[BRONCHIECTASIS--REVIEW OF LITERATURE AND CLINICAL CHARACTERISTICS OF BRONCHIECTASIS PATIENTS TREATED IN THE BRONCHIECTASIS CLINIC AT THE CARMEL MEDICAL CENTER].

AIMS: Bronchiectasis is a suppurative lung disease characterized by wide and distorted bronchi, with daily cough and sputum production punctuated by infectious exacerbations. Etiologies are diverse, and treatment is multidisciplinary, consisting of lung hygiene with mucolytic agents and physiotherapy, anti-inflammatory agents and antimicrobial agents, as needed. This study aims to review the literature and describe the clinical and radiological characteristics of patients with bronchiectasis treated at the Bronchiectasis clinic at Carmel Medical Center. METHODS: We included patients with Lung bronchiectasis according to chest HRCT treated at the Bronchiectasis clinic. We reviewed retrospective data regarding etiologic work up, age symptoms developed, extension of bronchiectasis, Lung function, microbiology of sputum, number of exacerbations and hospitalizations. RESULTS: Seventy four,patients were included, 39 women, mean age--65.7 years. Average lung involvement was two Lobes. Etiologies were: 42% idiopathic, 19% post-infectious and immune deficiency 5.6%. Cultures were positive for S. aureus in 9.5%, H. influenza in 19%, S pneumonia (4.8%), P aeruginosa (41.3%), non tuberculous mycobacteria (9.5%) and other bacteria in 11%. Patients suffered an average of 2.2 exacerbations per year, with 0.45 hospitalizations per year due to exacerbation of bronchiectasis. Mean predicted FEVI in spirometry was 74.32 ± 25%. Patients colonised with P aeruginosa suffered significantly more exacerbations and hospitalizations than patients without P aeruginosa colonization. CONCLUSIONS: Bronchiectasis led to significant morbidity with infectious complications. We suspect that there is under- diagnosis and under-referral of this condition.

Asymptomatic carriage of Pneumocystis jirovecii and cytomegalovirus in lungs of immunocompetent patients.

PURPOSE: Pneumocystis jirovecii (PCP) and cytomegalovirus (CMV) are opportunistic pathogens which cause lung infection in immunocompromised individuals. However, scarce data are available regarding the carriage of CMV or PCP in immunocompetent, non critically ill patients. The purpose of this study was to evaluate the prevalence of PCP and CMV in broncholaveolar lavage of adult immunocompetent, non critically ill patients. METHODS: BAL fluids from immunocompetent patients who underwent bronchoscopy were analyzed by polymerase chain reaction (PCR) for CMV and PCP DNA. We tested CMV antibodies in serum. In patients with positive CMV DNA in lavage fluid, we further analyzed peripheral blood for the presence of CMV DNA. RESULTS: Ninety three patients were included. We did not detect PCP DNA in BAL in any patient. CMV DNA was found in BAL of 5 of 86 CMV IgG positive patients (5.8 %). Patients who were positive for CMV did not differ from patients with negative PCR for CMV regarding demographic and clinical features. CONCLUSION: We did not find PCP colonization in our cohort of patients. However, we found significant prevalence of CMV DNA in BAL from immunocompetent patients, with no evidence of acute CMV infection. This finding may represent colonization by CMV in immunocompetent, non-critically ill individuals.

Multidrug-resistant Klebsiella pneumoniae acquisition in lung transplant recipients.

