[Distribution of pulmonologists and chest surgeons in Spain]. / Distribución de neumólogos y cirujanos torácicos en España.

OBJECTIVE: To study the real situation of respiratory medicine specialists and chest surgeons in the Spanish health service. SUBJECTS AND METHOD: Using the database of the secretary of the Spanish Society of Respiratory Medicine and Chest Surgery (SEPAR) for 1999, we gathered data on 326 Spanish hospitals. We were thus able to ascertain the level of staffing of respiratory medicine and chest surgery departments. The results were expressed as simple percentages showing distribution by age, duties and geographic area. The number of specialists per 100,000 inhabitants in each community was also calculated based on population data provided by the National Statistics Institute for 1997. RESULTS: We studied 1,786 physicians or surgeons (1,245 pneumologists, 185 surgeons and 356 from other specialties). The mean age was 41 9 years for pneumologists, 44 10 years for surgeons and 51 8 years for the others. We observed unequal distribution by geographic area, with a high of 6.66 pneumologists and 0.9 surgeons per 100,000 inhabitants in Asturias and Madrid, respectively and a low of 1.4 pneumologists per 100,000 inhabitants in Murcia and 0 surgeons in Extremadura. CONCLUSIONS: Specialist coverage by pneumologists and chest surgeons is inadequate in many provinces and communities in Spain. The professional market is not saturated, indicating that future specialists can look forward to market demand.

Investigation of tuberculosis contacts in a nonhospital pneumology practice.

The aim of this study was to analyze the results of the tuberculosis contact tracing carried out in an outpatient pneumology setting and to assess its performance with regard to the detection of new cases of tuberculosis and infected contacts. One thousand two hundred and twenty-eight contacts of 302 tuberculosis patients were evaluated in the Tuberculosis Unit of the Dr. Fleming Specialities Center between 1992 and 1996. Contacts were categorized into groups with regard to bacteriological status of the index case (Group A, smear-positive; Group B, culture-positive only; Group C, smear- and culture-negative) and intimacy of exposure to the index case (close or casual). The possible association between the existence of infection or disease and the bacteriological status of the index case and degree of intimacy of exposure was analyzed. There were 582 infected contacts (47.4%) and 42 new cases of tuberculosis (3.4%), six of which were smear-positive. The proportion of infected and diseased contacts was significantly higher for those who had contact with smear-positive patients and those who had close contact with the index case. Chemoprophylaxis was completed in 431 (35.1%) of the contacts evaluated. Systematic investigation of contacts represents an efficient means of discovering new cases of tuberculosis and infection, especially among contacts of smear-positive index cases and among those who are closer to the index case. The administration of appropriate treatment to these contacts will contribute to controlling the transmission of tuberculosis within the community.

[The endovascular treatment of cerebral arteriovenous aneurysms and malformations]. / Tratamento endovascular dos aneurismas e malformações arteriovenosas cerebrais.

Despite the progress made in cerebral aneurysm microneurosurgery, some morphologic and anatomic characteristics, or also clinical reasons, make surgical clipping of the aneurysmatic column difficult or unfeasible, justifying an endovascular therapeutic alternative. Despite the great progress made, the risk of endovascular intervention with microballoons is significant, particularly in the acute post-haemorrhagic phase: 17.9% mortality and 10.7% morbidity in endosaccular embolisation therapy with the detachable balloon maintaining the arterial lumen permeable. The use of the GDC system (Guglielmi Detachable Coil) has permitted the treatment of proximal and distal aneurysms in the carotid and vertebrobasilar arterial regions. Microcatheterisation also allows intravascular treatment of the vasospasm, by mechanical means--angioplasty, or by pharmacological vasodilatation. With the GDC system one can obtain a complete occlusion of small and medium aneurysms in over 85% of cases, definitive morbidity of 5% to 7% and mortality of 1% to 3%. The objective of AVM endarterial occlusions is to obliterate the nidus through the arterial pedicles that can be microcatheterised by means of a certain embolic agent (Cyanocrilate, PVA or other embolic products). Thus, it is possible to reduce the dimension of the nidus as well as diminish the severity of the arteriovenous shunt, later facilitating the operation or radiosurgery, with the possibility of complete surgical removal in 96% of patients after embolisation. The mortality directly related to this endovascular therapy is approximately 0.9% with severe morbidity below 2%. Complete obliteration of a cerebral AVM can be achieved with endovascular techniques in 15% to 20% of cases, particularly in small lesions, sustain AVMs require careful multidisciplinary discussion aimed at finding the best treatment for each case.

