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INTRODUCTION: Pleural effusion (PE) is a common manifestation of acute decompensated heart failure (ADHF); however, its influence on the quality of life (QoL) is unknown. OBJECTIVES: To identify whether PE detected using thoracic ultrasound (TUS) is associated with poorer QoL in patients with ADHF and a reduced ejection fraction (≤40 %). METHODS: We conducted a prospective, longitudinal, descriptive, observational, single-center study at a university hospital in Mexico. We included participants with a reduced left ventricular ejection fraction who were admitted for ADHF. We performed TUS and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) within the first 48 h of hospitalization. RESULTS: Forty patients with ADHF (30 males and 10 females; mean age, 51.24 ± 16.942 years) were included in this study. The participants were categorized into two groups: those with (n = 25, 62.5 %) or without (n = 15, 37.5 %) PE on TUS. We found a statistically significant association between the presence of PEs and a worse perception of QoL. The mean MLHFQ score in the group of patients with PEs was 40 points, compared to 12 points in the group without PEs (p < 0.001). Poorer QoL was associated with a higher quantity of pleural fluid, as evidenced by the greater number of intercostal spaces occupied by the PE (p < 0.001). CONCLUSIONS: Patients with ADHF and a reduced ejection fraction who present with PE have a worse perception of QoL than patients without PE.
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OBJETIVO: Proporcionar recomendaciones para la detección temprana de pacientes con alto riesgo de desarrollar cáncer de pulmón (CP) en el primer nivel de atención y su referencia oportuna. Material y métodos. Se realizó una búsqueda detallada de la evidencia científica disponible para responder las preguntas de investigación clínica y se utilizó el Panel Delphi modificado para lograr un consenso entre expertos. RESULTADOS: Se generaron 14 recomendaciones siguiendo los estándares de una GPC. Conclusión. El CP representa un problema de salud pública en México; por ello, esta guía establece recomendaciones que apoyan la toma de decisiones sobre la detección precoz y la referencia de pacientes con sospecha de CP en el primer nivel de atención.
Subject(s)
Early Detection of Cancer , Lung Neoplasms , Humans , Mexico , Referral and Consultation , Retrospective StudiesABSTRACT
Chronic liver disease (CLD) may be associated with pleural effusions (PEs). This article prospectively evaluates whether detection of PEs on thoracic ultrasound (TUS) at the bedside independently predicts mortality and length of stay (LOS) in hospitalized patients with a decompensated CLD. A total of 116 consecutive inpatients with decompensated cirrhosis underwent antero-posterior chest radiographs (CXR) and TUS to detect PEs. Their median age was 54 y (interquartile range, 47-62), 90 (70.6%) were male, and 61 (52.6%) fell into the Child-Pugh class C categorization. TUS identified PEs in 58 (50%) patients, half of which were small enough to preclude thoracentesis. CXR failed to recognize approximately 40% of PEs seen on TUS. The identification of PEs by TUS was associated with a longer LOS (10 vs. 5.5 d, p < 0.001) and double mortality (39.7% vs. 20.7%, p = 0.021). In multivariate analysis, PEs were independently related to poor survival (hazard ratio 2.08, 95% confidence interval [CI] 1.02-4.25; p = 0.044). Patients with both Child-Pugh C stage and PEs had the lowest survival rate (70 vs. 317 d, p = 0.001). In conclusion, PEs identified by TUS in hospitalized patients with decompensated CLD independently predict a poor outcome and portend a longer LOS.
Subject(s)
Pleural Effusion , Point-of-Care Systems , Humans , Liver Cirrhosis/complications , Liver Cirrhosis/diagnostic imaging , Male , Middle Aged , Pleural Effusion/diagnostic imaging , Point-of-Care Testing , UltrasonographyABSTRACT
Round pneumonia is an unusual radiological manifestation of a bacterial lung infection. We present the case of an elderly male patient who arrived at the emergency room with a productive cough and exertional dyspnea. His chest x-ray and CT showed a round opacity and air bronchograms in the right upper lobe. Taken together, the patient's symptoms and images strongly suggest a pulmonary infection. Empirical antibiotic therapy with ceftriaxone and clarithromycin was started. The sputum culture was positive for Enterobacter hormaechei and the bacterium was sensitive to levofloxacin; therefore, the antibiotic therapy was changed. Despite the treatment, the patient progressed to respiratory failure and septic shock, dying six days after admission. Although round pneumonia is uncommon, it is a potentially curable disease and clinicians should always consider it in their differential diagnosis.
