Relationship between type 2 diabetes mellitus and markers of cutaneous melanoma aggressiveness: an observational multicentric study in 443 patients with melanoma.

BACKGROUND: Some studies have suggested a relationship between type 2 diabetes mellitus (T2DM) and increased incidence of melanoma. Efforts are under way to identify preventable and treatable factors associated with greater melanoma aggressiveness, but no studies to date have examined the relationship between T2DM and the aggressiveness of cutaneous melanoma at diagnosis. OBJECTIVES: To explore potential associations between T2DM, glycaemic control and metformin treatment and the aggressiveness of cutaneous melanoma. METHODS: We conducted a cross-sectional multicentric study in 443 patients diagnosed with cutaneous melanoma. At diagnosis, all patients completed a standardized protocol, and a fasting blood sample was extracted to analyse their glucose levels, glycated haemoglobin concentration and markers of systemic inflammation. Melanoma characteristics and aggressiveness factors [Breslow thickness, ulceration, tumour mitotic rate (TMR), sentinel lymph node (SLN) involvement and tumour stage] were also recorded. RESULTS: The mean (SD) age of the patients was 55·98 (15·3) years and 50·6% were male. The median Breslow thickness was 0·85 mm. In total, 48 (10·8%) patients were diagnosed with T2DM and this finding was associated with a Breslow thickness > 2 mm [odds ratio (OR) 2·6, 95% confidence interval (CI) 1·4-4·9; P = 0·004)] and > 4 mm (OR 3·6, 95% CI 1·7-7·9; P = 0·001), TMR > 5 per mm2 (OR 4·5, 95% CI 1·4-13·7; P = 0·009), SLN involvement (OR 2·3, 95% CI 1-5·7; P = 0·038) and tumour stages III-IV (vs. I-II) (OR 3·4, 95% CI 1·6-7·4; P = 0·002), after adjusting for age, sex, obesity, alcohol intake and smoking habits. No significant associations emerged between glycated haemoglobin levels, metformin treatment and melanoma aggressiveness. CONCLUSIONS: T2DM, rather than glycaemic control and metformin treatment, is associated with increased cutaneous melanoma aggressiveness at diagnosis.

Spanish multidisciplinary consensus on the characteristics of severe asthma patients on biologic treatment who are candidates for at-home administration.

BACKGROUND AND OBJECTIVE: Biologic therapies are known to reduce exacerbations and improve severe uncontrolled asthma management. The at-home administration of biologics has increased during the COVID-19 pandemic, but the characteristics of severe uncontrolled asthma patients who may benefit from at-home administration of biologic therapy have yet to be identified. MATERIALS AND METHODS: This project is based on the Delphi method, designed to reach an expert consensus through a multidisciplinary scientific committee addressing the following questions: clinical characteristics, treatment adherence, patient or caregiver administration ability, patient self-care, relationship with the healthcare professional, patient preference, and access to the hospital. RESULTS: One hundred and thirty-one healthcare professionals (pulmonologists, allergists, nurses, and hospital pharmacists) completed two Delphi consensus questionnaires. Fourteen items were identified as priority characteristics, the first five being: 1. The patient follows the healthcare team's indications/recommendations to control their disease, 2. The patient is capable of detecting any deterioration in their disease and of identifying exacerbation triggers, 3. The patient receives biologic therapy and has stable disease with no vital risk, 4. The patient takes responsibility for their self-care, 5. The patient has occupational/educational obligations that prevent them from going to the hospital regularly. CONCLUSION: Disease stability and control plus the ability to identify exacerbation triggers are the most important characteristics when opting for at-home administration for a patient with severe uncontrolled asthma on biologic therapy. These recommendations could be applicable in clinical practice.

Effect of an ambulatory diagnostic and treatment programme in patients with sleep apnoea.

