COVID-19: presentación clínica inicial y su correlación con la gravedad de la enfermedad / COVID-19: initial clinical presentation and its correlation with the severity of the disease

Los pacientes con COVID-19 tienen un amplio espectro de presentación clínica y las tasas de mortalidad en los casos graves son relativamente altas. La identificación tem prana de los factores de riesgo que se relacionan con la gravedad de la enfermedad es de vital importancia. Con el objetivo de correlacionar los síntomas iniciales de COVID-19 con la gravedad de la enfermedad, se realizó el presente estudio de cohorte transversal retrospectivo y observacional de 413 pacientes con diagnóstico de COVID-19 entre enero y marzo 2021. De todos los síntomas iniciales estudiados, la disnea (p < 001), fiebre (p 0,001), tos (p 0,002), odinofagia (p 0,01), cefalea (p 0,01) y síntomas gastrointestinales (p 0,03), se asociaron con el desarrollo de una enfermedad grave. Las comorbilidades que se asociaron con peor pronóstico fueron: hipertensión arterial (p < 0,001), obesidad (p < 0,001), EPOC (p < 0,001), extabaquismo (p < 0,001), diabetes (p 0,01), enfermedad cardiovascular previa (p 0,03), y enfermedad oncológica activa (p 0,04). En conclusión, los pacientes con diagnóstico de COVID-19, cuya manifestación inicial es disnea, fiebre, tos, odinofagia, cefalea y síntomas gastrointestinales, deben ser monitoreados de cerca para prevenir el deterioro de la enfermedad.

Patients with COVID-19 have a broad spectrum of clinical presentations, and mortal ity rates are relatively high in severe cases. Early identification of risk factors that are related to the severity of the disease is of vital importance. In order to correlate the initial symptoms of COVID-19 with disease severity, the present retrospective, cross-sectional, observational cohort study was conducted, including 413 patients diagnosed with COVID-19 between January and March, 2021. Of all the initial symptoms that were studied, dyspnea (p < 001), fever (p 0.001), cough (p 0.002), odynophagia (p 0.01), headache (p 0.01), and gastrointestinal symptoms (p 0.03) were associated with the development of severe illness. The comorbidities that were associated with the worst prognoses were: arterial hypertension (p < 0.001), obesity (p < 0.001), COPD (chronic obstructive pulmonary disease) (p < 0.001), former smoking (p < 0.001), diabetes (p 0.01), previous cardiovascular disease (p 0.03), and active oncological disease (p 0.04). In conclusion, patients diagnosed with COVID-19 whose initial manifestations include dyspnea, fever, cough, odynophagia, headache, and gastrointestinal symptoms should be closely monitored to prevent disease deterioration.

Expresión atípica de enfermedad poco frecuente manifestada con nódulos pulmonares cavitados / Atypical Expression of Rare Disease Manifested with Cavitary Lung Nodules

Los nódulos pulmonares pueden ser variados: sólidos, en vidrio esmerilado; granulo matosos o no granulomatosos; cavitados o no cavitado. Son un hallazgo frecuente en las imágenes de tórax cuando el paciente llega a la consulta. Según sus características y en concordancia con los antecedentes del paciente (historia clínica, exámen físico y resultados de laboratorio) nos orienta a las distintas etiologías: infeccioso, autoinmune u oncológico. Sin embargo, muchas veces es un gran desafío clínico. Se presenta el caso de una paciente joven sin antecedentes que consulta por tos de 3 meses de evolución. En TC de tórax se evidencia masa mediastinal izquierda que desplaza tráquea y nódulos pulmonares bilaterales cavitados. Luego de descartarse etiologías más probables por frecuencia para su edad y forma de manifestación clínica, se arriba al diagnóstico de Linfoma de Hodgkin clásico Esclero Nodular con compromiso extranodal. Enfermedad poco frecuente y en nuestro caso, modo de presentación atípica.

