Development of saliva-based cardiac troponin I point-of-care test using alpha-amylase depletion: a feasibility study.

INTRODUCTION: Cardiac troponin (cTn) is the biomarker of choice for detection of myocardial injury. There is a great need for simple point-of-care (POC) troponin testing among patients with chest pain, mainly in the prehospital setting. The purpose of this study was to evaluate the presence of cardiac troponin I (cTnI) in saliva of patients with myocardial injury using alpha-amylase depletion technique. METHODS: Saliva samples were collected from 40 patients with myocardial injury who were tested positive for conventional high-sensitivity cardiac troponin T (cTnT) blood tests, and from 66 healthy volunteers. Saliva samples were treated for the removal of salivary alpha-amylase. Treated and untreated samples were tested with blood cTnI Rapid Diagnostic Test. Salivary cTnI levels were compared to blood cTnT levels. RESULTS: Thirty-six of 40 patients with positive blood cTnT had positive salivary samples for cTnI following alpha-amylase depletion treatment (90.00% sensitivity). Moreover, three of the four negative saliva samples were obtained from patients with relatively low blood cTnT levels of 100 ng/L or less (96.88% sensitivity for 100 ng/L and above). The negative predictive value was 93.65% and rose up to 98.33% considering the 100 ng/L cutoff. Positive predictive values were 83.72% and 81.58%, respectively. Among 66 healthy volunteers and 7 samples yielded positive results (89.39% specificity). CONCLUSION: In this preliminary work, the presence of cTnI in saliva was demonstrated for the first time to be feasibly identified by a POC oriented assay. The specific salivary alpha-amylase depletion technique was shown to be crucial for the suggested assay.

National Weekly SARS-CoV-2 RT-PCR Screening of All Workers in Long-Term Care Facilities Associated with Decrease in Resident Mortality Rate.

INTRODUCTION: Outbreaks of COVID-19 in long-term care facilities (LTCFs) have resulted mainly from disease transmission by asymptomatic health care workers. This study examines whether routine screening tests carried out on health care workers can help in reducing COVID-19 outbreaks, morbidity, and mortality of LTCF residents. METHODS: The study followed a weekly, nationwide, government-funded screening program of LTCF personnel for SARS-CoV-2, by using reverse transcription polymerase chain reaction as the main testing technology. It included all residents and employees in Israeli LTCFs who were screened weekly during the second wave of COVID-19, during the period of time between July 13, 2020, and November 21, 2020. RESULTS: During the study period, 1,107 LTCFs were screened on a weekly basis, including 62,159 HCWs and 100,046 residents. The program screened a median of 55,282 (range 16,249, min 45,910, max 62,159) employees per week, 0.05-1.5% of which were positive for SARS-CoV-2. LTCF mortality in the first wave accounted for 45.3% of all COVID-19 deaths recorded nationally (252 of 556), and in the second wave, this ratio was reduced to 30.3% (709 of 2,337) representing a reduction of 33.8% in expected mortality (p < 0.001). A significant reduction was detected also in hospitalization rate (13.59 vs. 11.41%, p < 0.001) and elder (≥75 years old) mortality rate (52.89 vs. 41.42%, p < 0.001). 214 outbreaks in the second wave were avoided by early identification of SARS-CoV-2 positive HCWs and successful prevention of subsequent infections in the facility. CONCLUSION: Routine weekly SARS-CoV-2 RT-PCR testing of LTCF employees was associated with reduced national LTCF residents' hospitalizations and mortality rate.

Comparison of Rate Control Efficacy between beta-blockers and Calcium Channel Blockers in Patients Hospitalized with Atrial Fibrillation.