BACKGROUND: Carbapenem-resistant Klebsiella pneumoniae (CRKP) is a pathogen that emerged in the late twentieth century and was associated with significant morbidity and mortality. We report for the first time the outcomes of lung transplant recipients infected with CRKP or extended spectrum-ß lactamases K. pneumoniae (ESBL-KP). METHODS: Retrospective review of 136 lung transplant recipients who underwent transplantation between 2004 and 2007 in Rabin Medical Center, Israel. MAIN RESULTS: There were 52 episodes of positive cultures for K. pneumoniae (KP) in 136 recipients - of them 11 (8.1%) with CRKP, 12 (8.8%) with ESBL-KP, and 29 (21.3%) with carbapenem-sensitive ESBL-negative KP. Isolation of CRKP/ESBL-KP was associated with death in the cohort (p < 0.0001) as well as recipients' age at transplantation (p < 0.005). Time-dependent age-adjusted CRKP or ESBL-KP acquisition was an independent factor for death in patients after lung transplant, compared to patients without KP isolation or carbapenem-sensitive ESBL-negative KP (p < 0.0001). CONCLUSION: CRKP and KP-ESBL acquisition was associated with reduced survival among lung transplant recipients.

Protective Effects of BNT162b2 Vaccination on Aerobic Capacity Following Mild to Moderate SARS-CoV-2 Infection: A Cross-Sectional Study Israel.

Patients previously infected with acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may experience post-acute adverse health outcomes, known as long COVID. The most reported symptoms are fatigue, headache and attention/concentration issues, dyspnea and myalgia. In addition, reduced aerobic capacity has been demonstrated in both mild and moderate COVID-19 patients. It is unknown whether COVID-19 vaccination mitigates against reduced aerobic capacity. Our aim was to compare the aerobic capacity of vaccinated and unvaccinated individuals previously infected with SARS-CoV-2. Methods: Individuals aged 18 to 65 years with laboratory-confirmed mild to moderate COVID-19 disease were invited to Ziv Medical Centre, Israel, three months after SARS-CoV-2 infection. We compared individuals unvaccinated at the time of infection to those vaccinated in terms of aerobic capacity, measured using symptom-limited cardiopulmonary exercise test (CPET). Results: We recruited 28 unvaccinated and 22 vaccinated patients. There were no differences in baseline demographic and pulmonary function testing (PFT) parameters. Compared with unvaccinated individuals, those vaccinated had higher V'O2/kg at peak exercise and at the anaerobic threshold. The V'O2/kg peak in the unvaccinated group was 83% of predicted vs. 100% in the vaccinated (p < 0.002). At the anaerobic threshold (AT), vaccinated individuals had a higher V'O2/kg than those unvaccinated. Conclusions: Vaccinated individuals had significantly better exercise performance. Compared with vaccinated individuals, a higher proportion of those unvaccinated performed substantially worse than expected on CPET. These results suggest that vaccination at the time of infection is associated with better aerobic capacity following SARS-CoV-2 infection.

Voriconazole and itraconazole in lung transplant recipients receiving tacrolimus (FK 506): efficacy and drug interaction.

BACKGROUND: The aim of this study was to compare the extent of interaction between tacrolimus and itraconazole vs. voriconazole. PATIENTS AND METHODS: This retrospective study included 60 lung transplant recipients who were treated with a tacrolimus-based regimen; 40 received prophylactic itraconazole for the first six months following lung transplantation (LTX), and 20 were treated with voriconazole. All patients had at least 12 months of follow-up. Tacrolimus levels and dosage requirements were compared during and after azole therapy. We assessed the rejection rate, fungal infection rate, and renal function during the study period. RESULTS: The mean tacrolimus dose during itraconazole treatment was 3.26 ± 2.1 mg/d compared with 5.74 ± 2.9 mg/d after itraconazole was stopped, p < 0.0001. Similarly, the mean tacrolimus dose during voriconazole treatment was 1.75 ± 0.9 mg/d compared with 4.85 ± 0.38 mg/d after voriconazole was stopped (p = 0.002). Thus, the mean increase in the total daily dose of tacrolimus after itraconazole and voriconazole withdrawal was 76% and 64%, respectively. No differences in the rejection or fungal infection rates or renal toxicity were observed during the study period, although an increase in positive fungal isolates was noted during itraconazole therapy. CONCLUSION: The tacrolimus dose was reduced more with itraconazole than with voriconazole, without an increase in the rejection rate and with renal function preservation.

Therapeutic effectiveness of rituximab in a patient with unresponsive autoimmune pulmonary alveolar proteinosis.

