Differentiating between malignant and idiopathic pleural effusions: the value of diagnostic procedures.

BACKGROUND: Which diagnostic procedures should be used to differentiate between idiopathic and malignant pleural effusions, is not well established. AIM: To identify which parameters allow differentiation between idiopathic and malignant pleural effusions. DESIGN: Case-note review. METHODS: Over a 12-year period, we treated 1014 consecutive pleural effusion patients, of whom 346 were diagnosed as having an idiopathic or malignant aetiology. We analysed medical history, chest X-ray, pleural fluid analysis (biochemical, microbiological and cytological), chest CT scan and additional examinations that were used according to clinical findings, and compared them with the eventual diagnosis and outcome. RESULTS: Eighty-three patients with idiopathic effusions and 263 with malignant effusions were included. Idiopathic pleural effusion resolved in 47 patients, improved in 20 and persisted in 16. Biochemical pleural fluid analysis did not predict these outcomes. A history of neoplasm, chest X-ray and CT features, as well as additional examinations according to clinical findings, established a diagnosis or suspicion of malignancy in 256 (97.7%) of the 263 patients who received a diagnosis of malignant effusion. Diagnostic thoracoscopy was helpful in seven patients in whom malignant disease was strongly suspected, despite the absence of other pathological findings. DISCUSSION: Non-invasive complementary examinations generally allowed accurate differentiation between malignant and idiopathic effusions. Patients with idiopathic pleural effusions generally had favourable outcomes.

Circulation of a novel human respiratory syncytial virus Group B genotype during the 2014-2015 season in Catalonia (Spain).

Human respiratory syncytial virus (HRSV) is one of the most common viral aetiological agents in the youngest population. In the present study a novel HRSV-B BA genotype is first described based on the phylogenetic analysis of the coding hypervariable region 2 sequences of G protein from strains detected during the 2014-2015 season. Among all strains detected in the last season, 44% belonged to this new genotype. Therefore, it highlights the importance of a continuous HRSV surveillance to monitor the emergence and spread of new genotypes or variants with genetic changes that may affect antigenic and tropism features.

Lack of evidence of M-cells in porcine left ventricular myocardium.

OBJECTIVE: The aim of this study was to analyze whether cells with long action potential duration, fast Vmax, and spike-and-dome configuration (M-cells) are present in porcine left ventricular myocardium. METHODS: Transmembrane action potentials (n = 505) of the left ventricle were recorded with conventional glass microelectrodes in an epicardial-endocardial direction at 2000 ms basic cycle length in 14 pigs. In 3 pigs, potentials were obtained at 1000, 2000, and 5000 ms cycle length before and after superfusion with quinidine HCl 1 microgram/ml. In addition, transmembrane potentials (n = 52) were recorded in 4 dogs at 2000 ms cycle length to verify the ability of our protocol to detect M-cells. RESULTS: In pigs, action potential duration at 90% repolarization was shorter (ANOVA, P < 0.001) and Vmax slower (P < 0.001) in the epicardium than in the other transmural sites, but there were no regional differences in resting membrane potential or in action potential amplitude. Potentials with particularly long phase 3 or with spike-and-dome configuration were not observed. All myocardial sites displayed rate dependence of action potential duration (P = 0.02) which was transmurally homogeneous and persisted after quinidine exposure. The drug did not induce afterdepolarizations. In dogs, potentials with spike-and-dome configuration, long duration, and fast Vmax, like those described in M-cells, were detected in deep epicardial and midmyocardial areas. CONCLUSION: The porcine left ventricular myocardium shows transmural differences in action potential duration and Vmax, but, unlike dogs, it lacks M-cells.

The value of chest roentgenography in the diagnosis of pneumothorax after thoracentesis.