BACKGROUND: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia. Previous studies showed that rhythm and rate control strategies are associated with similar rates of mortality and serious morbidity. Beta blockers (BB) and calcium channel blockers (CCB) are commonly used and the selection between these two medications depends on personal preference. OBJECTIVES: To compare real-time capability of BB and CCB for the treatment of rapid AF and to estimate their efficacy in reducing hospitalization duration. METHODS: We conducted a retrospective cohort study of 306 patients hospitalized at Soroka Hospital during a 5-year period with new onset AF who were treated by a rate control strategy. RESULTS: A significant difference between the two groups regarding the time (in hours) until reaching a target heart rate below 100 beats/min was observed. BB were found to decrease the heart rate after 5 hours (range 4-14) vs. 8 hours (range 4-18) for CCB (P = 0.009). Patients diagnosed with new-onset AF exhibited shorter duration of hospitalization after therapy with BB compared to CCB (median 72 vs. 96 hours, P = 0.012) in the subgroup of patients discharged with persistent AF. There was no significant difference between CCB and BB regarding the duration of hospitalization (P = 0.4) in the total patient population. CONCLUSIONS: BB therapy is more potent for rapid reduction of the heart rate compared to CCB and demonstrated better efficiency in shortening the duration of hospitalization in a subgroup of patients. This finding should be reevaluated in subsequent research.

Association of BNT162b2 Vaccine Third Dose Receipt With Incidence of SARS-CoV-2 Infection, COVID-19-Related Hospitalization, and Death Among Residents of Long-term Care Facilities, August to October 2021.

Importance: COVID-19 vaccine might be less immunogenic and effective among residents of long-term care facilities (LTCFs). Objective: To examine the association of BNT162b2 third dose (first booster dose) with overall SARS-CoV-2 infection, COVID-19 hospitalizations, and mortality among LTCF residents during a nationwide surge of the Delta variant in Israel. Design, Setting, and Participants: This observational cohort study conducted nationwide COVID-19 surveillance in LTCFs in Israel between August and October 2021. Participants were residents of LTCFs aged 60 years or older. Exposures: Vaccination with the third dose of BNT162b2 vaccine vs receipt of 2 doses at least 5 months earlier, based on self-preference and choice. Main Outcomes and Measures: The cumulative incidences of reverse transcription-polymerase chain reaction (RT-PCR)-confirmed SARS-CoV-2 infection, COVID-19 hospitalizations, and COVID-19-related deaths more than 7 days after vaccination with the third dose were compared between the groups using Kaplan-Meier curves. Hazard ratios (HRs) and 95% CIs were obtained using multivariable Cox regression models. Results: Among 18 611 residents included in the analysis, 12 715 (68.3%) were female, 463 (2.5%) were from the Arab population, 16 976 (91.2%) were from the general Jewish population, and 618 (3.3%) were from the ultraorthodox Jewish population; the mean (SD) age was 81.1 (9.2) years; 16 082 residents received their first booster dose (third dose) and 2529 were vaccinated with 2 doses at least 5 months earlier. The median (IQR) follow-up durations were 66 (60-70) days among 3-dose recipients and 56 (53-62) days among 2-dose-only recipients; 107 residents had SARS-CoV-2 infection after 7 days following vaccination with the booster dose compared with 185 among the 2-dose only group (cumulative incidence: 0.7% vs 7.5%; adjusted HR, 0.11 [95% CI, 0.07-0.15]). The respective adjusted HRs were 0.07 (95% CI, 0.03-0.14) and 0.10 (95% CI, 0.04-0.24) for the associations of vaccination with the third dose with hospitalization for mild-to-moderate COVID-19 and severe illness. Five COVID-19-related deaths occurred among the third dose vaccinees during the follow-up period compared with 22 among the 2-dose-only vaccinees (cumulative rate: 0.04% vs 0.9%; adjusted HR, 0.04 [95% CI, 0.009-0.16]). Conclusions and Relevance: This cohort study found significant inverse associations between vaccination with the third dose of the BNT162b2 vaccine with overall SARS-CoV-2 infection, COVID-19 hospitalizations, severe disease, and COVID-19-related deaths among LTCF residents during a massive surge caused by the Delta variant in Israel.

Association of Receipt of the Fourth BNT162b2 Dose With Omicron Infection and COVID-19 Hospitalizations Among Residents of Long-term Care Facilities.

