Massive right hemothorax due to idiopathic spontaneous rupture of a phrenic artery following cardiac surgery. / Hemotórax masivo derecho por rotura espontánea idiopática de una arteria frénica tras cirugía cardiaca.

We report a case of a 35-years-old man who presented a massive haemothorax and hypovolemic shock following cardiac surgery, from spontaneous rupture of a phrenic artery. A quick diagnosis and immediate intervention is crucial to manage the patient.

Evaluación de las competencias clínicas adquiridas por los estudiantes en Terapia Intensiva y Emergencias: análisis de 10 años en la Universidad de Buenos Aires / Competency evaluation clinics acquired by students in Intensive Therapy and Emergencies: analysis of 10 years at the University of Buenos Aires

Introducción: La educación médica debería garantizar la formación de profesionales competentes que posean los conocimientos, las destrezas y las actitudes planificados en la capacitación. En general, los programas no tienen en cuenta a la urgencia, que no figura como materia específica en los programas de grado. Objetivos: Cuantificar las competencias adquiridas por los internos en el Departamento de Urgencias y en Terapia Intensiva, estableciendo el grado de cumplimiento entre lo planificado y lo logrado; desglosar el grado de cumplimiento según las diferentes áreas de la competencia clínica. Materiales y Métodos: Diseño prospectivo, de observación, longitudinal, analítico. Se incluyeron 93 alumnos del ciclo clínico que realizaron el internado rotatorio (2000-2009). Se valoró el cumplimiento de 37 competencias que se clasificaron por área: actitudes, conocimientos y destrezas, en números de 9, 5 y 23, respectivamente. Resultados: El cumplimiento global de las competencias en el área de emergentología y terapia intensiva es del 61,18% (IC95% 59,20-63,13). Al desglosar por área de la competencia clínica, se halla que las actitudes fueron del 66,26%; los conocimientos, del 63,28% y las destrezas, del 58,15%. Clasificándolas según el grado de cumplimiento, se establece una escala con cumplimiento alto (76-100%), medio (51-75%) y bajo (<51%). Conclusiones: Los aspectos actitudinales y cognitivos de las competencias tuvieron un cumplimiento medio. La mitad de las competencias vinculadas a destrezas tuvo un cumplimiento medio-alto.(AU)

Introduction: Medical education should guarantee the formation of competent professionals with the knowledge, skills and attitudes planned in training. Generally programs do not bear in mind the urgency, which does not appear as a specific subject in the university. Objectives: To quantify the competitions acquired by the boarders in the Emergency Department and the Intensive Care Unit, establishing the degree of fulfillment between what was planned and what was achieved; to perceive the degree of fulfillment according to the different areas of clinical competition. Materials and Methods: Prospective, observational, longitudinal and analytical study. We included 93 students from the clinical cycle who performed rotating boarding school (2000-2009). Fulfillment of 37 competitions classified by area: attitudes, knowledge and skills, in numbers of 9, 5 and 23, respectively, was evaluated. Results: The global fulfillment of the competitions was 61.18% (CI95%: 59.20-63.13). Specifically, in each area of the clinical competition, we found that the attitudes were 66.26%, knowledge 63.28% and skills 58.15%. Classifying them according to the degree of fulfillment, a scale is established: high (76-100%), medium (51-75%) and low (<51%). Conclusions: Attitude and cognitive aspects of the competitions had average fulfillment. Half of the competitions linked to skills had average-high fulfillment.(AU)

[Lung cancer in the Pontevedra health area: incidence, clinical presentation and survival]. / Cancer de pulmon en el area sanitaria de Pontevedra: incidencia, presentación clinica y supervivencia.