Lung nodules can vary in nature: solid, ground glass, granulomatous or non-granulo matous, cavitary or non-cavitary. They are a common finding in chest imaging when the patient comes to the consultation. According to their characteristics and the patient's history (medical history, physical examination, and laboratory results), they guide us towards different etiologies: infectious, autoimmune, or oncological. However, many times it is a great clinical challenge. We present the case of a young patient with no previous medical history who came to the consultation with a cough of 3 months of evolution. The chest CT showed left mediastinal mass displacing the trachea and bilateral cavitary lung nodules. After ruling out more probable etiologies based on frequency for the patient's age and clinical manifestation, the diagnosis was: classic nodular sclerosing Hodgkin lymphoma with extranodal in volvement. A very rare disease, and in our case, with an atypical form of presentation.

Argentine consensus recommendations for lung cancer screening programmes: a RAND/UCLA-modified Delphi study.

BACKGROUND: Lung cancer (LC) screening improves LC survival; the best screening method in terms of improving survival is low-dose CT (LDCT), outpacing chest X-ray and sputum cytology. METHODS: A consensus of experts in Argentina was carried out to review the literature and generate recommendations for LC screening programmes. A mixed-method study was used with three phases: (1) review of the literature; (2) modified Delphi consensus panel; and (3) development of the recommendations. The Evidence to Decision (EtD) framework was used to generate 13 evaluation criteria. Nineteen experts participated in four voting rounds. Consensus among participants was defined using the RAND/UCLA method. RESULTS: A total of 16 recommendations scored ≥7 points with no disagreement on any criteria. Screening for LC should be performed with LDCT annually in the population at high-risk, aged between 55 and 74 years, regardless of sex, without comorbidities with a risk of death higher than the risk of death from LC, smoking ≥30 pack-years or former smokers who quit smoking within 15 years. Screening will be considered positive when finding a solid nodule ≥6 mm in diameter (or ≥113 mm3) on baseline LDCT and 4 mm in diameter if a new nodule is identified on annual screening. A smoking cessation programme should be offered, and cardiovascular risk assessment should be performed. Institutions should have a multidisciplinary committee, have protocols for the management of symptomatic patients not included in the programme and distribute educational material. CONCLUSION: The recommendations provide a basis for minimum requirements from which local institutions can develop their own protocols adapted to their needs and resources.

Progressive pulmonary fibrosis: an expert group consensus statement.

This expert group consensus statement emphasises the need for standardising the definition of progressive fibrosing interstitial lung diseases (F-ILDs), with an accurate initial diagnosis being of paramount importance in ensuring appropriate initial management. Equally, case-by-case decisions on monitoring and management are essential, given the varying presentations of F-ILDs and the varying rates of progression. The value of diagnostic tests in risk stratification at presentation and, separately, the importance of a logical monitoring strategy, tailored to manage the risk of progression, are also stressed. The term "progressive pulmonary fibrosis" (PPF) exactly describes the entity that clinicians often face in practice. The importance of using antifibrotic therapy early in PPF (once initial management has failed to prevent progression) is increasingly supported by evidence. Artificial intelligence software for high-resolution computed tomography analysis, although an exciting tool for the future, awaits validation. Guidance is provided on pulmonary rehabilitation, oxygen and the use of non-invasive ventilation focused specifically on the needs of ILD patients with progressive disease. PPF should be differentiated from acute deterioration due to drug-induced lung toxicity or other forms of acute exacerbations. Referral criteria for a lung transplant are discussed and applied to patient needs in severe diseases where transplantation is not realistic, either due to access limitations or transplantation contraindications. In conclusion, expert group consensus guidance is provided on the diagnosis, treatment and monitoring of F-ILDs with specific focus on the recognition of PPF and the management of pulmonary fibrosis progressing despite initial management.

Integrating Clinical Probability into the Diagnostic Approach to Idiopathic Pulmonary Fibrosis: An International Working Group Perspective.

