Research productivity during residency training in Spain: Comparison among medical specialties lasting 5 years.

OBJECTIVES: To compare the quantity and quality of publications during the residency training period in Cardiology, Intensive Care Medicine, Internal Medicine and Medical Oncology in Spain. METHODS: A retrospective cohort study of residents from 4 specialties lasting 5 years (2014-2019). The number and type of publications indexed in PubMed®, the names of the journals and their bibliometric indexes (impact factor and quartiles), and author's positions were evaluated. RESULTS: The 649 residents included in the study generated 801 publications (publication/resident ratio 1.23). Cardiology residents published significantly more (ratio 2.57) and Intensive Care Medicine residents less (ratio 0.42) than the remaining specialties (Internal Medicine, ratio 1.06; Medical Oncology, ratio 0.76; p < .001). Overall, only 44.5% of residents participated in a publication, with 27.6% participating in an original article; this latter percentage increased significantly among cardiologists (47.7%; p < .001). The predominant types of publications were original articles (47.9%) and clinical reports (36.8%). The proportion of publications in first quartile journals was higher for Cardiology residents (44.6% of total). The resident was the first or last author in only one-third of the publications. Scientific productivity was related to specialty, but not to gender or the size of the hospital in which the residency training occurred. CONCLUSIONS: Intensive Care Medicine, Internal Medicine and Medical Oncology residents publish insufficiently, while the scientific production from Cardiology residents could be considered acceptable.

FluoroType® MTB in pleural fluid for diagnosing tuberculosis.

OBJECTIVES: This work aims to investigate the diagnostic accuracy of a nucleic acid amplification test (FluoroType MTB®) in pleural fluid (PF) and sputum to diagnose tuberculous pleural effusion (TPE). We also analyzed the increase in diagnostic accuracy of a second FluoroType MTB® test on a second thoracentesis sample when the first was negative. METHODS: We conducted a prospective single-center study that included 207 patients with pleural effusion (31 tuberculous and 176 due to other causes). Of the 31 cases of TPE, 21 (68%) were confirmed histologically or microbiologically; the other cases were considered probable. RESULTS: The operational characteristics of FluoroType MTB® in PF for identifying tuberculosis were a sensitivity of 13%, a specificity of 99%, a positive likelihood ratio of 11, and a negative likelihood ratio of 0.9. The diagnostic efficacy data for sputum samples were 21%, 91%, 2.4, and 0.9, respectively. PF and sputum cultures in solid and liquid media had greater sensitivity (36% and 31%, respectively). A second FluoroType MTB® test in PF was negative for 24 patients who had TPE and for whom the first FluoroType MTB® test was also negative. Only two (6.5%) patients with TPE had a confirmed diagnosis based exclusively on the positive results of the FluoroType MTB® in PF. CONCLUSION: Due to its low sensitivity, the FluoroType MTB® test in PF has a limited role in diagnosing tuberculous pleurisy.

FluoroType® MTB in pleural fluid for diagnosing tuberculosis. / FluoroType® MTB en líquido pleural para el diagnóstico de tuberculosis.

OBJECTIVES: To assess the cost-effectiveness of a nucleic acid amplification test (FluoroType MTB®) in pleural fluid (PF) and sputum to diagnose tuberculous pleural effusion (TPE). We also analysed the increase in diagnostic yield of a second FluoroType MTB® test, obtained through a new thoracentesis, when the first had resulted negative. METHODS: We conducted a prospective single-centre study that included 207 patients with pleural effusion (31 tuberculous and 176 from other causes). Of the 31 cases of TPE, 21 (68%) were confirmed histologically or microbiologically; the other cases were considered probable. RESULTS: The operational characteristics of FluoroType MTB® in PF for identifying tuberculosis were a sensitivity of 13%, a specificity of 99%, a positive likelihood ratio of 11 and a negative likelihood ratio of 0.9. The diagnostic efficacy data for sputum samples was 21%, 91%, 2.4 and 0.9, respectively. The PF and sputum cultures in solid and liquid media had greater sensitivity (36% and 31%, respectively). A second FluoroType MTB® test in PF was negative for 24 patients with TPE, and a first FluoroType MTB® test also negative. Only 2 (6.5%) patients with TPE had a confirmed diagnosis based exclusively on the positive results of the FluoroType MTB® in PF. CONCLUSION: Due to its low sensitivity, the FluoroType MTB® test in PF has a limited role in diagnosing tuberculous pleurisy.