The aim of this study to evaluate the efficacy of a home-based programme on clinical response, continuous positive airway pressure (CPAP) compliance and cost in a population of high pre-test probability of suffering obstructive sleep apnoea syndrome (OSAS). Patients were randomised into the following three groups. Group A: home respiratory polygraphy (RP) and home follow-up; group B: hospital polysomnography and hospital follow-up; and group C: home RP and hospital follow-up. Evaluation during 6 months included Epworth Sleepiness Scale (ESS), Functional Outcomes Sleep Questionnaire (FOSQ), and daily activity and symptom questionnaires. Compliance was assessed by memory cards (group A) and using an hourly counter (groups B and C). 66 patients were included (22 per branch), 83% were males, aged mean±sd 52±10 yrs, body mass index 34±7kg·m(-2), apnoea/hypopnoea index 43±20 h(-1), CPAP pressure 8±2 cmH(2)O, with no between-group differences. Clinical response showed an ESS of mean±sd 15±3 to 6±4, a FOSQ of 16±3 to 18±2, symptoms of 43±7 to 25±7, and activity of 37±11 to 25±8. At the end of the study, compliance was: group A 73%, group B 68% and group C 57%. The cost per patient was: group A €590±43, group B €894±11 and group C €644±93 (p<0.001). In conclusion, patients with a high initial probability of having OSAS can be diagnosed and treated in a home setting, with a high level of CPAP compliance and lower cost than using either a hospital-based approach or home RP/hospital follow-up.

Effect of continuous positive airway pressure in very elderly with moderate-to-severe obstructive sleep apnea pooled results from two multicenter randomized controlled trials.

STUDY OBJECTIVE: There is very limited information about the effect of continuous positive airway pressure (CPAP) in the very elderly. Here we aimed to analysed the effect of CPAP on a clinical cohort of patients with obstructive sleep apnea (OSA) ≥80 years old. METHODS: Post-hoc pooled analysis of two open-label, multicenter clinical trials aimed to determine the effect of CPAP in a consecutive clinical cohort of elderly (≥70 years old) with moderate-to-severe OSA (apnea-hipopnea index ≥15 events/hour) randomized to receive CPAP or no CPAP for three months. Those consecutive patients ≥80 years old were included in the study. The primary endpoint was the change in Epworth Sleepiness scale (ESS). Secondary outcomes included sleep-related symptoms, quality of life, neurocognitive and mood status as well as office blood pressure measurements. RESULTS: From the initial 369 randomized individuals with ≥70 years, 97 (26.3%) with ≥80 years old were included (47 in the CPAP group and 50 in the no-CPAP group). The mean (SD) age was 81.5 (2.4) years. Average use of CPAP was 4.3 (2.6) hours/night (53% with good adherence) Patients in the CPAP group significantly improved snoring and witnessed apneas as well as AHI (from 41.9 to 4.9 events/hour). However no clinical improvements were seen in ESS (-1.2 points, 95%CI, 0.2 to -2.6), any domain of QSQ, any neurocognitive test, OSA-related symptoms, depression/anxiety or blood pressure levels. CONCLUSIONS: The present study does not support the use of CPAP in very elderly patients with moderate-to-severe OSA.

Fiberoptic bronchoscopy during nasal non-invasive ventilation in acute respiratory failure.

BACKGROUND: Various methods have been described for safely performing fiberoptic bronchoscopy (FB) while applying non-invasive positive pressure ventilation (NIPPV) in patients with acute respiratory failure (ARF). OBJECTIVES: To evaluate the safety of a new method to perform FB in patients with ARF. METHODS: Patients with ARF in whom FB was indicated were studied. The primary end-point was a mean drop in oxygen saturation (S(a)O(2)) after the procedure. During nasal NIPPV, FB was performed via the mouth using a bite block sealed with an elastic glove finger allowing bronchoscope insertion. RESULTS: Thirty-five patients were included in the final study (63 ± 17 years, 74% men, P(a)O(2)/F(i)O(2) ratio 168 ± 63). A total of 35 bronchoaspirates, 21 protected brushings, 11 bronchoalveolar lavages and 8 bronchial biopsies were done. The cardiorespiratory variables at the start and end of FB were: S(a)O(2) 93 ± 3 to 94 ± 5%, heart rate 95 ± 17 to 99 ± 22 b.p.m. and respiratory rate 24 ± 11 to 25 ± 11 respirations/min. The lowest S(a)O(2) value reached during the procedure was 86 ± 3% and the maximal ETCO(2) rise was 41 ± 4 mm Hg. Leakage was <50 ml/s in 32 patients. The clinical course was favorable in 66%. Invasive ventilation was necessary in 11%, 5 ± 4 days after FB. Twelve patients (33%) died 3 ± 2 days after FB as a result of their underlying disease. CONCLUSIONS: The system allowed to perform FB safely in patients with ARF. Although there is a relatively high rate of intubation and invasive mechanical ventilation due to illness severity, there was no worsening of oxygenation or complications attributable to the procedure.

