Diaphragmatic dysfunction.

The diaphragm is the main breathing muscle and contraction of the diaphragm is vital for ventilation so any disease that interferes with diaphragmatic innervation, contractile muscle function, or mechanical coupling to the chest wall can cause diaphragm dysfunction. Diaphragm dysfunction is associated with dyspnoea, intolerance to exercise, sleep disturbances, hypersomnia, with a potential impact on survival. Diagnosis of diaphragm dysfunction is based on static and dynamic imaging tests (especially ultrasound) and pulmonary function and phrenic nerve stimulation tests. Treatment will depend on the symptoms and causes of the disease. The management of diaphragm dysfunction may include observation in asymptomatic patients with unilateral dysfunction, surgery (i.e., plication of the diaphragm), placement of a diaphragmatic pacemaker or invasive and/or non-invasive mechanical ventilation in symptomatic patients with bilateral paralysis of the diaphragm. This type of patient should be treated in experienced centres. This review aims to provide an overview of the problem, with special emphasis on the diseases that cause diaphragmatic dysfunction and the diagnostic and therapeutic procedures most commonly employed in clinical practice. The ultimate goal is to establish a standard of care for diaphragmatic dysfunction.

Characteristics of patients with myelomatous pleural effusion. A systematic review. / Características de los pacientes con derrame pleural mielomatoso. Revisión sistemática.

BACKGROUND: Myelomatous pleural effusion (MPE) is rare in multiple myeloma, and therefore its characteristics are not well defined. METHODS: A systematic review (4 online databases) was conducted of articles describing the clinical characteristics of patients with MPE, pleural effusion's biochemical characteristics and treatment efficacy. We analysed isolated cases and small retrospective series. RESULTS: We included 98 articles with a total of 153 patients with MPE. The median age was 62years, and the ratio of males to females was 1.7:1. The most common symptoms were dyspnoea (98.8%), bone pain (100%) and chest pain (95.3%), and the most relevant abnormal laboratory test results were anaemia (90.1%) and renal failure (53.8%). MPE was predominantly unilateral (63.9%) and covered more than two-thirds of the hemithorax (54.5%). The pleural fluid (PF) had a haematologic/serohaematologic appearance (87%) and met the criteria for lymphocytic (78.6%) exudate (94.7%). The most cost-effective diagnostic procedures were pleural cytology (95.9%) and the observation of a monoclonal peak in the PF (94.7%). In a significant proportion of patients (54.7%), the MPE did not respond to treatment, and the best response was achieved when chemotherapy (with/without corticosteroids) was combined with therapeutic thoracentesis, chest drainage or pleurodesis. CONCLUSIONS: MPE predominates in middle to older age men, is symptomatic and is usually unilateral. PF is an exudate with a haemorrhagic appearance, and the most cost-effective diagnostic procedure is pleural cytology. Treatment response is unfavourable in more than half of patients.

Behaviour of nucleated cells in various types of pleural effusion. / Comportamiento de las células nucleadas en los distintos tipos de derrame pleural.

INTRODUCTION: To know the behavior of cellular components of pleural fluid can help focus the differential diagnosis of a pleural effusion. Our objective was to assess their composition in different types of pleural effusions and assess whether it provides relevant clinical information. PATIENTS AND METHODS: Observational, cross-sectional and retrospective study in which the cellular components of pleural effusions of different etiology were analyzed. Pleural effusions were classified as neutrophilic, lymphocytic (≥50% of each one of them), eosinophilic (≥10%) or mesothelial (>5%) and were grouped into six diagnostic categories RESULTS: 1.467 patients were studied (354 heart failure; 59 other transudates; 349 paraneumonic; 133 tuberculous; 397 malignant and 175 other exudates). The predominance cell was lymphocytic in heart failure (44,4%), uncomplicated parapneumonic (29,2%), tuberculosis (88%) and malignant (49,6%); neutrophilic in parapneumonic (57%) and malignant (9,6%); eosinophilic in malignant (6,3%) and mesotelial in tuberculosis (12%). The most frequent etiologies with lymphocyte count ≥80% were tuberculosis (35,1%) and malignant (23,3%). Parameters with higher discriminating accuracy were: leukocytes (transudates: AUC 0,835) and percentage of neutrophils (empyemas: AUC 0,906 and complicated parapneumonic+empyemas: AUC 0,907). CONCLUSIONS: Nucleated cell counts will help focus the etiology of pleural effusions, since each etiology often have a characteristic cell predominance. The percentage of nucleated cells in pleural fluid not ruled out tuberculosis if there is a high count of mesothelial cells, nor a parapneumonic effusion with lymphocytic predominance, or malignancy with ≥80% lymphocytes.