Pulmonary alveolar proteinosis (PAP) is a rare lung disease characterised by the accumulation of lung surfactant in the alveoli. In most cases it is an autoimmune disease with antibodies directed against the growth factor granulocyte-macrophage colony stimulating factor (GM-CSF). Standard of care consists of whole lung lavages in symptomatic patients. An alternative treatment is GM-CSF injections. The case history is reported of a patient with PAP and severe dyspnoea and hypoxaemia. Whole lung lavages and GM-CSF initially resulted in partial remission. However, the patient's condition deteriorated and her saturation during rest with high-flow oxygen treatment was 85%. The patient was treated with an anti-CD20 antibody rituximab which resulted in dramatic improvement. Room air saturation increased to 98% with exercise and she no longer required supplemental oxygen. The diffusion capacity for carbon monoxide increased from 27% to 48% of predicted and the chest x-rays improved. Rituximab may be useful in the treatment of patients with unresponsive PAP.

Lung transplantation in patients with scleroderma: case series, review of the literature, and criteria for transplantation.

BACKGROUND: The use of lung transplantation (LTX) to treat respiratory failure because of scleroderma is controversial. We present our experience, review the current literature, and suggest specific criteria for LTX in scleroderma. Of the 174 patients who underwent LTX at our center, seven (4%) had scleroderma-associated respiratory failure. PATIENTS AND METHODS: A MEDLINE search of the English literature was performed for studies of LTX in patients with scleroderma between 1986 and 2006. A Kaplan-Meier survival curve was calculated over the time of the studies. RESULTS: The MEDLINE search yielded one large review and four small case series. The small case series were included in the review. The review and our series yield a total of 54 patients. Mean patient age was 47.1 yr; 59.3% were female. Pre-operative lung data were available for 24 patients: 22 (92%) had pulmonary fibrosis and 17 (71%) had pulmonary hypertension. Most patients (69%) underwent single-lung transplantation. Mean forced expiratory volume at one s after LTX was 67% (range 56-87%). There was no difference in infection and rejection rates between the patients with scleroderma and other LTX recipients. The two- and five-yr survival rates were 72% and 55%, respectively. CONCLUSIONS: LTX is a valid option in well-selected patients with scleroderma and pulmonary fibrosis, yielding good pulmonary function and acceptable morbidity and mortality.

Long-term pulmonary function after recovery from pulmonary contusion due to blunt chest trauma.

BACKGROUND: Blunt chest trauma can cause severe acute pulmonary dysfunction due to hemo/pneumothorax, rib fractures and lung contusion. OBJECTIVES: To study the long-term effects on lung function tests after patients' recovery from severe chest trauma. METHODS: We investigated the outcome and lung function tests in 13 patients with severe blunt chest trauma and lung contusion. RESULTS: The study group comprised 9 men and 4 women with an average age of 44.6 +/- 13 years (median 45 years). Ten had been injured in motor vehicle accidents and 3 had fallen from a height. In addition to lung contusion most of them had fractures of more than three ribs and hemo/pneumothorax. Ten patients were treated with chest drains. Mean intensive care unit stay was 11 days (range 0-90) and mechanical ventilation 19 (0-60) days. Ten patients had other concomitant injuries. Mean forced expiratory volume in the first second was 81.2 +/- 15.3%, mean forced vital capacity was 85 +/- 13%, residual volume was 143 +/- 33.4%, total lung capacity was 101 +/- 14% and carbon monoxide diffusion capacity 87 +/- 24. Post-exercise oxygen saturation was normal in all patients (97 +/- 1.5%), and mean oxygen consumption max/kg was 18 +/- 4.3 ml/kg/min (60.2 +/- 15%). FEV1 was significantly lower among smokers (71.1 +/- 12.2 vs. 89.2 +/- 13.6%, P = 0.017). There was a non-significant tendency towards lower FEV1 among patients who underwent mechanical ventilation. CONCLUSIONS: Late after severe trauma involving lung contusion, substantial recovery was demonstrated with improved pulmonary function tests. These results encourage maximal intensive care in these patients. Further larger studies are required to investigate different factors affecting prognosis.