Importance: The administration of a fourth BNT162b2 COVID-19 vaccine dose was approved in Israel in December 2021 for individuals 60 years or older who were vaccinated with a third dose 4 months previously or earlier to control the substantial surge of the SARS-CoV-2 Omicron variant. Nonetheless, the association between receipt of the fourth dose and protection against infection remains elusive. Objective: To determine the association of the fourth BNT162b2 dose with protection against SARS-CoV-2-related infections, hospitalizations, and deaths during the Omicron surge in long-term care facility (LTCF) residents. Design, Setting, and Participants: This prospective cohort study was conducted in Israel between January 10 and March 31, 2022 and included LTCF residents 60 years or older. Exposures: Vaccination with the fourth dose of BNT162b2 vs 3 doses that were administered 4 months previously or earlier. Main Outcomes and Measures: Cumulative incidences of SARS-CoV-2 infections, hospitalizations, and deaths during the Omicron surge. The follow-up was initiated more than 7 days after receipt of the fourth dose, which was matched to the follow-up initiation date of those who had received 3 doses of vaccine in each facility. We obtained hazard ratios and 95% confidence intervals from multivariable Cox regression models. Results: The data of 43 775 residents (mean [SD] age, 80.1 [9.4] years; 29 679 women [67.8%]) were analyzed, of whom 24 088 (55.0%) and 19 687 (45.0%) received the fourth and third dose (4 months previously or earlier), respectively. The median follow-up time was 73 days (4-dose group: IQR, 6 days; 3-dose group: IQR, 56 days). More than 7 days postvaccination with the fourth dose, SARS-CoV-2 infection was detected among 4058 fourth-dose vs 4370 third-dose recipients (cumulative incidence, 17.6% vs 24.9%). The corresponding incidences of hospitalizations for mild-to-moderate COVID-19, severe illness, and mortality were 0.9% and 2.8%, 0.5% and 1.5%, and 0.2% and 0.5%, respectively. The adjusted protections were 34% (95% CI, 30%-37%), 64% (95% CI, 56%-71%), and 67% (95% CI, 57%-75%) against overall infection, hospitalizations for mild-to-moderate illness, and severe illness, respectively, and 72% (95% CI, 57%-83%) against related deaths. Conclusions and Relevance: The results of this cohort study suggest that receipt of a fourth BNT162b2 dose conferred high protection against COVID-19 hospitalizations and deaths among LTCF residents during a substantial Omicron variant surge, but protection was modest against infection. These findings are relevant to the control of COVID-19 pandemic globally, especially among the population of LTCFs.

BNT162b2 mRNA COVID-19 (Comirnaty) Vaccine Effectiveness in Elderly Patients Who Live in Long-Term Care Facilities: A Nationwide Cohort.

INTRODUCTION: In early 2020, the novel SARS-CoV-2 virus began to spread around the world and claim victims. Initially, in the Western world, COVID-19-related mortality was due to illness in long-term care facilities (LTCFs). To manage the COVID-19 crisis in LTCFs in Israel, the Ministry of Health established a task force named "Senior Shield." The task force executed a screening program of weekly polymerase chain reaction (PCR) SARS-CoV-2 tests for LTCF residents and caregivers, and at a later stage, the task force led the Ministry of Health vaccination program at LTCFs. This study aimed to estimate the effectiveness of the BNT162b2 mRNA COVID-19 (Comirnaty) vaccine in reducing COVID-19 morbidity and mortality in LTCF residents. METHODS: We designed a nationwide cohort study utilizing data from the Senior Shield task force. Residents had received the vaccines starting December 2020. The study follow-up period was 5 months (ending May 2021). We defined four outcomes: (a) documented SARS-CoV-2 infection, defined by a positive PCR test, (b) COVID-19 death, defined by a positive PCR test followed by death, (c) all-cause mortality, defined as death regardless of the result of a PCR test, and (d) a composite endpoint which included documented SARS-CoV-2 infection or death, the earliest of both. We used Kaplan-Meier curves with a log-rank comparison and Cox regression with a time-dependent covariate model to estimate adjusted hazard ratios for vaccine effectiveness (VE). The index date was the date of the first vaccine dose. In unvaccinated residents, the index date was the first date of vaccination in their LTCF. RESULTS: A total of 43,596 residents with a mean age of 83 years living in 454 LTCFs were found eligible for this study. Ninety-one percent of the study population received the first vaccine dose (39,482) and 86% received the second vaccine dose (37,656). Estimated VE 28 days after the first vaccine dose (approximately 7 days after the second vaccine dose) was 81.2% for SARS-CoV-2 infection, 85.3% for COVID-related death, 63.7% for all-cause mortality, and 71.1% for the composite endpoint (SARS-CoV-2 infection or death). CONCLUSION: This study shows that the BNT162b2 mRNA COVID-19 vaccine effectively prevents SARS-CoV-2 infection, COVID-19-related death, and all-cause mortality in LTCF residents. Further research is warranted on the effect of the third vaccine (booster) in this population.

