochemistry, IMRIC, The Hebrew University Faculty of Medicine, Jerusalem, Israel
- Lautenberg Center for General and Tumor Immunology, The Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Wayne Jonas
- Samueli Institute, Alexandria, Virginia, USA
| | - John Ives
- Samueli Institute, Alexandria, Virginia, USA
| | - Joan Walter
- Samueli Institute, Alexandria, Virginia, USA
| | - Zichria Zakay-Rones
- Department of Biochemistry, IMRIC, The Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Menachem Oberbaum
- The Center for Integrative Complementary Medicine, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Amos Panet
- Department of Biochemistry, IMRIC, The Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Dana G. Wolf
- Clinical Virology Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Lautenberg Center for General and Tumor Immunology, The Hebrew University Faculty of Medicine, Jerusalem, Israel
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Wald O, Sadeh BM, Bdolah-Abram T, Erez E, Shapira OM, Izhar U. Outcomes of sublobar resection vs lobectomy for invasive clinical stage T1N0 non-small-cell lung cancer: A propensity-match analysis. Cancer Rep (Hoboken) 2021; 4:e1339. [PMID: 33570255 PMCID: PMC8222555 DOI: 10.1002/cnr2.1339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/22/2020] [Accepted: 01/05/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The role of sub lobar resection (SLR; either segmentectomy or wedge resection) vs lobectomy (LBCT) for invasive clinical stage T1N0 non-small-cell-lung-cancer (NSCLC) has not been fully established yet. AIM We aimed to characterize the preoperative parameters leading to selecting SLR and compare the overall survival (OS) and disease-free survival (DFS) of these two surgical approaches. METHODS Clinical data on 162 patients (LBCT-107; SLR-55) were prospectively entered in our departmental database. Preoperative parameters associated with the performance of SLR were identified using univariate and multivariate cox regression analysis. The Kaplan-Meier method was used to compute OS and DFS. Comparison between LBCT and SLR groups and 32 propensity-matched groups was performed using Log-rank test. RESULTS Median follow-up time for the LBCT and SLR groups was 4.76 (Inter-quartile range [IQR] 2.96 to 8.23) and 3.38 (IQR 2.9 to 6.19) years respectively. OS and DFS rates were similar between the two groups in the entire cohort (OS-LBCT vs SLR P = .853, DSF-LBCT vs SLR P = .653) and after propensity matching (OS-LBCT vs SLR P = .563 DSF-LBCT vs SLR P = .632). Specifically, Two- and five-year OS rates for LBCT and SLR were 90.6.% vs 92.7%, 71.8% vs 75.9% respectively. Independent predictors of selecting for SLR included older age (P < .001), reduced FEV1% (P = .026), smaller tumor size (P = .025), smaller invasive component (P = .021) and higher American Society of Anesthesiology scores (P = .014). CONCLUSIONS In 162 consecutive and 32 matched cases, SLR and lobar resection had similar overall and disease-free survival rates. SLR may be considered as a reasonable oncological procedure in carefully selected T1N0 NSCLC patients that present with multiple comorbidities and relatively small tumors.
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Affiliation(s)
- Ori Wald
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Bar Moshe Sadeh
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Tali Bdolah-Abram
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Eldad Erez
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Oz Moshe Shapira
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Uzi Izhar
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Hospital, Jerusalem, Israel
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Shapira-Daniels A, Blumenfeld O, Korach A, Rudis E, Izhar U, Shapira OM. The American Society of Thoracic Surgery Score versus EuroSCORE I and EuroSCORE II in Israeli Patients Undergoing Cardiac Surgery. Isr Med Assoc J 2019; 21:671-675. [PMID: 31599509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Recently, Israel established the first national-level adult cardiac surgery database, which was linked to the Society of Thoracic Surgeons (STS). OBJECTIVES To validate and compare the STS predicted risk of mortality (PROM) to logistic EuroSCORE I (LESI) and EuroSCORE II (ESII) in Israeli patients undergoing cardiac surgery. METHODS We retrospectively studied 1279 consecutive patients who underwent cardiac surgeries with a calculable PROM. Data were prospectively entered into our database and used to calculate PROM, LESI, and ESII. Scores were normalized and correlated using linear regression and Pearson's test. To examine model calibration, we plotted the total observed versus expected mortality for each score and across five risk-score subgroups. Model discrimination was assessed by measuring the area under the receiver operating curves. RESULTS The observed 30-day operative mortality was 1.95%. The median (IQ1; IQ3) PROM, LESI, and the ESII scores were 1.45% (0.69; 3.22), 4.54% (2.28; 9.27), and 1.88% (1.18; 3.54), respectively, with observed over expected ratios of 0.63 (95% confidence interval [95%CI] 0.42-0.93), 0.59 (95%CI 0.40-0.87), and 0.24 (95%CI 0.17-0.36), respectively, (STS vs. ESII P = 0.36, STS vs. LESI P = 0.0001). There was good correlation among all scores. All models overestimated mortality. Model discrimination was high and similar for all three scores. Model calibration of the STS, PROM, and ESII were more accurate than the LESI, particularly in higher risk subgroups. CONCLUSIONS All scores overestimated mortality. In Israeli patients, the STS, PROM, and ESII risk-scores were more reliable metrics than LESI, particularly in higher risk patients.
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Affiliation(s)
- Ayelet Shapira-Daniels
- Department of Cardiothoracic Surgery, Hadassah-Hebrew University Medical Center, Ein Kerem Campus, Jerusalem, Israel
| | - Orit Blumenfeld
- Israel Center for Disease Control, Division of Medical Technologies and Research, Ministry of Health, Sheba Medical Center, Tel Hashomer, Israel
| | - Amit Korach
- Department of Cardiothoracic Surgery, Hadassah-Hebrew University Medical Center, Ein Kerem Campus, Jerusalem, Israel
| | - Ehud Rudis
- Department of Cardiothoracic Surgery, Hadassah-Hebrew University Medical Center, Ein Kerem Campus, Jerusalem, Israel
| | - Uzi Izhar
- Department of Cardiothoracic Surgery, Hadassah-Hebrew University Medical Center, Ein Kerem Campus, Jerusalem, Israel
| | - Oz M Shapira
- Department of Cardiothoracic Surgery, Hadassah-Hebrew University Medical Center, Ein Kerem Campus, Jerusalem, Israel
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Shapira OM, Korach A, Izhar U, Koler T, Wald O, Ayman M, Erez E, Blackmon SH, Reardon MJ. Radical multidisciplinary approach to primary cardiac sarcomas†. Eur J Cardiothorac Surg 2013; 44:330-5; discussion 335-6. [DOI: 10.1093/ejcts/ezt029] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Wald O, Shapira OM, Izhar U. CXCR4/CXCL12 axis in non small cell lung cancer (NSCLC) pathologic roles and therapeutic potential. Am J Cancer Res 2013; 3:26-33. [PMID: 23382783 PMCID: PMC3563078 DOI: 10.7150/thno.4922] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 10/03/2012] [Indexed: 12/14/2022] Open
Abstract
Lung cancer is the second most common malignancy and the leading cause of cancer-related death in the western world. Moreover, despite advances in surgery, chemotherapy and radiotherapy, the death rate from lung cancer remains high and the reported overall five-year survival rate is only 15%. Thus, novel treatments for this devastating disease are urgently needed. Chemokines, a family of 48 chemotactic cytokines interacts with their 7 transmembrane G-protein-coupled receptors, to guide immune cell trafficking in the body under both physiologic and pathologic conditions. Tumor cells, which express a relatively restricted repertoire of chemokine and chemokine receptors, utilize and manipulate the chemokine system in a manner that benefits both local tumor growth and distant dissemination. Among the 19 chemokine receptors, CXCR4 is the receptor most widely expressed by malignant tumors and whose role in tumor biology is most thoroughly studied. The chemokine CXCL12, which is the sole ligand of CXCR4, is highly expressed in primary lung cancer as well as in the bone marrow, liver, adrenal glands and brain, which are all sites for lung cancer metastasis. This review focuses on the pathologic role of the CXCR4/CXCL12 axis in NSCLC and on the potential therapeutic implication of targeting this axis for the treatment of NSCLC.
