Aspirin use is safe in patients undergoing transbronchial lung cryobiopsy.

Background: Aspirin has been shown to be safe for patients undergoing certain diagnostic bronchoscopy procedures, such as transbronchial biopsies and endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration. However, there are no studies documenting the safety of aspirin in patients undergoing trans-bronchial lung cryobiopsy (TBLC). Objective: To determine whether aspirin increases the risk of bleeding during or following TBLC. Methods: 172 consecutive patients undergoing TBLC were included in this retrospective cohort study. Data on demographic characteristics, comorbidities etc. were collected. Bleeding severity was defined by the intervention needed to stop the bleeding: mild-cold saline injection, moderate-adrenalin/hexakarpon injection, or severe - Intensive Care Unit admission after bronchoscopy. Results: Fifty-one patients (29.6 %) were under aspirin treatment at the time of TBLC. Overall, there was no significant difference between the aspirin and the control groups regarding the incidence of moderate-severe bleeding (41.2 % vs. 33.1 %, respectively, p.0.31). the Clopidogrel was found as a risk factor for increased bleeding when taken together with aspirin (Odds ratio = 9.8 (1.1-86), p = 0.013). When taken alone, clopidogrel was also found as a risk factor to increased bleeding, yet these results didn't reach significance due to low number of patients (fig. 1, N = 5, Odds ratio = 2.8 (0.46-17.35), p = 0.245). No difference was observed between the groups regarding additional post-procedural complications, including pneumothorax, hospitalizations, and mortality. Conclusion: To the best of our knowledge, this is the first study examining bleeding risk of cryobiopsy under aspirin treatment. Based on our results, it seems safe to perform TBLC under aspirin treatment, except for patients who are concurrently treated with clopidogrel. Further research should be conducted to substantiate this conclusion.

Well-Being of Israeli Nurse Practitioners During Times of Crisis: A Cross-Sectional Study.

Introduction: For healthcare workers, good work-related well-being positively affects enthusiasm, efficiency, and job satisfaction. Conversely, poor well-being is associated with burnout and negative patient outcomes. During times of crises, it is difficult to balance professional responsibilities with well-being. Objective: This study aimed to evaluate the degree of well-being among nurse practitioners in Israel who worked in COVID-19 units or allied units during the delta wave. Methods: This was a web-based, cross-sectional study. Nurse practitioners who worked within the COVID-19 units in Israeli hospitals were asked to complete several questionnaires: a sociodemographic questionnaire, the Subjective Happiness Scale, the Mental Health Continuum-Short Form, and the Center for Epidemiologic Studies-Depression. Results: Forty-nine nurse practitioners participated in the survey. Scores from the Subjective Happiness Scale and the Mental Health Continuum-Short Form indicate that most nurses have relatively positive mental health. Conversely, scores on the Center for Epidemiologic Studies indicated that participants are at risk for clinical depression. There was a positive moderate association between the number of years worked as a nurse practitioner and depression and a moderate negative association between the number of years worked as a nurse practitioner and happiness. Conclusions: Understanding how nurses' mental health is impacted during crises can provide healthcare systems with tools to prevent negative outcomes. This, in turn, may contribute to a lower burnout rate, higher satisfaction from work, and better patient outcomes.

Percutaneous tracheostomy in the ICU: a review of the literature and recent updates.

PURPOSE OF REVIEW: The following article summarizes the current available knowledge regarding tracheostomy techniques, indications, contraindications, procedure timing, use of assisted technologies and tracheostomy feasibility and safety in high-risk populations. In light of the ongoing corona virus disease (COVID-19) pandemic, a focus was placed on tracheostomy in this unique patient group. RECENT FINDINGS: Percutaneous dilatation tracheostomy (PDT) is commonly used in the ICU setting. It has been shown to be well tolerated and feasible in a diverse patient population including those regarded to be at high risk such as the obese, coagulopathic and acute respiratory failure patient. This patient profile presented itself frequently in the recent COVID-19 pandemic. Indeed studies showed that PDT is well tolerated in COVID-19 ICU patients leading to reduced ICU length of stay (LOS), decrease in ventilator-associated pneumonia rate (VAP) and reduced duration on invasive mechanical ventilation (IMV). Despite initial concerns, virus transmission from patient to healthcare provider (HCP) was shown to be negligible when proper precautions are taken. SUMMARY: Bedside PDT in the ICU is a well tolerated procedure having the potential to benefit both the individual patient as well as to improve resource utilization of the healthcare system.