Subject(s)
Enterobacter/isolation & purification , Enterobacteriaceae Infections/diagnosis , Lung/diagnostic imaging , Pneumonia/diagnosis , Adult , Aged , Anti-Bacterial Agents/therapeutic use , Cough , Dyspnea , Enterobacteriaceae Infections/drug therapy , Humans , Levofloxacin/therapeutic use , Male , Pneumonia/microbiology , Sputum/microbiology , Treatment OutcomeABSTRACT
INTRODUCTION: Twenty-five per cent of tuberculosis patients have pleural tuberculosis, which is the third most common form of presentation. Most cases present as an exudative pleural effusion with just few cases reported as chylothorax in the literature. All pleural effusions from confirmed cases, including tuberculous chylothorax, had exudate features. AIM: To describe a patient with Mycobacterium tuberculosis affecting the lungs and pleura, which laboratory testing demonstrated had features of transudate chylothorax. PATIENT AND METHODS: A 70-year-old man presented with constitutional symptoms, progressive exertional dyspnoea and right pleural effusion with fibrocavitary changes on chest imaging. Thoracentesis and pleural fluid analysis revealed chylous fluid with transudate features, high triglycerides, low cholesterol content and mononuclear cell predominance. Acid-fast sputum stains and pleural fluid were negative for Mycobacterium tuberculosis as was an adenosine deaminase test for pleural effusion. Tomography-directed lung biopsy sampling of a lung nodule revealed a chronic granulomatous inflammatory process associated with the presence of acid-fast bacilli. DISCUSSION: Tuberculosis-associated chylothorax is an uncommon presentation of the disease. A recent review found only 37 cases of confirmed tuberculous chylothorax had been reported in the literature. All cases had exudate characteristics. The diagnosis of pleural tuberculosis was made through culture or testing of sputum, pleural fluid or biopsy samples in 72.2% of cases, with the rest identified by histopathology. LEARNING POINTS: The main cause of non-traumatic chylothorax is malignancy, which is found in 39-72% of cases.Few cases of transudative chylothorax have been reported in the literature; the main aetiology is chronic hepatopathy.Tuberculosis-associated chylothorax is a rare presentation of infection caused by Mycobacterium tuberculosis, an uncommon aetiology.
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Introduction: Invasive respiratory support is a cornerstone of Critical Care Medicine, however, protocols for withdrawal of mechanical ventilation are still far from perfect. Failure to extubation occurs in up to 20% of patients, despite a successful spontaneous breathing trial (SBT). Methods: We prospectively included ventilated patients admitted to medical and surgical intensive care unit in a university hospital in northern Mexico. At the end of a successful SBT, we measured diaphragmatic shortening fraction (DSF) by the formula: diaphragmatic thickness at the end of inspiration - diaphragmatic thickness at the end of expiration/diaphragmatic thickness at the end of expiration×100, and the presence of B-lines in five regions of the right and left lung. The primary objective was to determine whether analysis of DSF combined with pulmonary ultrasound improves prediction of extubation failure. Results: Eighty-two patients were included, 24 (29.2%) failed to extubation. At univariate analysis, DSF (Youden's J: >30% [sensibility and specificity 62 and 50%, respectively]) and number of B-lines regions (Youden's J: >1 zone [sensibility and specificity 66 and 92%, respectively]) were significant related to extubation failure (area under the curve 0.66 [0.5-0.80] and 0.81 [0.70-0.93], respectively). At the binomial logistic regression, only the number of B-lines regions remains significantly related to extubation failure (OR 5.91 [2.33-14.98], P < .001). Conclusion: In patients with a successfully SBT, the absence of B-lines significantly decreases the probability of extubation failure. Diaphragmatic shortening fraction analysis does not add predictive power over the use of pulmonary ultrasound
Introducción: El soporte respiratorio invasivo constituye una piedra angular en la medicina de cuidados intensivos. Sin embargo, los protocolos para retirar la ventilación mecánica todavía están lejos de ser perfectos. El fallo de extubación ocurre en hasta un 20% de los pacientes, a pesar del éxito en la prueba de respiración espontánea (SBT). Métodos: Se incluyeron de forma prospectiva pacientes con ventilación ingresados en una unidad médica y quirúrgica de cuidados intensivos de un hospital universitario del norte de Méjico. Tras el éxito en una SBT, se midió la fracción de acortamiento diafragmático (DSF) mediante la fórmula: (grosor diafragmático al final de la inspiración - grosor diafragmático al final de la expiración)/grosor diafragmático al final de la expiración × 100, y la presencia de líneas