M E Wohl

Mount Sinai School of Medicine, Manhattan, NY, United States

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Publications (28)146.06 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Our objective was to describe the respiratory complications, clinical findings, and chest radiographic changes in the first year of life in infected and uninfected children born to HIV-1-infected women. We prospectively followed a cohort of 600 infants born to HIV-1-infected women from birth to 12 months in a multicenter study. Of these, 93 infants (15.5%) were HIV-1-infected, 463 were uninfected, and 44 were of unknown status prior to death or loss to follow-up. The cumulative incidence ( +/- SE) of an initial pneumonia episode at 12 months was 24.1 +/- 4.7% in HIV-1-infected children compared to 1.4 +/- 0.6% in HIV-1-uninfected children (P < 0.001). The rate of Pneumocystis carinii pneumonia (PCP) was 9.5 per 100 child-years. The HIV-1 RNA load was not higher in the group that developed pneumonia in the first year vs. those who did not. Children who developed lower respiratory tract infections or PCP had increased rates of decline of CD4 cell counts during the first 6 months of life. Lower maternal CD4 cell counts were associated with higher rates of pneumonia, and upper and lower respiratory tract infections. The rates of upper respiratory tract infection and bronchiolitis/reactive airway disease in infected children were not significantly different than in uninfected children. At 12 months, significantly more HIV-1-infected than uninfected children had tachypnea and chest radiographs with nodular and reticular densities. There was no relationship between cytomegalovirus infection in the first year of life and radiographic changes or occurrences of pneumonia. In conclusion, despite a low incidence of PCP, rates of pneumonia remain high in HIV-infected children in the first year of life. The incidence of pneumonia in uninfected infants born to HIV-1-infected mothers is low. Chest X-ray abnormalities and tachypnea suggest that subacute disease is present in infected infants. Further follow-up is warranted to determine its nature.
    Pediatric Pulmonology 04/2001; 31(4):267-76. · 2.70 Impact Factor
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    ABSTRACT: Cystic fibrosis (CF) is a complex illness characterized by chronic lung infection leading to deterioration in function and respiratory failure in over 85% of patients. An understanding of the risk factors for that progression and the interaction of these factors with current therapeutic strategies should materially improve the prevention of this progressive lung disease. The Epidemiologic Study of Cystic Fibrosis (ESCF) was therefore designed as a multicenter, longitudinal, observational study to prospectively collect detailed clinical, therapeutic, microbiologic, and lung function data from a large number of CF treatment sites in the U.S. and Canada. The ESCF also serves an important role as a phase-IV study of dornase alfa. To be eligible for enrollment, subjects must have the diagnosis of CF and receive the majority of their care at an ESCF site. In this paper, the authors present the ESCF study design in detail. Further, enrollment data collected at 194 study sites in 18,411 subjects enrolled from December 1, 1993 to December 31, 1995 are presented in summary form. This comprehensive study is unique in the detail of clinical data collected regarding patient monitoring and therapeutic practices in CF care. Two companion articles present data regarding practice patterns in cystic fibrosis care, including data on resource utilization and prescribing practices.
    Pediatric Pulmonology 11/1999; 28(4):231-41. · 2.70 Impact Factor
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    C Johnson · ME Wohl · SM Butler
    Value in Health 05/1999; 2(3):133-133. DOI:10.1016/S1098-3015(11)70835-X · 3.28 Impact Factor
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    ABSTRACT: The purpose of this study was to determine predictors of accelerated deterioration in radiographic manifestations of cystic fibrosis. The incidence and distribution of focally accentuated disease were also studied. From 230 patients, 3038 chest radiographs were scored using the Brasfield system. Scores were plotted against age, and a single age-based severity curve was created. Specific observations (at least one episode in the first 5 years of life of air trapping, linear markings, nodular cystic lesions, or large lesions) were assessed to determine predictors of accelerated decline in scores compared with the aggregate scores plotted in the age-based severity curve. Specific observations were noted as present or absent and graded as to severity. A specific observation was counted as present if seen on at least one occasion. (The number of occasions on which the observation was made did not affect statistical analysis.) We also evaluated the distribution of lung disease by assessing the severity and nature of disease through specific lobar distribution. Males showed a slightly greater rate of radiologic decline. Early development of air trapping or bronchiectasis was associated with an accelerated rate of decline over time. Lobe-dominant disease occurred in one third of all images and in two thirds of the patients. It varied with age in its incidence, location, and etiology. Hyperinflation or bronchiectasis that occurs before age 5 is associated with accelerated radiographic deterioration. The incidence and location of lobe-dominant disease varied with age in these patients.