The Diagnostic Yield of Endobronchial Ultrasound Transbronchial Needle Aspiration (EBUS-TBNA) in Respiratory Compromised Patients under General Anesthesia.

BACKGROUND: Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a frequently used method for obtaining tissue samples for the diagnosis of various respiratory conditions, including lung cancer staging. In most cases, EBUS-TBNA is performed under moderate sedation (MS). However, in cases of respiratory compromised patients, if this procedure is performed, it is conducted under general anesthesia (GA). OBJECTIVES: To assess the diagnostic yield of EBUS-TBNA among respiratory compromised patients. METHODS: Data of consecutive patients (n=191) who underwent EBUS-TBNA at our medical center between January 2019 and December 2019 were retrospectively analyzed. Respiratory compromised patients underwent GA and patients without respiratory compromise were mostly moderately sedated (MS). Characteristics, diagnostic yield, and complication rates were compared. RESULTS: Diagnostic yield was similar between the two sedation modes (89% in GA group and 78% in the MS group, P = 0.11). The number of total samples obtained per procedure was significantly higher in the GA vs. the MS group (4.1 ± 2.1 vs. 2.1 ± 1.33, P < 0.01). The overall complication rate was 13% and 20.9% in the GA vs. the MS groups, respectively (P = 0.14), with the most frequent complication being minor bleeding. Interestingly, while the number of brushings, bronchoalveolar lavage, and endobronchial biopsy were similar, the percent of subjects who underwent transbronchial biopsy was significantly higher in the GA group (49% vs. 24.2%, P < 0.01). CONCLUSIONS: EBUS-TBNA performed under GA among respiratory compromised patients is safe and has similar diagnostic yield to that of patients without a respiratory compromise.

Identifying factors affecting latent tuberculosis treatment acceptance among healthcare workers: a retrospective analysis in a tertiary care centre.

OBJECTIVE: Official guidelines recommend tuberculosis (TB) screening programmes for all healthcare workers (HCWs), along with offering treatment when latent TB infection (LTBI) is diagnosed. However, adherence to treatment among HCWs is lower compared with non-HCWs. The aim of the present study was to examine the rate of LTBI treatment acceptance among HCWs and to characterise the factors associated with non-acceptance. DESIGN AND SETTING: This was a retrospective cohort study. All HCWs diagnosed with LTBI, who had tuberculin skin test (TST) conversion during their work, between 2000 and 2015, in a single tertiary academic medical centre, and who consented to answer a questionnaire, were enrolled. RESULTS: Overall, 147 of 219 (67%) with TST conversion agreed to participate. Acceptance rate for LTBI treatment was only 16%. The overall completion rate among those who accepted treatment was 87%. HCWs' recall of discussing the importance of LTBI treatment with their caregiver had the strongest association with LTBI treatment acceptance: 23 of 52 HCWs (44%) who recalled this discussion accepted treatment (adjusted OR=10.2, 95% CI: 2.2 to 47.6, p=0.003). Knowing the risk of developing TB was associated with 3.7 increased odds to accept treatment (95% CI: 1.2 to 11.8, p=0.02). CONCLUSIONS: LTBI acceptance rate was very low among our HCWs. Focusing on educating HCWs is potentially the key step towards an increased rate of LTBI treatment acceptance.

Predictors of respiratory cancer-related mortality for Jews and Arabs in Israel.