Background: When considering the diagnosis of idiopathic pulmonary fibrosis (IPF), experienced clinicians integrate clinical features that help to differentiate IPF from other fibrosing interstitial lung diseases, thus generating a "pre-test" probability of IPF. The aim of this international working group perspective was to summarize these features using a tabulated approach similar to chest HRCT and histopathologic patterns reported in the international guidelines for the diagnosis of IPF, and to help formally incorporate these clinical likelihoods into diagnostic reasoning to facilitate the diagnosis of IPF. Methods: The committee group identified factors that influence the clinical likelihood of a diagnosis of IPF, which was categorized as a pre-test clinical probability of IPF into "high" (70-100%), "intermediate" (30-70%), or "low" (0-30%). After integration of radiological and histopathological features, the post-test probability of diagnosis was categorized into "definite" (90-100%), "high confidence" (70-89%), "low confidence" (51-69%), or "low" (0-50%) probability of IPF. Findings: A conceptual Bayesian framework was created, integrating the clinical likelihood of IPF ("pre-test probability of IPF") with the HRCT pattern, the histopathology pattern when available, and/or the pattern of observed disease behavior, into a "post-test probability of IPF." The diagnostic probability of IPF was expressed using an adapted diagnostic ontology for fibrotic interstitial lung diseases. Interpretation: The present approach will help incorporate the clinical judgment into the diagnosis of IPF, thus facilitating the application of IPF diagnostic guidelines and, ultimately improving diagnostic confidence and reducing the need for invasive diagnostic techniques.

Utility of PET-CT in non-small cell lung cancer clinical stage IB-IIA according to AJCC 8th edition staging system: an alternative to invasive mediastinal staging?

OBJECTIVE: Mediastinal nodal staging in lung cancer is essential to determine treatment strategy and prognosis. There are controversies as to whether a mediastinal negative result in PET-CT may spare the invasive staging of the mediastinum. The main endpoint is to evaluate the negative predictive value (NPV) of PET-CT in non-small cell lung cancer (NSCLC) clinical stage IB-IIA without clinical nodal involvement. The secondary endpoint is to evaluate the prevalence of mediastinal and hilar nodal affection in this population. METHODS: We performed an observational descriptive study from January 2010 to January 2020, including 76 patients with clinical stage IB-IIA, who underwent pulmonary resection with systematic nodal sampling (pre-determined lymph node stations based on tumour location) for primary NSCLC. Clinically, nodal involvement was defined as any lymph node greater than 1 cm in the short axis on a CT or with metabolic uptake greater than 2.5 SUV on PET-CT. The prevalence of nodal metastases was recorded. RESULTS: Fifty six patients had clinical stage IB and 20 had clinical stage IIA. Mean tumour size was 3.74 ± 0.5 cm. Lobectomy was the resection procedure most frequently performed. Of the 76 patients with clinical N0 by PET-CT who underwent surgical resection, 10 (13.1%) were upstaged to pN1 and none were upstaged to pN2. NPV of PET-CT for overall nodal metastasis was 87% (95% CI: 0.79-0.94). NPV of PET-CT for N2 metastasis was 100%. CONCLUSION: PET-CT might be an alternative to invasive mediastinal staging in patients with NSCLC clinical stage IB-IIA who are surgical candidates. Further prospective multi-institutional studies are necessary to verify the external validity of our study.

Síndrome antisintetasa en paciente con COP como afección pulmonar / Antisynthetase Syndrome in Patient with COP as Pulmonary Disease

El síndrome antisintetasa es una miopatía inflamatoria autoinmune que puede presentar afectación pulmonar intersticial. La presencia de anticuerpos antisintetasa se relaciona con una mayor incidencia de enfermedad pulmonar intersticial. El patrón imagenológico y anatomopatológico de la EPID es variable, fundamentalmente inflamatorio. En el caso presentado se describe una paciente con miopatía inflamatoria y compromiso pulmonar presentando un patrón tomográfico de neumonía organizativa. Se destaca la importancia de elevar el índice de sospecha de síndrome antisintetasa ante un paciente con compromiso pulmonar y miopatía, siendo fundamental para arribar a un diagnóstico la evaluación multidisciplinaria. Se realiza una revisión de la evidencia al respecto en la discusión del caso

The antisynthetase syndrome is an autoimmune inflammatory miopathy that may show interstitial pulmonary involvement. The presence of antisynthetase antibodies is related to a higher incidence of interstitial pulmonary involvement. The imaging and anatomopathological pattern of diffuse interstitial pulmonary disease (DIPD) is variable, mainly inflammatory. This case describes a female patient with inflammatory miopathy and pulmonary involvement who shows a tomographic pattern of organizing pneumonia. It is important to increase suspicion for antisynthetase syndrome in a patient with pulmonary involvement and miopathy, where multidisciplinary evaluation is fundamental to reach a diagnosis. A review of the evidence is made in the discussion of the case.