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Fahham D, Weiss ID, Abraham M, Beider K, Hanna W, Shlomai Z, Eizenberg O, Zamir G, Izhar U, Shapira OM, Peled A, Wald O. In vitro and in vivo therapeutic efficacy of CXCR4 antagonist BKT140 against human non–small cell lung cancer. J Thorac Cardiovasc Surg 2012; 144:1167-1175.e1. [DOI: 10.1016/j.jtcvs.2012.07.031] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 06/27/2012] [Accepted: 07/25/2012] [Indexed: 01/31/2023]
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Yaacov B, Lazar I, Tayeb S, Frank S, Izhar U, Lotem M, Perlman R, Ben-Yehuda D, Zakay-Rones Z, Panet A. Extracellular matrix constituents interfere with Newcastle disease virus spread in solid tissue and diminish its potential oncolytic activity. J Gen Virol 2012; 93:1664-1672. [PMID: 22622327 DOI: 10.1099/vir.0.043281-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Advanced melanoma cells, characterized by resistance to chemotherapy, have been shown to be highly sensitive to oncolysis by Newcastle disease virus (NDV). In the present study, we investigated the capacity of NDV to specifically infect and spread into solid tissues of human melanoma and lung carcinoma, in vivo and ex vivo. For this purpose a new model of SCID-beige mice implanted with human melanoma was developed. Surprisingly, the replication competent NDV-MTH and the attenuated, single-cycle replication NDV-HUJ strains, demonstrated a similar oncolytic activity in the melanoma-implanted mice. Further, ex vivo analysis, using organ cultures derived from the melanoma tissues indicated a limited spread of the two NDV strains in the tissue. Extracellular matrix (ECM) molecules, notably heparin sulfate and collagen, were found to limit viral spread in the tissue. This observation was validated with yet another solid tumour of human lung carcinoma. Taken together, the results indicate that the ECM acts as a barrier to virus spread within solid tumour tissues and that this restriction must be overcome to achieve effective oncolysis with NDV.
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Affiliation(s)
- Barak Yaacov
- Department of Biochemistry, the Chanock Center for Virology, IMRIC, Hadassah Medical Center-Hebrew University, Jerusalem 91120, Israel
| | - Itay Lazar
- Department of Hematology, Hadassah Medical Center-Hebrew University, Jerusalem 91120, Israel
| | - Shay Tayeb
- Department of Biochemistry, the Chanock Center for Virology, IMRIC, Hadassah Medical Center-Hebrew University, Jerusalem 91120, Israel
| | - Sivan Frank
- Department of Hematology, Hadassah Medical Center-Hebrew University, Jerusalem 91120, Israel
| | - Uzi Izhar
- Department of Cardiothoracic Surgery, Hadassah Medical Center-Hebrew University, Jerusalem 91120, Israel
| | - Michal Lotem
- Department of Oncology, Hadassah Medical Center-Hebrew University, Jerusalem 91120, Israel
| | - Riki Perlman
- Department of Hematology, Hadassah Medical Center-Hebrew University, Jerusalem 91120, Israel
| | - Dina Ben-Yehuda
- Department of Hematology, Hadassah Medical Center-Hebrew University, Jerusalem 91120, Israel
| | - Zichria Zakay-Rones
- Department of Biochemistry, the Chanock Center for Virology, IMRIC, Hadassah Medical Center-Hebrew University, Jerusalem 91120, Israel
| | - Amos Panet
- Department of Biochemistry, the Chanock Center for Virology, IMRIC, Hadassah Medical Center-Hebrew University, Jerusalem 91120, Israel
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10
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Kirshberg S, Izhar U, Amir G, Demma J, Vernea F, Beider K, Shlomai Z, Wald H, Zamir G, Shapira OM, Peled A, Wald O. Involvement of CCR6/CCL20/IL-17 axis in NSCLC disease progression. PLoS One 2011; 6:e24856. [PMID: 21949768 PMCID: PMC3174223 DOI: 10.1371/journal.pone.0024856] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 08/22/2011] [Indexed: 01/17/2023] Open
Abstract
Objectives Autocrine and paracrine chemokine/chemokine receptor-based interactions promote non-small-cell-lung-cancer (NSCLC) carcinogenesis. CCL20/CCR6 interactions are involved in prostatic and colonic malignancy pathogenesis. The expression and function of CCL20/CCR6 and its related Th-17 type immune response in NSCLC is not yet defined. We sought to characterize the role of the CCL20/CCR6/IL-17 axis in NSCLC tumor growth. Methods A specialized histopathologist blindly assessed CCL20/CCR6 expression levels in 49 tissue samples of NSCLC patients operated in our department. Results were correlated to disease progression. Colony assays, ERK signaling and chemokine production were measured to assess cancer cell responsiveness to CCL20 and IL-17 stimulation. Results CCL20 was highly expressed in the majority (38/49, 77.5%) of tumor samples. Only a minority of samples (8/49, 16.5%) showed high CCR6 expression. High CCR6 expression was associated with a shorter disease-free survival (P = 0.008) and conferred a disease stage-independent 4.87-fold increased risk for disease recurrence (P = 0.0076, CI 95% 1.52–15.563). Cancerous cell colony-forming capacity was increased by CCL20 stimulation; this effect was dependent in part on ERK phosphorylation and signaling. IL-17 expression was detected in NSCLC; IL-17 potentiated the production of CCL20 by cancerous cells. Conclusion Our findings suggest that the CCL20/CCR6 axis promotes NSCLC disease progression. CCR6 is identified as a potential new prognostic marker and the CCL20/CCR6/IL-17 axis as a potential new therapeutic target. Larger scale studies are required to consolidate these observations.
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Affiliation(s)
- Sophie Kirshberg
- Goldyne Savad Institute of Gene Therapy, Hadassah University Hospital, Jerusalem, Israel
| | - Uzi Izhar
- Department of Cardiothoracic Surgery, Hadassah University Hospital, Jerusalem, Israel
| | - Gail Amir
- Department of Pathology, Hadassah University Hospital, Jerusalem, Israel
| | - Jonathan Demma
- Laboratory for Surgical Research, Hadassah University Hospital, Jerusalem, Israel
- Department of Surgery, Hadassah University Hospital, Jerusalem, Israel
| | - Fiona Vernea
- Department of Pathology, Hadassah University Hospital, Jerusalem, Israel
| | - Katia Beider
- Goldyne Savad Institute of Gene Therapy, Hadassah University Hospital, Jerusalem, Israel
| | - Zippora Shlomai
- Laboratory for Surgical Research, Hadassah University Hospital, Jerusalem, Israel
| | - Hanna Wald
- Goldyne Savad Institute of Gene Therapy, Hadassah University Hospital, Jerusalem, Israel
| | - Gideon Zamir
- Laboratory for Surgical Research, Hadassah University Hospital, Jerusalem, Israel
- Department of Surgery, Hadassah University Hospital, Jerusalem, Israel
| | - Oz M. Shapira
- Department of Cardiothoracic Surgery, Hadassah University Hospital, Jerusalem, Israel
| | - Amnon Peled
- Goldyne Savad Institute of Gene Therapy, Hadassah University Hospital, Jerusalem, Israel
| | - Ori Wald
- Department of Cardiothoracic Surgery, Hadassah University Hospital, Jerusalem, Israel
- * E-mail:
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11
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Massler A, Kolodkin-Gal D, Meir K, Khalaileh A, Falk H, Izhar U, Shufaro Y, Panet A. Infant lungs are preferentially infected by adenovirus and herpes simplex virus type 1 vectors: role of the tissue mesenchymal cells. J Gene Med 2011; 13:101-13. [DOI: 10.1002/jgm.1544] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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12
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Wald O, Shapira OM, Murar A, Izhar U. Paraganglioma of the mediastinum: challenges in diagnosis and surgical management. J Cardiothorac Surg 2010; 5:19. [PMID: 20356401 PMCID: PMC2862032 DOI: 10.1186/1749-8090-5-19] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2009] [Accepted: 03/31/2010] [Indexed: 11/10/2022] Open
Abstract
Mediastinal paraganglioms are rare, highly vascularized tumors arising from chromaffin tissue located in the para-aortic ganglia. Tumors tend to invade bordering structures and may also form metastasis. Up to 50% of patients are asymptomatic and diagnosis is incidental. Presenting symptoms are related to catecholamine hypersecretion or to a mass effect. Complete surgical resection remains the standard of care due to malignant potential of the tumor and poor response to chemotherapy or radiation. Strategic location of the tumor in proximity to great vessels, trachea, and recurrent laryngeal nerve poses challenge for the surgeon. We report a case of a 59-year old asymptomatic female who was incidentally diagnosed with a middle mediastinal mass on a positron-emission tomography (PET-CT) scan performed as part of breast cancer surveillance. Complete resection of the tumor was achieved using cardiopulmonary bypass. The patient recovered uneventfully and in a ten-month follow up there is no evidence of recurrence.