Effectiveness of BNT162b2 mRNA Coronavirus Disease 2019 (COVID-19) Vaccine Against Acquisition of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Among Healthcare Workers in Long-Term Care Facilities: A Prospective Cohort Study.

BACKGROUND: We assessed vaccine effectiveness (VE) of BNT162b2 mRNA coronavirus disease 2019 (COVID-19) vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) acquisition among healthcare workers (HCWs) of long-term care facilities (LTCFs). METHODS: This prospective study, in the framework of the "Senior Shield" program in Israel, included routine weekly nasopharyngeal SARS-CoV-2 RT-PCR testing from all LTCF HCWs since July 2020. All residents and 75% of HCWs were immunized between December 2020 and January 2021. The analysis was limited to HCWs adhering to routine testing. Fully vaccinated (14+ days after second dose; n = 6960) and unvaccinated (n = 2202) HCWs were simultaneously followed until SARS-CoV-2 acquisition or end of follow-up, 11 April 2021. Hazard ratios (HRs) for vaccination versus no vaccination were calculated (Cox proportional hazards regression models, adjusting for sociodemographics and residential-area COVID-19 incidence). VE was calculated as (1- HR) × 100. RT-PCR cycle threshold (Ct) values were compared between vaccinated and unvaccinated HCWs. RESULTS: At >14 days post-second dose, 40 vaccinated HCWs acquired SARS-CoV-2 (median follow-up, 66 days; cumulative incidence, 0.6%) versus 84 unvaccinated HCWs (median follow-up, 43 days; cumulative incidence, 5.1%) (HR, .11; 95% CI, .07-.17; unadjusted VE, 89%; 95% CI, 83-93%). Adjusted VE >7 and >14 days post-second dose were similar. The median PCR Ct targeting the ORF1ab gene among 20 vaccinated and 40 unvaccinated HCWs was 32.0 versus 26.7, respectively (P value  = .008). CONCLUSIONS: VE following 2 doses of BNT162b2 against SARS-CoV-2 acquisition in LTCF HCWs was high. The lower viral loads among SARS-CoV-2-positive HCWs suggest further reduction in transmission.

Overuse of reliever inhalers and associated healthcare utilization of asthma patients.

Global Initiative for Asthma 2019 guidelines recommend to avoid strengthening patients' reliance on relievers since they increase exacerbation risk. Our aim was to examine the association between reliever inhalers overuse and all-cause healthcare utilization (HCU). A retrospective study among Clalit Health Services (CHS) adult enrollees (n = 977) for 2012-2017. Reliever inhalers overuse was defined as consistent prescription refills of ≥ 3 canisters annually. Adherence to controllers was calculated using the proportion of days covered. HCU included: hospitalizations, diagnostic and surgical procedures, medications, emergency room (ER) visits, and clinic visits. 27% of the study population (n = 264) consistently refilled ≥ 3 relievers prescriptions annually, and had higher adherence to controllers (0.38 vs. 0.24, p < 0.001). Their total 6-year HCU costs were not higher than that of others ($5,550 vs. $5,562, p = 0.107). Most HCU components [including hospitalization (p = 0.405) and ER visits (p = 0.884)] were comparable; however, medication costs were higher ($1734 vs. $1504, p < 0.001). A multivariable ordered-logit model revealed that frequent and regular use of relievers was not associated with higher HCU costs (OR = 0.82, 95% CI 0.62-1.09, p = 0.175). Higher adherence to maintenance and reliever therapy (OR = 2.18, 95% CI 1.44-3.28, p < 0.001), other controllers (OR = 3.30, 95% CI 2.11-5.16, p < 0.001), and nebulized SABAs and SAMAs (OR = 1.08, 95% CI 1.02-1.14, p = 0.007) was associated with higher costs. Overuse of reliever inhalers was prevalent and associated with higher adherence to controllers, yet not associated with higher all-cause HCU. This highlights the need to examine the sources of elevated usage in order to develop intervention strategies to optimize pharmaceutical therapy of asthma patients.