Experiencia inicial en la atención de pacientes con Covid-19 en un hospital privado de alta complejidad de la Ciudad de Buenos Aires / Initial experience in the attention of patients with COVID-19 in a private third-level hospital in Buenos Aires city

Resumen La infección por COVID-19 tiene presentaciones variadas, siendo aún escasos los datos de evolución de pacientes afectados en Argentina. Este es un estudio retrospectivo, observacional de pacientes con confirmación virológica de coronavirus atendidos entre marzo y mayo 2020 en un hospital privado universitario de tercer nivel de Buenos Aires. Se incluyeron 155 pacientes adultos de los cuales 47 (30.3%) concurrieron solo para realizarse un hisopado; 92 (59.4%) fueron internados en el hospital y 16 (10.3%) tuvieron internación domiciliaria con seguimiento telefónico diario. El 54.2% fueron mujeres con mediana de edad de 35 años (rango intercuartil [RIC] 29 a 50). El 59.4% (92) tenían algún factor de riesgo, incluyendo edad igual o mayor a 65 años, enfermedad crónica predisponente, eran personal de salud o trabajaban/residían en geriátrico. En los 108 que tuvieron seguimiento, el síntoma más frecuente fue fiebre (75.9%), seguido de tos (65.7%), y odinofagia (48.2%). La odinofagia fue más frecuente en mujeres (p = 0.035) y la disnea en hombres (p = 0.014). El 93.5% de los participantes (101) experimentaron síntomas, mientras que 17.6% (19) presentó algún síntoma, pero encontrándose afebriles. En 5 participantes a los que se les realizó una tomografía se observó que la radiografía había sido normal o no diagnóstica. Catorce pacientes requirieron terapia intensiva y 6 de ellos necesitaron ventilación mecánica, falleciendo cuatro. Los 2 pacientes restantes fueron derivados a centros de cuidados crónicos. Ningún paciente con internación domiciliaria requirió ser hospitalizado ni falleció. Si bien esta observación resulta alentadora, deberá ser confirmado en nuevos estudios.

Abstract Infection with the SARS coronavirus type 2 (COVID-19) has a variety of presentations, with little data on the evolution of affected patients in Argentina. This is a retrospective and observational study of patients with virological confirmation of coronavirus treated during the months of March to May in a private third-level university hospital in Buenos Aires. One hundred and fifty-five adult patients were included, of which 30.3% attended only for a swab; 59.4% were admitted to the hospital and 10.3% were hospitalized at home with daily telephone follow-up. Fifty-four point two percent of participants were women and the median age was 35 years (ICQ 29 to 50). About 59.3% of patients had some risk factor, including age (65 years old or more), underlying chronic disease, were health workers or personnel/residents in a nursing home. The most frequent symptom was fever (75.9%), followed by cough (65.7%), and odynophagia (48.2%). Globally, 93.5% experienced some symptoms while 17.6% of the participants presented some symptoms but without fever. Chest tomographies were performed to 5 patients. Their chest radiograph was normal or non-diagnostic. Fourteen patients required intensive therapy and 6 of them required mechanical ventilation, 4 of them died. The remaining 2 patients were referred to chronic care centers. No patient with home hospitalization required admission to hospital or died. While this observation is encouraging, it will need to be confirmed with new studies.

An International Survey of Mediastinal Staging Practices amongst Interventional Bronchoscopists.

INTRODUCTION: In potentially curable non-small-cell lung cancer, different practice guidelines recommend invasive me-diastinal staging in tumors larger than 3 cm, central, or hy-permetabolic N1 lymph nodes. There is no consensus concerning the use of an endosonographic procedure or a mediastinoscopy in the first line in patients with a radiologically normal mediastinum, while in case of a mediastinal involvement, the latest European guidelines recommend the combination of endobronchial ultrasound (EBUS) and endoscopic ultrasound/endoscopic ultrasound with EBUS endoscope (EUS/EUS-B), using a systematic endosonographic procedure. This international survey was conducted to describe current medical practices in endoscopic mediastinal staging amongst interventional bronchoscopists. METHODS: A survey was developed and sent to all members of different interventional pulmonology societies, with the purpose to describe who, when and how an endoscopic mediastinal staging was performed. RESULTS: One hundred and fifty-three bronchoscopists responded to the survey. Most of them practiced in Europe (n = 84, 55%) and North America (n = 52, 34%). In the first line, EBUS alone was the most widely used endoscopic procedure for mediastinal staging. Half of the responders performed a systematic endoscopic staging procedure, including a systematic examination of all accessible nodal stations and a sampling of all lymph nodes >5 mm in the short axis at each station. A higher proportion of bronchoscopists who have completed a dedicated fellowship program performed systematic endoscopic mediastinal staging. Few endoscopists routinely perform combined EBUS/EUS(-B) for mediastinal staging and use the combination only in selected cases. CONCLUSION: There are several areas of divergence between published guidelines and current practices reported by interventional bronchoscopists. EBUS alone is the most widely used endoscopic procedure for mediastinal staging in lung cancer, and a combined endoscopic approach is frequently omitted by the responders. A fellowship program appears to be associated with a higher rate of systematic endoscopic staging procedures.