PURPOSE: We sought to assess the yield of chest roentgenography for the detection of pneumothorax among hospitalized patients with pleural effusion who have undergone diagnostic or therapeutic thoracentesis. SUBJECTS AND METHODS: We performed a prospective study of 506 thoracentesis procedures in 370 patients. After the procedure, each operator filled out a note recording patient data and the characteristics of the thoracentesis. A chest radiograph was performed within 12 hours after the procedure in all patients. RESULTS: Eighteen (4%) pneumothoraces occurred in 17 patients, 9 (2%) of which required chest tube drainage. Of the 488 patients without symptoms, only 5 (1%) developed a pneumothorax, only 1 of which required chest tube drainage. By contrast, of the 18 patients with symptoms, 13 developed a pneumothorax, 8 of which required chest tubes. There were two independent predictors of pneumothorax: presence of symptoms (odds ratio [OR] = 250; 95% confidence interval [CI]: 65 to 980) and male gender (OR = 5.4; 95% CI: 1.9 to 69). CONCLUSIONS: Among the symptom-free patients in our sample, the risk of developing pneumothorax with clinical consequences was so low that the practice of routine chest roentgenography may not be justified.

Nosocomial infections in pediatric patients: a prevalence study in Spanish hospitals. EPINE Working Group.

BACKGROUND: The magnitude of the problem of nosocomial infection in children has never been studied in Spain. METHODS: In 1990, a nationwide cross-sectional study was conducted to determine the prevalence of nosocomial infection and associated risk factors. RESULTS: Among 38,489 patients surveyed, 4081 were pediatric patients. Three hundred forty-five patients (8.4%) had active nosocomial infection at the time of the survey. Pediatric intensive care units (29.7%), hematology (23%), and special units (22%) showed the highest rates. Infections were most common in patients younger than 1 year (prevalence, 12.3%). Frequencies of nosocomial infection by site were as follows: bloodstream, 22.1%; urinary tract, 13.1%; lower respiratory tract, 12.3%; postoperative wound, 8%; gastrointestinal tract, 7.6%; skin, 6.5%; eye, 5.8%; and others 24.6%. The factors most closely associated with a higher prevalence of nosocomial infection in pediatrics were as follows: age younger than 1 year, surgery, moderate and severe baseline risk, number of diagnoses, and all categories of extrinsic risk factors. The most frequent etiologic agents were gram-positive bacteria (45.8%). CONCLUSIONS: Although the overall prevalence is at an acceptable level, future efforts should be focused on developing more effective prevention strategies in specific areas.

Investigation of an outbreak of nosocomial infection due to a multiply drug-resistant strain of Pseudomonas aeruginosa.

A nosocomial outbreak of Pseudomonas aeruginosa infections which occurred in the Urology Service of a large city hospital was studied. A case-control methodology was used to analyse patients' characteristics and the main risk factors of all cases with a positive culture during the period between March 1987 and March 1988. The usefulness of factor analysis in the definition of a case was examined. There were 74 infections of which 35 (47.3%), had a nosocomial origin. The outbreak took place in December 1987, with a peak incidence of infections of 10.5%, compared with a 2.2% frequency during the preceding months (P less than 0.005). Six of the nine infections occurring in that month, were caused by strains resistant to ticarcillin and gentamicin. The epidemic cases had longer hospital stays than the non-epidemic cases (P less than 0.038) and occurred more frequently in a specific area of the hospital (P less than 0.001). The odds ratio for resistance to gentamicin was 15 (P less than 0.018) and that of resistance to ticarcillin, 127 (P less than 0.0001). Our results suggest that inaccurate case definitions may produce misleading conclusions. Factor analysis appears to be a useful analytical tool when defining a case.

Effects of oleic-rich and omega-3-rich diets on serum lipid pattern and lipid oxidation in mildly hypercholesterolemic patients.