    American Journal of Roentgenology 12/1998; 171(5):1311-5. DOI:10.2214/ajr.171.5.9798870 · 2.73 Impact Factor
  • WM Robinson · S Ravilly · C Berde · ME Wohl
    Pediatrics 08/1998; 102(2):436-437. · 5.47 Impact Factor
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    ABSTRACT: This study presents a radiography-based database scoring changes over time in a large population of patients with cystic fibrosis. The purpose of this database is to provide comparison for groups of patients undergoing experimental treatment to assess effect of the treatment. The data may also be used to compare individuals with their age-matched cohorts with cystic fibrosis. From 230 patients, 3038 chest radiographs were scored using the Brasfield system. The scores from radiographs from all the patients were individually plotted for age, and a single age-based severity curve was created. The age-based severity curve was compared with similar curves derived from pulmonary function studies of a subset of the same patient population. We found high inter- and intraobserver reliability. The difference between the observers averaged 1.3 Brasfield points, the scale of which ranges up to 25 points. The age-based severity curve was presented as mean Brasfield scores versus age (birth to > 30 years) plotted with 95% confidence limits; the curve was also plotted in percentiles. The rate of decline of this curve was similar to the decline of pulmonary function studies in this patient population. The age-based curve, a structural anatomic parameter, differs from pulmonary function studies, which are functional. Thus the age-based severity curve provides an additional, independent basis for comparison between groups and individuals. It may be used for the initial assessment of lung disease and for gauging and predicting the rate of decline. The curve may be used as a long-range outcome criterion to evaluate new treatments in groups of patients with cystic fibrosis.
    American Journal of Roentgenology 04/1998; 170(4):1067-72. DOI:10.2214/ajr.170.4.9530060 · 2.73 Impact Factor
  • D D Rees · J D Brain · M E Wohl · J L Humes · R A Mumford
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    ABSTRACT: Elastases in cystic fibrosis (CF) pulmonary fluids damage lung tissue and perpetuate cycles of infection, inflammation and injury. Elastases from three different sources may be present in CF airways: neutrophils, macrophages and Pseudomonas. We measured how well the cephalosporin-based antielastase L-658,758 blocks the activity of human neutrophil elastase (NE), human proteinase-3, human macrophage metalloelastase, mouse macrophage metalloelastase and Pseudomonas aeruginosa elastase. We also examined the ability of L-658,758 to block elastases in CF sputum in vitro. Sputum samples from adult CF patients were fractionated to obtain the aqueous sol phase. These were then studied individually or pooled. Elastinolytic activity, which ranged from 3.2 microg elastin degraded/ml sol/min to 26.3 microg elastin degraded/ml sol/min, was measurable in every individual sol sample and in the pooled sol. L-658,758 effectively inhibited elastinolysis by NE, proteinase-3 and the pooled sol but did not inhibit the activity of the metalloelastases, human and mouse macrophage metalloelastase and Pseudomonas elastase. Secretory leukoprotease inhibitor, which inhibited NE but did not inhibit proteinase-3, blocked 90% of sol elastinolytic activity; this suggests that the majority of this activity in the pooled sol derived from NE. L-658,758 was an effective inhibitor of sol elastase, blocking more than 97% of elastinolytic activity in the individual sol samples. We conclude that L-658,758 is an effective inhibitor of NE, proteinase-3 and CF sputum sol elastase.