Tuberculous empyema necessitatis. A rare cause of cutaneous abscess in the XXI century.

A 24-year-old Moroccan man was admitted to the hospital because of a tumor of the abdominal wall, fever, and purulent sputum. Imaging tests showed the presence of a pleural effusion and tumor in the right abdominal wall. The organized collection of liquid in the mass was contiguous with the thoracic collection and that of the subphrenic space. Thoracocentesis removed purulent material suggestive of empyema. Cultures and polymerase chain reaction (PCR) tests confirmed the diagnosis of tuberculous empyema. Empyema necessitatis refers to empyema that extends into the extrapleural space through a defect in the pleural surface. Various infectious etiologies may be responsible. Tuberculous empyema necessitatis is a rare complication of tuberculosis (TB); our case is even more unusual because this condition presented as an abdominal wall abcess and the patient was immunocompetent. His only predisposing factors were his country of origin, where there is a high prevalence of TB and the delay in diagnosis due to a lack of access to health care.

[Tuberculosis epidemiology in area 15 of the Spanish autonomous community of Valencia: evolution from 1987 through 2001]. / Evolución de las características epidemiológicas de la tuberculosis en el Area 15 de la Comunidad Valenciana en el período 1987-2001.

OBJECTIVES: To describe the evolution of tuberculosis epidemiology in Area 15 of the Autonomous Community of Valencia. MATERIAL AND METHODS: Cases of tuberculosis were identified by active case finding in Area 15 from January 1987 through December 2001. Clinical and epidemiological data were extracted from case records and a patient interview. RESULTS: Four hundred seventy-six diagnosed cases of mycobacterial infection were identified (459 tuberculosis, 16 atypical, and 1 mixed); 423 tuberculosis patients were residents of Area 15. The mean annual incidence rate was 24.6/100 000 population, representing a rate decrease of 41.5% from 1990. The most frequent risk factors were smoking (38%), alcoholism (20%), human immunodeficiency virus (HIV) infection (18%), and contact with a tuberculosis patient (14%). The site of tuberculosis involvement was the lung in 61% (49% bacillus positive, with a nonsignificant trend to decrease over time), nonpulmonary in 26%, and mixed in 13%. The radiographic pattern observed most often was pulmonary infiltrates (67%), and lower lobe involvement tended to increase over time. Diagnosis was by acid-fact bacillus stain for 77%, clinical picture for 16%, and histological for 7%. Isoniazid resistance was detected in 1.5% and rifampicin resistance in 0.3%. Patients were hospitalized during diagnosis in 79% of cases; the mean stay was 18 days. CONCLUSIONS: The incidence of tuberculosis has decreased in spite of the HIV pandemic. Risk factors have not changed, bacteriological diagnosis has improved, and the location of pulmonary infiltrates has changed. No influence of immigration on the incidence rate of tuberculosis has been detected to date.

[Description of a new procedure for fiberoptic bronchoscopy during noninvasive ventilation through a nasal mask in patients with acute respiratory failure]. / Descripción de un nuevo procedimiento para la realización de fibrobroncoscopia durante ventilación no invasiva mediante mascarilla nasal en pacientes con insuficiencia respiratoria aguda.