Acute exacerbation of idiopathic pulmonary fibrosis: international survey and call for harmonisation.

Acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) is an often deadly complication of IPF. No focussed international guidelines for the management of AE-IPF exist. The aim of this international survey was to assess the global variability in prevention, diagnostic and treatment strategies for AE-IPF.Pulmonologists with ILD expertise were invited to participate in a survey designed by an international expert panel.509 pulmonologists from 66 countries responded. Significant geographical variability in approaches to manage AE-IPF was found. Common preventive measures included antifibrotic drugs and vaccination. Diagnostic differences were most pronounced regarding use of Krebs von den Lungen-6 and viral testing, while high-resolution computed tomography, brain natriuretic peptide and D-dimer are generally applied. High-dose steroids are widely administered (94%); the use of other immunosuppressant and treatment strategies is highly variable. Very few (4%) responders never use immunosuppression. Antifibrotic treatments are initiated during AE-IPF by 67%. Invasive ventilation or extracorporeal membrane oxygenation are mainly used as a bridge to transplantation. Most physicians educate patients comprehensively on the severity of AE-IPF (82%) and consider palliative care (64%).Approaches to the prevention, diagnosis and treatment of AE-IPF vary worldwide. Global trials and guidelines to improve the prognosis of AE-IPF are needed.

Two-year disease remission of an unresectable basaloid thymic carcinoma with second line chemotherapy drugs: report of a case.

Thymic carcinomas are extremely infrequent neoplasms (15% of all thymic epithelial tumors). Basaloid carcinoma is a peculiar tumor that represents no more than 2% of those infrequent thymic carcinomas. Surgical excision is the recommended treatment. As it's extremely rare, there is no evidence of the impact of different modalities of treatment. There are no reported cases that did not include surgery as part of their management. We herein present a case of an unresectable thymic basaloid carcinoma treated only with concurrent chemotherapy and radiotherapy that obtained a complete remission and free of disease after 2 years.

Patrón tomográfico de neumonía intersticial usual en paciente con exposición laboral / Tomographic pattern of usual interstitial pneumonia in a patient with occupational exposure

La neumonitis por hipersensibilidad (NH) puede ser causada por múltiples agentes presentes en el lugar de trabajo y en el hogar, como microbios, proteínas animales o vegetales y químicos orgánicos o inorgánicos. El diagnóstico basa en la evaluación de una serie de características clínicas incluyendo antecedentes de exposición significativa a un potencial antígeno, examen físico, tomografía computada de tórax, linfocitosis en el lavado bronquioalveolar, y, en casos seleccionados, histología. La NH puede ser aguda o crónica. Esta última puede ser fibrosante o no. La NH fibrosante tiene una amplia lista de diagnósticos diferenciales y tiene peor pronóstico. Describimos el caso de un varón, tabaquista, trabajador en una fábrica de quesos, con diagnóstico de NH "muy probable", y mala evolución.