Use of Amplatzer device for endobronchial closure of bronchopleural fistulas.

Bronchopulmonary fistula (BPF) is associated with high morbidity and mortality. It occurs as an uncommon but often severe complication of pneumonectomy. BPF may be treated by a range of surgical and medical techniques, including chest drain, Eloesser muscle flap, omental flap, transsternal bronchial closure, thoracoplasty, and prolonged therapy with antibiotic regimens. The use of bronchoscopy has been reported for the delivery of biological glue, coils, covered stents, and sealants. In this work, we describe a novel method of BPF closure using the Amplatzer device, which is commonly used for transcatheter closure of atrial septal defects.

The value of D-dimer in lung transplant recipients with bronchiolitis obliterans syndrome.

Bronchiolitis obliterans syndrome (BOS) following lung transplantation is common and potentially devastating. Its exact cause is undefined, but multiple immune and nonimmune processes contribute to its pathogenesis. The diagnosis of BOS syndrome is based on clinical presentation of progressive decline in the lung functions together with appropriate pathological findings. Severe acute rejection and recurrent acute rejection have been shown to confer the greatest risk for obliterative bronchiolitis, signifying the central importance of alloimmunity in the disease process. BOS is associated with activation of the coagulation system, and is a major cause of lung allograft loss. The aim of the study was to determine if there is an association between D-dimer levels and functional exercise capacity in lung transplant recipients with BOS. This prospective group comparison study was conducted at a tertiary-care, university-affiliated medical center. The sample included 46 patients (29%) who underwent lung transplantation between January 1997 and May 2006 and had positive findings on screening for BOS. Blood samples were collected for measurement of plasma D-dimer levels by the rapid MiniQuant assay. Correlational analysis was used to determine the association of D-dimer levels with demographic clinical data, pulmonary function, and functional exercise capacity parameters, including the 6-min walk test and cardiopulmonary exercise testing. D-dimer levels were associated with FEV1 (r=-0.43, p=0.001), 6-min walk test (r=-0.53, p=0.04), and VO2/kg/min (r=-0.36, p=0.04). No correlations were noted between D-dimer levels and total lung capacity, diffusion capacity, and oxygen saturation. On multivariate logistic regression, only FEV1 was a significant predictor of BOS (OR 0.885, CI: 0.812-0.965). We conclude that in lung transplant recipients with BOS, D-dimer levels are highly associated with functional exercise capacity and may serve as a useful marker for noninvasive monitoring. Further coagulation assays are needed to complete our observations.

Use of the 15-steps climbing exercise oximetry test in patients with idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is often associated with exercise-induced hypoxemia. Although maximal oxygen consumption (VO2(max)) is considered the gold-standard index of functional capacity in IPF, its measurement requires sophisticated equipment and trained personnel. The aim of the present study was to investigate the value of the simple 15-steps climbing exercise oximetry test in patients with IPF. The 15-steps climbing test was administered to 51 patients with IPF. Pulmonary function tests (PFTs), cardiopulmonary exercise test (CPET), and the 6-min walk distance (6MWD) test were performed in the same session. Oxygen saturation in the 15-steps climbing test was measured by continuous oximetry, and quantified oxygen desaturation was determined by calculating the area under the curve of oxygen saturation from the beginning of exercise through the lowest desaturation point until recovery to baseline ("desaturation area"). There was a statistically significant correlation between all parameters of the 15-steps climbing test and both VO2(max)) on the CPET (lowest saturation, p=0.002, r=0.43; saturation difference, p=0.02, r=-0.33; recovery time, p=0.02, r=-0.32; and desaturation area, p=0.005, r=-0.39), and carbon dioxide diffusion in the lungs (DLCO) on the PFTs (lowest saturation, p=0.0001, r=0.52; saturation difference, p=0.0002, r=-0.50; recovery time, p=0.0001, r=-0.53; and desaturation area, p=0.0001, r=-0.53). On stepwise linear regression analysis, independent significant predictors of VO2(max) were lowest saturation on the 15-steps test and the 6MWD. We concluded that the 15-steps oximetry test is a simple and accurate bedside tool for the evaluation of functional capacity in patients with IPF.