AIMS: To evaluate which dietary fat elicits the best response in terms of plasma lipids, lipoproteins, and oxidative processes. METHODS: After a 4-week run-in period, 14 mildly hypercholesterolemic subjects were fed two balanced diets for 6-week periods. During the first intervention period, patients received a monounsaturated fatty acid (MUFA)-enriched diet (olive oil diet). During the second period this diet was supplemented by n-3 polyunsaturated fatty acids (PUFAs) (n-3 diet). RESULTS: After the olive oil diet, a significant decrease in total serum cholesterol (-8.54%, P<0.01), and in apolipoprotein B (Apo B) (-10.0%, P<0.01) was observed. With the addition of n-3 fatty acids no further significant changes in serum lipid concentrations were found. However, the n-3 diet was followed by an increase in lipoperoxides in isolated native low-density lipoprotein (LDL) (67.23%, P<0.01). CONCLUSIONS: A beneficial effect on the serum lipid pattern was observed with the olive oil-enriched diet. The lack of further beneficial modifications on blood lipids and lipoproteins and the increase in the oxidative susceptibility of LDL observed after the addition of n-3 PUFA to the olive oil diet does not favor the use of this diet in hypercholesterolemic patients if it is not associated with a high intake of antioxidants.

[Multicenter study of the variability and adequacy of antimicrobial therapy for community-acquired pneumonia in adults]. / Estudio multicéntrico de variabilidad e idoneidad de la prescripción antibiótica en la neumonía adquirida en la comunidad del adulto.

We performed a study to evaluate the variability and adequacy of prescribing antibiotics in community-acquired pneumonia (CAP) in 10 Spanish hospitals. We studied 452 patients with CAP. Initial empirical administration of antibiotics was prescribed in 90.7% of the cases, 82.5% as monotherapy. Macrolides and third and second generation cephalosporins were the most widely used groups of antibiotics. Penicillin and amoxicillin were only prescribed in 1. 7% of the patients. A significant variability between hospitals was observed. Reference patterns for the use of antibiotics in CAP were devised by a panel of experts. According to the recommendations of this panel, 29% of the total prescriptions were not adequate, with this percentage reaching 65% in outpatients older than 65 years or with comorbidity. This was mainly due to the fact that monotherapy with erythromycin, which was considered inadequate, was the most widely prescribed treatment.

[The impact of the clinical data and the interhospital agreement in the interpretation of myocardial perfusion tomography]. / Impacto de los datos clínicos y concordancia interhospitalaria en la interpretación de la tomogammagrafía miocárdica de perfusión.

INTRODUCTION AND OBJECTIVES: The aim of this study is to analyze the impact of clinical data and the interhospital agreement in the interpretation of myocardial perfusion single photon emission tomography (SPECT) images and polar mapping. METHODS: 150 patients from 5 hospitals were studied. Each center contributed with tomographic images and polar maps of 99mTc-tetrofosmin exercise SPECT and clinical reports of 30 patients. Thus, 300 images (150 of tomographic images and 150 of polar maps) were interpreted by each center without knowledge of clinical data of the patient ("blinded" report). RESULTS: 90 (60%) out of 150 patients had a coronary stenosis > or = 50%. Sensitivity and specificity of "non blinded" report were 91% and 86%, respectively. Sensitivity determined by majority decision (three or more centers) was 82% for tomographic images and 83% for polar maps (p = 0.002 and p = 0.03, respectively, regarding the "non-blinded" report). Specificity was 88% for tomographic images and 79% for polar map (p = 0.05 with respect to tomographic images). Interhospital agreement was good not only for tomographic images (kappa: 0.625) but for polar maps (kappa: 0.7) as well. CONCLUSIONS: Sensitivity of clinical or "non blinded" report of myocardial perfusion SPECT is significantly higher than the "blinded" report. Specificity of the "blinded" report of polar mapping is lower than that of tomographic images. A good interhospital agreement in interpretation of both types of images was observed.

[Myocardial SPET in hypertrophic cardiomyopathy]. / Tomogammagrafía miocárdica de esfuerzo en los pacientes con miocardiopatía hipertrófica.