A new method is described for performing oral fiberoptic bronchoscopy during noninvasive ventilation through the nose. The technique was successfully applied in 2 patients suffering from acute respiratory failure. The bronchoscope was inserted through a glove finger fitted into a mouth guard. The system works as a valve and does not affect performance of the bronchoscopy procedure or the pressures administered during noninvasive ventilation. We conclude that the procedure has potential advantages over bronchoscopy through the nose and face masks or helmets, particularly for the management of secretions or in special clinical circumstances (hemoptysis or presence of foreign bodies). This method can be used to substitute for or complement other bronchoscopy techniques performed with other interfaces.

[Thoracic actinomycosis: an old disorder with new clinical manifestations]. / Actinomicosis torácica: una vieja entidad con nuevas expresiones clínicas.

Three cases of thoracic actinomycosis are described, two associated to bronchial obstruction (foreign body and bronchogenic carcinoma) and one in a patient with empyema. The clinical and radiological manifestations and diagnostic criteria are reviewed and all published cases in the Spanish literature are thoroughly analyzed.

Amiloidosis secundaria a bronquiectasias, una patología excepcional aún presente / Amyloidosis secondary to bronchiectasis, an unusual but still present disease

Se describe el caso de una paciente joven con amiloidosis secundaria (AA) a bronquiectasias no tuberculosas y no filiadas hasta el momento del diagnóstico, como causante de enfermedad inflamatoria crónica, responsable de la producción mantenida de SAA (proteína sérica amiloide), y depósito amiloide A en los diferentes tejidos. Se discute la rareza del caso, más habitual en el contexto de otras enfermedades inflamatorias, pero como en el pasado, aún potencialmente presente en nuestros días

The case of a young patient with amyloidosis (AA) secondary to nontuberculous bronchiectasis, which was undetermined at the time of diagnosis, is described as a cause of chronic inflammatory disease, responsible for the maintained production of SAA (serum AA protein) and amyloid A deposit in different tissues. The case is argued to be rare, being more common in the context of other inflammatory diseases, but, like in the past, potentially still present today

Mesotelioma pleural por exposición indirecta al asbesto en paciente anciana / Pleural mesothelioma by indirect exposure to asbestos in an elderly patient

Se describe el caso de una paciente de 93 años que fue ingresada por mesotelioma pleural de tipo linfoepitelial, atribuido a la exposición indirecta a fibras de asbesto procedente del lavado de la ropa de su marido, con un largo periodo de latencia. Se revisa la exposición ocupacional al asbesto y su baja incidencia en mujeres, más frecuente en estos casos por exposición indirecta o medioambiental. Se concluye con la necesidad de efectuar una correcta anamnesis para valorar los factores de riesgo de exposición, aun con largo tiempo de latencia

We describe the case of a 93-year-old patient who was diagnosed with lymphoepithelial-type pleural mesothelioma, attributed to indirect exposure to asbestos fibers from washing her husband's clothes, with a long latency period, reviewing occupational exposure to asbestos and its low incidence in women, more frequent in these cases due to indirect or environmental exposure. It concludes with the need to carry out a correct anamnesis to assess the risk factors of exposure even with a long latency time

Endobronchial tuberculosis in HIV-infected patients.

OBJECTIVE: To evaluate the presence of endobronchial tuberculosis in HIV-infected patients. METHODS: Review of the clinical records of HIV-infected patients in whom diagnostic bronchoscopy was performed because of pulmonary signs or symptoms during a 3-year period. RESULTS: Seventy bronchoscopies were performed in 59 HIV-infected patients. tuberculosis was diagnosed in 25 patients, of whom six showed endobronchial tuberculosis. The most noteworthy radiological finding was mediastinal and/or hilar lymphadenopathy in five patients, occasionally associated with chest miliary infiltrates (in one), or a small pleural effusion (in two). Chest radiograph was normal in one case. The endoscopic findings were hyperaemia in five, caseating bronchial masses in four, or protrusion of extratracheal lymph nodes (broad, thickened carina and patchy bronchial lesions) in three out of the six patients. Mycobacterium tuberculosis infection was confirmed by smear and culture from bronchial aspirate, bronchoalveolar lavage or bronchial biopsies. In three cases the diagnosis was confirmed by transcarinal needle mediastinal puncture aspiration. Tuberculosis was the first opportunistic pulmonary infection in every case. The clinical course with standard treatment was satisfactory in all cases with no bronchial sequelae. CONCLUSION: Endobronchial tuberculosis may be more frequent than suspected in HIV-infected patients. Routine fibrobronchoscopy in HIV-positive patients with tuberculosis could show the true frequency of endobronchial tuberculosis.