BACKGROUND: To describe the clinical and epidemiological characteristics, and survival of patients with lung cancer (LC) in the Pontevedra Health Area. METHODS: A retrospective observational study was conducted on all patients with a diagnosis of LC in the Pontevedra Hospital Complex (CHOP) health area over a three-year period. The data recorded included, age, gender, smoking history, comorbidity, functional status, diagnostic method, histology type, stage, treatment received, and survival. The patients were followed up for 3 years. RESULTS: A total of 358 cases of LC were included in the study, which gave a crude incidence rate adjusted to the standard European population of 37.33/100,000 inhabitants/year in males and 4.88/100,000 inhabitants/year in females. The large majority were males (87%). The mean age was 68.7 years, and 82% were smokers or ex-smokers. The most common histology type was epidermoid, with 35.2% of the cases. The diagnosis was made in stages III-B or IV in 79% of cases. Chemotherapy was the first treatment in 53% of the cases. Survival after the first year was 25%, which decreased to 4% at the third year. CONCLUSIONS: The incidence of LC in our health area continues to be mainly in male smokers, although the incidence in females and in people who never smoked is higher than in other populations in our country. It is diagnosed in the advance stages of the disease, and survival is poor.

[Infant mortality in a third level paediatric hospital. therapeutic effort limitation, clinical-pathological agreement and diagnostic accuracy]. / Mortalidad infantil en un hospital de nivel terciario. Limitación de esfuerzo terapéutico, correspondencia clínico-patológica y precisión diagnóstica.

OBJECTIVE: To study infant and child mortality in a third level children's hospital treating highly complex patients. PATIENTS AND METHODS: All children dying in the period 2007- 2009 at La Paz Children's Hospital were evaluated. Epidemiological data, autopsy rate, clinical and autopsy diagnoses and their correspondence and the number of, patients with precise final diagnoses were analysed. Therapeutic effort limitation and palliative care were also evaluated as well as if the final result was expected according to the initial disease or clinical condition of the patients. All the variables were prospectively defined at the start of the study period. RESULTS: A total of 253 cases (6.08‰ admissions) were analysed. The two leading causes of death were disorders related to prematurity and low birth weight, and haematology oncology malignant diseases. Most patients (87%) died in an intensive care unit (neonatal or paediatric). During the study period 134 autopsies (53%) were performed, and new clinically significant findings were observed in 12 of these (7.8%) but in only one case the treatment could have possibly modified the prognosis (class I discrepancy). Therapeutic effort limitation and palliative care were implemented in 41.9%. Death was initially expected in 83.9% of cases. An accurate final diagnosis was defined in 92%, and the aetiology of the disease was considered to be identified in 86.4% of all deaths. CONCLUSIONS: Hospital mortality analysis is useful to evaluate the quality of the paediatric care and to detect adverse results that could be corrected. Paediatric autopsy continues to provide clinically significant data for paediatricians and families. Therapeutic effort limitation and palliative care is increasingly applied in paediatric end of life care. The number of infants and children dying without a final aetiological diagnosis is still considerably high.

Utilidad de la profilaxis para hemorragia digestiva. Estudio multicéntrico con 3438 casos / Utility of prophylaxis for digestive hemorrhage. Multicenter study with 3438 cases

Objetivos. Establecer la importancia de la profilaxis para prevenir la hemorragia digestiva en pacientes críticos, determinar los predictores del desarrollo de hemorragia digestiva en estos enfermos y cuantificar la neumonía intrahospitalaria. Materiales y métodos. Diseño prospectivo, observacional, longitudinal. Se estudiaron 3438 pacientes durante dos años. Luego de aplicar los criterios de exclusión y de eliminación, se evaluó a 3213 pacientes. La muestra fue consecutiva, se formaron dos grupos: con profilaxis (sucralfato o ranitidina) y sin profilaxis. Se registraron los siguientes datos: puntaje Apache II, disfunciones, diagnósticos de riesgo, hemorragia digestiva, neumonía intrahospitalaria, mortalidad. Resultados. Incidencia de hemorragia digestiva: 4,57%; con profilaxis frente a sin profilaxis: 4,64% y 4,50% (p = 0,91). Predictores de hemorragia digestiva en análisis multivariado: trauma grave (p = 0,0004), insuficiencia respiratoria (p = 0,0021), pancreatitis (p = 0,0202), insuficiencia renal aguda (p = 0,0220) y ayuno (p <0,0001). En pacientes con puntaje Apache II ≥15: trauma grave (p = 0,0228) y ayuno (p = 0,0000). Incidencia de neumonía intrahospitalaria 10,05%; con profilaxis y sin profilaxis: 11,47% y 8,68% (p = 0,001)(AU)