BACKGROUND: Respiratory cancers, including lung, tracheal and bronchus cancers, are a leading cause of cancer-related mortality in Israel; however, incidence can differ among demographic groups. Despite the importance of sociodemographic characteristics and the interactions between them to incidence and mortality, this topic is understudied. This study analyzes sociodemographic disparities by sex and ethnicity among Jews and Arabs to understand cancer outcome differences stratified by SES, marital status, and number of children as potential contextual factors. METHODS: This retrospective cohort study analyzed respiratory cancer-related mortality rates among Israelis born between 1940 and 1960 over 21-years. The follow up period was between January 1, 1996 and 12.31.2016. Mortality rates for Jews and Arabs were calculated. Using a Cox Regression, a multivariate model was constructed to determine the association between ethnicity and respiratory cancer mortality. The study population was then divided into four groups, by sex and ethnicity, to determine the association between marital status, number of children, and SES with respiratory cancer mortality for each subgroup. RESULTS: The overall mortality rate was 0.6%. Arabs had higher mortality rates compared to Jews, even after adjusting for demographic factors including age, sex and SES (Adjusted Hazard Ratio (AHR) = 1.442, 99% confidence intervals (CI) = 1.354,1.546). Among men, a higher mortality rate was found among Arabs (AHR = 1.383, 99%CI = 1.295,1.477), while among women, Arabs had lower mortality rates (AHR = 0.469, 99%CI = 0.398,0.552). Significant mortality rate differences were observed by ethnicity and sex for each sociodemographic variable. CONCLUSIONS: This study highlights the importance and implications of understanding differences in respiratory cancer mortality between Jews and Arabs, a minority group in Israel, and is relevant for minority groups in general. There is a need to tailor interventions for these groups, based on differing underlying causes and contextual factors for these cancers. Cancer outcomes among these groups should also be studied separately, by sex, to better understand them.

The Short- and Long-Term Impact of Pulmonary Rehabilitation in Subjects with Sarcoidosis: A Prospective Study and Review of the Literature.

BACKGROUND: Sarcoidosis is a heterogeneous multisystemic disorder of unknown etiology. Dyspnea and fatigue are two of the most common and debilitating symptoms experienced by subjects with sarcoidosis. There is limited evidence regarding the short- and long-term impact of pulmonary rehabilitation (PR) on exercise capacity and fatigue in these individuals. OBJECTIVE: To evaluate the benefit of PR in subjects with pulmonary sarcoidosis at different severity stages and to review the current literature about PR in sarcoidosis. METHODS: PR included a 12-week training program of a twice-weekly 90-min workouts. Fifty-two subjects with stable pulmonary sarcoidosis were recruited. Maximal exercise capacity, defined as VO2max, was measured using the cardiopulmonary exercise test (CPET). Pulmonary function tests, 6-min walking distance (6MWD), St. George's Respiratory Questionnaire (SGRQ), and the modified Medical Research Council (mMRC) and Hospital Anxiety and Depression Scale (HADS) questionnaires were given before and after PR and following 6 months (follow-up). RESULTS: The PR program significantly increased the VO2max (1.8 ± 2.3 mL/kg/min, p = 0.002), following 12 weeks. mMRC and SGRQ scores were also improved (-0.3 ± 0.8, p = 0.03, and -3.87 ± 10.4, p = 0.03, respectively). The impact of PR on VO2max was more pronounced in subjects with pulmonary parenchymal involvement. The increase in VO2max correlated with initial disease severity (indicated by FEV1/FVC, p = 0.01). Subjects with FEV1/FVC <70% showed greater improvement in 6MWD. 6MWD also improved in those with a transfer coefficient of the lung for CO (KCO) above 80% predicted (p < 0.05). At 6-month follow-up, the VO2max, 6MWD, and SGRQ scores remained stable, thus suggesting lasting effects of PR. CONCLUSION: PR is a promising complementary therapeutic intervention for subjects with sarcoidosis. Further study is needed to validate these findings.

Identification of Asthma-COPD Overlap, Asthma, and Chronic Obstructive Pulmonary Disease Phenotypes in Patients with Airway Obstruction: Influence on Treatment Approach.