The Association of Glucocorticosteroid Treatment with WBC Count in Patients with COPD Exacerbation.

Systematic glucocorticosteroids (GCS) are used to treat chronic obstructive pulmonary disease (COPD) and can cause leukocytosis. Distinguishing the effect of GCS on leukocyte level from infection-induced leukocytosis is important. We sought to quantify the effect of chronic GCS treatment on leukocytosis level in patients with COPD exacerbation. We reviewed the records of patients with COPD exacerbation and fever hospitalized in a tertiary medical center in 2003-2014. Patients were classified according to the GCS treatment they received: chronic GCS treatment (CST), acute GCS treatment (AST), and no prior GCS treatment (NGCS). We used the eosinophil absolute count as a marker of compliance and efficacy of steroid treatment. The primary outcome was the maximal white blood cell (WBC) count within the first 24 h of admission. Of 834 patients, 161 were categorized as CST, 116 AST, and 557 NGCS. The overall maximal leukocyte count was higher and the eosinophil count lower in the two GCS therapy groups. In patients with COPD exacerbation and fever, acutely treated with GCS, the mean increase in the WBC count was more evident when the eosinophils were undetectable (absolute count of zero). This supports leukocytosis level as a marker of disease course in COPD and fever.

The Presence of Snoring as Well as its Intensity Is Underreported by Women.

STUDY OBJECTIVES: Women are underrepresented and thus sleep conditions are underdiagnosed at sleep clinics that evaluate sleep-disordered breathing. The most common sign of obstructive sleep apnea (OSA) is snoring; therefore, it is one of the main red flags for suspected OSA. The aim of this study is to determine whether self-reported snoring and snoring intensity by women and men correlates with snoring volume measured objectively during sleep laboratory study. METHODS: Consecutive patients who were referred to a polysomnography (PSG) study in a university hospital over a 2-year period had their snoring volume quantified by means of a calibrated digital sound survey meter. Participants were given a questionnaire in which they were asked to rate the severity of their snoring. The correlation between objective snoring intensity as measured during PSG and the self-reported snoring intensity was evaluated. RESULTS: A total of 1,913 patients were enrolled in the study. A positive correlation was found between objectively measured snoring intensity and the intensity listed by each participant in the questionnaire. Measurement of the volume of snoring revealed that women snored as loudly as men; however, 28% of the females (189/675) considered themselves to be nonsnorers compared to only 6.9% of men (P < .05). Furthermore, 36.5% of women (69/189) who reported themselves as nonsnorers turned out to have severe or very severe snoring intensity, whereas, in contrast, only 11.7% of men (10/85) of men had this discrepancy. These findings are in concordance with the finding that fewer women quantified their snoring as very severe or severe (38.4%), significantly less than men of whom 61.5% reported their snoring to be severe or very severe. CONCLUSIONS: In a population of individuals referred to a PSG study, although no difference in snoring intensity was found between sexes, women tend to underreport the fact that they snore and to underestimate the loudness of their snoring. Improved awareness of this discrepancy may increase women's access to sleep laboratories, and improve diagnostic rates of sleep apnea in females.

Estimations of a degree of steroid induced leukocytosis in patients with acute infections.

BACKGROUND: Glucocorticosteroids (GCS) are known to cause the hematologic effect of leukocytosis and neutrophilia. Leukocytosis is a key parameter in establishing the diagnosis of sepsis and in the estimation of its severity. OBJECTIVE: To quantify the effect of chronic or acute GCS treatment on the level of leukocytosis in patients with acute infectious process. METHODS: We conducted a retrospective cohort study of patients with an acute infection hospitalized in tertiary medical center between the years 2003-2014. Patients were classified into three categories: chronic GCS treatment, acute GCS treatment, no GCS treatment. The primary outcome was the maximal WBC count within the first 24h from admission. RESULTS: We identified 5468 patients with acute infection: 333 of them with chronic GCS treatment, 213 with acute GCS treatment and 4922 with no GCS treatment. The overall maximal leukocytes count was higher in GCS therapy groups: 15.4±8.3×109/L for the acute GCS treatment, 14.9±7.4×109/L for chronic GCS treatment and 12.9±6.4×109/L for the no GCS group (P<0.001). CONCLUSION: In patients with acute infections chronically treated with GCS, an increase in the WBC is at average of 5×109/L. These data must be taken into consideration while using the level of leukocytosis as a parameter in the diagnosis of the infectious process.