Post-transplant diabetes mellitus in lung transplant recipients: incidence and risk factors.

OBJECTIVE: Post-transplant diabetes mellitus (PTDM) is a common and potentially serious complication after solid organ transplantation. There are only a few data, however, about the incidence of DM in patients undergoing lung transplantation. PATIENTS AND METHODS: The medical records of 119 consecutive patients who underwent lung transplantation from 1998 to September 2004 were reviewed. Patients were divided in three groups according to their diabetes status, including pre-transplant DM, the PTDM group and those without DM. Patient records and all laboratory data were reviewed and the clinical course of diabetes was monitored. All recipients were treated with tacrolimus based regimen. RESULTS: Mean follow-up for all patients was 25+/-10. Twenty-three patients had DM in the pre-lung transplantation (LTX) DM group. PTDM developed in 34 of the remaining 96 patients (35.4%) with an incidence of 20%, 23% after 6 months and 12 months post-transplant. No significant difference was noted between 12 and 24 months post-LTX. The patients who developed DM were older (57+/-15 vs 53+/-13 years, p=0.009), had increased BMI (26+/-5 vs 24+/-4, p=0.0001), shorter time from diagnosis to LTX (21+/-13 vs 28+/-18 months, p=0.007) more cytomegalovirus infection and more acute rejection and hyperglycemia in the first month after LTX. Four patients died in the PTDM group compared to nine patients in the no-DM group (12% vs 14%; p=0.72). CONCLUSIONS: Post-transplant diabetes is a common complication in lung transplant patients receiving tacrolimus-based immunosuppression. The risk for developing PTDM is greatest among older recipients, those obese, and among recipients with more rejections episodes.

Risk factors for death while awaiting lung transplantation in Israeli patients: 1997-2006.

OBJECTIVE: Patients with end-stage lung disease very frequently die while awaiting lung transplantation. The aim of this study was to identify factors associated with mortality in patients referred for lung transplant assessment. METHODS: The files of all consecutive patients listed for lung transplantation in Israel between 1997 and 2006 were reviewed and the data were compared statistically between those who survived to transplantation. RESULTS: A total of 229 patients were listed for lung transplantation, of whom 42 (18.3%) died while awaiting transplantation. Comparison of the patients who survived to transplantation with those who did not using univariate analysis revealed that the died-waiting group was significantly older, used steroids to a greater extent, had more IPF patients and less emphysematous, and lower mean oxygen saturation at rest (p=0.005). There were no between-group differences in comorbid diseases or pulmonary function measurements. The 6 min walk distance was strongly and inversely correlated with risk of death before transplantation (p=0.005). On multivariate analysis, only oxygen saturation at rest was a significant independent risk factor for death while awaiting transplantation (OR 0.886; C.I. 0.805-0.974). CONCLUSIONS: There are several risk factors for death in the Israeli population listed for LTX, including age, steroid use, emphysematous patients and lower saturation at rest.

Development of malignancy following lung transplantation.