BACKGROUND: Many studies have described asthma-COPD overlap (ACO) among patients diagnosed with asthma or chronic obstructive pulmonary disease (COPD), but less so in broad populations of patients with chronic airway obstruction. OBJECTIVE: This study aimed to (i) examine the prevalence of ACO, asthma, and COPD phenotypes among subjects referred for pulmonary function testing (PFT), who had airway obstruction in spirometry (forced expiratory volume in 1 s [FEV1]/forced vital capacity [FVC] <0.7); and (ii) delineate the therapeutic approach of each group. METHODS: Cross-sectional study of patients who were referred for PFT at the Rokach Institute, in Jerusalem. Working definitions were as follows: (a) COPD: post-bronchodilator (BD) FEV1/FVC <0.70; (b) asthma: physician-diagnosed asthma before age 40 and/or minimum post-BD increase in FEV1 or FVC of 12% and 200 mL; and (c) ACO: the combination of the 2. Demographics, smoking habits, episodes of exacerbation, health-related quality of life (HRQL), and respiratory medication utilization were analyzed. RESULTS: Of 3,669 referrals from January 1 to April 30, 2017, 1,220 had airway obstruction of which 215 were included. Of these, 82 (38.1%) had ACO, 49 (22.8%) asthma, and 84 (39.1%) COPD. ACO subjects tended to (a) be predominantly female; (b) be older than asthmatics, (c) be smokers; (d) have worse HRQL in the activity domain; and (d) have more exacerbations. Treatment of ACO and COPD patients differed from that of asthmatics, but not from each other, in the proportion of subjects on maintenance treatment, use of LABA, LAMA, and ICS, alone or in combination, and in the number of inhaler devices used by patients. CONCLUSION: ACO represented >1/3 of patients referred for PFT. Despite a clearly identifiable phenotype, ACO patients received treatment similar to COPD patients, suggesting poor ACO identification. Our data emphasize the need to raise the awareness of ACO among clinicians, in order to guide better recognition and appropriate treatment in individual patients.

The Effect of Pulmonary Rehabilitation on Non-chronic Obstructive Pulmonary Disease Patients.

BACKGROUND: Pulmonary rehabilitation has shown significant benefit for patients with chronic obstructive pulmonary disease (COPD). The effect on non-COPD pulmonary patients is less well established. OBJECTIVES: To determine whether pulmonary rehabilitation is also beneficial for non-COPD pulmonary patients. METHODS: Clinical and demographic data on non-COPD pulmonary patients who participated in our institutional pulmonary rehabilitation program between January 2009 and December 2016 were collected. Participants engaged in a 60-minute, twice-weekly, ambulatory hospital-based program lasting 12 to 24 sessions. Sessions included both endurance and muscle training as well as healthy lifestyle educational activities. The six-minute walk test (6MWT) and the St. George's Respiratory Questionnaire (SGRQ) were conducted before and after the rehabilitation program. RESULTS: We recruited 214 non-COPD patients, of whom 153 completed at least 12 sessions. Of these, 59 presented with interstitial lung disease (ILD), 18 with non-ILD restrictive lung defects, 25 with asthma, 30 with lung cancer, and 21 with other conditions (e.g., pulmonary hypertension, bronchiectasis) The groups demonstrated significant improvement in 6MWT and in SGRQ scores. Non-COPD patients gained a 61.9 meter (19%) improvement in the 6MWT (P < 0.0001) and 8.3 point reduction in their SGRQ score (P < 0.0001). CONCLUSIONS: Pulmonary rehabilitation is effective in non-COPD pulmonary patients. As such, it should be an integral part of the treatment armament provided to the vast majority of those suffering from chronic respiratory disease.

Avoiding Routine Chest Radiography after Transbronchial Biopsy Is Safe.

