Empiema pleural recidivante por Staphylococcus aureus tratado con instilaciones de vancomicina a través de un catéter pleural tunelizado / Recidivant pleural empyema from staphylococcus aureus treated with instilations of vancomycin through an indwelling pleural catheter

Los catéteres pleurales tunelizados (indwelling pleural catheter, IPC) tienen su indicación principal en el alivio sintomático de derrames pleurales malignos. No obstante, han sido empleados también en el tratamiento sintomático de derrames pleurales benignos de diferentes etiologías. Presentamos un caso de un empiema pleural recidivante por Staphylococcus aureus en un paciente pluripatológico, que fue tratado con instilaciones intrapleurales de antibióticos a través de un IPC

Indwelling pleural catheter (IPC) is mainly indicated in the treatment of symptomatic and malignant pleural effusions. Nevertheless it have also been used in treatment of benign pleural effusions of different etiologies. We present a case of recidivant pleural empyema from Staphylococcus aureus in a pluripathologic patient, who was treated with intrapleural instilations of antibiotics through an IPC

Variación del gasto sanitario por la participación de pacientes en ensayos clínicos. Estudio piloto en asma bronquial / Variation of health care cost by the participation of patients in clinical trials. Pilot study in bronchial asthma

En Europa occidental la incidencia de asma se ha duplicado en los últimos 10 años, generando una gran carga económica para los sistemas de salud. El objetivo de este estudio fue cuantificar el ahorro para el sistema sanitario derivado de la participación de un paciente asmático en un ensayo clínico (EC) en un hospital de nivel terciario. El análisis se realizó con un diseño descriptivo y retrospectivo. Como variable principal se tomó el coste total para el sistema de salud durante los periodos de participación en el EC y durante el periodo control y como variables secundarias el coste por pruebas complementarias, el coste por consultas y el coste por fármacos antiasmáticos. En promedio, la participación de un paciente asmático en un EC supuso un ahorro total (fármacos, consultas y pruebas complementarias) para el sistema sanitario de 21,18 € por semana. Si se contabiliza como ahorro sólo la medicación que reciben los pacientes durante el período de tratamiento del ensayo, el ahorro asciende a 9,71 € por paciente y semana. El ahorro bruto y neto no pudieron explicarse adecuadamente a partir de los factores considerados: costes control, gravedad, tipo de ensayo, edad y sexo. Para el ahorro bruto, sólo el nivel de gravedad del paciente reveló una cierta influencia. Concluimos que la participación de un paciente en un EC de asma en un hospital terciario genera un beneficio económico para el sistema sanitario que se hace más patente a medida que aumenta la gravedad del proceso (AU)

In Western Europe, the incidence of asthma has doubled in the last 10 years, generating a greater economic burden for the health care systems. The purpose of this study was to quantify the savings for the health care system derived from the participation of an asthmatic patient in a clinical trial (CT) in a tertiary level hospital. The analysis was conducted with a descriptive and retrospective design. As principal variable, the total cost was obtained for the health care system during the periods of participation in the CT and during the control period as the secondary variables were cost per complementary tests, cost per consultation and cost per anti-asthma drugs. On an average, participation of an asthma patient in a CT meant a total savings (drugs, consultations, and complementary tests) for the health care system of 21,18 € per week. When analyzing the medication by itself that the patients receive during the trial treatment period, the savings reaches 9,71 € per patient and week. The gross and net savings could not be adequately explained from the factors considered: control costs, severity, type of trial, age and gender. We conclude that the participation of a patient in an Asthma CT in a tertiary hospital generates a financial benefit for the health care system that becomes clearer as the severity of the condition increases (AU)

Carcinoma bronquial de células pequeñas con osteoartropatía hipertrófica (OAH) secundaria / Small cell bronchial carcinoma with associated hypertrophic osteoarthropathy

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Utility of transfer factor to detect different bronchodilator responses in patients with chronic obstructive pulmonary disease.

