Monitoring changes in anti-tuberculosis treatment: associated factors determined at the time of diagnosis.

OBJECTIVES: To determine predictive factors for changes in standard anti-tuberculosis chemotherapy at the time of diagnosis. METHODS: A prospective study was performed among tuberculosis (TB) patients treated at specialised centres during 2008-2009. Treatment outcome was monitored per standard guidelines. Treatment was considered successful if the patient was cured or completed treatment. Factors associated with treatment modification were analysed at the bivariate and multivariate levels using logistic regression. RESULTS: A total of 427 patients were included in the study. The initial standard treatment regimen was retained for 249 patients (58.3%), extended to 9 months for 36 (8.4%) and changed for 142 (33.3%). Factors associated with a change of regimen at the multivariate level were female sex, age ≥ 50 years, human immunodeficiency virus infection, comorbidities, alcoholism, hospitalisation and culture-positive sputum. Drug resistance and toxicity were analysed independently. Treatment outcome was successful in 97.2% of cases without a regimen change and in 87.3% of those with a changed regimen (P < 0.001). CONCLUSION: Factors associated with changes in the initial anti-tuberculosis regimen should be considered for rigorous follow-up. Results obtained through individualised treatment provided by specialists were good despite the complexity of the cases treated.

[Usefulness of transcutaneous carbon dioxide pressure monitoring to measure blood gases in adults hospitalized for respiratory disease]. / Utilidad de la presión transcutánea del anhídrido carbónico en la valoración gasométrica de adultos hospitalizados con enfermedad respiratoria.

OBJECTIVE: To evaluate the usefulness of transcutaneous carbon dioxide pressure (TcPCO2) monitoring in patients hospitalized for respiratory disease. PATIENTS AND METHODS: We used a SenTec TcPCO2 monitor that also determines transcutaneous oxygen saturation (SpO2) by means of a sensor placed behind the ear lobe at a temperature of 42 degrees C. We compared arterial blood gas measurements--PaCO2 and arterial oxygen saturation (SaO2)--with transcutaneous measurements and analyzed the correlation, regression line, and agreement between the 2 methods. RESULTS: Thirty patients (20 men and 10 women) with various respiratory diseases and a mean (SD) age of 71 (13) years were included in the study. The median TcPCO2 was 43.25 mm Hg and the median PaCO2 was 42.6 mm Hg with no significant differences between the 2 measurements. The correlation was significant (rho=0.979; P< .0001) and the corresponding regression equation was TcPCO2=-2.475+1.058 PaCO2. The mean difference was 0.16 mm Hg (95% confidence interval [CI], --0.74 to 1.06). The lower limit of agreement (mean -1.96 SD) was -4.64 mm Hg, and the upper limit (mean +1.96 SD) was 4.96 mm Hg. For SaO2, the median was 94% and for SpO2, 95%. The difference between the 2 medians was significant (P< .004). The correlation was also significant (rho=0.822; P< .0001) with SpO2=4.427+0.97 SaO2. The mean difference was 1.14% (95% CI, 0.381% to 1.899%). The lower limit of agreement (mean -1.96 SD) was --2.93% and the upper limit (mean +1.96 SD) was 5.21% CONCLUSIONS: Transcutaneous determination of carbon dioxide pressure and oxygen saturation is useful for patients hospitalized for respiratory disease in view of its good correlation and agreement, although SpO2 does tend to overestimate SaO2.

Utilidad de la presión transcutánea del anhídrido carbónico en la valoración gasométrica de adultos hospitalizados con enfermedad respiratoria / Usefulness of transcutaneous carbon dioxide pressure monitoring to measure blood gases in adults hospitalized for respiratory disease

Objetivo: Estudiar la utilidad de la medida de la presión transcutánea de anhídrido carbónico (PtcCO2) en pacientes con enfermedad respiratoria hospitalizados. Pacientes y métodos: Utilizamos el analizador de PtcCO2 SenTec®, que también determina la saturación transcutánea de oxígeno (SpO2), mediante un sensor colocado en el lóbulo de la oreja a una temperatura de 42 °C. Se compararon los valores gasométricos ­--presión arterial de anhídrido carbónico (PaCO2) y saturación arterial de oxígeno (SaO2)--­ con los transcutáneos, analizando la correlación, recta de regresión y la concordancia entre ambos métodos. Resultados: Se incluyó a 30 pacientes (20 varones y 10 mujeres) con diversas enfermedades respiratorias, con una media (± desviación estándar [DE]) de edad de 71 ± 13 años. La mediana de la PtcCO2 era de 43,25 mmHg, y la de la PaCO2 de 42,6 mmHg, sin existir diferencias entre ellas. La correlación era significativa (ρ = 0,979; p < 0,0001), siendo la PtcCO2 = -­2,475 + 1,058 PaCO2. La media de las diferencias fue de 0,16 mmHg (intervalo de confianza del 95%, de ­-0,74 a 1,06); la media de las diferencias menos 1,96 DE fue de ­-4,64 mmHg, y más 1,96 DE, de 4,96 mmHg. En cuanto a la SaO2, la mediana era del 94%, y la de la SpO2 del 95%, con diferencias entre ambas (p < 0,004). La correlación fue significativa (ρ = 0,822; p < 0,0001), con SpO2 = 4,427 + 0,97 SaO2. La media de la concordancia era del 1,14% (intervalo de confianza del 95%, 0,381-1,899%); la media menos 1,96 DE era del ­-2,93%, y más 1,96 DE, del 5,21%. Conclusiones: La determinación transcutánea de anhídrido carbónico y de la SaO2 es de utilidad en pacientes con enfermedad respiratoria hospitalizados, dada su buena correlación y concordancia, aunque la SpO2 tiende a sobrevalorar la SaO2