Can tuberculous pleural effusions be diagnosed by pleural fluid analysis alone?

OBJECTIVE: To assess whether pleural fluid analysis (PFA) can confidently diagnose tuberculous pleural effusion (TPE). METHODS: PFA of 548 TPEs was performed between January 1991 and December 2011. The control group consisted of patients with malignant PE (MPE), complicated parapneumonic/empyema (infectious) PE (IPE), miscellaneous PE (MisPE) and transudative PE (TrPE). RESULTS: The PFA of 548 histologically or culture-positive consecutive cases of TPE was compared with that of 158 consecutive cases of MPE, 113 cases of IPE, 37 cases of MisPE and 115 cases of TrPE. Statistically significant differences were noted in pleural fluid glucose, pH, cholesterol, triglycerides, adenosine deaminase (ADA), and total percentages of lymphocytes, neutrophils and macrophages when TPEs were compared to all other groups. Of the TPEs, 99.1% were exudates. Pleural fluid protein ≥ 5.0 g/dl, lymphocytes > 80% and ADA > 45 U/l were diagnostic of TPE, with a specificity of 100%, a sensitivity of 34.9% and an area under the curve of 0.975. CONCLUSION: PFA alone was diagnostic in one third of the TPE cases, with a high probability in nearly 60%.

Asthma and risk of lung cancer.

Asthma is a very common chronic disease that occurs in all age groups. Its high prevalence has significant health costs, which are even higher in the most severe disease forms. Lung cancer has the highest incidence of all cancers in the developed world and is an important cause of mortality. Patients with lung cancer are a big economic burden on health services, both in direct and indirect costs. Different authors suggest that atopic constitution, including different manifestations of allergy and asthma, are possible risk factors for lung cancer, above all in never-smokers. Given the high asthma prevalence and lung cancer incidence and mortality in developed countries, this association would have important public health implications. Uncertainties about the association and the underlying physiopathological mechanisms, however, seem to require further studies.

Asthma and risk of lung cancer

Asthma is a very common chronic disease that occurs in all age groups. Its high prevalence has significant health costs, which are even higher in the most severe disease forms. Lung cancer has the highest incidence of all cancers in the developed world and is an important cause of mortality. Patients with lung cancer are a big economic burden on health services, both in direct and indirect costs. Different authors suggest that atopic constitution, including different manifestations of allergy and asthma, are possible risk factors for lung cancer, above all in never-smokers. Given the high asthma prevalence and lung cancer incidence and mortality in developed countries, this association would have important public health implications. Uncertainties about the association and the underlying physiopathological mechanisms, however, seem to require further studies (AU)

Effect of delays on survival in patients with lung cancer

BACKGROUND: The effect on survival of delays in the consultation, diagnostic and treatment processes of lung cancer (LC) is still under debate. The objective of our study was to analyse these time delays and their possible effect on survival. METHODS: A retrospective study has been performed on all patients in our health area diagnosed with LC (confirmed by cytohistology) over 3 years. The delay in specialist consultation (time between start of symptoms and the first consultation with a specialist), hospital delay (time between first consultation and start of treatment) and overall delay (the sum of the previous two delays) were analysed. The influence of each of these delays was calculated using Cox regression, adjusted for other factors. RESULTS: A total of 415 patients were included. Of these, 92.5% were male and 75.4% were in stages III-B or IV. The overall delay gave a mean of 123.6 days, the delay in consulting a specialist 82.1 days and the delay in hospitalisation was 41.4 days. A greater overall delay or greater hospital delay was associated with longer survival. No relationship was observed between the specialist consultation delay and survival. CONCLUSIONS: Globally analysing all the cases and all the stages with LC, it is seen that longer delays are associated with longer survival. This probably reflects the fact that patients with more symptoms are treated more rapidly (AU)

Trends in hospital admissions due to asthma in north-west Spain from 1995 to 2007

Purpose: Asthma is the most common chronic disease in childhood. Hospital admissions in the child population appear to be reducing in different populations. Methods: We have retrospectively analysed admissions into hospitals in our region due to asthma in a 0 to 14 years population, between the years 1995 and 2007. The age, sex, date of admission, and length of hospital stay of each patient was recorded and analysed. Results: A total of 9106 admissions (64% males) have been included. A gradual trend towards a reduction in admissions is observed during the period analysed. There were more admissions in 1996, with 2.91 per thousand inhabitants, gradually reducing to 1.33 per thousand in 2007. There were more admissions in May and between September and December, being less frequent in July and August. The mean stay in this period was 4.18 days, which was stable during the whole period of the study. Older children tended to have a longer hospital stay. Conclusions: Our study shows that admissions due to childhood asthma tend to be decreasing, particularly due to younger males, with no change in the length of hospital stay. Asthma exacerbations seemed to be associated with infections and exposure to allergens

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Diagnostic value of interleukin-12 p40 in tuberculous pleural effusions.