Previous studies have described that there are different types of disease in patients with established chronic obstructive pulmonary disease (COPD) with different clinical course and functional responses. The aim of this study was to evaluate if the presence of low transfer factor (LTF) values can predict the effectiveness of bronchodilator therapy, and to assess whether this group has different risk factors that may be related with the responses. Eighty patients with COPD were evaluated on three occasions. Initial assessment included a standard respiratory questionnaire, blood analysis, skin prick test and baseline lung function, all performed on the first visit. Bronchodilator response was evaluated after low (0.2 mg) and high (1 mg) doses of salbutamol, and after 2 weeks of oral prednisone. In patients with normal TLCO/VA % (NTF), a higher proportion of subjects with previous history of atopy was the only statistically significant difference compared to those with LTF (odds ratio 4.33; 95% confidence interval 1.06-25.15). Although the mean response in forced expiratory volume in 1 s (FEV1) to treatment was analogous in both groups, when bronchodilation was expressed as percent of predicted, there was a clear trend to a lower response in patients with LTF (0.2 mg salbutamol: 6.99 +/- 5.64 vs. 8.94 +/- 6. 61, p = 0.15; 1 mg salbutamol: 10.18 +/- 6.37 vs. 13.45 +/- 7.90, p < 0.05; oral prednisone: 5.51 +/- 6.94 vs. 8.74 +/- 10.81, p = 0.06). The percentage of patients who had >12% improvement from that predicted in FEV1 was also lower in this group (42 vs. 72%; p < 0. 05). Moreover, TLCO/VA% was significantly lower in those subjects with a negative bronchodilator trial with salbutamol (68 +/- 25 vs. 81 +/- 26; p < 0.05) and prednisone (69 +/- 26 vs. 90 +/- 22; p < 0. 01). In patients with LTF and NTF, airway responsiveness was only significantly related with basal airflow limitation (LTF, r = 0.44; NTF, r = 0.38). All other interaction terms were not statistically significant. These results indicate that in patiens with similar serverity of COPD, the presence of LTF indicates a decreased probability of a positive bronchodilator response, probably reflecting different pathological lesions. We suggest that transfer factor should be taken into consideration when bronchial response is evaluated in large clinical trials.

[The spectrum of bronchiolitis]. / El espectro de las bronquiolitis.

Over the last years numerous entities affecting small airways of respiratory tract has been described. It has gone accompanied of a considerable degree of confusion, leading to gather together different diseases which only share the term bronchiolitis. Our aim is to report three patients, one bronchiolitis, noticing their characteristic features and analysing the origin of this situation.

[Mounier-Kuhn syndrome. 2 representative cases of its clinical spectrum]. / Síndrome de Mounier-Kuhn. Dos casos representativos de su espectro clínico.

Tracheobronchomegaly is characterized by tracheal and main bronchial dilatation usually associated with pulmonary parenchymatous disease. It is a rare condition and less than a hundred cases have been reported so far. Two cases of tracheobronchomegaly are here reported, one of them in an asymptomatic patients who came to medical attention because of pneumothorax (a previously non reported association); the other case was in a female patient with advanced age and history of recurrent pneumonic episodes and with marked parenchymatous involvement. In both cases the diagnostic confirmation was made by CT.

[An evaluation of the bronchodilator response with beta agonists in patients with chronic obstructive pulmonary disease]. / Evaluación de la respuesta broncodilatadora con agonistas beta en pacientes con enfermedad pulmonar obstructiva crónica.