BACKGROUND: A substantial excess risk of certain malignancies has been demonstrated after organ transplantation. Immunosuppressive treatment to prevent allograft rejection is probably the main cause. METHODS: We reviewed retrospectively all medical records of the 121 patients that underwent lung and heart-lung transplantation from 1992 until December 2004. We compared our results to the International Society for Heart and Lung Transplantation (ISHLT) registry data and previous reports concerning lung transplantation. RESULTS: 102 of the 121 patients survived for 3 months to 12 years. Malignancies developed in 16 patients, as follows: lymphoproliferative disorder in 3, Kaposi's sarcoma in 3, other nonmelanoma skin cancers in 7, urinary bladder transitional cel carcinoma in 3, and colon cancer in 1. Patients with malignancy were older at transplantation than those without (mean +/- SD, 54.1+/-7.8 vs. 49.5+/-14.2 years; P=0.03). Fourteen had smoked in the past. Four died of bronchiolitis obliterans. In comparison with the ISHLT, we observed more skin cancer and transitional cell carcinoma (12.8% vs. 0.7% and 3.8% vs. 0.03%, respectively) and a similar frequency of posttransplant lymphoproliferative disease. CONCLUSIONS: We conclude that malignancy is a common complication after lung transplantation. In Israel, which is sunny most of the year, skin cancers and transitional cell carcinoma of bladder are more common. Modification of the immunosuppression late posttransplantation may reduce the risk of cancer. Patients should also be counseled to avoid sun exposure and ensure adequate hydration.

Artificial stone silicosis [corrected]: disease resurgence among artificial stone workers.

BACKGROUND: Silicosis is a progressive, fibrotic, occupational lung disease resulting from inhalation of respirable crystalline silica. This disease is preventable through appropriate workplace practices. We systematically assessed an outbreak of silicosis among patients referred to our center for lung transplant. METHODS: This retrospective cohort analysis included all patients with a diagnosis of silicosis who were referred for evaluation to the National Lung Transplantation Program in Israel from January 1997 through December 2010. We also compared the incidence of lung transplantation (LTX) due to silicosis in Israel with that of the International Society for Heart and Lung Transplantation (ISHLT) registry. RESULTS: During the 14-year study period, 25 patients with silicosis were referred for evaluation, including 10 patients who went on to undergo LTX. All patients were exposed by dry cutting a relatively new, artificial, decorative stone product with high crystalline silica content used primarily for kitchen countertops and bathroom fixtures. The patients had moderate-to-severe restrictive lung disease. Two patients developed progressive massive fibrosis; none manifested acute silicosis (silicoproteinosis). Three patients died during follow-up, without LTX. Based on the ISHLT registry incidence, 0.68 silicosis cases would have been expected instead of the 10 observed (incidence ratio, 14.6; 95% CI, 7.02-26.8). CONCLUSIONS: This silicosis outbreak is important because of the worldwide use of this and similar high-silica-content, artificial stone products. Further cases are likely to occur unless effective preventive measures are undertaken and existing safety practices are enforced.

The lung in rheumatoid arthritis.

Rheumatoid arthritis (RA) is a common inflammatory disease, affecting about 1% of the population. Although a major portion of the disease burden including excess mortality is due to its extra-articular manifestations, the prevalence of RA-associated lung disease is increasing. RA can affect the lung parenchyma, airways, and the pleura; and pulmonary complications are directly responsible for 10 to 20% of all mortality. Even though pulmonary infection and drug toxicity are frequent complications of RA, lung disease directly associated with the underlying RA is more common. The prevalence of a particular complication varies based on the characteristics of the population studied, the definition of lung disease used, and the sensitivity of the clinical investigations employed. An overview of lung disease associated with RA is presented here with an emphasis on parenchymal lung disease, pleural effusion, and airway involvement.

Lung cancer in lung transplant recipients: experience of a tertiary hospital and literature review.

BACKGROUND: Lung transplantation is a viable therapy for patients with end-stage lung disease and is being increasingly performed worldwide. The incidence of lung cancer after lung transplantation has increased concomitantly, although data are still sparse. METHODS: The computerized medical records of the Pulmonary Institute of a tertiary care medical center were searched for patients who underwent lung transplantation from 1997 to 2009 and acquired lung cancer postoperatively. The prevalence, potential contributing factors, and outcome of bronchogenic cancer were determined, and the medical literature was reviewed. RESULTS: Bronchogenic cancer developed in 7 of the 290 lung transplant recipients (2.4%). All had received a single lung transplant and in most cases, the cancer developed in the native lung. These findings were similar to reports in the literature. The indication for transplantation was chronic obstructive pulmonary disease or idiopathic pulmonary fibrosis/interstitial lung disease. All had a history of smoking. The average interval from transplantation to development of lung cancer was 5 years (range 1-9). Five patients had stage 4 cancer at diagnosis and 2 had stage 1. Six patients died from 10 days to 1 year after diagnosis. CONCLUSION: Lung transplantation is associated with a relatively high prevalence of bronchogenic cancer, particularly in the native lung, in patients with primary chronic obstructive pulmonary disease/idiopathic pulmonary fibrosis, and a history of smoking. The cancer is usually diagnosed at an advanced stage with poor outcome. Efforts to improve screening are recommended, as aggressive management and treatment may be beneficial for earlier stage disease.