Impact of the human immunodeficiency virus on the epidemiology of tuberculosis in area 15 of the Valencian community in Spain.

SETTING: Area 15 in Valencia. OBJECTIVES: To describe the epidemiology (1987-2001) of tuberculosis (TB) in human immunodeficiency virus (HIV) patients. METHODS: Study of annual incidence, age distribution, excess cases attributed to HIV, etiological risk fraction (ERF), population attributable fraction (PAF) and f factor. RESULTS: Of 476 cases diagnosed, 459 were TB, 16 environmental and one mixed; 76% of environmental cases were HIV-positive (P < 0.001). There was a mean annual TB incidence of 24.6/100000, with an annual reduction of 4%. Seventy-three patients were HIV coinfected (16%) (mean incidence 3834/100 000 seropositives). The principal risk factor was drug use (59%) for HIV+ and contact with TB for HIV-. We found no difference in pulmonary or extra-pulmonary location between groups, contrary to mixed cases (P < 0.001). In HIV+ there was a lower frequency of infiltrates (P < 0.001) and cavitation (P < 0.01), and a higher frequency of adenitis (P < 0.001), miliary or nodular pattern and normal X-ray (P < 0.001). Seropositives had a 174 times higher probability of developing TB. The mean ERF attributed to HIV was 99%, the PAF was 16% and the f factor was 1.19. Highly active antiretroviral therapy (HAART) reduced the risk of TB in HIV+ by 80%. CONCLUSIONS: TB has continued its decline, although HIV generated an excess of cases in the 1990s. HAART has reduced the TB risk in HIV+ and possibly the overall rate of TB.

[Obstructive sleep apnea syndrome in the Community of Valencia: current situation, study of needs and future prospects]. / Síndrome de la apnea obstructiva del sueño en la Comunidad Valenciana: situación actual, estudio de necesidades y perspectivas de futuro.

To analyze the infrastructure needs for diagnosing sleep apnea syndrome (SAS) in the Community of Valencia, we studied available resources and the diagnostic approaches to SAS in departments of pneumology and neurophysiology in 23 of the 25 public hospitals by means of a telephone interview. Only 52% of pneumology departments and 56% of neurophysiology departments studied SAS at any level. Level I study (conventional polysomnography) was performed by 42% of the pneumology departments and 100% of the neurophysiology departments. The remaining pneumology units used nighttime oximetry (a level IV technique). A special unit and trained personnel were available at 40% of hospitals. Home studies were performed by only 17%. Although 2,000 studies are performed annually, only 1,100 are level I and large interdepartmental differences were detected. The average waiting period was 16 months. Relations between pneumology and neurophysiology units were few and only one hospital took an interdisciplinary approach. The ratio of polysomnographs to inhabitants was 0.52/250,000 and the prevalence of nasal continuous positive airway pressure treatment was 36/100,000, lower than in other communities. We conclude that Valencia is understaffed and under-equipped, and that in some cases resources are under-used. Interdisciplinary approaches are scarcely used by the various specialists involved and the waiting lists for diagnostic tests required for prescribing empirical treatment are long. To attend the approximately 100,000 SAS patients estimated to reside in Valencia, it would be necessary to have 14 polysomnograph devices rather than the 8 available now, as well as to increase staff to meet demand and shorten waiting lists.

[Microepidemics of tuberculosis; apropos of 2 school outbreaks in the area 15 of the Valencia community]. / Microepidemias de tuberculosis: a propósito de dos brotes escolares en el área 15 de la Comunidad Valenciana.