The aim of this study was to analyze the functional reversibility and establish the most appropriate index and minimum dose of beta-2-agonist in patients with chronic obstructive pulmonary disease (COPD). Sixty patients with COPD (FEV1/FVC < 70%) in stable phase. After taking baseline forced spirometry readings, we applied the accumulated dose-response technique, administering 0.2 mg salbutamol every 10 minutes up to a maximum dose of 1 mg. Spirometric readings were taken 10 minutes after each dose. Response was evaluated with absolute values of FEV1 and with percent improvement over baseline FEV1 over the theoretical value and over the possible value. We calculated the correlation coefficient between baseline FEV1 and response, as measured by each of the aforementioned indices. No significant improvement was observed for doses higher than 0.4 mg salbutamol in either absolute values or percentage of baseline or theoretical values. Response was not significantly improved over 0.2 mg as measured by percent of possible response. Percent of theoretical value was the index that showed the least dependence on baseline FEV1 for each dose of salbutamol. A minimum dose of 0.4 mg salbutamol, or an equivalent dose of another similar sympathicomimetic drug, should be used for evaluation of bronchodilation response in patients with COPD. Response should be evaluated by percent of theoretical value.

[Diabetes insipidus and Langerhans-cell histiocytosis without changes in cerebral CAT and NMR]. / Diabetes insípida en histiocitosis de células de Langerhans, sin alteraciones en la TAC y RMN cerebral.

In LCH extended disease CNS involvement in is not infrequent. Diabetes insipidus, due to the affectation of hypothalamus-hypophysis axis, is its most frequent finding. The solitary affectation of hypothalamus-hypophysis axis is exceptional. At times, it's a difficult diagnosis and could precede the diagnosis of LCH several years. Usually, CAT and NMR show morphologic lesions. We report a patient who was diagnosed of idiopathic diabetes insipidus when he was 16 years old. Seven year later, he was diagnosed of LCH after underwent a bone marrow biopsy examination, just when the disease involved the bone and lung. Cerebral CAT and NMR didn't show morphologic lesions. In the presence of morphologic lesions in hypothalamus and/or hypophysis, proved by cerebral CAT and NMR, or a clinical setting of DI, the possibility of LCH must be considered.

[The role of BCG in the prevention of tuberculosis]. / El papel de la BCG en la prevención de la tuberculosis.

Tuberculosis is still a major international public health problem. The role of vaccination with BCG in the prophylaxis of the tuberculosis has been a source of controversy almost since ist introduction in the thirties, because of the disparity of the results regarding efficacy and protection of the several studies that have been done. Currently, everybody seems to agree that in countries with annual infection risk lower than 1%, a massive vaccination campaign with BGC is not profitable. On the other hand, BCG interferes the lecture of the Mantoux intra-dermo-reaction and, thus, it invalidates the most effective test that we have for the diagnosis of the tuberculosis infection. In our country, the battle against tuberculosis is currently focused on the identification and treatment of the tuberculous patient, chemoprophylaxis with contacts of these patients and avoidance of the development of the tuberculosis infection to tuberculosis disease.

[Current status of the antipneumococcal vaccine: a pending issue]. / Situación actual de la vacuna antineumocócica: una asignatura pendiente.

In spite of antibiotic treatment, mortality due to pneumonia caused by Streptococcus pneumoniae is still considerable and it is related to the presence of bacteremia. Prophylaxis with 23-polyvalent anti-pneumococcus vaccine would prevent severe processes in high risk populations. We present in this work the current status of our knowledge about this vaccine, regarding its efficacy in preventing bacteremia, economic cost, and secondary effects, we point out the indications of this vaccine according to IPAC (Immunization Practices Advisory Committee) and those special situations which modify prophylaxis (pregnancy, revaccination and massive immunizations) are discussed.

[Tuberculin test: usefulness of an old technique]. / Prueba tuberculínica: utilidad de una antigua técnica.

Tuberculin test was first used as a diagnostic test of tuberculous infection during the first decades of this century. From the up to date, no other method has proven to be more efficient for this task. In the present work we try to explain what the test consists of, what is its use, how it is interpreted, and which are the indications for the Mantoux intradermal reaction. We emphasize the importance of performing this technique correctly so as to not invalidate the results of this test which is essential both from a individual as from an epidemiological point of view.