The diagnosis of tuberculous pleural effusion (TBPE) is frequently problematic. Several markers of TBPE in pleural fluid have been evaluated, with different results. Pleural effusions from 96 patients were classified on the basis of definitive diagnosis as tuberculous (n = 39), neoplastic (n = 42) or parapneumonic (n = 15). Adenosine deaminase (ADA), ADA isoform ADA-2, interferon (IFN)-gamma, CD3(+)/DR(+) T-lymphocytes and interleukin (IL)-12 p40 were determined in all 96 effusions. The efficiency of IL-12 p40 for diagnosis of TBPEs was evaluated, in comparison with those of the other parameters, by comparing the areas under their receiver operating characteristics. With the threshold value of 550 pg.mL(-1), IL-12 p40 had a sensitivity of 92.3% (36 out of 39) and specificity of 70.2% (17 false positives). The misclassification rate of IL-12 p40 was significantly greater than those of ADA-2 and ADA. Among TBPEs, ADA correlated significantly with ADA-2, and IFN-gamma with ADA and IL-12 p40. Although tuberculous pleural effusions show values of interleukin-12 p40 that are significantly higher than neoplastic and parapneumonic fluids, this parameter is less efficient than adenosine deaminase, adenosine deaminase isoform 2 and interferon-gamma. Its routine determination is, accordingly, not justified.

[Symptoms of sleep apnea syndrome in the general population]. / Sintomatología del síndrome de apnea del sueño en la población general.

The aim of this study was to determine the clinical features of patients with sleep apnea syndrome (SAS) in the general population. One hundred ten individuals were selected randomly from the census and given hospital appointments. Case histories were taken and complete physical examinations were made. Nighttime respiratory polysomnograms were performed. Twenty-two (20%) of the 110 subjects presented SAS. In the SAS group, 59.1% were habitual snorers and 22.7% reported daytime hypersomnolence. The SAS patients has a mean age of 59.6 +/- 8.8 years and 45.4% showed alterations of the pharynx. No differences in spirometric variables were observed. Only age and daytime hypersomnolence predicted SAS in the multivariate analysis. We conclude that the prevalence of snoring, daytime hypersomnolence, pharyngeal alterations are higher in patients with SAS. The patients are also older. Only age and daytime hypersomnolence predicted of SAS.

[Most common cardiovascular diseases and sleep apnea syndrome. A general population study]. / Enfermedades cardiovasculares más frecuentes y síndrome de apnea del sueño. Un estudio en población general.

BACKGROUND: The sleep apnea syndrome (SAS) is a frequent disease associated with significant morbidity. The aim of our study was to investigate diseases associated with the sleep apnea syndrome (SAS) in general population. METHODS: We selected a random sample of 110 people from the electoral census. These people were invited to the clinic where medical history, physical examination and monitoring for sleep-disordered breathing was done. RESULTS: Twenty two subjects were diagnosed of SAS. The prevalence of arterial hypertension in the SAS group was 36.4%, and coronary artery disease 13.6%. CONCLUSIONS: Although the prevalence of this diseases was increased in the SAS group, we do not see significant association with this disease.

[Epidemiological study of tuberculosis in the health area of Santiago de Compostella in 1992, 1993 and 1994]. / Estudio epidemiológico de la tuberculosis en el área sanitaria de Santiago de Compostela durante 1992, 1993 y 1994.