    Journal of Pharmacology and Experimental Therapeutics 01/1998; 283(3):1201-6. · 3.97 Impact Factor
  • W M Robinson · S Ravilly · C Berde · M E Wohl
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    ABSTRACT: End-of-life clinical care in cystic fibrosis (CF) differs substantially from terminal care in childhood cancer. To examine this difference, we reviewed the medical care of a cohort of CF patients treated at Children's Hospital, Boston, to document the use of preventive, therapeutic, and palliative care in the month preceding death. We reviewed the medical records of 44 patients older than 5 years who died of CF-related respiratory failure for the years 1984 to 1993. Thirty-eight patients (86%) received opiates for the treatment of severe dyspnea and pain; the duration of opiate use varied from less than 1 hour to greater than 1 month. The dose of opiates varied from less than 5 mg per hour to greater than 30 mg per hour. Thirty-three patients (75%) continued to receive intravenous antibiotics in the last 12 hours of life; 32 (72%) continued to receive preventive or therapeutic oral medications in the last 12 hours of life. All patients were designated as do not resuscitate at the time of death; 43 of the patients died in the hospital with 1 patient dying at home under hospice care. The model of comfort care developed in childhood cancer does not adequately describe the combination of preventive, therapeutic, and palliative care given at the end of life for CF at our institution. The majority of CF patients continued to receive intravenous antibiotics and/or oral vitamin preparations while being treated with opiates for terminal pain and dyspnea. Small doses of opiates seem to be effective in the treatment of the pain and dyspnea at the end of life in CF.
    Pediatrics 09/1997; 100(2 Pt 1):205-9. DOI:10.1542/peds.100.2.205 · 5.47 Impact Factor
  • S Ravilly · Robinson WM · S Suresh · M E Wohl · C B Berde
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    ABSTRACT: The objective of this study was to examine the incidence and therapy of chronic pain in a group of older patients with cystic fibrosis (CF). We identified two groups of patients followed at the CF Center at Children's Hospital (Boston); the first group consisted of all patients above the age of 5 years who died between 1984 and 1993, and the second was a cohort of 23 additional CF patients who had been referred to the Pain Treatment Service. Medical charts were reviewed for the etiology and therapy of all pain episodes requiring medical intervention. The incidence of chronic pain in this population increased sharply in the last 6 months of life. Headaches (55% of patients) and chest pain (65%) were frequently reported, although back pain (19%), abdominal pain (19%), and limb pain (16%) were also reported. In patients with headache, the main etiologies were hypercarbia or hypoxia, migraine, and sinusitis. The majority of chest pain was musculoskeletal, with pleuritis, pneumothorax, and rib fracture also reported as the cause of chest pain. A variety of nonpharmacological and pharmacological therapies were reported. Forty-one patients (53%) had pain severe enough to require opioid treatment, and 10 patients (13%) received opioids for more than 3 months. In eight patients with more severe pain, regional analgesia was found to be particularly effective. Chronic pain is a common problem in CF, particularly as the patient population ages. When administered with caution, opioids have proven to be effective and safe in this population; regional anesthesia can be used to preserve pulmonary toilet while adequately treating severe pain.
    Pediatrics 11/1996; 98(4 Pt 1):741-7. · 5.47 Impact Factor
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    ABSTRACT: Purulent sputum from patients with chronic obstructive pulmonary disease has long been known to contain large DNA-rich fibers believed to impede airway drainage. We present a novel approach to study sputum structure using fluorescence microscopy to confirm the presence of large DNA-rich fibers and visualize for the first time filamentous actin in all sputum samples examined from patients with cystic fibrosis and chronic bronchitis. Both actin and DNA co-localize in the filaments previously identified as DNA alone. Treatment of sputum samples with recombinant human DNase I or the actin-filament-severing protein, gelsolin, both previously found to decrease viscosity, dissolves the sputum fiber bundles. Purified human DNA does not form large fibers alone in vitro but does so in the presence of filamentous actin, and these fiber bundles dissolve when treated with either gelsolin or DNase I. These findings implicate actin-DNA interactions in the pathogenesis of airway disease and identify both polymers as targets for therapy.