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Affiliation(s)
- Ori Wald
- Department of Cardiothoracic Surgery, Hadassah University Hospital, Jerusalem, Israel
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13
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Kedmi M, Cohen-Poradosu R, Gilon D, Izhar U, Sviri S. Thoracic actinomycosis with extension of the infection to the pericardium and chest wall. Isr Med Assoc J 2007; 9:490-1. [PMID: 17642405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Meirav Kedmi
- Departments of Internal Medicine A, Hebrew University-Hadassah Medical Center, Jerusalem, Israel.
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14
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Mintz Y, Easter DW, Izhar U, Edden Y, Talamini MA, Rivkind AI. Minimally Invasive Procedures for Diagnosis of Traumatic Right Diaphragmatic Tears: A Method for Correct Diagnosis in Selected Patients. Am Surg 2007. [DOI: 10.1177/000313480707300416] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Traumatic rupture of the diaphragm is no longer uncommon. Because of the increasing frequency of motor vehicle accidents, the rate of blunt trauma to the chest and abdomen, which are the most common causes of diaphragmatic rupture, is increased as well. However, the diagnosis is frequently missed or delayed because of the lack of sensitivity and specificity of imaging modalities. Diagnostic laparoscopy is considered a standard tool for penetrating injuries to the left diaphragm and is widely practiced in selected cases. Right diaphragmatic tears, however, are more difficult to diagnose because of the sealing effect of the liver. Blunt abdominal trauma can cause large right diaphragmatic tears, causing liver incarcerations and respiratory compromise, therefore demanding the need for a comparable diagnostic tool. A high index of suspicion, together with knowledge of the mechanism of trauma, is the key factor for the correct diagnosis. Once the diagnosis has been considered, diagnostic laparoscopy and/or diagnostic thoracoscopy should be performed to confirm or rule out this injury. Factors suggestive of a right diaphragmatic tear include newly or progressive elevation of the right diaphragm and respiratory distress without underlining lung injury. The timing of the procedure should be in accordance with the hemodynamic and respiratory status of the patient. This procedure should be performed semielectively if there are no other indications for surgical intervention.
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Affiliation(s)
- Yoav Mintz
- University of California San Diego Medical Center, San Diego, California, and
| | - David W. Easter
- University of California San Diego Medical Center, San Diego, California, and
| | - Uzi Izhar
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yair Edden
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Mark A. Talamini
- University of California San Diego Medical Center, San Diego, California, and
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15
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Mintz Y, Easter DW, Izhar U, Edden Y, Talamini MA, Rivkind AI. Minimally invasive procedures for diagnosis of traumatic right diaphragmatic tears: a method for correct diagnosis in selected patients. Am Surg 2007; 73:388-92. [PMID: 17439035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Traumatic rupture of the diaphragm is no longer uncommon. Because of the increasing frequency of motor vehicle accidents, the rate of blunt trauma to the chest and abdomen, which are the most common causes of diaphragmatic rupture, is increased as well. However, the diagnosis is frequently missed or delayed because of the lack of sensitivity and specificity of imaging modalities. Diagnostic laparoscopy is considered a standard tool for penetrating injuries to the left diaphragm and is widely practiced in selected cases. Right diaphragmatic tears, however, are more difficult to diagnose because of the sealing effect of the liver. Blunt abdominal trauma can cause large right diaphragmatic tears, causing liver incarcerations and respiratory compromise, therefore demanding the need for a comparable diagnostic tool. A high index of suspicion, together with knowledge of the mechanism of trauma, is the key factor for the correct diagnosis. Once the diagnosis has been considered, diagnostic laparoscopy and/or diagnostic thoracoscopy should be performed to confirm or rule out this injury. Factors suggestive of a right diaphragmatic tear include newly or progressive elevation of the right diaphragm and respiratory distress without underlining lung injury. The timing of the procedure should be in accordance with the hemodynamic and respiratory status of the patient. This procedure should be performed semielectively if there are no other indications for surgical intervention.
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Affiliation(s)
- Yoav Mintz
- University of California San Diego Medical Center, San Diego, California 92103, USA
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16
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Arish N, Eldor R, Fellig Y, Bogot N, Laxer U, Izhar U, Rokach A. Lymphocytic interstitial pneumonia associated with common variable immunodeficiency resolved with intravenous immunoglobulins. Thorax 2007; 61:1096-7. [PMID: 17114373 PMCID: PMC2117067 DOI: 10.1136/thx.2004.029819] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Lymphocytic interstitial pneumonia (LIP) is a rare form of interstitial lung disease. A few case reports have described an association with common variable immunodeficiency (CVID). Corticosteroids are usually used to treat symptomatic patients but their efficacy has never been studied in a controlled trial. We describe a patient with LIP and CVID who was treated monthly with intravenous immunoglobulins (IVIG) without steroids. The patient improved dramatically. We believe that, in selected cases of LIP and immunodeficiency, IVIG given monthly should be considered as the only treatment without adding steroids.
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Affiliation(s)
- N Arish
- Department of Medicine C, Hadassah-Hebrew University Medical Center, Jerusalem, Israel 91120
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17
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Wald O, Izhar U, Amir G, Avniel S, Bar-Shavit Y, Wald H, Weiss ID, Galun E, Peled A. CD4+CXCR4highCD69+ T Cells Accumulate in Lung Adenocarcinoma. J Immunol 2006; 177:6983-90. [PMID: 17082613 DOI: 10.4049/jimmunol.177.10.6983] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The chemokine receptor CXCR4 is involved in the growth and metastasis of tumor cells. However, the expression of its ligand, the chemokine CXCL12, in tumors and its role in regulating the accumulation of immune cells within the tumors is not clear. Using ELISA and immunohistochemistry we found that CXCL12 is expressed in the majority of nonsmall cell lung cancer tissue sections obtained from stage IA to IIB nonsmall cell lung cancer patients undergoing operation. Histopathologic examination of these sections indicated that high CXCL12 expression correlated with increased tumor inflammation. In addition, disease recurrence rates in a subgroup of adenocarcinoma patients showed a tendency to correlate with high CXCL12 expression in the tumor. Isolation of adenocarcinoma-infiltrating immune cells demonstrated an increase in the percentage of CD4+CD69+CXCR4+ T cells as compared with normal lung tissue. About 30% of these cells expressed the regulatory T cell markers CD25high and FoxP3. The percentage of CD8 T cells within the tumor did not change, however; the percentage of NK and NK T cells was significantly reduced. In correlation with CXCR4 expression, CD4 T cells showed increased migration in response to CXCL12 compared with CD8 T cells and NK cells. Overall, these observations suggest that CXCL12 expression may influence tumor progression by shaping the immune cell population infiltrating lung adenocarcinoma tumors.