An exhaustive search for the clinical records of patients diagnosed with tuberculous disease was done in the hospitals of the area under study, which involves 392,000 population. During the years 1992, 1993 and 1994. There were included: 1) patients who had positive bacilloscopy and/or positive Lowenstein's culture in any specimen: 2) patients younger than 35-years-old who had pleural effusion, significant Mantoux and adenosine deaminase (ADA) over 47 U/I in the pleural effusion. In total 814 patients remained in the study with an average age of 38.39(19.39 DE) in 1992, 39.02 (20.04 DE) in 1993, and 34.1 years-old (19.2 DE) in 1994, with extreme ages of 2 months and 87 years-old. The incidence/100,000 H was: in 1992: 67.86, in 1993: 66.58 and in 1994: 73.2. The contagious forms incidence/100,000 H was: 1.5 in 1992 and 1993; and 1.79 in 1994. The hospital mortality incidence/100,000 H was 2.04 in 1992, 2.30 in 1993 and 2.6 in 1994. We conclude that tuberculosis is endemic in our area with moderately high and stationary incidence.

[An epidemiological study of tuberculosis in the health area of Santiago de Compostela during the years 1989, 1990 and 1991]. / Estudio epidemiológico de la tuberculosis en el área sanitaria de Santiago de Compostela durante los años 1989, 1990 y 1991.

In order to assess the incidence of tuberculous disease in our health area, we reviewed the clinical records of patients from the three hospitals of the area under study during the years 1989, 1990 and 1991, who had positive bacilloscopy, positive Lowenstein's culture in any specimen and/or compatible anatomopathologic report. After excluding 26 patients because they belonged to other health areas, 885 patients remained in the study, out of which 251 (64% men and 36% women) were from the year 1989, 270 (64% men and 36% women) from the year 1990 and 364 (62% men and 38% women) from the year 1991. The mean age was 38.4 (SD 20.5). Fifty-one percent of the patients were between 20 and 35 years old. The rate of new cases was 65.87 per 100.000 population in 1989, 71.05 in 1990 and 95.53 in 1991. Seventy-four cases were HIV-positive (8%). Tuberculous meningitis was present in 12 patients. The highest mortality was 1.79 per 100.000 population in 1990. We conclude that tuberculosis presents a medium-high incidence in our health area.

Diagnosis of tuberculous pleurisy using the biologic parameters adenosine deaminase, lysozyme, and interferon gamma.

We compared the parameters pleural adenosine deaminase (PADA, determined in 405 patients), the PADA/serum ADA ratio (P/SADA; 276 cases), pleural lysozyme (PLYS, 276 cases), the PLYS/serum LYS ratio (P/SLYS; 276 cases), and pleural interferon gamma (IFN, 145 cases) regarding their ability to differentiate tuberculous pleural effusions from others. The 405 pleural effusions were classified by previously established criteria as tuberculous (91), neoplastic (110), parapneumonic (58), empyemas (10), transudates (88), or miscellaneous (48). The intermean differences between the tuberculous group and each of the others were statistically significant for all five parameters (p < 0.01 for PLYS and P/SLYS with respect to the empyema group; p < 0.001 otherwise), except for PADA and P/SADA with respect to the empyema group. All the tuberculous pleurisy cases had PADA values of 47 U/L or more, as compared to only 5 percent of the other cases (sensitivity, 100 percent; specificity, 95 percent). P/SADA was above 1.5 in 85.7 percent of tuberculous effusions and 11 percent of the others (sensitivity, 85.7 percent; specificity, 89 percent). PLYS, with a diagnostic threshold of 15 g/ml, had a sensitivity of 85.7 percent and a specificity of 61.6 percent; P/SLYS, with a threshold of 1.1, had a sensitivity of 67.3 percent and a specificity of 90.3 percent; and IFN, with a threshold of 140 pg/ml, had a sensitivity of 94.2 percent and a specificity of 91.8 percent. The lowest misclassification rate was achieved by PADA, with statistically significant differences (p < 0.001) with respect to P/SADA, PLYS, and P/SLYS, but not with respect to IFN. The only significant pairwise correlations among these parameters were between P/SLYS and PADA and between P/SLYS and P/SADA. We conclude that PADA and IFN are useful parameters for early diagnosis of tuberculous pleurisy, and that the other parameters considered have no advantages over PADA and IFN for this purpose (though the high specificity of P/SLYS may be noted).

[Bronchiolitis obliterans with organized pneumonia: apropos 2 new cases]. / Bronquiolitis obliterante con neumonía organizativa: a propósito de dos nuevos casos.

We present two cases of bronchiolitis obliterans organizing pneumonia (BOOP) with different clinical and radiological characteristics. In one case, the chest X-ray demonstrated bilateral migrating infiltrates. The pathology showed bronchiolar and intra-alveolar occupation by granulation tissue in both cases. It should be noted that both patients responded well to treatment with prednisone although alterations in gas exchange persisted in one case.