    American Journal Of Pathology 04/1996; 148(3):919-27. · 4.59 Impact Factor
  • A A Colin · M E Wohl
    Pediatrics in Review 06/1994; 15(5):192-200. · 0.82 Impact Factor
  • A. A. Colin · M. E. B. Wohl
    Pediatrics in Review 05/1994; 15(5):192-200. DOI:10.1542/pir.15-5-192 · 0.82 Impact Factor
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    ABSTRACT: Obstruction of airways by viscous sputum causes lung damage in patients with cystic fibrosis (CF). Sputum samples from CF patients were shown to contain filamentous actin. Human plasma gelsolin, a protein that severs actin filaments, rapidly decreased the viscosity of CF sputum samples in vitro. Gc globulin and deoxyribonuclease I, proteins that sequester monomeric actin but do not sever actin filaments, were less efficient than gelsolin in diminishing sputum viscosity. These results suggest that gelsolin may have therapeutic potential as a mucolytic agent in CF patients.
    Science 03/1994; 263(5149):969-71. DOI:10.1126/science.8310295 · 33.61 Impact Factor
  • R Zinman · M. E. B. Wohl · R H Ingram
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    ABSTRACT: In spontaneous asthma after a deep inhalation (DI) obstruction occurs in direct proportion to disease severity. Since this has been associated with peripheral inflammation, which is present in cystic fibrosis (CF), we tested whether worsening obstruction after DI also occurs in CF in 12 patients. We assessed volume history effects by comparing isovolumic expiratory flows (Vmax) during forced exhalation begun at the end of tidal inspiration (partial P) with those begun at TLC (maximal M) to obtain M/P. As in asthma there was a correlation between M/P and FEV1 (% predicted; r = 0.64, p less than or equal to 0.03, n = 12). To control for a time dependency effect due to preferential emptying of fast compartments early in both the P and M maneuvers, we compared Vmax obtained from a first partial (P1) with a second (P2) obtained after inspiration to TLC and slow exhalation to the same starting volume as P1 (P2/P1). In contrast to asthma the P2/P1 was greater than the M/P and not related to disease severity. A further index of nonhomogeneous lung emptying was the relationship between M/P and the slope ratio at 70% TLC (r = -0.67, p less than or equal to 0.03). After isoetharine inhalation the M/P decreased (-0.12 +/- 0.12, p less than or equal to 0.01) but no change was apparent in P2/P1, indicating further increases in the degree of nonhomogeneity. We conclude that although volume history effects on M/P are similar in asthma and CF, this is due to a predominance of parenchymal hysteresis in the former and nonhomogeneity in the latter, which worsens with bronchodilator use.
    The American review of respiratory disease 07/1991; 143(6):1257-61. DOI:10.1164/ajrccm/143.6.1257 · 10.19 Impact Factor
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    ABSTRACT: As the shape, compliance, and deformability of the rib cage (RC) change during infancy, RC participation in quiet breathing may increase. We used respiratory inductive plethysmography (RIP) to determine the relative contributions of the RC and abdomen (AB) to tidal volume (VT) in 20 studies in 14 healthy infants 1 to 26 months of age during quiet natural sleep. RIP was calibrated with simultaneous flow measurements (anesthesia mask and pneumotachograph) by the least squares method of statistical analysis. We analyzed segments of breathing with and without flow measurement for RIP-derived VT, change in RC volume (Vrc) and AB volume (Vab) with each breath and the RC contribution to tidal breathing (%RC = Vrc/Vrc + Vab). The %RC increased with age: %RC = 1.4 age (months) + 33 (r = 0.69, p less than 0.01). After 9 months of age, %RC resembled that found in quietly sleeping adolescents. Mask placement increased VT in all but one subject (mean increase, 29 +/- 23% of baseline +/- SD; p less than 0.001, paired t test). In infants younger than 10 months of age, mask placement also increased %RC (without mask, 40 +/- 9%; with mask, 46 +/- 10% p less than 0.02). We conclude that by 1 yr of age, the RC contribution to tidal breathing during quiet sleep is similar to that of the adolescent, suggesting that major developmental changes in RC shape, compliance, and deformability take place during infancy.