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MESH Headings
- Adenocarcinoma/chemistry
- Adenocarcinoma/immunology
- Adenocarcinoma/pathology
- Aged
- Antigens, CD/biosynthesis
- Antigens, Differentiation, T-Lymphocyte/biosynthesis
- Biomarkers, Tumor/biosynthesis
- Biomarkers, Tumor/chemistry
- CD4-Positive T-Lymphocytes/immunology
- CD4-Positive T-Lymphocytes/metabolism
- CD4-Positive T-Lymphocytes/pathology
- CD8-Positive T-Lymphocytes/immunology
- CD8-Positive T-Lymphocytes/metabolism
- CD8-Positive T-Lymphocytes/pathology
- Carcinoma, Non-Small-Cell Lung/chemistry
- Carcinoma, Non-Small-Cell Lung/immunology
- Carcinoma, Non-Small-Cell Lung/pathology
- Cell Movement/immunology
- Chemokine CXCL12
- Chemokines, CXC/metabolism
- Female
- Humans
- Killer Cells, Natural/immunology
- Killer Cells, Natural/metabolism
- Killer Cells, Natural/pathology
- Lectins, C-Type
- Lung Neoplasms/chemistry
- Lung Neoplasms/immunology
- Lung Neoplasms/pathology
- Lymphocytes, Tumor-Infiltrating/immunology
- Lymphocytes, Tumor-Infiltrating/metabolism
- Lymphocytes, Tumor-Infiltrating/pathology
- Male
- Receptors, CXCR4/biosynthesis
- Receptors, CXCR4/metabolism
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Affiliation(s)
- Ori Wald
- Goldyne Savad Institute of Gene Therapy, Hadassah University Hospital, Jerusalem, Isreal
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18
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Shuvy M, Rav-Acha M, Izhar U, Ron M, Nir-Paz R. Massive empyema caused by Mycoplasma pneumoniae in an adult: a case report. BMC Infect Dis 2006; 6:18. [PMID: 16451727 PMCID: PMC1397845 DOI: 10.1186/1471-2334-6-18] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2005] [Accepted: 02/01/2006] [Indexed: 01/27/2023] Open
Abstract
Background Mycoplasma pneumoniae is responsible for more than 20% of community acquired pneumonia cases, and capable of causing upper respiratory illness as well. Complications of M.pneumoniae infections include CNS involvement but other as pericarditis were also reported. The lack of feasible culture methods and under appreciation of the pathogens ability to cause invasive disease leads to reduced number of diagnosed M.pneumoniae related complications. In contrast to many other respiratory pathogens causing pneumonia, M. pneumoniae related severe pleural complications were almost never reported. Case presentation We report a previously healthy 57 years old woman presented with indolent massive right pleural effusion, leukocytosis and elevated ESR. Extensive microbiological evaluation didn't reveal any pathogen in the pus even before antibiotic treatment was started. Surprisingly, M.pneumoniae DNA was detected in the pus from the empyema using PCR designed to detect M.pneumoniae. A serological assay (Serodia-Myco II) using convalescent serum was indeterminate with a titer of 1:80. The patient responded well to a treatment that included right thoracotomy with pleural decortication and a combination of antibiotics and anti-inflammatory medications. Conclusion M.pneumoniae related empyema was never reported before in adult patients and was reported in only a few pediatric patients. In our patient there was no evidence to any common pathogens even before initiating antibiotic treatment. The only pathogen detected was M.pneumoniae. In this patient, serology was not helpful in establishing the diagnosis of M.pneumoniae related diseases, as was suggested before for older patients. We suggest that M.pneumoniae related empyema is probably under-diagnosed complication due to insensitivity of serology in older patients and under use of other diagnosis methods.
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Affiliation(s)
- Mony Shuvy
- Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Moshe Rav-Acha
- Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Uzi Izhar
- Department of Cardiothoracic surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Merav Ron
- Department of Clinical Microbiology and Infectious diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ran Nir-Paz
- Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Department of Clinical Microbiology and Infectious diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Department of Molecular & Cell Biology, 510 Barker Hall #3202, University of California, Berkeley, CA 94720-3202, USA
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19
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Shaham D, Breuer R, Copel L, Agid R, Makori A, Kisselgoff D, Goitein O, Izhar U, Berkman N, Heching N, Sosna J, Bar-Ziv J, Libson E. Computed Tomography Screening for Lung Cancer: Applicability of an International Protocol in a Single-Institution Environment. Clin Lung Cancer 2006; 7:262-7. [PMID: 16512980 DOI: 10.3816/clc.2006.n.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The purpose of this study was to assess the applicability of an annual low-dose computed tomography (CT) screening program for lung cancer in a single institution in Israel, which has a relatively lower prevalence of lung cancer compared with other Western countries, and to examine stage distribution of detected lung cancers. PATIENTS AND METHODS A cohort of 842 former and current smokers underwent baseline low-dose CT screening and a total of 942 annual repeat screenings over a period of 68 months. The definition of positive results on baseline and repeat screening and their diagnostic workup were guided by the common International Early Lung Cancer Action Program protocol. Recommendations for biopsy of suspicious nodules were based on nodule size, nodule growth, non-resolution following antibiotic therapy, and positron emission tomography scan. RESULTS The test result was positive in 102 of the 842 baseline screenings (12%) and in 45 of the 942 annual repeat screenings (5%), and biopsy was recommended in 12 baseline and 2 annual screenings. Twelve of the 14 cancers diagnosed (86%) were stage I tumors. CONCLUSION Our study indicates that the adoption of a common international protocol is feasible, even in a very different clinical setting, yielding a high proportion of early-stage lung cancers.
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Affiliation(s)
- Dorith Shaham
- Department of Radiology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
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20
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Wald O, Amir G, Avniel S, Bar-Shavit Y, Weiss I, Peled A, Izhar U. P-130 The chemokine CXCL12 is involved in shaping the immune cellpopulation infiltrating NSCLC. Lung Cancer 2005. [DOI: 10.1016/s0169-5002(05)80624-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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21
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Izhar U, Ad N, Rudis E, Milgalter E, Korach A, Viola N, Levi E, Asraff G, Merin G, Elami A. When should we discontinue antiarrhythmic therapy for atrial fibrillation after coronary artery bypass grafting? A prospective randomized study. J Thorac Cardiovasc Surg 2005; 129:401-6. [DOI: 10.1016/j.jtcvs.2004.06.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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22
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Abstract
Urine thromboxane, plasma creatinine, and creatinine clearance were determined perioperatively in 20 patients undergoing coronary bypass surgery. Ten patients took aspirin until the day of surgery, and 10 discontinued aspirin at least one week before surgery. A significant increase in urine thromboxane following establishment of cardiopulmonary bypass was observed only in the control group. Plasma creatinine increased in the control group on the 1st postoperative day (from 81.9 +/- 13.2 to 97.6 +/- 13.2 micromol.L(-1), p = 0.02) and decreased next day to the preoperative level (82.7 +/- 9 micromol.L(-1), p = 0.03). In the aspirin group, creatinine remained unchanged on the 1st postoperative day (89.4 +/- 14.2 vs. 87.2 +/- 7.7 micromol.L(-1), p = 0.6), and increased significantly on the 2nd day (101.4 +/- 8.5 micromol.L(-1), p = 0.01). The aspirin group had higher creatinine levels (p < 0.0001) and lower creatinine clearance (60.2 +/- 16.5 vs. 82 +/- 25.7 mL.min(-1), p < 0.0001) than the control group on the 2nd postoperative day. A significant positive correlation was seen between urine thromboxane and creatinine on day 2 in both groups (r = 0.6). Aspirin administrated before coronary surgery may have a beneficial effect on renal function, probably mediated by its antiplatelet activity and thromboxane inhibition.
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Affiliation(s)
- Rabin Gerrah
- Department of Cardiothoracic Surgery, Hebrew University-Hadassah Medical School, PO Box 12000, Jerusalem 91120, Israel.
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23
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Goldschmidt N, Nusair S, Gural A, Amir G, Izhar U, Laxer U. Disseminated Mycobacterium kansasii infection with pulmonary alveolar proteinosis in a patient with chronic myelogenous leukemia. Am J Hematol 2003; 74:221-3. [PMID: 14587059 DOI: 10.1002/ajh.10410] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A 64-year-old woman with chronic myelogenous leukemia (CML) was admitted due to prolonged fever and lung infiltrates. An open lung biopsy was required to make the diagnosis of pulmonary alveolar proteinosis (PAP) and infection with Mycobacterium kansasii. She was treated successfully with combined antimycobacterial therapy for 14 months. However, the leukemia progressed and the patient developed recurrent bilateral lung infiltrates. Blood and bronchoalveolar fluid cultures yielded growth of Acinetobacter. She died shortly thereafter due to septic shock. The relationship between M. kansasii infection, PAP, and abnormal host defense in CML is discussed.
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Affiliation(s)
- Neta Goldschmidt
- Department of Haematology, Hadassah University Hospital and Hebrew University-Hadassah School of Medicine, Jerusalem, Israel
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24
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Schneider A, Ad N, Izhar U, Khaliulin I, Borman JB, Schwalb H. Protection of myocardium by cyclosporin a and insulin: in vitro simulated ischemia study in human myocardium. Ann Thorac Surg 2003; 76:1240-5. [PMID: 14530018 DOI: 10.1016/s0003-4975(03)00830-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The efficacy of myocardial protection by cyclosporin A (CSA) and insulin was tested in human right atrial myocardial slices subjected to simulated ischemia and reoxygenation. METHODS Slices of right atrial trabeculae were obtained from patients undergoing elective cardiac surgery. Trabeculae were incubated with oxygenated glucose containing phosphate buffered saline (O(2), G-PBS). After 30 minutes of stabilization the sections were exposed to 90 minutes of simulated ischemia (N(2), PBS without glucose) followed by 90 minutes reoxygenation (O(2), G-PBS). Cyclosporin A (0.2 micromol/L) or insulin (5 mU/mL) was added during the stabilization period prior the ischemia. Cell viability was measured by using 3-[4.5 dimethylthiazol 2-yl]-2,5-diphenyltetrazolium bromide (MTT), which is cleaved by active mitochondrial dehydrogenases of living cells. RESULTS The viability of untreated slices (control) was 30.45% +/- 2.5% versus 52.65% +/- 4.4% in the CSA treated slices, p less than 0.001. The extent of protection by CSA was affected by oral antiglycemic drugs (glibenclamide). The effect obtained by CSA was inhibited by 5-hydroxydecanoate (5HD), a specific blocker of mitochondrial K(ATP) channels. Protection of the myocardial slices with insulin appears to be superior and not affected by the medication before surgery. This protection was maximal when insulin was present during both preischemic equilibration and reoxygenation periods (68.9% +/- 9.3% viability with insulin versus 33.2% +/- 6.9% in the control, p < 0.001). CONCLUSIONS Protection of right atrial trabeculae slices with insulin is superior to that obtained with CSA and is independent of preoperative medication.