B en cinco regiones del pulmón derecho y del izquierdo. El objetivo primario fue determinar si el análisis de la DSF combinado con la ecografía pulmonar mejora la predicción del fallo de extubación. Resultados: Se incluyeron 82 pacientes, 24 (29,2%) con fallo de extubación. En el análisis univariante, la DSF (Índice de Youden: >30% [sensibilidad y especificidad del 62% y el 50%, respectivamente]) y el número de regiones con líneas B (Índice de Youden: >zona 1 [sensibilidad y especificidad del 66% y el 92%, respectivamente]) se relacionó significativamente con el fallo de extubación (área bajo la curva 0,66 [0,52-0,80] y 0,81 [0,70-0,93] respectivamente). En la regresión logística binaria, solo el número de regiones con líneas B se relacionó significativamente con el fallo de extubación (OR 5,91 [2,33-14,98], p<0,001). Conclusión: En pacientes con éxito en la SBT, la ausencia de líneas B disminuye significativamente la probabilidad de fallo de extubación. La fracción de acortamiento diafragmático no añade valor predictivo respecto al uso de la ecografía pulmonar
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Diaphragm/anatomy & histology , Lung/diagnostic imaging , Airway Extubation/mortality , Diaphragm/physiology , Ultrasonography/methods , Respiration, Artificial/standards , Prospective Studies , Critical Care , Diagnostic Imaging/methods , Respiration, Artificial/methods , Ventilators, Mechanical , Ventilator Weaning/mortalityABSTRACT
INTRODUCTION: Invasive respiratory support is a cornerstone of Critical Care Medicine, however, protocols for withdrawal of mechanical ventilation are still far from perfect. Failure to extubation occurs in up to 20% of patients, despite a successful spontaneous breathing trial (SBT). METHODS: We prospectively included ventilated patients admitted to medical and surgical intensive care unit in a university hospital in northern Mexico. At the end of a successful SBT, we measured diaphragmatic shortening fraction (DSF) by the formula: diaphragmatic thickness at the end of inspiration - diaphragmatic thickness at the end of expiration/diaphragmatic thickness at the end of expiration×100, and the presence of B-lines in five regions of the right and left lung. The primary objective was to determine whether analysis of DSF combined with pulmonary ultrasound improves prediction of extubation failure. RESULTS: Eighty-two patients were included, 24 (29.2%) failed to extubation. At univariate analysis, DSF (Youden's J: >30% [sensibility and specificity 62 and 50%, respectively]) and number of B-lines regions (Youden's J: >1 zone [sensibility and specificity 66 and 92%, respectively]) were significant related to extubation failure (area under the curve 0.66 [0.52-0.80] and 0.81 [0.70-0.93], respectively). At the binomial logistic regression, only the number of B-lines regions remains significantly related to extubation failure (OR 5.91 [2.33-14.98], P<.001). CONCLUSION: In patients with a successfully SBT, the absence of B-lines significantly decreases the probability of extubation failure. Diaphragmatic shortening fraction analysis does not add predictive power over the use of pulmonary ultrasound.
Subject(s)
Airway Extubation , Critical Care , Diaphragm/diagnostic imaging , Lung/diagnostic imaging , Respiration, Artificial , Ventilator Weaning , Adult , Aged , Diaphragm/physiology , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Prospective Studies , Treatment Failure , UltrasonographyABSTRACT
BACKGROUND: Allogeneic stem cell transplantation (ASCT) represents the only option with a potential cure rate of 30% to 50% in myelodysplastic syndrome (MDS); however, < 5% of patients are optimal candidates for this management. Therapeutic options are limited in patients unsuitable for ASCT. Evidence that androgens might be beneficial in MDS is controversial. We aimed to document the clinical outcomes of patients diagnosed with MDS treated with danazol as first-line therapy. PATIENTS AND METHODS: We retrospectively reviewed patients diagnosed in our center with MDS according to the World Health Organization 2008 criteria and treated with danazol between 2005 and 2015. Response was defined according to international working group criteria. RESULTS: We included 42 patients treated exclusively with danazol. Median dose was 400 mg/d (range, 100-600 mg/d). Median follow-up was 12 (range, 3-76) months. Twenty-four of these patients (60%) achieved clinical response. Median overall survival was 24 months (95% confidence interval, 5.1-42). Responders were older than nonresponders (P = .025) and had higher baseline hemoglobin concentration (P = .009). No patients discontinued danazol because of toxicity. Fifteen patients died (35.7%) and 5 progressed to acute myeloid leukemia. CONCLUSION: Danazol as first-line therapy is an acceptable treatment option with low side effects for patients with MDS who cannot receive ASCT.