[Outpatient emergency care in pneumology. A method to alleviate pressure of hospital emergency services]. / Atención urgente extrahospitalaria en neumología. Un método para aliviar la presión asistencial de servicios de urgencias hospitalarios.

We analyze the result of using a pneumological rapid-attention facility for diagnosis and immediate treatment of patients with respiratory symptoms arriving at the emergency room of University Hospital Virgen del Rocío in Seville (Spain). In the first six months the outpatient service saw 321 patients (male/female ratio 2.6), most of whom were between 55 and 75 years of age and had never before seen a pneumologist (83.4%). Dyspnea was the most common respiratory symptom named (by 35% of patients), and acute exacerbation of chronic obstructive pulmonary disease was the most usual diagnosis (in 19.1%). Only 21 (7%) were admitted to the hospital. We that creating the outpatient unit effectively met a societal need for rapid diagnosis and treatment of patients with respiratory complaints in the area served by our hospital emergency service.

[Respiratory polygraphy in the diagnosis of obstructive sleep apnea syndrome]. / Poligrafía respiratoria en el diagnóstico del síndrome de apneas obstructivas durante el sueño.

The traditional way of diagnosing obstructive sleep apnea syndrome (OSAS) is all-night polysomnographic recording. A proposed alternative is respiratory polygraphy, a simplified procedure that consists in nighttime monitoring of oxygen saturation, oronasal flow and respiratory movements. Our aim was to evaluate the efficacy of respiratory polygraphy in diagnosing OSAS in comparison with conventional polysomnography. We studied 101 patients (92 men and 9 women) who had undergone polysomnography. An apnea-hypopnea index (AHI) > or = 10 was considered to be the diagnostic criterion for OSAS. To assess the diagnostic validity of respiratory polygraphy we considered that an AHI per hour of recording > or = 10 and a desaturation index per hour of recording > or = 10 were consistent with a diagnosis of OSAS. Sixty patients were diagnosed of OSAS. The AHI per hour of recording was > or = 10 in 56 patients, with 4 false negatives (sensitivity 93.3% and specificity 100%). The desaturation index per hour of recording was > or = 10 in 65 patients, with 7 false positives and 2 false negatives (sensitivity 96.6% and specificity 82.9%). We conclude that respiratory polysomnography is a specific, highly sensitive method for diagnosing OSAS.

[Hypercapnic stimulation and ventilation response in the syndrome of sleep obstructive apnea. Comparison of reinhalation and steady state]. / Estimulación hipercápnica y respuesta ventilatoria en el síndrome de apnea obstructiva del sueño. Comparación de reinhalación y estado-estable.

The objective of this study was to assess ventilatory response to stimulation with CO2 in patients suffering obstructive sleep apnea syndrome (OSAS) but without chronic obstructive pulmonary disease (COPD), by examining differences between hyper- and normocapnic patients and comparing the results obtained with the usual techniques used to stimulate hypercapnia (rebreathing and stable-state). To this end, we studied 15 obese patients, all with an apnea-hypopnea index greater than 10 from a polysomnograph lasting a full night. The following lung function tests were performed: spirometry, air way resistance measures and static lung volumes by plethysmograph and arterial gasometry. We later analyzed ventilatory response by the stable-state method, with increasing CO2 concentrations (from 1 to 9%) and by the rebreathing method. Results from the two methods were similar for all patients: delta VE/delta PCO2 (0.64 +/- 0.35 vs 0.67 +/- 0.48 l/min/mmHg; p = 0.59), delta Vt/delta PCO2 (28.33 +/- 16.23 vs 26.42 +/- 16.94 ml/mmHg; p = 0.9), delta Vt/Ti/delta PCO2 (28.82 +/- 20.9 vs 29.41 +/- 23.78 ml/s/mmHg; p = 0.89) y delta P0.1/delta PCO2 (0.11 +/- 0.07 vs 0.117 +/- 0.05 cmH2O/mmHg; p = 0.58). We compared the results obtained by the two techniques by dividing the sample into two groups of 7 and 8 patients, respectively, depending on whether PaCO2 level before stimulation was higher or lower than 45 mmHg. The hypercapnic patients (group I) were older (61 +/- 3.5 vs 50 +/- 9 years; p = 0.04) but were not different with respect to body mass from the normocapnic patients (group II) (37.59 +/- 6.4 vs 34.56 +/- 4.75 kg/m2; p = 0.33). The results from the two techniques for stimulating hypercapnia were similar within each group, with a statistically significant decrease (p < 0.03) in patients with daytime hypercapnia in delta VE/delta PCO2 delta Vt/delta PCO2, delta Vt/Ti/delta PCO2 and delta P0.1/delta PCO2. We conclude that there are no differences in the results obtained with the rebreathing and stable state techniques. Likewise, ventilatory response to stimulation with CO2 in individuals with OSAS and daytime hypoventilation is less than of normocapnic patients.