Schools are settings with high concentrations of young people with little exposure to Mycobacterium tuberculosis and greater risk of developing disease when infection occurs as the result of sporadic localized outbreaks. We studied two outbreaks in two elementary schools (A and B) after two cases of bacilliferous pulmonary tuberculosis were detected in teachers in 1990 and 1994. Contacts were trace din school A by the primary care physician and in school B by the pneumologist and public health authorities. Contacts were classified as belonging to the risk group (RG) or the low risk group (LRG). The RG was composed of 187 contacts in school A and 59 in school B. Individuals in the LRG numbered 429 and 116 respectively. Mantoux positives numbered 108 in the RG and 45 in the LRG in school A (p < 0.001). In school B 50 RG individuals and 29 LRG individuals were positive (p < 0.001). The proportion of Mantoux positives was greater in the RG of school B than in the RG of school A (p < 0.01), probably owing to longer time of evolution of disease and possible laryngeal involvement in the index case. Likewise, tuberculin positives were fewer in the LRG of school A than in the LRG of school B (p < 0.001), owing to the small size of the LRG in school A. Thirteen cases of tuberculosis were seen in school A, six of which called for drug prophylaxis after contacts were traced. The nature of the index case and the conditions of exposure are both important in such outbreaks, demonstrating the need to act appropriately to trace contacts, preferably under the supervision of a pneumologists.

[Validation of the Spanish version of the Epworth Sleepiness Scale in patients with a sleep apnea syndrome]. / Validación de la versión española del test de somnolencia Epworth en pacientes con síndrome de apnea de sueño.

A Spanish version of the Epworth Sleepiness Scale (ESS-Sp) was developed by translation, back-translation, formal discussion, and a meeting of researchers with a group of patients with sleep apnea syndrome (SAS). The translated questionnaire was then tested in 345 patients, 275 with SAS at various levels of severity and 70 without SAS. Significant differences existed between the two groups as to age (53 +/- 11 years versus 47 +/- 13, p < 0.001) and BMI (32 +/- 5 versus 29.5 +/- 5, p < 0.001). Patients with SAS had significantly higher scores (14 +/- 5) than did those without SAS (10 +/- 5) (p < 0.001). Reproducibility was tested in 146 patients (113 SAS and 33 non-SAS), with no significant differences found among patients with SAS (14.9 +/- 5 versus 14.2 +/- 5, p = n.s.); significant differences in BMI were found, however, among the 33 non-SAS patients (12 +/- 5 versus 10 +/- 5, p < 0.01). Total scores and individual item scores were related in both groups. Likewise, each item was related to total score in patients with SAS. Sensitivity to post-treatment changes was assessed in 77 SAS patients, with initial scores of 16 +/- 4 seen to decrease to 4 +/- 3 after continuous positive airway pressure. ESS-Sp scores over 10 were recorded for 85% of patients with SAS: 78% of those with mild SAS, 85% of those with moderate disease and 92% of those whose SAS was severe. Significant inter-group differences were found upon applying a test of variance (p < 0.001). Differences continued to be detected when multiple correlations were looked for, with differences increasing with severity. SAS patients with ESS-Sp level one scores (< 10) had lower apnea-hypopnea indices (AHI) (35 +/- 18 versus 42 +/- 20, p < 0.05), lower desaturation levels (21 +/- 21 versus 34 +/- 28, p < 0.01) and higher minimum saturation (80 +/- 10 versus 75 +/- 12, p < 0.05), with no differences in age or BMI. A significant correlation was found between ESS-Sp score and respiratory variables recorded during polysomnography: AHI, r = 0.23 (p < 0.001); percent time in apnea-hypopnea, r = 0.18 (p < 0.01); desaturation index, r = 0.27 (p < 0.01) and minimum saturation (r = -0.14, p < 0.05). We conclude that the Spanish version of the ESS is equivalent to the original, is reproducible in patients with SAS, sensitive to post-treatment changes and seems to discriminate level of severity, showing correlation with polysomnograph variables.