Hallazgo incidental de cuerpo extraño en vía aérea / Incidental finding of foreign body in airway

Paciente de 71 años ingresa por traumatismo de tórax secundario a una caída de propia altura. Antecedentes personales: Ex fumador. Tiene diagnóstico de EPOC, GOLD grado 3, en tratamiento con fluticasona 1000 mcg/día y salmeterol 100 mcg/dia, no adherente a glicopirronio. Cirrosis hepática por alcohol con várices esofágicas y requerimiento de banding

Vacunación en pacientes con enfermedades reumatológicas / Vaccination in patients with rheumatological diseases

Los pacientes con enfermedades reumáticas autoinmunes tienen el doble de riesgo de presentar una infección respecto de cualquier persona de la misma edad y género. Tanto es así que la expectativa de vida es más corta en personas con artritis reumatoidea en comparación con la población general y, la mayor cantidad de muertes se debe, en parte, a causas infecciosas, muchas de las cuales son de origen respiratorio. Entre las vacunas que los pacientes con artritis reumatoidea deben recibir se mencionan: la anti Haemophilus influenzae (intramuscular), trivalente que brinda protección contra las dos cepas de H. influenzae A y una de H. influenzae B. También de inmunizarse a estos pacientes contra el neumococo; actualmente existen dos tipos: la conjugada 13-valente y la polisacárida 23-valente. Estos pacientes también deben protegerse contra el virus del papiloma humano, una bivalente y otra valente; y contra el virus de la hepatitis B para uso en adultos, ya sea la de antígeno simple o en combinación con la anti-hepatitis A. Creemos que esta revisión actualizada de inmunización en pacientes con patología reumática es necesaria y resultará de mucha utilidad en nuestra práctica diaria.

Patients with autoimmune rheumatic diseases have twice the risk of having an infection with respect to any person of the same age and gender. So much so that life expectancy is shorter in people with rheumatoid arthritis than controls and the greater number of deaths are due, in part to infectious causes, many of which are of respiratory origin. Among the vaccines that patients with rheumatoid arthritis should receive are: the intramuscular influenza vaccine, this traditional vaccine is trivalent and provides protection against two strains of influenza A and one of influenza B, the pneumococcal vaccine, which currently exists two: 13-valent conjugate vaccine and 23-valent polysaccharide vaccine, human papillomavirus vaccines: a bivalent and a univalent and the hepatitis B virus vaccine for use in adults either as a single antigen vaccine or in combination with the hepatitis A virus. We believe that this updated immunization review in patients with rheumatic disease is necessary and will be very useful in our daily practice.

Neumonía por varicela / Varicella pneumonia

La varicela es una infección exantemática producida por el virus varicela zoster. La enfermedad se adquiere por inhalación de partículas que contienen el virus expulsadas de la nasofaringe de individuos infectados, ello resulta en una infección inicial del epitelio respiratorio. Afecciones como el cáncer, corticoides, edad avanzada, tabaquismo o la infección por virus inmunodeficiencia adquirida deterioran la inmunidad celular constituyéndose en factores de riesgo para desarrollar neumonía, aunque la varicela también puede afectar a personas con inmunidad normal. El compromiso pulmonar varía entre formas poco sintomáticas e insuficiencia respiratoria, la hipoxemia grave temprana es el principal factor de mal pronóstico1. De las complicaciones asociadas a la varicela, encefalitis, meningitis, síndrome de Guillain Barré, pericarditis y pancreatitis, la neumonía es la más grave y frecuente y aparece casi exclusivamente en adultos

Management and attitudes about IPF (Idiopathic Pulmonary Fibrosis) among physicians from Latin America.

BACKGROUND: The aim of our study was to assess current practice patterns and attitudes towards diagnosis and management of idiopathic pulmonary fibrosis (IPF) patients in Latin America. METHODS: A Cross-sectional survey was developed and up to 455 physicians were enrolled. We used a rigorous method of validation using the translated version of the AIR Survey. RESULTS: Mean age was 47.5 years (SD 12.6) with 20.4 years (SD 12.3) of practice. In around 30% of physicians were reported access to radiologist, pathologist and multidisciplinary team. Despite almost all physicians reported that (ATS/ERS/JRS/ALAT) guidelines are useful, half of them prescribed corticoids for treatment of disease. Most respondents (69.9%) reported cough as the presenting symptom. Around 80% considered IPF to be an important clinical disorder, and felt that identifying patients at risk for IPF was important or extremely important. However, only 59.7% felt confident in managing patients with IPF, and similar numbers (60.8%) felt confident about their knowledge. Pulmonologist have more confidence and management of IPF that no pulmonologist. CONCLUSION: The results of this survey of Latin American physicians could help to fill gaps regarding awareness, management and treatment of IPF and improve earlier diagnosis of IPF.