[Imaging findings in hypertensive encephalopathy]. / Achados imagiológicos na encefalopatia hipertensiva.

Hypertensive encephalopathy is a neurologic syndrome caused by a marked and rapid rise of blood pressure above baseline levels. Efficacy of current anti-hypertensive drugs greatly diminished the frequency of this situation in which diagnosis is essentially based on clinical parameters. This can justify the few papers found in radiologic literature. Nevertheless it is sometimes important to exclude ischemic or hemorrhagic complications or establish a differential diagnosis with other neuropathologic conditions. Then a striking imagiologic picture of focal or diffuse reversible edema of cerebral white matter can be found. We present three clinical cases of hypertensive encephalopathy. Imagiologic findings are reviewed and correlated with the pathophysiologic basis of the disease.

[Prediction of maximal ventilation during exercise in patients with chronic obstructive pulmonary disease]. / Predicción de la ventilación máxima alcanzada en el esfuerzo en pacientes con enfermedad pulmonar obstructiva crónica.

To analyze the validity of baseline lung function parameters as predictors of maximal exercise ventilation (VEmax) in patients with chronic obstructive pulmonary disease (COPD), we studied 33 stable patients (FEV1 43.6 +/- 16.8%, FEV1/FVC% 48.4 +/- 9.2, FRC 156.8 +/- 32.7% and RV 212 +/- 53.9%). The sample was later divided into 3 groups based on severity of disease (severe, moderate or mild) in order to determine whether ability to predict VEmax increased with airways obstruction (FEV1 26.9 +/- 4.9%, 40.2 +/- 3.5% and 63.9 +/- 10%, respectively). The patients underwent lung function testing at rest and after a progressive stress test, with the maximal reading taken with the subject on a tread mill. We found greater correlation between VEmax and RV, FEV1 and FRC (r = -0.77, 0.75 and -0.74, respectively); the correlation was stronger in patients with severe COPD, in whom FEV1 was under 35% of the predicted value (r = -0.88, 0.753 and -0.83, respectively). Correlation decreased or disappeared with less functional impairment. Prediction of VEmax was more reliable with equations that employed FEV1 accompanied by data reflecting degree of insufflation, RV or FRC (VEmax = 45.2 +/- 8.98 x FEV1 - 5.07 x RV; r2 = 0.72) than with equations based on FEV1 alone (VEmax = 14.79 + 15.03 x FEV1; r2 = 0.56). We therefore conclude that ventilatory limitation during exercise in patients with COPD is better defined by considering parameters related to lung insufflation along with those reflecting degree of expiratory obstruction, given that the former affect the greater or lesser efficacy of muscles under stress.(ABSTRACT TRUNCATED AT 250 WORDS)

Perimesencephalic and nonperimesencephalic subarachnoid haemorrhages with negative angiograms.

BACKGROUND: van Gijn and co-workers identified "Perimesencephalic haemorrhage" (PM) as distinct, benign, non-aneurysmal subarachnoid haemorrhage. However, there is only one retrospective series of this entity outside the Netherlands. PURPOSE: to confirm (or not) the benign nature of perimesencephalic subarachnoid haemorrhage by evaluating its clinical course and long-term follow-up in a consecutive series of patients admitted to a University Hospital. METHODS: Patients with subarachnoid haemorrhage and negative cerebral angiography admitted between January 1985 and April 1992 were classified according to the distribution of blood on a CT scan performed within 72 hours after onset, in perimesencephalic and non-perimesencephalic haemorrhages. Demographic and clinical data (collected consecutively), complications and long-term follow-up (obtained by chart review and follow-up by mail) were compared in the two groups. RESULTS: Seventy one cases, 36 perimesencephalic and 35 nonperimesencephalic were included. Sex and age distribution were similar in the two groups. A normal examination on admission was the rule in the perimesencephalic group. Only one patient with perimesencephalic haemorrhage had a complication--transient neurological signs during angiography--and there were no deaths or morbidity during follow-up. In the non-perimesencephalic group three patients rebleed, four developed hydrocephalus and two had delayed cerebral ischaemia. Mean duration of follow-up was 27.6 months for the perimesencephalic and 30.8 months for the non-perimesencephalic group. After discharge there was a fatal rebleed in the latter group. Fifteen percent of the subjects (11% of the perimesencephalic group and 20% of the non-perimesencephalic group) retired from work during the follow-up period. Headaches and depression were found in similar percentages (22-25%) in both groups. CONCLUSIONS: This study confirms that perimesencephalic haemorrhage is a distinct entity within the larger group of subarachnoid haemorrhage with negative angiograms, with a good short term and long-term prognosis, and no need for repeated angiographic investigation.