Examination of cytological smears and cell blocks of pleural fluid: Complementary diagnostic value for malignant effusions.

OBJECTIVES: To evaluate the independent usefulness of pleural fluid smear and cell block (CB) preparations for the diagnosis of malignant effusions. PATIENTS AND METHODS: A total of 632 cytological smears and 554 CBs from 414 consecutive patients with malignant effusions were retrospectively evaluated. RESULTS: The diagnostic yield of a first specimen was 44% regardless of whether a smear or CB cytologic examination was performed. The use of subsequent separated specimens increased the identification of malignancy to 56%. Overall, 11% of samples found to be negative by cytologic smears showed malignant cells on CBs, whereas 15% of negative CBs were reported as positive on smear slides. Pleural fluid specimens with low red and/or white blood cell counts more frequently resulted in the generation of suboptimal CB preparations. CONCLUSIONS: If CBs and smears are prepared and examined, the percentage of positive diagnoses will be greater than if only one method is used.

A survey to medical residents on the performance of diagnostic and therapeutic thoracenteses: a training gap? / Una encuesta a médicos residentes sobre la realización de toracocentesis diagnósticas y terapéuticas: ¿una laguna en la formación?

OBJECTIVE: Pleural fluid aspiration is a routine procedure for pulmonologists and internists. Our aim was to evaluate technical and methodological aspects of diagnostic and therapeutic thoracenteses performed by last two-year residents of Pulmonology and Internal Medicine. METHODS: An online 24-item questionnaire was sent to participants, and responses were evaluated according to the medical specialty. RESULTS: The survey was completed by 139 (17.1%) residents (71 internists and 68 pulmonologists). 29.5% and 41% performed one or no diagnostic or therapeutic thoracenteses monthly, respectively. Only 44% used ultrasonography to guide pleural procedures. Less than half of respondents used local anesthesia for diagnostic aspirations. Contrary to current recommendations, 25% of residents employed intramuscular needles for therapeutic aspirations. More than 80% of residents routinely ordered pleural fluid cultures and cytological studies, regardless of the clinical suspicion. About 40% requested imaging studies after a diagnostic thoracentesis. Half or more of the respondents were unaware of pH measurement methodologies, culture type for mycobacteria, and performance of cell blocks. Pulmonologists were more experienced than internists, and also made use of ultrasonography more frequently. CONCLUSION: This survey highlights gaps of knowledge and skills in conducting diagnostic and therapeutic thoracenteses.

Factors influencing pleural drainage in parapneumonic effusions.

OBJECTIVE: The identification of parapneumonic effusions (PPE) requiring pleural drainage is challenging. We aimed to determine the diagnostic accuracy of radiological and pleural fluid findings in discriminating between PPE that need drainage (complicated PPE (CPPE)) and those that could be resolved with antibiotics only (uncomplicated PPE (UPPE)). SUBJECTS AND METHODS: A retrospective review of 641 consecutive PPE, of which 393 were categorized as CPPE and 248 as UPPE. Demographics, radiological (size and laterality on a chest radiograph) and pleural fluid parameters (pus, bacterial cultures, biochemistries) were compared among groups. Logistic regression was performed to determine variables useful for predicting chest drainage, and receiver-operating characteristic curves assisted in the selection of the best cutoff values. RESULTS: According to the likelihood ratios (LR), findings increasing the probability of chest tube usage the most were: effusions occupying ≥1/2 of the hemithorax (LR 13.5), pleural fluid pH ≤7.15 (LR 6.2), pleural fluid glucose ≤40mg/dL (LR 5.6), pus (LR 4.8), positive pleural fluid cultures (LR 3.6), and pleural fluid lactate dehydrogenase >2000U/L (LR 3.4). In the logistic regression analysis only the first two were selected as significant predictors of CPPE. In non-purulent effusions, the effusion's size and pleural fluid pH retained their discriminatory properties, in addition to a pleural fluid C-reactive protein (CRP) level >100mg/L. CONCLUSION: Large radiological effusions and a pleural fluid pH ≤7.15 were the best predictors for chest drainage in patients with PPE. In the subgroup of patients with non-purulent effusions, pleural fluid CRP also contributed to CPPE identification.