INTRODUCTION AND OBJECTIVES: The aim of this study was to evaluate the diagnostic accuracy of myocardial SPET in patients with hypertrophic cardiomyopathy (HC). PATIENTS AND METHODS: One hundred and six consecutive patients (aged 53 +/- 12 years, 50 women, 66 with dynamic obstruction) with an echocardiographic diagnosis of HC were studied with exercise-rest myocardial SPET with 99mTc-tetrofosmin. Forty-six (43%) of these patients had chest pain and in 31 (29%) a coronary angiography was performed. Fifty-six per cent of the patients were treated with beta-blockers and 23% with verapamil. RESULTS: Angina during the exercise test was observed in only 8% of the patients. Perfusion defects were observed in 35% of the patients. Only 8 (26%) out of the 31 patients with angiography had coronary artery disease (stenosis > 50%). When fixed and reversible defects were considered as positive, the sensitivity was 50%, the specificity was 65%, the positive predictive value was 33% and the negative predictive value was 79%. CONCLUSIONS: Myocardial perfusion defects can be observed in more than one third of medically treated patients with HC. Only a quarter of catheterized patients, even with chest pain, have associated coronary artery disease. The accuracy of SPET for the diagnosis of coronary artery disease in hypertrophic cardiomyopathy is low. Thus, the value of this technique is limited in these patients.

[Value of Doppler-echocardiography in the prognosis and follow up of hypertrophic myocardiopathy]. / Valor del ecocardiograma-Doppler en el pronóstico y en el seguimiento de la miocardiopatía hipertrófica.

INTRODUCTION AND OBJECTIVES: The aim of this study was to assess the value of Doppler-echocardiogram for the prognosis and follow up of a hospital-based series of adult patients with hypertrophic cardiomyopathy (HC). METHODS: One-hundred nineteen consecutive patients with HC (52 +/- 12 years, 60 women) were studied over a follow up period of 9.7 +/- 6.7 years. Echocardiographic evolution was analyzed in 104 patients (67 with dynamic obstruction) who had, at least, two echocardiograms performed within an interval of 3.7 +/- 3 years (1 to 7 years). RESULTS: Seven patients died during follow up and 31 patients developed severe complications (7 deaths, 15 syncopes, 4 class IV angina, 3 class IV dyspnea and 2 acute myocardial infarctions). The presence of mitral insufficiency (p = 0.001) and dynamic gradient > 50 mmHg (p = 0.02) were predictive of mortality and a left atrial index > 25 mm/m2 was predictive (p = 0.028) of severe complications. Fifteen percent of the patients without dynamic obstruction in the first Doppler-echo showed a gradient > 25 mmHg in the last echo. A greater number of patients with mitral insufficiency (80% vs 66%; p = 0.01) and an increase in its severity (p = 0.038) was observed during follow up. CONCLUSIONS: Mitral insufficiency, a dynamic gradient > 50 mmHg and a left atrial index > 25 mm/m2 are variables of a bad prognosis in adult patients with HC. An evolution to obstructive HC was observed in 15% of non obstructive HC, and a tendency to increased severity of mitral insufficiency was observed during follow up.

[Residual pleural thickening in tuberculous pleuritis. Associated factors]]. / Engrosamiento pleural residual en la pleuritis tuberculosa. Factores asociados.

BACKGROUND: To study the factors related to the development of residual pleural thickening in pleural tuberculosis. PATIENTS AND METHODS: We studied 39 patients with tuberculous pleural effusion. A chest X-ray was taken of each patient at the end of treatment. The patients' medical histories, pleural fluid findings and diagnostic chest films were evaluated. Residual pleural thickening was defined as thickening that was visibly greater than 2 mm in the lower side portion of the chest film. RESULTS: Residual pleural thickening developed in 26% of patients and was found mainly in men (RR = 3.86). In no patients with Löwenstein-Jensen cultures positive for Mycobacterium tuberculosis did pleural complications develop. CONCLUSION: Residual pleural thickening is a common complication of tuberculous pleural effusion. Residual pleural thickening in tuberculous pleurisy occurs more often in men and older patients, and in cases in which pleural liquid culture is negative for M. tuberculosis.