Subject(s)
Danazol/therapeutic use , Myelodysplastic Syndromes/drug therapy , Adult , Aged , Aged, 80 and over , Danazol/adverse effects , Estrogen Antagonists/adverse effects , Estrogen Antagonists/therapeutic use , Female , Gastrointestinal Diseases/chemically induced , Humans , Male , Middle Aged , Retrospective Studies , Survival Analysis , Treatment Outcome , Weight Gain/drug effectsABSTRACT
OBJECTIVES: Hypertriglyceridemic pancreatitis (HP) is an uncommon condition accounting for 1% to 4% of cases of acute pancreatitis, mostly associated with poor glycemic control. Diabetic ketoacidosis (DKA) may complicate the clinical course of HP. Our objective was to identify clinical and demographic differences between HP and DKA patients compared with those without DKA. METHODS: Fifty-five patients with HP were included. Diabetic ketoacidosis was diagnosed in 8 patients. We analyzed the severity, hospital stay, delay in oral intake, duration of insulin infusion, complete blood cell count, and triglyceride levels. RESULTS: Diabetic ketoacidosis was associated with a more severe HP. There were no differences in hospital stay, delay in oral intake, or duration of insulin treatment in both groups. Serum amylase, lipase, and triglyceride levels were similar. Previous diagnosis of diabetes mellitus, higher Ranson and APACHE II scores, and higher serum glucose level at admission were the only predictive risk factors for DKA and HP. CONCLUSIONS: Coexistence of DKA does not modify the clinical course of HP, although a more severe episode of HP in DKA patients. Diabetic ketoacidosis was associated with higher insulin doses, without impact in triglyceride levels. Diabetic ketoacidosis and HP should be considered when a previous diagnosis of diabetes mellitus and a severe HP are present.
Subject(s)
Diabetic Ketoacidosis/complications , Hypertriglyceridemia/complications , Pancreatitis/complications , Acute Disease , Adolescent , Adult , Aged , Aged, 80 and over , Case-Control Studies , Cross-Sectional Studies , Diabetic Ketoacidosis/diagnosis , Diabetic Ketoacidosis/therapy , Female , Humans , Hypertriglyceridemia/diagnosis , Hypertriglyceridemia/therapy , Length of Stay , Male , Middle Aged , Pancreatitis/diagnosis , Pancreatitis/therapy , Retrospective Studies , Severity of Illness Index , Treatment Outcome , Young AdultABSTRACT
Mucormycosis (MCM) is a life-threatening infection that carries high mortality rates despite recent advances in its diagnosis and treatment. The objective was to report 14 cases of mucormycosis infection and review the relevant literature. We retrospectively analyzed the demographic and clinical data of 14 consecutive patients that presented with MCM in a tertiary-care teaching hospital in northern Mexico. The mean age of the patients was 39.9 (range 5-65). Nine of the patients were male. Ten patients had diabetes mellitus as the underlying disease, and 6 patients had a hematological malignancy (acute leukemia). Of the diabetic patients, 3 had chronic renal failure and 4 presented with diabetic ketoacidosis. All patients had rhinocerebral involvement. In-hospital mortality was 50%. All patients received medical therapy with polyene antifungals and 11 patients underwent surgical therapy. Survivors were significantly younger and less likely to have diabetes than nonsurvivors, and had higher levels of serum albumin on admission. The clinical outcome of patients with MCM is poor. Uncontrolled diabetes and age are negative prognostic factors.
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CONTEXT: Acute pancreatitis can lead to prolonged fasting and malnutrition. Many metabolic changes, including thiamine deficiency, may lead to the well know pancreatic encephalopathy. In this condition however the thiamine deficiency is rarely suspected. CASE REPORT: We report the case of a 17-year-old woman with severe acute pancreatitis who developed mental status changes and ophthalmoplegia. A magnetic resonance image showed hyperintensive signals in periventricular areas, medial thalamus, and mammillary bodies, findings consistent with the diagnosis of Wernicke encephalopathy. Thiamine treatment reversed neurological complications. CONCLUSION: Wernicke encephalopathy secondary to thiamine deficiency should be considered as a possible cause of acute mental status changes in patients with acute pancreatitis and malnutrition. Prophylactic doses of thiamine could be considered in susceptible patients.