[Neurocysticercosis. An imaging analysis of 35 cases]. / Neurocisticercose. Análise imagiológica de 35 casos.

Neurocysticercosis (NCC) is the most frequent parasitic disease of the central nervous system. Other Portuguese works showed it to be endemic in the north of our country. The purpose of this paper is to aid the characterization of NCC in the geographic area of our Institution. We retrospectively reviewed the findings of computed tomography (CT) in 35 patients with NCC, including 23 adults and 12 children. There was no significant sex predominance in adults, however, in children the female/male ratio was 2. We found important clinical and radiological differences between adults and children. In the pediatric age group, the active forms were characteristically solitary or scarce inflammatory lesions. This radiologic picture was associated with neurologic focal signs. In these cases, a trial with anticysticercoid drugs is important to settle the diagnosis and avoid brain biopsy. Almost all of our cases (94%) were parenchymatous forms. This can be explained, in part, by the limitations of CT in the ventricular and cisternal compartments. Magnetic resonance is the ideal method in these locations. About half our patients (49%) were of African origin, most of them immigrants from the former Portuguese colonies where NCC is endemic.

[Neuroradiology in the physiopathologic diagnosis of subarachnoid hemorrhage--cerebral aneurysm]. / A neurorradiologia no diagnóstico fisiopatológico da hemorragia subaracnoideia--aneurisma cerebral.

The clinical importance of the cerebral aneurismatic lesion in well known. In Portugal we still do not have reliable statistics regarding the occurrence of the subarachnoid hemorrhage, however we can make a comparison through Kassel's and Drake's studies where they refer that annually 28,000 North-Americans suffer from subarachnoid hemorrhage attributed to the rupture of the cerebral aneurysm. This is a clinical situation that needs to be analyzed, more so because if it is not diagnosed and treated in time, it can cause a high level of morbidity and mortality. From 1984 to 1990, the authors studied 208 clinical cases of in-patients at the Santa Maria Hospital who had been diagnosed as having subarachnoid hemorrhage-cerebral aneurysm. They analyzed 172 cranium-encephalic Tomographies and 190 cerebral Angiographies. They found levels that overlapped the series already published with respect to the location of the lesion, dimensions and age groups involved. They tried to relate the presence aneurysm in the willis arterial circle with the occurrence of locoregional anatomic variants that were detected in 51% of the patients with aneurysm of the anterior communicating artery and in 33% of the cases in the posterior communicating artery. The high occurrence of serious forms of tomodensitrometric presentation should also be emphasized. As a matter of fact, 42.6% of the patients studied were grouped in degree IV of the Fisher Scale. This result translates the effort that is still required towards an early clinical and imaging diagnosis of warning hemorrhage to avoid or prevent a catastrophic hemorrhage recurrence.

[Perimesencephalic hemorrhage]. / Hemorragia perimesencefálica.

Among 293 subarachnoid hemorrhages admitted to the Neurology and Neurosurgery departments of Sta Maria Hospital, 108 patients had a normal cerebral angiography. Twenty-three meet the radiological criteria for perimesencephalic hemorrhage (center of the hemorrhage located in front of the mesencephalon, without blood in the interhemispheric and lateral sylvian fissures, nor significant intraventricular hemorrhage). The clinical picture was one of sudden, severe headache with meningeal signs, without focal signs or decreased alertness. Evolution was benign: there was no intrahospital mortality, morbidity or rebleeds on follow-up (3.5 years). In this subgroup of subarachnoid hemorrhage there is no need for a repeated angiogram if the first angiography is considered normal.