BACKGROUND: Fiberoptic bronchoscopy (FOB) with transbronchial biopsy (TBB) is complicated by a pneumothorax in 1-4% of cases. Performance of routine post-TBB chest radiography (CXR) results in an extremely low diagnostic yield but nevertheless is the common clinical practice prevailing today. It has previously been suggested that routine post-TBB CXR could be avoided in asymptomatic patients. OBJECTIVE: The objective of this study was to prospectively assess the feasibility and safety of this approach. METHODS: The study group included 201 consecutive patients who underwent FOB with TBB at our institution between January 2009 and September 2014. All subjects completed a preprocedural, a 2-hour postprocedural, and a 24- to 48-hour postprocedural symptom questionnaire (chest pain, dyspnea, and cough). Post-TBB CXR was ordered by the treating physician only if indicated. All cases of pneumothorax were documented. Additionally, the following information was recorded: sex, age, immune status, indication for FOB, total number of biopsies done, lobe sampled, and pulse oxygen saturation. RESULTS: Sixteen CXRs were ordered by the treating physician due to suspected pneumothorax (8%). Early-onset pneumothorax (i.e. within 2 h of TBB) was diagnosed radiologically in 6 patients (3%). Two late-onset pneumothoraxes (1%) were diagnosed more than 24 h after TBB. No pneumothoraxes of clinical significance were diagnosed among asymptomatic patients without significant oxygen desaturation events. CONCLUSIONS: Among asymptomatic patients without significant desaturation events, pneumothorax is rare and usually of negligible clinical significance. Therefore, performance of routine CXR after TBB is not necessary and can be safely avoided in this category of patients.

Pain management at the end of life: A comparative study of cancer, dementia, and chronic obstructive pulmonary disease patients.

BACKGROUND: Limited data exist concerning the unique pain characteristics of patients with non-cancer terminal diseases referred for inpatient hospice care. AIMS: To define the unique pain characteristics of patients admitted to an acute inpatient hospice setting with end-stage dementia or chronic obstructive lung disease (or chronic obstructive pulmonary disease) and to compare them to patients with end-stage cancer. DESIGN: Retrospective patient chart review. Demographic, physiological, pain parameters, and medication utilization data were extracted. Associations between pain characteristics, medication utilization, and admission diagnoses were assessed. Analyses included descriptive statistics. SETTING/PARTICIPANTS: In total, 146 patients admitted to an acute inpatient hospice between 1 April 2011 and 31 March 2012 with an underlying primary diagnosis of chronic obstructive pulmonary disease (n = 51), dementia (n = 48), or cancer (n = 47). RESULTS: Pain was highly prevalent in all diagnostic groups, with cancer patients experiencing more severe pain on admission. Cancer patients received a significantly higher cumulative opioid dose compared with dementia and chronic obstructive pulmonary disease patients. Pain control within 24 h of pain onset was achieved in less than half of all patient groups with chronic obstructive pulmonary disease patients the least likely to achieve pain control. CONCLUSIONS: Despite the fact that pain is the most common complaint at the end of life, pain management may be suboptimal for some primary diagnoses. Admission diagnosis is the strongest predictor of pain control. Patient with cancer achieve the best pain control, and chronic obstructive pulmonary disease patients are the least likely to have their pain adequately treated.

Pulse oximetry: fundamentals and technology update.

Oxygen saturation in the arterial blood (SaO2) provides information on the adequacy of respiratory function. SaO2 can be assessed noninvasively by pulse oximetry, which is based on photoplethysmographic pulses in two wavelengths, generally in the red and infrared regions. The calibration of the measured photoplethysmographic signals is performed empirically for each type of commercial pulse-oximeter sensor, utilizing in vitro measurement of SaO2 in extracted arterial blood by means of co-oximetry. Due to the discrepancy between the measurement of SaO2 by pulse oximetry and the invasive technique, the former is denoted as SpO2. Manufacturers of pulse oximeters generally claim an accuracy of 2%, evaluated by the standard deviation (SD) of the differences between SpO2 and SaO2, measured simultaneously in healthy subjects. However, an SD of 2% reflects an expected error of 4% (two SDs) or more in 5% of the examinations, which is in accordance with an error of 3%-4%, reported in clinical studies. This level of accuracy is sufficient for the detection of a significant decline in respiratory function in patients, and pulse oximetry has been accepted as a reliable technique for that purpose. The accuracy of SpO2 measurement is insufficient in several situations, such as critically ill patients receiving supplemental oxygen, and can be hazardous if it leads to elevated values of oxygen partial pressure in blood. In particular, preterm newborns are vulnerable to retinopathy of prematurity induced by high oxygen concentration in the blood. The low accuracy of SpO2 measurement in critically ill patients and newborns can be attributed to the empirical calibration process, which is performed on healthy volunteers. Other limitations of pulse oximetry include the presence of dyshemoglobins, which has been addressed by multiwavelength pulse oximetry, as well as low perfusion and motion artifacts that are partially rectified by sophisticated algorithms and also by reflection pulse oximetry.