[Protein-calorie malnutrition and lymphocytopenia as predictors of hospital infection in the elderly]. / Malnutrición caloricoproteica y linfocitopenia como predictores de infección hospitalaria en ancianos.

BACKGROUND: Clinical and epidemiological studies have established that malnutritionis a risk factor for infection in patients being submitted to surgery. To date no study has been carried out to establish the association between the nutritional condition and the incidence of hospital-acquired infections in patients in the medical area. We study the incidence of hospital-acquired infections in the elderly in an attempt to determine the rate of this infection and its association with protein-calorie malnutrition. Another aim of this study has been to determine the predictive value of the parameters used to evaluate the patient's state of nutrition and immunity. PATIENTS AND METHOD: We included 240 patients over 64 years old, 118 males and 122 females, admitted to the medical area of a general hospital. The nutritional and immunity condition of the patients was evaluated through determinations of weight, height, body mass index, hypoalbuminemia and total lymphocyte count. The psichophisical degree of dependence was evaluated through of Norton scale. The details on the hospital infections came from a clinical and microbiological follow-up of patients, in accordance with the criteria of the Centers for Disease Control of Atlanta. RESULTS: The frequency of protein-calorie malnutrition was 12.5% and the accumulated incidence of hospital-acquired infections was 19.6%. Functional incapacity of the elderly prior to hospitalization (odds ratio,4.70; 95% CI: 1.1-19.0) as well as the presence of certain extrinsicrisk factors (odds ratio, 2.35; 95% CI: 1.1-5.1) were, in addition to hypoalbuminemia (odds ratio, 3.60; 95% CI: 1.3-10.2) and lymphocytopenia(odds ratio, 2.67; 95% CI: 1.3-5.7), the independent variables that showed the most significant association with the incidence of hospital-acquired infections. CONCLUSIONS: The nutritional parameters associated with the immune system determinedgreater risk of hospital-acquired infections among elderly patients admitted to the medical area of a hospital. The initial evaluation of elderly patients hospitalitzed in accordance whit the psychophysical degree of dependence based on the Norton scale is useful to evaluate those patients who were at greater risk for hospital infections.

[Study of the capillary microscopy changes in scleroderma and their association with organ disease, clinical manifestations and disease progression]. / Estudio de las alteraciones capilaroscópicas en la esclerodermia y su asociación con la afección orgánica, las formas clínicas y la progresión de la enfermedad.

BACKGROUND: The changes of nailfold capillaries detected by capillary microscopy is a characteristic frequently observed in systemic sclerosis. The relationship between the different capillary microscopic changes and clinical manifestation, organic disease and disease progression were studied. METHODS: Sixty-three patients were studied in whom capillary microscopy was performed and organic disease was determined by analytical and morphological examination. The presence of association between the capillary microscopic signs and clinical manifestation and disease progression were investigated by the chi-square and Fisher tests. RESULTS: Capillary microscopic alterations were found in 95% of the patients. The extense capillary loss was associated as statistically significant to the diffuse form of scleroderma. Statistically significant associations were not found between the different capillary microscopic signs and disease progression and organic disease (global and individual per each organ). CONCLUSIONS: Although capillary microscopic changes are present in most scleroderma patients they are not useful in the evaluation of organ involvement of the disease. The presence of extense capillary loss is linked to worse prognosis in its association to the diffuse form of scleroderma.

[Parenteral nutrition: a utilization study in a general hospital]. / Nutrición parenteral: estudio de utilización en un hospital general.