Objectives. Set the importance of prophylaxis for gastrointestinal bleeding in criticallly ill patients; determine predictors of gastrointestinal bleeding and quantify hospital-acquired pneumonia. Materials and methods. Prospective, observational and longitudinal design. A total of 3438 patients were studied during two years. After applying exclusion and elimination criteria, 3213 patients were left. It was a consecutive sample, and there were two groups; with prophylaxis (sucralfate or ranitidine) and without prophylaxis. Apache II, organ failures, risk diagnoses, digestive tract bleeding, hospital-acquired pneumonia and mortality were registered. Results. Gastrointestinal bleeding incidence: 4.57%, with vs. without prophylaxis: 4.64% vs. 4.50% (p = 0.91). Gastrointestinal bleeding predictors in the multivariate analysis: serious trauma: (p = 0.0004), respiratory failure (p = 0.0021), pancreatitis (p = 0.0202), acute renal failure (p = 0.0220) and fasting (p <0.0001). In Apache II ≥15 patients: serious trauma (p = 0.0228) and fasting (p = 0.0000). Incidence of hospital-acquired pneumonia: 10.05%, with vs. without prophylaxis: 11.47% vs. 8.68% (p = 0.001). Conclusions. Prophylaxis did not reduce gastrointestinal bleeding, it was associated with serious trauma, respiratory failure, pancreatitis, acute renal failure and fasting, and considering only patients with the worst Apache II score, it was associated with serious trauma and fasting. Acquired pneumonia was higher in the prophylaxis group.(AU)

Peroxisome proliferator-activated receptor-alpha reduces inflammation and vascular leakage in a murine model of acute lung injury.

Acute lung injury (ALI) still represents a major cause of morbidity and mortality in intensive care units. Beneficial effects have been described after activation of the peroxisome proliferator-activated receptor (PPAR)-alpha by fibrates such as WY 14,643 (WY) in inflammatory models. In the present study, the impact of WY was investigated in a model of endotoxin (lipopolysaccharide; LPS)-induced ALI in mice. Intratracheal LPS challenge dose-dependently resulted in leukocyte invasion, protein leakage and release of tumour necrosis factor-alpha as well as macrophage inflammatory protein-2, prostaglandin E(2) and thromboxane B(2) into the alveolar space after 8 and 24 h. Lung ventilator compliance was reduced at both time-points. In isolated perfused mouse lungs, platelet-activating factor (PAF) induced an acute increase in pulmonary artery pressure (P(pa)) and in capillary filtration coefficient (K(fc)). WY significantly improved all features of ALI in vivo and blunted the increase in K(fc) in isolated perfused mice lungs. In mice with genetic deletion of PPAR-alpha, all characteristics of ALI, P(pa), and K(fc) were not significantly different from wild-type mice but WY failed to improve ALI and PAF-induced increase in K(fc). Activation of peroxisome proliferator-activated receptor-alpha by WY 14,643 reduced acute lung injury and vascular leakage. Fibrates may possess beneficial effects in acute pulmonary diseases beyond their lipid-lowering capability.

Patología prehospitalaria prevalente en el Servicio de Emergencias Médicas del Partido de General San Martín / Prevalent prehospitalary pathology in the Medical Emergencies Service at General San Martín District

Anßlisis retrospectivo de una muestra de prestaciones médicas, donde se tomaron como referencia los diagnósticos finales obtenidos de la base informatizada del sistema, y se presentan los resultados numéricos y porcentuales de los auxilios realizados entre 2001 y Junio de 2003

Tuberculous pleurisy: a study of 254 patients.