Diagnosis of obstructive sleep apnea using pulse oximeter derived photoplethysmographic signals.

OBJECTIVES: Increasing awareness of the high prevalence of obstructive sleep apnea (OSA) and its impact on health in conjunction with high cost, inconvenience, and short supply of in-lab polysomnography (PSG) has led to the development of more convenient, affordable, and accessible diagnostic devices. We evaluated the reliability and accuracy of a single-channel (finger pulse-oximetry) photoplethysmography (PPG)-based device for detection of OSA (Morpheus Ox). METHODS: Among a cohort of 73 patients referred for in-laboratory evaluation of OSA, 65 were simultaneously monitored with the PPG based device while undergoing PSG. Among these, 19 had significant cardiopulmonary comorbidities. Using the PSG as the "gold standard," the sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), as well as the positive likelihood ratio (+LR) for an apnea hypopnea index (AHI)PSG > 5/h and AHIPSG > 15/h were calculated for the PPG. RESULTS: Valid results were available for 65 subjects. Mean age: 52.1 ± 14.2, Male: 52%, and BMI: 36.3 ± 9.7 kg/m(2). Positive correlation was found between PPG-derived and PSG-derived AHI (r = 0.81, p < 0.001). For AHIPSG > 5/h, sensitivity was 80%, specificity 86%, PPV 93%, NPV 68%, and +LR was 5.9. For AHIPSG > 15/h, sensitivity was 70%, specificity 91%, PPV 80%, NPV 85%, and +LR was 7.83. The corresponding areas under the receiver operator curves were 0.91 and 0.9. CONCLUSIONS: PPG-derived data compare well with simultaneous in-lab PSG in the diagnosis of suspected OSA among patients with and without cardiopulmonary comorbidities. CITATION: Romem A; Romem A; Koldobskiy D; Scharf SM. Diagnosis of obstructive sleep apnea using pulse oximeter derived photoplethysmographic signals.

[Going forward--five years experience in pulmonary rehabilitation].

INTRODUCTION: Pulmonary rehabilitation is regarded as a crucial component of the therapeutic armamentarium in chronic lung disease. Ten years ago the Pulmonary Rehabilitation Service at the Shaare Zedek Medical Center (SZMC) was established as part of the Cardiac Rehabilitation Center. Over the last six years this service operates independently within the physiotherapy center under the supervision of the Pulmonary Institute, in collaboration with the social and nutritional services. AIMS: To evaluate the efficacy of pulmonary rehabilitation in improving the patients' quality of life and functional capacity. METHODS: Prospective follow-up of patients referred for pulmonary rehabilitation at the SZMC between the years 2009-2013. The participants were required to complete a pulmonary function test, a 6 minute walk test (6MWT) and a quality of life questionnaire, the Saint George Respiratory Questionnaire (SGRQ). The SGRQ and the 6MWT were readministered after completion of the program. RESULTS: During the follow-up period 415 patients underwent pulmonary rehabilitation at SZMC, of them 330 completed a series of at least 12 sessions. Complete data pertaining to the 6MWTwas obtained for 276 subjects. Participation in the program led to an improvement of 57.5 meters (p < 0.001) in the walking distance. Complete data regarding the SGRQ were available for 94 patients. Completion of the pulmonary rehabilitation program led to a decrease of 8.9 points in the SGRQ (p < 0.001). CONCLUSIONS: Our results indicate that pulmonary rehabilitation was clinically useful as well as statistically significant in improving the functional capacity and quality of life among patients with chronic lung diseases.

Obstructive sleep apnea in patients with end-stage lung disease.