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Affiliation(s)
- Aviva Schneider
- Joseph Lunenfeld Cardiac Surgery Research Center, and Cardiothoracic Sugery Department, Hadassah University Hospital, Jerusalem, Israel
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25
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Gerrah R, Izhar U, Elami A, Milgalter E, Rudis E, Merin G. Cardiac surgery in octogenarians--a better prognosis in coronary artery disease. Isr Med Assoc J 2003; 5:713-6. [PMID: 14719466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
BACKGROUND Cardiac surgery is being performed with increasing frequency in patients aged 80 years and older. OBJECTIVES To examine the long and short-term results of surgery in this age group. METHODS We retrospectively investigated 202 consecutive patients aged 80 years or older who underwent cardiac surgery between 1991 and 1999, Ninety-six operations (48%) were urgent. RESULTS The study group comprised 140 men (69%) and 62 women (31%) with a mean age of 82.1 years (range 80-89). Preoperatively, 120 patients (59%) had unstable angina, 37 (18%) had left main coronary artery disease, 22 (11%) had renal failure, 17 (8.5%) had a history of stroke and 13 (6.5%) had previous cardiac surgery. Hospital mortality for the whole group was 7.4%. Postoperative complications included: re-exploration for bleeding in 15 (7.4%), stroke in 8 (4%), sternal wound infection in 3 (1.5%), low cardiac output in 17 (8.4%), new Q wave myocardial infarction in 5 (2.5%), renal failure in 17 (8.5%), and atrial fibrillation in 71 (35%). The actuarial survival for patients discharged from the hospital was 66% at 5 years and 46% at 8 years. The type of surgical procedure was significantly associated with increased early mortality (coronary artery bypass grafting only in 2.9%, CABG + valve in 16.1%, valve only in 16.7%; P = 0.01). Significant predictors (P < 0.05) for late mortality included type of surgical procedure, congestive heart failure, and postoperative low cardiac output. CONCLUSIONS When appropriately applied in selected octogenarians, cardiac surgery can be performed with acceptable mortality and good long-term results.
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Affiliation(s)
- Rabin Gerrah
- Department of Cardiothoracic Surgery, Hadassah University Hospital, Hebrew University-Hadassah Medical School, Jerusalem, Israel.
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Gerrah R, Rudis E, Elami A, Milgalter E, Izhar U, Merin G. The surgical approach to infective endocarditis: 10 year experience. Isr Med Assoc J 2003; 5:641-5. [PMID: 14509154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
BACKGROUND About 40% of patients with infective endocarditis will require surgical treatment. The guidelines for such treatment were formulated by the American College of Cardiology and American Heart Association in 1998. OBJECTIVES To examine our experience with surgical treatment of infective endocarditis in light of these guidelines. METHODS Surgery was performed in 59 patients with infective endocarditis between 1990 and 1999. The patients' mean age was 48 years (range 13-80). The indications for surgery were hemodynamic instability, uncontrolled infection, and peripheral embolic events. The surgical treatment was based on elimination of infection foci and correction of the hemodynamic derangement. These objectives were met with valve replacement in the majority of patients. Whenever conservative surgery was possible, resection of vegetation and subsequent valve repair were performed and the native valve was preserved. RESULTS Six patients (10%) died perioperatively from overwhelming sepsis (n = 3), low cardiac output (n = 2) and multiogran failure (n = 1). The mean hospital stay was 15.6 days. Of 59 patients, 47 (80%) underwent valve replacement and in 11 (19%) the surgical treatment was based on valve repair. After 1 year of follow-up there was no re-infection. CONCLUSION The new guidelines for surgical treatment of infective endocarditis allow better selection of patients and timing of surgery for this aggressive disease, which consequently decreases the mortality rate. Valve repair is feasible and is preferred whenever possible. According to the new guidelines, patients with neurologic deficit in our series would not have been operated upon, potentially decreasing the operative mortality to 7%.
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Affiliation(s)
- Rabin Gerrah
- Department of Cardiothoracic Surgery, Hadassah University Hospital, Hebrew University-Hadassah Medical School, Jerusalem, Israel.
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Landesberg G, Mosseri M, Wolf YG, Bocher M, Basevitch A, Rudis E, Izhar U, Anner H, Weissman C, Berlatzky Y. Preoperative thallium scanning, selective coronary revascularization, and long-term survival after major vascular surgery. Circulation 2003; 108:177-83. [PMID: 12835211 DOI: 10.1161/01.cir.0000080292.11186.fb] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ischemia on thallium scanning is a strong predictor of long-term mortality in CAD patients. Whether coronary revascularization (CR) in patients with significant ischemia on preoperative thallium scanning (PTS) improves long-term survival after major vascular surgery has not been determined. METHODS AND RESULTS The perioperative data, including PTS and subsequent CR in patients with moderate to severe reversible ischemia on PTS, and long-term survival of 502 consecutive patients who underwent 578 major vascular procedures were analyzed retrospectively. Patients with PTS who ultimately did not undergo the planned vascular operation were also studied. Cox regression and propensity score analyses were used to analyze survival. A total of 407 patients (81.1%) had PTS: 221 (54.3%) had no or mild defects (group I); 50 (12.3%) had moderate-severe fixed defects (group II); 62 (15.2%) had moderate-severe reversible ischemia yet did not undergo CR (group III); and 74 (18.2%) had moderate-severe reversible ischemia and subsequent CR by CABG (36) or PTCA (38; group IV). Patients who sustained major complications as a result of the preoperative cardiac workup were included in group IV. By multivariate analysis, age, type of vascular surgery, presence of diabetes, previous myocardial infarction, and moderate-severe ischemia on PTS independently predicted mortality (P=0.001, 0.009, 0.039, 0.006, and 0.029, respectively), and preoperative CR predicted improved survival (OR 0.52, P=0.018). Group IV had better survival than group III even when subdivided according to normal and reduced left ventricular function (OR 0.40 and 0.41, P=0.035 and 0.021, respectively). CONCLUSIONS Long-term survival after major vascular surgery is significantly improved if patients with moderate-severe ischemia on PTS undergo selective CR.
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Affiliation(s)
- Giora Landesberg
- Department of Anesthesiology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel.
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Affiliation(s)
- Samir Nusair
- Institute of Pulmonology, Hadassah University Hospital, and the Hebrew University-Hadassah School of Medicine, Jerusalem, Israel.
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Connolly HM, Schaff HV, Izhar U, Dearani JA, Warnes CA, Orszulak TA. Posterior pericardial ascending-to-descending aortic bypass: an alternative surgical approach for complex coarctation of the aorta. Circulation 2001; 104:I133-7. [PMID: 11568044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
BACKGROUND Coarctation of the aorta is commonly associated with recoarctation or additional cardiovascular disorders that require intervention. The best surgical approach in such patients is uncertain. Ascending-to-descending aortic bypass graft via the posterior pericardium (CoA bypass) allows simultaneous intracardiac repair or an alternative approach for the patient with complex coarctation. METHODS AND RESULTS Between 1985 and 2000, 18 patients (13 males and 5 females, mean age 43+/-13 years) with coarctation of the aorta underwent CoA bypass through median sternotomy. Before operation, average New York Heart Association class was II (range I to IV), and 15 patients (83%) had systemic hypertension. One or more previous cardiovascular operations had been performed in 12 patients (67%); 10 patients had >/=1 prior coarctation repair. Two patients had prior noncoarctation cardiovascular surgery. Concomitant procedures performed in 14 patients (78%) included the following: aortic valve replacement in 9; coronary artery bypass surgery in 3; mitral valve repair in 2; and septal myectomy, mitral valve replacement, aortoplasty, subaortic stenosis resection, ventricular septal defect closure, and ascending aorta replacement in 1 patient each. All patients survived the operation and were alive with patent CoA bypass at a mean follow-up of 45 months. No graft-related complications occurred, and there were no instances of stroke or paraplegia. Systolic blood pressure fell from 159 mm Hg before surgery to 125 mm Hg after surgery. CONCLUSIONS CoA bypass via median sternotomy can be performed with low morbidity and mortality. Although management must be individualized, extra-anatomic CoA bypass via the posterior pericardium is an excellent single-stage approach for patients with complex coarctation or recoarctation and concomitant cardiovascular disorders.