Entirely thoracoscopic resection of a giant emphysematous bulla.

A 38-year-old man with longilinear shape, smoker (38 packs/year) and no other relevant medical history was referred to our department due to the finding of left pulmonary hyperlucency on a chest x-ray. A computed tomography (CT) was performed and a giant emphysematous bulla with thin-walled partitions inside was shown that replaced almost the entire left upper lobe, The patient underwent an exploratory thoracoscopy. Intraoperatively a giant bulla was seen that initially impressed to replace the entire upper lobe. Despite the large size we decided to attempt thoracoscopic resection preserving the remaining healthy parenchyma. Bullectomy was done using linear endoscopic stapling devices. To our knowledge this is the only case with such a large bulla resected entirely by VATS.

Final del Juego / game over

En su célebre cuento (Final del Juego, 1956), Cortázar nos cuenta la historia de tres chiquilinas en tránsito hacia la adolescencia (Holanda, Leticia y la voz narradora del relato que permanece anónima) que todos los días, a la misma hora después de comer, se escapan a las vías del tren del Central Argentino a jugar. Ellas mismas han ideado un juego al que llaman "estatuas y actitudes", en el que eligen quién representa qué papel cada día. En el juego de estatua, las niñas se visten de "adornos", que son piezas de ropa y accesorios para recrear personajes o inventar temas para la estatua. Delante del patio de la casa donde las chicas viven y juegan, pasan trenes todos los días y con mucha gente. Pero las niñas no se intimidan con las posibles miradas de los pasajeros, piensan que nadie se da cuenta de ellas y al mismo tiempo, parte de la gracia del montaje, es justamente esa audiencia trashumante y fugaz: "Por supuesto que las actitudes y las estatuas no eran para nosotras mismas, porque nos hubiéramos cansado en seguida. El juego marcaba que la elegida debía colocarse al pie del talud, saliendo de la sombra de los sauces, y esperar el tren de las dos y ocho que venía del Tigre. A esa altura de Palermo los trenes pasan bastante rápido, y no nos daba vergüenza hacer la estatua o la actitud. Casi no veíamos a la gente de las ventanillas, pero con el tiempo llegamos a tener práctica y sabíamos que algunos pasajeros esperaban vernos"

Immune diffuse alveolar hemorrhage: Clinical presentation and outcome.

BACKGROUND: Diffuse alveolar haemorrhage (DAH) is a manifestation of several immune and nonimmune diseases. OBJECTIVE: The objective of this study was to characterize the clinical characteristics and short-term outcomes of patients with immune-mediated DAH requiring hospital admission. METHODS: A retrospective study from December 2010 to December 2015, was conducted by analyzing the clinical records of 39 patients with DAH with a proven immunological origin. The diagnosis of individual collagen vascular diseases (CVD) was made according to the criteria of the corresponding societies. RESULTS: Thirty-nine patients were included (median age 44.8 years, range 16-76). The main causes of DAH were ANCA-related vasculitis (74.3%) mainly granulomatosis with polyangiitis (n = 14) and microscopic polyangiitis (n = 13). Thirty patients (76.9%) had hemoptysis. An alveolar airspace filling pattern was found in most of patients (59%). All the patients had a drop in hemoglobin level that ranged from 1.0 to 3.0 g/dL. BAL fluid was macroscopically bloody in 43.6% of patients (n = 17) and showed siderophagic alveolitis on BAL cytology in 100%. All patients received high doses of corticosteroids. Other additional treatments were antibiotics (53,8%, n = 21), intravenous cyclophosphamide (87.2%, n = 34), plasma exchange (35.9%, n = 14); intravenous immunoglobulin (12.8%, n = 5) and rituximab in 5 patients (12.8%). Mortality rate was higher amongst patients who required dialysis (50.0 vs 15.4%, p = 0.045), with SaO2 <90% at admission (50.0 vs 5.3%, p = 0.003) or those who required mechanical ventilation (76.9 vs 6.8%, p = < 0.001). CONCLUSION: DAH may present without hemoptysis and requires an early bronchoscopy to confirm the diagnosis and exclude infection. Other characteristics could be included in the abstract which are relevant to the paper. (relation between mortality, dialysis, ventilation, etc.).