A follow-up of 116 patients initiating parenteral nutrition was performed from December 1990 to March 1991 (average of 18 patients on parenteral nutrition per day, which accounted for a prevalence of 2% compared to total patients admitted), in order to determine a series of characteristics related to the use of parenteral nutrition in our hospital, by means of obtaining concrete, updated information. With regard to the patients, it was observed that 37% of these were suffering from chronic ailments, with more or less incapacitating pathologies. The nutritional state prior to parenteral nutrition was normal in 53% of cases, and the most common reasons for admittance to hospital were neoplasias (27%) and digestive pathology (18%). 42% of the patients were admitted to the ICU and 34% to General Surgery. Indication for parenteral nutrition was intestinal pathology in 23% of cases, followed by pancreatic pathology in 16% of cases and pathology of the oesophagus in 10%; in 45% of cases, it was commenced during the postoperative period. With regard to the composition of the parenteral nutrition, we should mention the use of polyols instead of glucose in 80% of diabetic patients and 75% of patients with pancreatitis, the widespread use of mixture of 50% medium and long chain triglycerides and the use of amino acid solutions with 20% branched chain in most patients, both in situations of stress and maintenance.

[Repercussion of age on management of neoplastic patients in an Internal Medicine Service]. / Relación de la edad con el manejo de los pacientes diagnosticados de neoplasia en un Servicio de Medicina Interna.

AIM: To determine whether age is a factor affecting the management of patients diagnosed with neoplastic disease in an internal medicine service. PATIENTS AND METHODS: Prospective study of 388 patients diagnosed with cancer in the internal medicine service of a large public health teaching hospital. We evaluated clinical characteristics, diagnostic procedures, types and stage of neoplasm, referral after hospital discharge and treatment. A comparative study based on age was performed between patients 65 years older and patients under this age. RESULTS: The 388 cancer patients accounted for 12% of hospital admissions in our service. Among the total, 62% were > or = 65 years old. Constitutional syndrome, the most frequently associated symptom and the main reason for the consultation, was more common in the > or = 65-year-old group. Lung cancer was predominant in men and hematologic neoplasms in women. Patients > or = 65 were referred more frequently to internal medicine physicians, general practitioners and home palliative assistance services (p < 0.05) and they received only palliative treatment in a greater percentage of cases (50% vs. 37%, p = 0.001). CONCLUSIONS: The incidence of neoplasms in our service was high (12%), with a considerable percentage of patients in advanced phases of the disease (83%). Age was not related to diagnostic methods nor was it determinant in the staging, but it did have repercussions on treatment; patients > or = 65 received palliative treatment alone more often than younger patients.

[Myocardial perfusion SPECT and isotopic ventriculography in obstructive and non-obstructive hypertrophic myocardiopathy]. / SPET miocárdico de perfusión y ventriculografía isotópica en la miocardiopatía hipertrófica obstructiva y no obstructiva.

OBJECTIVE: To evaluate the role of myocardial perfusion SPET and radionuclide ventriculography in patients with hypertrophic cardiomyopathy (HC). METHODS: Exercise myocardial perfusion SPET with 99mTc-tetrofosmin and radionuclide ventriculography were performed in a consecutive series of 101 patients (54 15 years, 50 women, 55 with dynamic obstruction) diagnosed of HC by echo. Follow-up from the diagnosis was 9,9 6,7 years (1 to 28 years). RESULTS: Thirty six percent of patients had perfusion defects (non reversible in 15 and reversible in 21). In non obstructive HC higher number of patients with non reversible defects (p = 0.01 was obseved and in patients with no reversible defects higher incidence of pathologic Q waves in ECG (p = 0.01), Higher ventricular volumes (p < 0.05), lower ejection fraction (p = 0,0001) and longer time to peak emptying velocity (p < 0.05). There were 4 cardiac deaths, 15 syncopes, 18 pacemakers and 6 myectomy. Ejection fraction was higher in patients with syncope (p = 0,034) and there was no isotopic variable predictive of mortality, pacemaker or myectomy. CONCLUSIONS: Neither SPET nor radionuclide ventriculography have a prognostic role in patients with HC, but patients with syncope have higher values of ejection fraction. Patients with non reversible defects have higher rate of pathologic Q waves in ECG, higher ventricular volumes and lower ejection fraction. This is indicative of evolution to dilated form of HC.