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Affiliation(s)
- H M Connolly
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.
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Schneider A, Izhar U, Merin G, Borman JB, Schwalb H. In vitro preconditioning of the human myocardium by cyclosporin A. J Mol Cell Cardiol 2001. [DOI: 10.1016/s0022-2828(01)90425-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Izhar U, Schwalb H, Borman JB, Hellener GR, Hotoveli-Salomon A, Marom G, Stern T, Cohn D. Novel synthetic selectively degradable vascular prostheses: a preliminary implantation study. J Surg Res 2001; 95:152-60. [PMID: 11162039 DOI: 10.1006/jsre.2000.6042] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Vascular grafts perform less well than autologous arterial or vein grafts. The purpose of this study was to evaluate the short-term performance of selectively biodegradable filament-wound vascular prostheses, comprising elastomeric poly(ether urethane) (Lycra) scaffolds and flexible, hydrophilic biodegradable coatings. MATERIALS AND METHODS Two types of selectively biodegradable vascular grafts were manufactured, comprising a filament-wound Lycra scaffold, subsequently coated with a biodegradable poly(ethylene glycol)/poly(lactic acid) (PELA) block copolymer. The two types of grafts differed in both the overall porosity of the scaffold and the hydrophilicity of the biodegradable constituent. A 60-mm-long and 6-mm-diameter filament-wound and polytetrafluoroethylene (ePTFE) grafts were implanted as interposition prostheses, randomly, at the right- and left-side carotid arteries. RESULTS Implantation studies proved the grafts to be patent and pulsatile for periods of up to 3 months. Increasing the scaffold porosity and enhancing the hydrophilicity of the biodegradable component improved both the transmural tissue ingrowth process and the vascularization of the prosthesis wall. Also, a well-adhered peripheral tissue and a thin, uniform intima and endothelial lining were obtained. All ePTFE graft controls, although patent, were rather stiff and nonpulsatile. A thick pseudointima, poorly attached to the prosthesis inner surface, was observed. The compliance of the wet grafts was significantly higher than in the dry state, stemming mainly from the water-plasticizing effect on the biodegradable component. The grafts explanted after a period of 6 weeks exhibited compliance only slightly lower than that of the wet grafts. After 12 weeks, however, the hoop compliance was 20% lower than that prior to implantation. At 100 mm Hg, for example, the original compliance of the wet graft was 2.5%/100 mm Hg decreasing to 2.0%/100 mm Hg after a 3-month implantation. The compliance reduction with implantation is attributed to the ingrowth of the perigraft tissue as revealed by the histological study. A compliance of 2.0%/100 mm Hg is slightly better than that of a standard PTFE graft with an original compliance of 1.6%/100 mm Hg. Yet it is still an order of magnitude smaller than that of a canine carotid artery. CONCLUSIONS The improved mechanical properties and enhanced healing of the highly porous filament-wound Lycra scaffold graft coated with hydrophilic biodegradable PELA has the potential of being a highly effective small caliber prosthetic graft.
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Affiliation(s)
- U Izhar
- Joseph Lunenfeld Cardiac Surgery Research Center, Hadassah University Hospital, Jerusalem, Israel
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Abstract
BACKGROUND Bypass grafting for repeat operation or complex forms of descending aortic disease is an alternative approach to decrease potential complications of anatomic repair. METHODS Between December 1985 and February 1998, 17 patients (13 men, 4 women; mean age, 47.6 +/- 18.5 years) underwent ascending aorta-to-descending aorta bypass through a median sternotomy and posterior pericardial approach. Indications for operation were coarctation or recoarctation of aorta in 8 patients, Takayasu's aortitis in 2, prosthetic aortic valve stenosis associated with coarctation of aorta, complex descending aortic arch aneurysm, reoperation for chronic descending aortic dissection, long-segment stenosis of descending aorta, acquired coarctation after repair of traumatic transection of descending aorta, severe aortic atherosclerosis, and false aneurysm of descending aorta after repair of coarctation in 1 patient each. Concomitant procedures were performed in 12 patients. RESULTS No early or late mortality has occurred. Follow-up was 100% complete and extended to 12 years (mean, 2.7 +/- 3.3 years). No late graft-related complications have occurred; 1 patient had successful repair of perivalvular leak after mitral valve replacement, and 1 patient had replacement of lower descending and abdominal aorta. CONCLUSIONS Exposure of the descending aorta through the posterior pericardium for ascending aorta-descending aorta bypass is a safe alternative and particularly useful when simultaneous intracardiac repair is necessary.
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Affiliation(s)
- U Izhar
- Section of Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Korach A, Izhar U, Rudis E, Elami A. [Concomitant surgery--coronary artery bypass and pulmonary lobectomy]. Harefuah 2000; 138:825-8, 911. [PMID: 10883246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Coronary artery disease amenable to percutaneous interventions or coronary artery bypass grafting, and resectable lung cancer are major causes of morbidity and mortality. We present our experience in the treatment of 3 patients (men aged 64 and 66 and a woman of 77) who each had significant coronary artery disease and a resectable lung tumor. They underwent combined coronary artery bypass grafting and pulmonary lobectomy. We conclude from our experience and review of the literature that concomitant surgery in such cases is safe and effective, decreases suffering, and decreases the cost of 2 separate invasive procedures.
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Affiliation(s)
- A Korach
- Dept. of Cardiothoracic Surgery, Hadassah University Hospital, Jerusalem
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Abstract
BACKGROUND Insulin and insulin-like growth factor-I (IGF-I) are endogenous peptides with vasoactive activities. OBJECTIVE To evaluate the vasodilatory effects of insulin and IGF-I on human vessels taken from patients with and without noninsulin-dependent diabetes mellitus (NIDDM) and to elucidate their mechanisms of action. METHODS Vascular rings of human internal mammary artery (IMA) and saphenous vein harvested from 54 patients with and without NIDDM undergoing coronary bypass surgery were studied in vitro. RESULTS For samples from patients without NIDDM both insulin and IGF-I (10(-12)-10(-7) mol/l) evoked greater relaxation in IMA rings (30 +/- 4 and 29 +/- 6%, maximal relaxation +/- SEM, respectively) than they did in saphenous-vein rings (43 +/- 4 and 42 +/- 5%, respectively, P < 0.05 both for insulin and for IGF-I). Similar results were obtained with vessels from patients with NIDDM. Relaxation was not affected by the removal of the endothelium and by inhibition of the production of nitric oxide. However, the vascular relaxation caused by insulin and IGF-I was completely abolished by KCI, and was attenuated by the nonspecific potassium-channel blocker tetraethylammonium (for IMA rings, to 77 +/- 8 and 66 +/- 4% with insulin and IGF-I, respectively; for saphenous vein rings, 73 +/- 2 and 77 +/- 1% for insulin and IGF-I, respectively, P < 0.001). CONCLUSIONS Both insulin and IGF-I induced endothelial-independent, nitric oxide-independent vasorelaxation of rings from human IMA and saphenous veins, through a mechanism involving activation of potassium channels. This response remained intact in vessels from patients with NIDDM. This result supports the hypothesis that insulin and IGF-I play roles in the regulation of vascular tone in human vessels.