OBJECTIVES: Little is known about the rate of obstructive sleep apnea (OSA) in patients with end stage lung disease (ESLD). Given the potential deleterious effect of OSA in these patients, we assessed the case-rate and severity of OSA and described associated patient characteristics. METHODS: Retrospective survey of 60 patients with ESLD referred for lung transplantation evaluation. Demographic, polysomnographic, spirometric, and medication utilization data were extracted and analyzed. RESULTS: As demographic and polysomnographic data did not differ between obstructive and restrictive patients, we present analysis of pooled data. Demographics/physiology: median age was 58.5 years, 52% males, mean BMI 32.3 kg/m(2), 52% obstructive. Sleep variables (all medians): total sleep time (TST) 312 min, sleep efficiency 77%, minimal oxygen saturation 84%, apnea hypopnea (AHI) 9.7, respiratory disturbance index (RDI) 12.7 events/h of sleep. Sixty-seven percent had RDI > 5; 21% had RDI between 15 and 30; and 21% had RDI > 30. Periodic limb movement index ≥ 15/h sleep was present in 21.7%. An independent positive correlation between DLCO% and RDI was noted (r = 0.41, p < 0.01). The minimal oxygen saturation was negatively correlated with the RDI (r = -0.34, p < 0.01). The use of ACE inhibitors was associated with moderate-to-severe OSA (odd ratio of 4.67, CI 1.45-15.03; p = 0.017). CONCLUSIONS: In patients with ESLD, organic sleep disorders are common. Greater severity of OSA was associated with the higher DLCO% and lower oxygen saturation.

[Popliteal cyst rupture due to unusual physical stress].

Popliteal cyst rupture is a known phenomenon following strenuous labor or sport activity. We present a case in which popliteal cyst rupture followed an unusual strenuous physical activity--devoted prayer during the holy month of the Ramadan.

Acute coronary syndrome associated with myocardial bridging due to ergotamine treatment for migraine.

A 48-year-old woman presented with acute coronary syndrome and underwent coronary angiography which revealed myocardial bridging at the distal end of the left anterior descending artery with otherwise normal coronary arteries. The patient used to take ergotamine for her chronic migraine. Possible association with myocardial bridging which was found in this patient is discussed.

Postexposure treatment with doxycycline for the prevention of tick-borne relapsing fever.

BACKGROUND: Tick-borne relapsing fever (TBRF) is an acute febrile illness. In Israel, TBRF is caused by Borrelia persica and is transmitted by Ornithodoros tholozani ticks. We examined the safety and efficacy of postexposure treatment to prevent TBRF. METHODS: In a double-blind, placebo-controlled trial, 93 healthy subjects with suspected tick exposure (52 with signs of tick bites and 41 close contacts--those without signs but with a similar risk of contact with ticks) were randomly assigned to receive either doxycycline (Dexxon, in a dose of 200 mg the first day and then 100 mg per day for four days) or placebo after presumed exposure to TBRF. Cases of TBRF were defined by fever and a positive blood smear. Serologic analysis for cross-reactivity to Borrelia burgdorferi and polymerase chain reaction (PCR) for the borrelia glpQ gene were also performed. RESULTS: After randomization, 47 subjects (26 with signs of tick bites and 21 close contacts) received doxycycline. Forty-six other subjects (26 with signs of tick bites and 20 close contacts) received placebo. All 10 cases of TBRF identified by a positive blood smear were in the placebo group of subjects with signs of a tick bite (P<0.001). These findings suggested a 100 percent efficacy of preemptive treatment (95 percent confidence interval, 46 to 100 percent). PCR for the borrelia glpQ gene was negative at baseline for all subjects and subsequently positive in all subjects with fever and a positive blood smear. Seroconversion was detected in eight of nine cases of TBRF. PCR and serum samples were negative for all of the other subjects tested. No major treatment-associated adverse effects were identified. CONCLUSIONS: Treatment with doxycycline is safe and efficacious in preventing TBRF after suspected exposure to ticks in a high-risk environment. (ClinicalTrials.gov number, NCT00237016 [ClinicalTrials.gov].).