    The American review of respiratory disease 05/1990; 141(4 Pt 1):922-5. DOI:10.1164/ajrccm/141.4_Pt_1.922 · 10.19 Impact Factor
  • F A Ratjen · A A Colin · A R Stark · J Mead · M E Wohl
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    ABSTRACT: We used respiratory inductance plethysmography to record tidal respiration in 27 healthy unsedated infants and children 1 mo to 8 yr of age during sleep. Rib cage and abdominal outputs were present at approximately equal gains and summed to obtain an estimate of volume. Flow-volume curves were generated from the uncalibrated volume signal and its flow derivative. Expiratory time constants (tau) were obtained by visually drawing a line through the linear portion of the expiratory flow-volume relationship. tau increased significantly during the first 10 mo of life. After 10 mo, the estimated rate of increase of tau for older children was less than 5% of the estimated initial rate and not significantly different from zero. Prolongation of tau was paralleled by an increase in expiratory time (Te), and no changes in Te/tau were observed in the first 2 yr of life. These changes in tau likely reflect the increase in lung compliance induced by rapid alveolar growth during infancy. After the first year, expiratory time constants appear to remain relatively constant and may be consistent with balanced changes in compliance and resistance beyond infancy.
    Journal of Applied Physiology 12/1989; 67(5):2112-5. · 3.06 Impact Factor
  • AA Colin · M E Wohl · J Mead · FA Ratjen · G Glass · AR Stark
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    ABSTRACT: Newborn infants, in contrast to adults, dynamically maintain end-expiratory lung volume (EEV) above relaxation volume. The purpose of this study was to determine at what age children develop a breathing strategy that is relaxed, i.e., determined by the mechanical characteristics of the lung and chest wall. Forty studies were performed in 27 healthy infants and children aged 1 mo to 8 yr during natural sleep. Volume changes were recorded with the use of respiratory inductance plethysmography (RIP). The volume signal was differentiated to yield flow. Flow-volume representations were generated for a random sample of the recorded breaths to determine the predominant breathing strategy utilized, i.e., relaxed, interrupted, or indeterminate. The respiratory pattern was predominantly interrupted below 6 mo of age and predominantly relaxed over 1 yr of age. Mixed patterns were observed in children 6-12 mo of age. The number of breaths that could not be classified (indeterminate) decreased with age. Respiratory frequency measured from the sample of breaths decreased with age and was accompanied by an increase in expiratory time. We conclude that a relaxed EEV develops at the end of the first year of life and may be related to changes in the mechanical properties of the chest wall associated with growth as well as changes in respiratory timing.
    Journal of Applied Physiology 12/1989; 67(5):2107-11. · 3.06 Impact Factor
  • F Ratjen · R Zinman · M E Wohl
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    ABSTRACT: Partial expiratory flow-volume (PEFV) curves in infants are generated by applying a compressive pressure over the chest wall with an inflatable jacket. This study addresses two issues: pressure transmission to and across the chest wall and whether flow limitation can be identified. Eleven infants sedated with chloral hydrate were studied. Pressure transmission to the chest wall, measured with neonatal blood pressure cuffs placed on the infant's body surface, was 72 +/- 4% of jacket pressure during compression maneuvers. The pressure transmission to the air spaces, determined by measuring airway pressure during a compression maneuver against an occluded airway, was 56 +/- 6% of jacket pressure. A significant amount of the applied pressure is therefore lost across both the jacket and chest wall. Rapid pressure oscillations (RPO) were superimposed on static jacket pressures while expiratory flow was measured. Absence of associated oscillations of flow measured at the mouth was taken to indicate that flow was independent of driving pressure and therefore limited. Flow limitation was demonstrable with the RPO technique in all infants for jacket pressures greater than 50 cmH2O; however, it was evident at jacket pressures less than 30 cmH2O jacket pressure in four infants with obstructive airway disease. The RPO technique is a useful adjunct to the compression maneuver utilized to generate PEFV curves in infants because it facilitates the recognition of expiratory flow limitation.