OBJECTIVES: To determine the age at which tuberculous pleural effusions occur, the radiological and biochemical characteristics of the effusions, the sensitivities of the various diagnostic tests, and the utility of combining clinical, radiological, and analytic data in diagnosis. METHODS: We studied the case histories of 254 patients in whom tuberculous pleural effusions were diagnosed with certainty between January 1, 1989, and June 30, 1997, in a Spanish university hospital in a region with a high incidence of tuberculosis. RESULTS: The mean (+/-SD) age of the patients was 34.1+/-18.1 years, and 62.2% were younger than 35 years. The effusion was on the right side in 55.9% of patients, on the left side in 42.5% of patients, and on both sides in 1.6% of patients. In 81.5% of patients, less than two thirds of the hemithorax was affected. Associated pulmonary lesions were detected in 18.9% of patients, of whom 14.6% exhibited cavitation. In 93.3% of the effusions, more than 50% of leukocytes were lymphocytes, and almost all had the biologic characteristics of exudates (98.8% had high total protein contents, 94.9% had high cholesterol levels, and 82.3% had high lactate dehydrogenase levels). All but 1 effusion (99.6%) had an adenosine deaminase (ADA) concentration higher than 47 U/L, 96.8% (123/127) of the effusions had high ADA2 levels, and 89% (73/82) of the effusions had high interferon gamma levels. Adenosine deaminase 2 contributed 72.2%+/-12.5% (mean +/- SD) of total ADA activity. Total ADA activity was significantly correlated with ADA2 (r = 0.83) and with interferon gamma (r = 0.30) levels. Definitive diagnosis was based on the observation of caseous granulomas in pleural biopsy tissue samples in 79.8% of patients, on the results of biopsy cultures in 11.7% of patients, and on pleural effusion cultures in the remaining 8.5% of patients. Results of the tuberculin skin test were positive in only 66.5% of patients. CONCLUSIONS: In these patients, lymphocyte-rich exudative pleural effusions occurred, on average, at a young age, with no preference for either the right or the left side; normally affected no more than two thirds of the hemithorax; and were generally unaccompanied by pulmonary infiltrates. High ADA concentration was a highly sensitive diagnostic sign and was caused by a rise in ADA2 concentration. The most sensitive criterion based on pleural biopsy was the observation of caseous granulomas, and culture of biopsy material further increased overall sensitivity. Negative skin test results were no guarantee of the effusion being nontuberculous. This, together with the low mean age of the patients and the low frequency of associated pulmonary lesions, suggests that tuberculous pleural effusion is a primary form of tuberculosis in this region.

Cirrhosis of the liver, an exceptional cause of chylothorax: two cases.

Chylothorax, a condition featuring an infrequent form of pleural effusion, is generally caused by tumours or traumatism. Only about 1% of chylothorax cases are caused by cirrhosis of the liver. Two such cases are described in these case reports.

The etiology of pleural effusions in an area with high incidence of tuberculosis.

To investigate the etiology of pleural effusions in our region, we undertook a prospective study of patients with this condition in our centers. During a 5-year period, we studied 642 pleural effusion patients aged 57.1 +/- 21.1 years, of whom 401 were men aged 56.5 +/- 21 years and 241 were women aged 57.8 +/- 21.4 years; the male/female ratio was 1.6:1. The most frequent cause of pleural effusion was tuberculosis (25%), followed by neoplasia (22.9%) and congestive heart failure (17.9%). The etiology of 48 cases (7.5%) remained uncertain. In the neoplastic effusion group, the most frequent locations of the primary tumor were lung (32.6%), breast (11.5%), lymphoma (10.8%), and ovary (7.5%); in 21 cases (14.3% of the neoplastic group), it was not possible to identify the primary tumor. The 111 patients aged younger than 40 years with tuberculous effusions made up 69.4% of tuberculous effusion cases and the same percentage of patients younger than 40 years; the proportion of effusions that were tuberculous peaked in the 11- to 30-year-old age group and declined steadily thereafter. Of the patients with neoplastic effusions, 83% were older than 50 years; the proportion of effusions that were neoplastic rose steadily from zero in the 0- to 30-year-old age group to a peak among 60- to 70-year-olds. The age-wise distribution of effusions secondary to congestive heart failure was similar to that of neoplastic effusions. Of the effusions secondary to congestive heart failure, 86% (99/115) affected the right pleura or both, and 83% of effusions secondary to pulmonary thromboembolism (15/18) affected the right side. Neoplastic, tuberculous, parapneumonic, empyematous, and other exudative effusions showed no preference for either side. Of the 97 bilateral effusions, 77 (79.4%) were secondary to heart failure (59, 60.8%) or neoplasia (18, 18.6%). We conclude that in our region, the most frequent cause of pleural effusion is tuberculosis, followed by neoplasia and congestive heart failure. We suggest that all those interested in pleural disease should determine the etiologic pattern of pleural effusion in their region with a view to the adoption of regionally optimized diagnostic and therapeutic attitudes.