Bronchoscopic balloon dilatation of tracheobronchial stenosis: long-term follow-up.

OBJECTIVES: Bronchoscopic balloon dilatation (BBD) has become a valuable tool in the treatment of tracheobronchial stenosis (TBS). The objective of this study was to assess the short- and long-term effects of BBD. METHODS: A retrospective study that included all patients with confirmed, symptomatic stenosis, who underwent BBD between 2002 and 2008. A total of 92 BBD procedures were performed in 35 patients at our institute. Lung function studies were recorded for all patients before, immediately after and 1 month following the BBD. Long-term follow-up was for a mean of 33+/-4 months. RESULTS: All patients had initial success, including increased airway dimensions and symptom relief. No complications were noted related to BBD. Forced expiratory volume after one second (FEV(1)) was significantly increased after BBD (10.5%, p=0.03). These effects persisted for at least 1 month. Long-term follow-up, however, demonstrated the need for stent placement in 25 of 35 patients (71%), 210+/-91 days after BBD. Ten of 35 patients died 456+/-119 days after BBD due to progression of primary disease; all deaths were unrelated to the BBD procedures. CONCLUSIONS: BBD is a safe method that offers immediate symptomatic relief in both tracheal and bronchial stenosis. However, BBD is a temporary measure, as many patients will require definitive or additional treatment with laser or stent placement.

Postcoital hemoptysis: our experience and review of the literature.

Hemoptysis after physical activity is a well-known phenomenon. Hemoptysis following sexual intercourse is rarely reported. We describe three patients with hemoptysis occurring only after sexual activity and not following other types of physical effort. The underlying causes were congestive heart failure, uncontrolled hypertension and Takayasu arteritis. The literature is reviewed. We conclude that hemoptysis can present rarely following sexual activity and is usually associated with cardiovascular decompensation. It is always necessary to search for other underlying diseases. We suggest that patients with unexplained hemoptysis should be specifically asked about postcoital hemoptysis should be included in the differential diagnosis of every patient with unexplained hemoptysis.

Long-term follow-up of flexible bronchoscopic treatment for bronchial carcinoids with curative intent.

Background. Typical pulmonary carcinoids represent less than 5% of primary lung tumors. In patients with typical bronchial carcinoid, formal surgical resection still remains the gold-standard treatment. Data regarding long-term outcome in using flexible bronchoscope-based modalities under conscious sedation is very limited. Objectives. We sought to investigate, over extended follow-up period, the effectiveness of endobronchial resection for carcinoid tumors with curative intent using flexible bronchoscopy. Methods. Nd:YAG laser photoresection using flexible bronchoscope under conscious sedation. Follow-up included repeat bronchoscopy every 6 months and chest CT every year. Results. Ten patients aged 24 to 70 years with endobronchial carcinoid were treated. The tumor location was variable: 2 left Main bronchus, 1 left upper lobe bronchus, 2 right main bronchus, 2 right middle lobe bronchus and 3 right lower lobe bronchus. No major complications were observed. The patients required between 2 and 4 procedures. Patients were followed for a median period of 29 months with no evidence of tumor recurrence. Conclusions. Endobronchial laser photoresection of typical bronchial carcinoids using flexible bronchsocopy under conscious sedation is an effective treatment modality for a subgroup of patients that provides excellent long-term results that are similar to outcome obtained by more invasive procedures.