Influence of storage time on pleural fluid adenosine deaminase activity.

BACKGROUND: Storing pleural fluid samples for research purposes is a common practice, but whether adenosine deaminase (ADA), an enzyme used for the diagnosis of tuberculous pleuritis, is stable over long periods of time is unknown. METHODS: We evaluated the stability of pleural ADA concentrations in 223 samples frozen at -800C as compared to values obtained immediately following the initial thoracentesis. Sample storage time ranged from several months to slightly more than 10 years. RESULTS: ADA activity was stable for up to 2.6 years. Afterwards, it decreased 6 to 8 U/L, enough to drop 2 (3.3%) tuberculous patients below the diagnostic ADA cutoff. CONCLUSIONS: As far as ADA enzymatic activity is concerned, pleural fluid samples are viable for extended periods of time. However, some caution in interpreting results from specimens stored for > 2.6 years is prudent.

Diagnostic yield of fine-needle aspiration puncture for cytology of multifocal liver lesions: a comparison between image-guided and blind aspirations.

BACKGROUND: In patients with palpable hepatomegaly and space occupying lesions demonstrated by imaging techniques, blind fine needle aspiration puncture (FNAP) at the patient's bedside is feasible. OBJECTIVE: To compare the diagnostic yield of the fine needle aspiration puncture (FNAP) performed blindly or under radiological control in patients with hepatomegaly and multiple solid space occupying lesions in the liver, demonstrated by ultrasonography. METHODS: A retrospective study was made of 169 consecutive FNAPs of liver tumors performed either blindly at the bedside by an internist (55 patients) or imaged-guided by a radiologist (114 patients). RESULTS: The diagnostic yield of the technique performed blindly to demonstrate malignancy was 78% (95% confidence interval [CI]: 66-87%) versus 83% (95% CI: 75-89%, P=.42) obtained in the image-guided FNAPs. The diagnostic yield did not vary based on type of tumor invading the liver. CONCLUSION: Blind FNAP procedures in patients with palpable enlarged liver due to solid space occupying lesions is as effective as those performed under radiological control.

Xpert® MTB/RIF in pleural fluid for the diagnosis of tuberculosis.

An automated nucleic acid amplification assay that simultaneously identifies Mycobacterium tuberculosis and rifampicin resistance, the Xpert® MTB/RIF test, has undergone extensive evaluation in sputum samples. Our aim was to define its diagnostic accuracy when performed on pleural fluid specimens. In 67 patients with pleural effusions, of whom half had tuberculous pleuritis, Xpert yielded 15% sensitivity and 100% specificity in the detection of tuberculosis (TB). Positive Xpert results tended to be more common in patients with microbiologically confirmed TB. Due to its low sensitivity, Xpert testing of pleural fluids has a limited role in the work-up of pleural effusions.

Comparison of polymorphonuclear- and lymphocyte-rich tuberculous pleural effusions.

SETTING: Most patients with tuberculous pleural effusions (TPE) have more than 50% lymphocytes in the pleural fluid. Data on patients in whom polymorphonuclear leukocytes (PMNLs) are the predominant cell type are scarce. OBJECTIVE: To compare the clinical, biochemical, microbiological and radiological characteristics between patients with predominantly PMNL and those with lymphocytic TPE. DESIGN: Retrospective analysis of 214 consecutive patients with TPE. RESULTS: The pleural fluid was PMNL-rich in 24 (11%) cases at the time of first thoracocentesis. Compared with those whose pleural fluid was predominantly lymphocytic, these patients showed a higher yield of mycobacteria in culture of sputum (50% vs. 25%, P = 0.03) and pleural fluid (50% vs. 10%, P < 0.01) on solid media, as well as higher pleural adenosine deaminase (ADA) levels (80 vs. 62 U/l, P = 0.02) at the expense of both ADA1 and ADA2 isoenzymes. A shift towards pleural lymphocytic predominance was observed in more than half of the PMNL-predominant patients subjected to repeat thoracocentesis. CONCLUSIONS: The finding of a predominantly PMNL exudate should not rule out TPE, particularly when pleural ADA activity is elevated. The collection of sputum and pleural fluid samples for mycobacterial culture should be encouraged in the case of suspected PMNL-rich TPE, as they are frequently positive in this early stage.