[THE UTILITY OF BRONCHOSCOPY IN INTENSIVE CARE UNIT PATIENTS WITH VENTILATOR ASSOCIATED PNEUMONIA].

BACKGROUND: Ventilator associated pneumonia (VAPI is a common complication leading to lengthier hospitalizations and higher mortality. Prompt adequate initial antibiotic coverage is the crucial issue affecting survival. Currently, there is no gold standard diagnostic test. No conclusive data regarding the benefit of bronchoscopy exists in the literature reviewed. AIM: This study aims to evaluate the change of prognosis for patients who developed VAP, following a positive culture from bronchoalveolar lavage (BAL). DESIGN: This is a retrospective cohort study. SETTING: General intensive care unit in a tertiary university healthcare center. PARTICIPANTS: All patients who were admitted to Surgical ICU and developed VAP and who then underwent diagnostic bronchoscopy with BAL between the period 01/02/2007 - 31/02/2011. MEASUREMENTS AND RESULTS: A total of 66 patients who were admitted to the ICU, developed VAP and underwent bronchoscopy while ventilated; 30 patients were excluded. The positive BAL culture group was compared to the negative BAL culture group; there was no difference between demographic and clinical characteristics, mortality rates (for 30 days) or therapy change between the two groups. No complications were reported regarding the bronchoscopy procedure. CONCLUSIONS: Our findings demonstrate that performing y a diagnostic bronchoscopy with BAL does not improve the prognosis of patients with VAP. Furthermore, expanded prospective studies will be needed to conclude regarding its benefit in diagnosis and subsequent rectifying of therapy.

[THE ROLE OF CLOSED PLEURAL BIOPSY IN THE DIAGNOSIS OF TUBERCULOUS PLEURISY IN A POPULATION AT-RISK].

BACKGROUND: Tuberculous pleurisy is the most common form of extrapulmonary tuberculosis, and a common cause of exudative pleural effusion. Closed pleural biopsy can be used for diagnosis. In recent years, more invasive methods are used for the diagnostic process in the western world. Contrary to the global trend, physicians at the Pulmonary Institute of the Soroka University Medical Center still perform a closed pleural biopsy as the first diagnostic step. In this article, we report our experience in the diagnosis of tuberculous pleurisy by closed pleural biopsy. METHODS: A retrospective cohort analysis, conducted among patients, who were admitted for investigation of pleural effusion between 2008 and 2013, and underwent closed pleural biopsy with an Abrams needle in the evaluation of tuberculous pleurisy (n=25). Histopathological evidence of tuberculosis bacterium infection included a positive staining for acid-fast bacteria, identification of Langerhans giant cells, demonstration of chronic granulomatous inflammation or demonstration of granulomas with central necrosis in samples of pleural fluid or pleural biopsy. RESULTS: Closed pleural biopsy was performed in 22/25 (88%) of patients. In 15/22 subjects (68%) histopathotogical evidence of tuberculous pleurisy was found. No significant complications were evident after the procedure. In addition, it was found that acid-fast bacteria in sputum samples, gastric fluid and pleural fluid is of very low diagnostic yield for the diagnosis of tuberculous pleurisy, while in cultures of sputum, gastric fluid or pleural fluid infection it was diagnosed in 27, 28 and 28% of subjects respectively. CONCLUSIONS: In subjects with a high probability for tuberculous pleurisy, closed pleural biopsy using Abrams needle is available, inexpensive and has a good diagnostic yield and low complication rate. We believe that there is great importance in preserving the ability to perform a closed pleural biopsy in all. medical centers in Israel.

Respiratory deterioration following laparoscopic adjustable gastric banding: A three-year follow-up of over 3,000 subjects.