    Journal of Applied Physiology 11/1989; 67(4):1662-9. · 3.06 Impact Factor
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    ABSTRACT: Total respiratory system compliance (Crs) at volumes above the tidal volume (VT) was studied by use of the expiratory volume clamping (EVC) technique in 10 healthy sleeping unsedated newborn infants. Flow was measured with a pneumotachograph attached to a face mask and integrated to yield volume. Volume changes were confirmed by respiratory inductance plethysmography. Crs measured by EVC was compared with Crs during tidal breathing determined by the passive flow-volume (PFV) technique. Volume increases of approximately 75% VT were achieved with three to eight inspiratory efforts during expiratory occlusions. Crs above VT was consistently greater than during tidal breathing (P less than 0.0005). This increase in Crs likely reflects recruitment of lung units that are closed or atelectatic in the VT range. Within the VT range, Crs measured by PFV was compared with that obtained by the multiple-occlusion method (MO). PFV yielded greater values of Crs than MO (P less than 0.01). This may be due to braking of expiratory airflow after the release of an occlusion or nonlinearity of Crs. Thus both volume recruitment and airflow retardation may affect the measurement of Crs in unsedated newborn infants.
    Journal of Applied Physiology 10/1989; 67(3):1192-7. · 3.06 Impact Factor
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    S H Loring · S C Kurachek · M.E.B. Wohl
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    ABSTRACT: Chemical sclerosis of the pleural space is used to prevent recurrence of spontaneous pneumothorax. To test whether sclerosis restricts diaphragmatic excursion, we measured diaphragmatic excursion by ultrasonography in subjects with unilateral pleural sclerosis and compared it with diaphragmatic excursions in normal subjects, in subjects with cystic fibrosis (a diffuse bilateral lung disease), and in those who underwent surgical procedures that obliterate the pleural space. In five subjects with unilateral chemical sclerosis, diaphragmatic excursion was significantly less on the sclerosed side than on the contralateral side (10.7 +/- 1.3 vs 17.3 +/- 1.7 mm, mean +/- SEM; p less than .01). Compared with those of normal subjects, the side-to-side differences in excursion were increased by pulmonary disease (p less than .03) and additionally by unilateral sclerosis (p less than .015). There was no significant difference between diaphragmatic excursions on left and right sides of subjects without history of pleural disease. These data suggest that chemical pleural sclerosis causes a measurable reduction in diaphragmatic excursion on the affected side. The physiologic significance of this effect is not known.
    Chest 03/1989; 95(2):374-8. DOI:10.1378/chest.95.2.374 · 7.48 Impact Factor

Publication Stats

812 Citations
146.06 Total Impact Points


  • 2001
    • Mount Sinai School of Medicine
      • Department of Pediatrics
      Manhattan, NY, United States
  • 1998
    • Harvard University
      Cambridge, Massachusetts, United States
  • 1989–1998
    • Boston Children's Hospital
      • Department of Anesthesia
      Boston, Massachusetts, United States
  • 1982–1998
    • Harvard Medical School
      • • Department of Radiology
      • • Department of Pediatrics
      Boston, Massachusetts, United States
  • 1988
    • St. Michael's Hospital
      Toronto, Ontario, Canada
    • Wolfson Childrens Hospital
      Jacksonville, Florida, United States