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Affiliation(s)
- U Izhar
- Division of Cardiovascular Disease, Mayo Clinic and Foundation, Rochester, Minnesota, USA
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Abstract
BACKGROUND Patients who have had previous CABG may subsequently develop significant mitral valve (MV) dysfunction that requires surgical intervention. METHODS AND RESULTS We reviewed 80 consecutive patients who had had previous CABG and who underwent MV surgery between January 1972 and March 1997. Forty-seven (59%) had initial CABG elsewhere, and 5 had had previous CABG twice. The mean interval between the previous CABG and the MV surgery was 6.3 years (range, 4.4 months to -17 years). At least 15 patients had grade 1/4 to 2/4 mitral regurgitation at initial CABG. The study group included 59 men and 21 women, with a mean study group age of 65.5 years. Ninety-four percent had symptoms of congestive heart failure, 60% had angina, 96% were in NYHA class III to IV, and 37% had an ejection fraction (EF) <50%. Origin of the MV disease was ischemic in 33 patients, myxomatous in 19, combined ischemic and myxomatous in 16, rheumatic in 5, infective in 3, and unknown in 4. MV repair was performed in 46 patients (58%) and MV replacement (MVR) in 34. Concomitant repeat CABG was performed in 38 (48%) patients. In-hospital mortality was 7 of 80 (8.8%); no early death occurred among patients with myxomatous disease. EF <50% was the only significant predictor of early mortality. Overall 1-, 5-, and 10-year survival was 83.8%, 55.6%, and 34.4% respectively. Predictors of late cardiac death were preoperative NYHA class IV (P=0.0006), urgent or emergency operation (P<0.0001), use of intra-aortic balloon pump (P=0.002), and EF <50% (P=0.01). Seven patients had an additional reoperation: 4 received CABG, 2 MVR, and 2 MV repair. CONCLUSIONS Ischemic, myxomatous, rheumatic, or infective MV dysfunction may develop subsequently after CABG. MVR or MV repair after previous CABG is associated with an acceptably low operative risk and good relief of symptoms. Left ventricular function is strongly correlated with both hospital and late mortality. Surgery should be done before LV dysfunction develops.
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Affiliation(s)
- U Izhar
- Division of Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
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Rivkind AI, Eid A, Weingart E, Izhar U, Barach P, Richter ED, Belzberg H. Complications from supervised mask use in post-operative surgical patients during the Gulf War. Prehosp Disaster Med 1999; 14:107-8. [PMID: 10558314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
This is a report of three patients in a surgical ward of a hospital who developed complications seemingly related to the use of full-face-fitting masks associated with the first Scud Missile attack on Israel during the Gulf War. Patient 1 developed atrial fibrillation with an uncontrolled ventricular rate; Patient 2 redeveloped a gastrointestinal hemorrhage; and Patient 3 developed a severe anxiety attack. Each of the three was severely ill prior to the event. Special attention should be given to severely ill patients during such events.
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Affiliation(s)
- A I Rivkind
- Department of General Surgery, Hebrew University-Hadassah Medical Center, Jerusalem, Israel.
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Hasdai D, Holmes DR, Richardson DM, Izhar U, Lerman A. Insulin and IGF-I attenuate the coronary vasoconstrictor effects of endothelin-1 but not of sarafotoxin 6c. Cardiovasc Res 1998; 39:644-50. [PMID: 9861307 DOI: 10.1016/s0008-6363(98)00144-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To examine the hypothesis that insulin and insulin-like growth factor I (IGF-I) attenuate endothelin-induced contraction of porcine coronary epicardial arteries in vitro. BACKGROUND Endothelin-induced coronary vasoconstriction is mediated by two types of receptors, A (ETA) and B (ETB), resulting in calcium influx. Both insulin and IGF-I attenuate endothelin-induced calcium influx into porcine coronary artery smooth muscle. METHODS Epicardial arteries harvested from juvenile pigs were contracted with cumulative concentrations of endothelin-1 (ETA- and ETB-receptor agonist; 10(-10)-10(-6) M) or of sarafotoxin-6c (ETB-receptor agonist; 10(-11)-10(-7) M). In additional experiments, endothelin-1 or sarafotoxin-6c were added after incubation with 10(-8) M regular insulin or IGF-I. These experiments were repeated in vessels without endothelium. Contraction for each vessel was calculated relative to the response to 60 mM KCl. RESULTS The maximal contractions to endothelin-1 in vessels with and without endothelium were 158 +/- 8 and 200 +/- 21%, respectively (p < 0.05 at 10(-8.5)-10(-6.5) M). Both insulin (at 10(-7)-10(-6) M) and IGF-I (at 10(-6.5)-10(-6) M) attenuated the contraction to endothelin-1 in vessels with intact endothelium, as well as in vessels without endothelium (at 10(-7) and 10(-6) M for insulin and 10(-7.5)-10(-6) M for IGF-I). The maximal contractions to sarafotoxin-6c in vessels with and without endothelium were 54 +/- 13 and 84 +/- 7%, respectively (p < 0.05 at 10(-9), 10(-8.5) and 10(-7) M). Insulin and IGF-I did not affect the response to sarafotoxin-6c in vessels with and without endothelium. CONCLUSION Insulin and IGF-I attenuated ETA-receptor-mediated coronary contraction through an endothelium-independent mechanism. The IGF axis may serve as an endogenous modulator of endothelin-mediated vasoconstriction.
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Affiliation(s)
- D Hasdai
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA
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Izhar U, Lerman A, Olney BA, Schaff HV. Minimally invasive direct coronary artery bypass--a surgical approach for anomalous right coronary artery from left aortic sinus of Valsalva. Mayo Clin Proc 1998; 73:661-4. [PMID: 9663197 DOI: 10.1016/s0025-6196(11)64892-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Anomalous origin of the right coronary artery from the left aortic sinus of Valsalva, although rare, has been associated with myocardial ischemia and sudden death. Methods of surgical correction include ostial reconstruction, excision and translocation of the vessel origin, and coronary artery bypass grafting. We describe a 39-year-old man with symptoms of myocardial ischemia and an anomalous right coronary artery in whom we performed the new, minimally invasive direct coronary artery bypass procedure with use of the right internal mammary artery.
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Affiliation(s)
- U Izhar
- Division of Thoracic and Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, USA
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Izhar U, Schwalb H, Borman JB, Merin G. Cardioprotective effect of L-arginine in myocardial ischemia and reperfusion in an isolated working rat heart model. J Cardiovasc Surg (Torino) 1998; 39:321-9. [PMID: 9678555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Studies in myocardial ischemia and reperfusion have demonstrated damage to endothelium, impaired production and release of vasoactive substances such as nitric oxide, and marked alteration in endothelium-dependent relaxatin of the coronary vasculature. This study was designed to examine the cardioprotective effect of exogenous administration of L-arginine, a precursor of nitric oxide, during ischemia and reperfusion, particularly using oxygenated crystalloid cardioplegia. METHODS Seventy energy-depleted isolated working rat hearts were arrested by cardioplegia and subjected to 60 min normothermic global ischemia followed by 10 min nonworking and 30 min working reperfusion (Gr 1). L-arginine (3mM or 10mM) was added to the cardioplegic solution (Gr 2,3 respectively), reperfusion (Gr 6,7 respectively), throughout the experiment (Gr 4,5 respectively), and with Nw-nitro-L-arginine methyl ester (L-NAME), a competitive inhibitor of nitric oxide synthase (Gr 8). RESULTS At 30 min of working heart reperfusion, compared to control all arginine containing groups (Gr 2-7) exhibited a significant improved recovery of cardiac output (64.7+/-21.2, 98.1+/-21.1, 90.9+/-11.7, 88.9+/-16.2, 83.1+/-7.4, and 90.8+/-10.6, mean +/- SD% Gr 2 to 7 respectively, vs Gr 1 36.3+/-20%, p<0.01). Significant recovery improvement was observed also in other hemodynamic parameters (coronary flow, aortic peak pressure), as well as biochemical recovery assessed by O2 consumption ratio, release of lactic dehydrogenase at reperfusion and regeneration of ATP. The L-NAME group had a significant poorer hemodynamic and biochemical recovery. L-arginine had no effect on the preischemic hemodynamic parameters. CONCLUSIONS These results support the cumulative data considering L-arginine as a cardioprotective agent in postischemic reperfusion injury.