BACKGROUND: Obesity is considered a global epidemic. Until recently, laparoscopic adjustable gastric binding (LAGB) was routinely offered as a means of weight reduction for selected patient populations. Previous case series have documented several pulmonary complications following LAGB. In the current study, we explored the rate of long-term respiratory deterioration associated with LAGB. METHODS: The study is a historical cohort study of medical records of subjects who underwent LAGB at Soroka University Medical Center in Israel between January 1997 and July 2008. After the exclusion of short-term respiratory events, respiratory morbidity during the three years following the operation was compared with that three years prior to the operation. Subjects whose respiratory status worsened following surgery were further compared with those whose status either remained unchanged or improved. RESULTS: The final analysis included 3084 subjects, of whom 709 (22.9%) had documented respiratory morbidity following surgery. Compared to pre-operative respiratory status, respiratory deterioration following LAGB was found in 590 subjects (19.1%). Risk factors associated with the worsening of respiratory status were age ≤28 or ≥46 years (odds ratio [OR] = 1.32, 95% confidence interval [CI]: 1.02-1.71 and OR = 1.42, 95% CI: 1.09-1.85, respectively), female gender (OR = 1.31, 95% CI: 1.06-1.63), and pre-operative documentation of respiratory morbidity. CONCLUSIONS: The rate of deterioration in the respiratory status observed among subjects who underwent LAGB was high. Consequently, physicians should be aware of the possible link, even years after the surgery, between respiratory symptoms and a history of LAGB.

Snoring intensity and excessive daytime sleepiness in subjects without obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: Snoring and excessive daytime sleepiness (EDS) are major obstructive sleep apnea (OSA) symptoms. Snorers with apnea/hypopnea index < 5 are designated "simple snorers" and do not meet OSA criteria. This study aimed to explore a possible association between snoring intensity and EDS defined as Epworth Sleepiness Scale (ESS) scores ≥ 11 in non-OSA subjects. STUDY DESIGN: Prospective cohort study. METHODS: From a total of 2,225 subjects who underwent polysomnography (PSG), 307 simple snorers qualified for the study and were assessed for snoring intensity and ESS score. The correlation between PSG-based snoring intensity measurements and ESS score was evaluated. A prediction model for EDS was derived using multivariate logistic regression. RESULTS: Subjects with EDS tended to be male and of heavier body habitus. Although both genders exhibited similar snoring intensities, men had higher ESS scores than women. A strong linear correlation was demonstrated between the maximal snoring intensity and the ESS score. Maximal snoring sound and male gender were shown to be predictors of EDS, with odds ratios of 1.93 (95% confidence interval [CI]:1.63-2.26, P < .001) and 3.70 (95% CI: 1.29-12.5, P = .01), respectively. CONCLUSIONS: In a population of non-OSA subjects referred to a PSG study, snoring intensity was associated with EDS in both men and women. A positive linear correlation was observed between snoring intensities and ESS scores. Additional studies are needed to further consolidate the evidence regarding the implications of simple snoring for public health. LEVEL OF EVIDENCE: 2b Laryngoscope, 126:1696-1701, 2016.

[THE ASSOCIATION BETWEEN OBESITY AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)].

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease, with major respiratory and systemic expressions. Obesity is defined as a BMI>30 kg/ m2 and its prevalence has doubled in recent decades. The possible relationship of obesity to COPD, and its influence on respiratory pathophysiology, is considered a mystery. Studies show obesity to be a survival advantage among COPD patients, unlike in the general population, in which obesity correlates to decreased life expectancy. This study aims to assess the differences between obese and non-obese COPD patients. The main clinical aspect assessed is the number of COPDexacerbation related hospital admissions. METHODS: We conducted a retrospective cohort study of 323 COPD patients (95 obese, 228 non-obese), who had been followed from 2003-2010 by the Pulmonology Institute at the Soroka Medical Center. We collected demographics, medical history, BMI, lung function tests, information about hospital admissions and mortality. RESULTS: Non-obese COPD patients are 1.6 times more likely to be hospitalized due to COPD exacerbation. Additionally, women are 1.8 times more likely to be hospitalized due to COPD exacerbation. The FEV1 and FEV1/FVC ratios, which were measured latest during the study period, were higher among obese COPD patients. There was no significant difference in mortality. CONCLUSIONS: Obesity and male gender act as protective factors against COPD exacerbations requiring hospitalization. Lung function test values are higher among obese patients. Despite this, obesity has no influence on COPD patient survival. Subsequent studies are required, in order to define nutrition recommendations and target weights for COPD patients.