Dietary intervention focused on phosphate intake in hemodialysis patients with hyperphosphoremia.

BACKGROUND: Elevated serum phosphorus has been identified as a cardiovascular risk factor. This study aimed to assess the effectiveness of dietary intervention to reduce phosphorus intake and to improve the calcium-phosphorus metabolism in hemodialysis patients. DESIGN: Patients were included in a 6-month, 2-group experimental study if their previous 3-month average serum phosphorus was over 5.5 mg/dl. Patients were allocated to intensive dietary intervention or usual dietary recommendations. The clinical end-points were the multivariate-adjusted change in serum phosphorus and the number of patients who achieved serum phosphorus levels of < 5.5 mg/dl and serum phosphorus levels of < 5 mg/dl. RESULTS: 80 dialysis patients completed the study, 41 in the experimental group and 39 in the control group. After 6 months, phosphorus intake (702 ± 168 vs. 872 ± 242 mg/24 h; p = 0.002) was lower in the experimental group than in the control group, with no inter-group differences in protein-caloric intake. Serum phosphorus decreased 1.67 mg/dl in the experimental group and 0.58 mg/dl in the control group (multivariate-adjusted difference 0.93 mg/ dl; 95% CI 0.34 - 1.52; p = 0.003). Serum phosphorus < 5.5 mg/dl and serum phosphorus < 5 mg/dl were attained more frequently in the experimental group (51 vs. 18%, p = 0.002 and 31.7 vs. 15.4%, p = 0.08 respectively). CONCLUSIONS: Intensive dietary intervention focusing on phosphorus intake may be useful to reduce phosphorus retention and to improve calcium-phosphorus metabolism in hemodialysis patients.

Objective and subjective measures for assessing anxiety in paediatric dental patients.

AIM: Anxiety has been defined as a nonspecific feeling of apprehension towards a concrete situation that does not necessarily involve a previous experience. Dental anxiety can prevent patients from cooperating fully during dental treatment. Given that there is a connection between dental anxiety and uncooperative behaviour, it is important for dentists to be able to assess anxiety in their patients. There are many methods for such assessment, and in children they depend on age and intellectual development. These measures can be objective or subjective, depending on the method used to quantify the degree of anxiety. The aim of this literature review was to analyse the objective and subjective scales that are used most commonly to assess the degree of anxiety of children in a dental setting. CONCLUSION: Knowing the degree of anxiety of dental children is important in order to guide them through their dental experience. Their level of cooperation will also improve and anxiety will be reduced as well.

Predictive factors, microbiology and outcome of patients with parapneumonic effusion.

We aimed to determine the incidence, clinical consequences and microbiological findings related to the presence of pleural effusion in community-acquired pneumonia, and to identify predictive factors for empyema/complicated parapneumonic effusion. We analysed 4,715 consecutive patients with community-acquired pneumonia from two acute care hospitals. Patients were classified into three groups: no pleural effusion, uncomplicated parapneumonic effusion and empyema/complicated parapneumonic effusion. A total of 882 (19%) patients had radiological evidence of pleural fluid, of whom 261 (30%) met criteria for empyema/complicated parapneumonic effusion. The most important event related to the presence of uncomplicated parapneumonic effusion was a longer hospital stay. Relevant clinical and microbiological consequences were associated with empyema/complicated parapneumonic effusion. Five independent baseline characteristics could predict the development of empyema/complicated parapneumonic effusion: age < 60 yrs (p = 0.012), alcoholism (p = 0.002), pleuritic pain (p = 0.002), tachycardia >100 beats·min⁻¹ (p = 0.006) and leukocytosis >15,000 mm⁻³ (p < 0.001). A higher incidence of anaerobes and Gram-positive cocci was found in this subgroup of patients. We conclude that only the development of empyema/complicated parapneumonic effusion carried relevant consequences; this condition should be suspected in the presence of some baseline characteristics and managed by using antimicrobials active against Gram-positive cocci and anaerobes.