Value of adenosine deaminase in the diagnosis of tuberculous pleural effusions in young patients in a region of high prevalence of tuberculosis.

BACKGROUND: Pleural biopsy is usually considered important for the diagnosis of pleural effusions, especially for distinguishing between tuberculosis and neoplasia, even though tuberculous pleural fluid contains sensitive biochemical markers. In regions with a high prevalence of tuberculosis, and in patient groups with a low risk of other causes of pleurisy, the positive predictive value of these markers is increased. The criteria for performing a pleural biopsy under these circumstances have been investigated, using adenosine deaminase (ADA) as a pleural fluid marker for tuberculosis. METHODS: One hundred and twenty nine patients with a pleural effusion aged < or = 35 years (mean (SD) 25.2 (4.9) years) were studied. Seventy three were men. Eighty one effusions (62.8%) were tuberculous, 12 (9.3%) parapneumonic, and 10 (7.7%) neoplastic, five were caused by pulmonary thromboembolism, four by systemic lupus erythematosus, seven by empyema, three following surgery, one was the result of asbestosis, and one of nephrotic syndrome. In five cases no definitive diagnosis was reached. ADA levels were determined by the method of Galanti and Giusti. RESULTS: The diagnostic yield of procedures not involving biopsy was 94.5% (122/129). Pleural biopsy provided a diagnosis in a further two cases, but not in the remaining five. All tuberculous cases had pleural fluid levels of ADA of > 47 U/l (mean (SD) 111.1 (36.6) U/l). The only other cases in which ADA exceeded this level were six of the seven patients with empyema. Cytological examination of the pleural fluid diagnosed eight of the 10 neoplastic cases, compared with six diagnosed by pleural biopsy. CONCLUSIONS: In a region with a high prevalence of tuberculosis procedures not involving pleural biopsy have a very high diagnostic yield in patients with a pleural effusion aged < or = 35 years, making biopsy necessary only in cases in which pleural levels of ADA are below 47 U/l, pleural fluid cytology is negative and, in the absence of a positive basis for some other diagnosis, neoplasia is suspected.

Gradiente venoarterial de anhídrido carbónico: valor pronóstico y relaciones con el índice cardíaco en pacientes críticos / Carbon anhydride arterial vein gradient: prognosis value and relationships with heart rate in critical patients

En 64 pacientes (P) se midió dentro de las 6 horas de la admisión, el gradiente venoarterial de CO2 (Gv-aCO2) (G) diferenciando 2 grupos A (G < a 6 mmHg) y B (> 6 mmHg) evaluándose en ellos el desarrollo de fallas múltiples (FM) y la mortalidad (M). En 35 P se midió concomitantemente el G y el índice cardíaco (IC) en 50 oportunidades correlacionándose sus valores; a la vez se midió en ellos el pHi. El desarrollo de FM y la M fueron significativamente mayores en el grupo B; la correlación entre G e IC fue débil, los niveles de IC y G en estos P definieron 4 grupos de determinaciones: I: IC < 2,7, G > 6; II: IC < 2,7, G ? 6; III: IC > 2,7, G ? a 6 y IV: IC > 2,7, G > 6 (en el último no se ubicaron mediciones). En I la X ñ DE fue significativamente menor que II y en este último que en III. El G puede ser de utilidad para establecer pronóstico en la admisión. El más reducido pHi en las determinaciones del grupo I evidencia las consecuencias de la caída efectiva del volumen circulante sumado a alteraciones en la regulación del microflujo en relación al II en el cual esas últimas estarían ausentes (similar IC con G normal)

Diagnosis of tuberculous pleurisy using the biologic parameters adenosine deaminase, lysozyme, and interferon gamma.