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Affiliation(s)
- U Izhar
- Cardiothoracic Surgery Department and Joseph Lunenfeld Cardiac Surgery Research Center Hadassah University Hospital, Jerusalem, Israel
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40
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Medalion B, Merin G, Milgalter E, Elami A, Borman J, Shimon D, Deviri E, Izhar U, Deeb M, Shargal Y, Grienfeld G, Kramer MR. Early experience in lung transplantation. Isr J Med Sci 1996; 32:292-6. [PMID: 8641866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Lung transplantation is becoming an acceptable mode of therapy worldwide for the end-stage lung disease. We present our initial experience with the first 10 consecutive lung transplant patients at Hadassah University Hospital. There were 5 males and 5 females with an age range 27 to 59 years. Eight patients underwent single lung transplantation, one patient had double lung transplantation and one had heart-lung transplantation. Indications were: pulmonary fibrosis in 4, emphysema in 4, cystic fibrosis in 1, and cystic bronchiectasis in 1. Two patients had primary graft failure (1 death). Nine patients had a serious infection after transplantation (1 death). Four patients developed airway complications including dehiscence of bronchial anastomosis (1 death), bronchial stenosis requiring placement of a stent in 2 patients, and pneumothorax in 1 patient. One patient required tracheostomy. One patient died of massive brain infarction secondary to pulmonary venous thrombosis and embolization. Six patients are intermediate-term survivors, with a follow-up period of 4-24 months. Four of them had at least one episode of rejection each. In all survivors pulmonary functions and quality of life improved and they do not need supplemental oxygen. We conclude that lung transplantation is a viable option for end-stage lung disease. Better selection of patients and perhaps improved immunosuppression agents will further improve outcome in lung transplantation. Shortage of donor supply is currently the limiting factor in successful lung transplantation in Israel.
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Affiliation(s)
- B Medalion
- Department of Cardiothoracic Surgery, Hadassah University Hospital, Jerusalem, Israel
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Borman JB, Arbell D, Izhar U, Glick Y, Deeb M, Grunfeld G, Milgalter E, Shimon DV, Drenger B, Gozal Y. Luke warm blood cardioplegia for CAB surgery in patients with severely impaired LV function. Improved results. J Cardiovasc Surg (Torino) 1995; 36:545-50. [PMID: 8632022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Ward blood cardioplegia (WBC) has recently been reported to improve myocardial protection in adult open heart surgery, especially in high risk cases. However, WBC has been reported to have some disadvantages including narrow safety margins concerning brain and kidney perfusion. We therefore modified our technique to utilize luke-warm blood cardioplegia (LWBC). We carried out 470 open heart procedures using luke-warm cardioplegia (anterograde + retrograde perfusion) from 1/2/1991 - 30/9/1992; 94 had LVEF < 30% and form the basis of this study. Other major risk factors in this group included: > 70 yrs - 26 patients, L main > 50% - 14 patients, emergencies - 11 patients, redo's - 3 patients. Eightyone patients underwent CAB only; 3 had additional MVR, 3 additional closure acute VSD of whom one underwent additional LV aneurysmectomy, one additional AVR; 4 patients underwent AVR only, and 2 MVR. Average number of grafts/patient for the 81 isolated CAB's was 4.5. IABP was necessary postbypass in 4 patients (9 emergencies were on IABP support at time of operation). Thirty day mortality was 3 patients (3.2%). Late mortality was 5 cases. These results are superior to those achieved using cold protection and warm blood cardioplegia. LWBC is a safe method for myocardial protection in patients undergoing CAB, particularly when LV function is severely compromised.
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Affiliation(s)
- J B Borman
- Department of Cardiothoracic Surgery, Hadassah University Hospital, Jerusalem, Israel
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Krausz MM, Ravid A, Izhar U, Feigin E, Horowitz M, Gross D. The effect of heat load and dehydration on hypertonic saline solution treatment of controlled hemorrhagic shock. Surg Gynecol Obstet 1993; 177:583-92. [PMID: 8266269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Small volume hypertonic saline solution has been suggested for initial effective resuscitation of hemorrhagic shock. The effect of hypertonic saline solution in controlled hemorrhagic shock was studied in rats subjected to dehydration or heat, or both. The rats were randomly divided into four groups--group 1 (n = 19), normal rats; group 2 (n = 21), water deprivation for 12 hours; group 3 (n = 20), heating at 37 degrees C. for five hours, and group 4 (n = 19), water deprivation for 12 hours and heating at 37 degrees C. for five hours. Controlled hemorrhagic shock was induced in all rats by arterial bleeding of 15 milliliters per kilogram and the rats were divided into three treatment subgroups--group a was untreated, group b was treated with 5 milliliters per kilogram 0.9 percent NaCl and group c was treated with 5 milliliters per kilogram 7.5 percent NaCl. Arterial bleeding of 15 milliliters per kilogram in group 1 resulted in decrease in mean arterial pressure (MAP) to 44 +/- 2 millimeters of mercury (p < 0.001) and pulse rate to 280 +/- 13 per minute (p < 0.01). A similar decrease in MAP and pulse rate was observed in all four groups. Infusion of hypertonic solution (HTS) in group 1c was followed by an increase in MAP to 89.0 +/- 9.7 milliliters of mercury (p < 0.01) in 15 minutes. This was significantly higher than infusion of normal saline solution in group 1b (p < 0.01) or untreated group 1a (p < 0.01). This difference remained significant also after 45 minutes from infusion (p < 0.05 and p < 0.05, respectively). The increase in MAP in response to HTS in group 1c after 15 minutes was significantly higher than the rise in groups 2c (p < 0.05), 3c (p < 0.05) and 4c (p < 0.05). This difference in response to HTS remained significant 45 minutes from infusion in groups 3c (p < 0.05) and 4c (p < 0.05), but not in dehydrated rats in group 2c. Arterial bleeding did not alter serum sodium significantly in all four groups. Infusion of HTS in group 1c was followed by an increase in serum sodium from 149.1 +/- 1.4 to 161.1 +/- 2.4 milliequivalent per liter (p < 0.001), while infusion of HTS in group 4c, where serum sodium was initially elevated to 157.1 +/- 3.0 milliequivalent per liter, did not further elevate the serum sodium level.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- M M Krausz
- Department of Surgery, Hebrew University-Hadassah Medical School, Jerusalem, Israel
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Izhar U, Katz S, Verstandig A, Abu-Dalu K, Schiller M. [Nonoperative treatment of pancreatic pseudocyst in children]. Harefuah 1992; 122:568-71, 615. [PMID: 1526581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
3 children with pseudocyst of the pancreas resulting from blunt abdominal trauma are described (boys 6 and 8.5 years old, and a 6.5-year-old girl). Based on abdominal ultrasound and CT findings, nonoperative treatment was elected. There was spontaneous resolution in 1 and in the other 2 the pseudocyst was successfully drained. Previous reports and our own results indicate that it is safe to treat pancreatic pseudocysts in children after blunt abdominal trauma.
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Affiliation(s)
- U Izhar
- Dept. of Pediatric Surgery, Hadassah-University Hospital, Ein Kerem, Jerusalem
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Schwalb H, Izhar U, Yaroslavsky E, Borman JB, Uretzky G. The effect of amino acids on the ischemic heart. Improvement of oxygenated crystalloid cardioplegic solution by an enriched branched chain amino acid formulation. J Thorac Cardiovasc Surg 1989; 98:551-6. [PMID: 2796362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This study was designed to test the effect of glucose and a formulation enriched with branched chain amino acids as additives to oxygenated crystalloid cardioplegic solution in the ischemic heart. Energy-depleted isolated working rat hearts were subjected to 68 minutes of normothermic global ischemia during which oxygenated cardioplegic solution was used to protect them. The hearts were then reperfused in the nonworking mode for 10 minutes and for a further 30 minutes in the working mode. The hearts were randomly divided into three groups, in which various oxygenated cardioplegic solutions were perfused. Group 1 (control) was subjected to modified St. Thomas' Hospital cardioplegic solution and groups 2 and 3 to the same solution with the addition of glucose (11.1 mmol/L) and glucose (11.1 mmol/L) and branched chain amino acids, respectively. Recovery of aortic flow, coronary flow, cardiac output, aortic pressure, adenosine triphosphate, creatine phosphate, and oxygen consumption was significantly better in group 2 than in group 1. In addition, recovery of aortic flow, coronary flow, cardiac output, aortic pressure, stroke volume, minute work, adenosine triphosphate, and creatine phosphate was found to be significantly enhanced in group 3. Release of adenine catabolites and lactic dehydrogenase from these hearts during postischemic reperfusion was significantly decreased. Thus, during global ischemia in the energy-depleted heart, the presence of glucose and branched chain amino acids in oxygenated crystalloid cardioplegic solution enhanced myocardial protection.
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Affiliation(s)
- H Schwalb
- Joseph Lunenfeld Cardiac Surgery Research Center, Hadassah University Hospital, Jerusalem, Israel
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