We compared the parameters pleural adenosine deaminase (PADA, determined in 405 patients), the PADA/serum ADA ratio (P/SADA; 276 cases), pleural lysozyme (PLYS, 276 cases), the PLYS/serum LYS ratio (P/SLYS; 276 cases), and pleural interferon gamma (IFN, 145 cases) regarding their ability to differentiate tuberculous pleural effusions from others. The 405 pleural effusions were classified by previously established criteria as tuberculous (91), neoplastic (110), parapneumonic (58), empyemas (10), transudates (88), or miscellaneous (48). The intermean differences between the tuberculous group and each of the others were statistically significant for all five parameters (p < 0.01 for PLYS and P/SLYS with respect to the empyema group; p < 0.001 otherwise), except for PADA and P/SADA with respect to the empyema group. All the tuberculous pleurisy cases had PADA values of 47 U/L or more, as compared to only 5 percent of the other cases (sensitivity, 100 percent; specificity, 95 percent). P/SADA was above 1.5 in 85.7 percent of tuberculous effusions and 11 percent of the others (sensitivity, 85.7 percent; specificity, 89 percent). PLYS, with a diagnostic threshold of 15 g/ml, had a sensitivity of 85.7 percent and a specificity of 61.6 percent; P/SLYS, with a threshold of 1.1, had a sensitivity of 67.3 percent and a specificity of 90.3 percent; and IFN, with a threshold of 140 pg/ml, had a sensitivity of 94.2 percent and a specificity of 91.8 percent. The lowest misclassification rate was achieved by PADA, with statistically significant differences (p < 0.001) with respect to P/SADA, PLYS, and P/SLYS, but not with respect to IFN. The only significant pairwise correlations among these parameters were between P/SLYS and PADA and between P/SLYS and P/SADA. We conclude that PADA and IFN are useful parameters for early diagnosis of tuberculous pleurisy, and that the other parameters considered have no advantages over PADA and IFN for this purpose (though the high specificity of P/SLYS may be noted).

Cholesterol: a useful parameter for distinguishing between pleural exudates and transudates.

Previously established criteria were used to classify 253 pleural effusions as transudates (65 cases), neoplastic exudates (67 cases), tuberculous exudates (65 cases), or miscellaneous exudate (56 cases). The parameters pleural LDH (PLDH), pleural LDH/serum LDH ratio (P/SLDH), and pleural protein/serum protein ratio (P/SPROT) were compared with pleural cholesterol (PCHOL) and the pleural cholesterol/serum cholesterol ratio (P/SCHOL) with regard to their usefulness for distinguishing between pleural exudates and transudates. The PCHOL values determined were 28.5 +/- 12.8 mg/dl for transudates, 88.1 +/- 30 mg/dl for neoplastic exudates, 96.5 +/- 28 mg/dl for tuberculous exudates, and 88 +/- 35.9 mg/dl for the miscellaneous group; the differences between the transudate group and the others are statistically significant (p less than 0.001). The sensitivity and specificity of P/SPROT for diagnosis of exudates were both 89 percent; the sensitivity of PLDH was 67 percent and its specificity was 95 percent; the sensitivity and specificity of P/SLDH were both 84.6 percent. Using Light's three criteria as a battery, the sensitivity was 94.6 percent and its specificity was 78.4 percent. All the transudates and 17 (9 percent) of the 188 exudates had PCHOL values below 55 mg/dl, so that with this threshold, PCHOL had a sensitivity of 91 percent and a specificity of 100 percent for diagnosis of exudates. With a threshold of 0.3, P/SCHOL had a sensitivity of 92.5 percent and a specificity of 87.6 percent. The number of misclassifications by PCHOL was less than with any other of the parameters, with statistically significant differences with respect to PLDH (p less than 0.001) and P/SLDH (p less than 0.01). We conclude that determination of PCHOL and P/SCHOL is of great value for distinguishing between pleural exudates and transudates, and should be included in routine laboratory analysis of pleural effusions.