Objective: To evaluate the usefulness of transcutaneous carbon dioxide pressure (TcPCO2) monitoring in patients hospitalized for respiratory disease. Patients and methods: We used a SenTec TcPCO2 monitor that also determines transcutaneous oxygen saturation (SpO2) by means of a sensor placed behind the ear lobe at a temperature of 42ºC. We compared arterial blood gas measurements--PaCO2 and arterial oxygen saturation (SaO2)--with transcutaneous measurements and analyzed the correlation, regression line, and agreement between the 2 methods. Results: Thirty patients (20 men and 10 women) with various respiratory diseases and a mean (SD) age of 71 (13) years were included in the study. The median TcPCO2 was 43.25 mm Hg and the median PaCO2 was 42.6 mm Hg with no significant differences between the 2 measurements. The correlation was significant (ρ=0.979; P<.0001) and the corresponding regression equation was TcPCO2=­-2.475+1.058 PaCO2. The mean difference was 0.16 mm Hg (95% confidence interval [CI], ­-0.74 to 1.06). The lower limit of agreement (mean ­-1.96 SD) was ­-4.64 mm Hg, and the upper limit (mean +1.96 SD) was 4.96 mm Hg. For SaO2, the median was 94% and for SpO2, 95%. The difference between the 2 medians was significant (P<.004). The correlation was also significant (ρ=0.822; P<.0001) with SpO2=4.427+0.97 SaO2. The mean difference was 1.14% (95% CI, 0.381% to 1.899%). The lower limit of agreement (mean ­1.96 SD) was ­-2.93% and the upper limit (mean +1.96 SD) was 5.21% Conclusions: Transcutaneous determination of carbon dioxide pressure and oxygen saturation is useful for patients hospitalized for respiratory disease in view of its good correlation and agreement, although SpO2 does tend to overestimate SaO2

[Intimal sarcoma of the pulmonary artery: a rare cause of pulmonary hypertension]. / Sarcoma intimal de arteria pulmonar: una causa infrecuente de hipertensión pulmonar.

Intimal sarcoma of the pulmonary artery is a rare tumor that is usually diagnosed during surgery or autopsy. Such tumors are characterized by local growth, with only slight ability to metastasize. Diagnosis is difficult and often delayed owing to the nonspecific nature of the symptoms. Since intimal sarcoma of the pulmonary artery is so rare and insidious it is often confused with pulmonary thromboembolism and is therefore treated inappropriately with prolonged anticoagulation or thrombolysis. With a mean survival of 12 months from the onset of symptoms, the prognosis is poor. We present the case of a woman who was preoperatively diagnosed with intimal sarcoma of the pulmonary artery and who underwent surgical resection with no apparent recurrence at long term follow-up. A review of the literature is also included.

Sarcoma intimal de arteria pulmonar: una causa infrecuente de hipertensión pulmonar / Intimal sarcoma of the pulmonary artery: a rare cause of pulmonary hypertension

El sarcoma intimal de la arteria pulmonar es un tumor infrecuente que habitualmente se diagnostica en el acto quirúrgico o la autopsia. Por lo general crece regionalmente, con poca capacidad de metastatizar. El diagnóstico es difícil y con frecuencia se retrasa debido a la naturaleza inespecífica de los síntomas. Su baja frecuencia y el crecimiento insidioso hacen que a menudo se confunda con una tromboembolia pulmonar, y por ello se trata inadecuadamente con anticoagulación prolongada o trombólisis. El pronóstico es malo, con una media de supervivencia de 12 meses desde el inicio de los síntomas. Presentamos el caso de una paciente a quien se diagnosticó preoperatoriamente un sarcoma intimal de la arteria pulmonar que se sometió a resección quirúgica, sin que se evidenciase recurrencia en el seguimiento a largo plazo. También se realiza una revisión de la bibliografía

Intimal sarcoma of the pulmonary artery is a rare tumor that is usually diagnosed during surgery or autopsy. Such tumors are characterized by local growth, with only slight ability to metastasize. Diagnosis is difficult and often delayed owing to the nonspecific nature of the symptoms. Since intimal sarcoma of the pulmonary artery is so rare and insidious it is often confused with pulmonary thromboembolism and is therefore treated inappropriately with prolonged anticoagulation or thrombolysis. With a mean survival of 12 months from the onset of symptoms, the prognosis is poor. We present the case of a woman who was preoperatively diagnosed with intimal sarcoma of the pulmonary artery and who underwent surgical resection with no apparent recurrence at long term follow-up. A review of the literature is also included

[Bronchioloalveolar adenoma associated with bronchiolitis obliterans and leishmaniasis with lung involvement in acquired immunodeficiency syndrome]. / Adenoma bronquioloalveolar asociado a bronquiolitis obliterante y leishmaniasis pulmonar en el sida.

Visceral leishmaniasis is not unusual in patients with acquired immunodeficiency syndrome (AIDS), but lung infiltration is uncommon. Leishmaniasis involving the lung often manifests as interstitial pneumonitis. We report a case in which the discovery of amastigotes in the transbronchial biopsy led to a diagnosis of leishmaniasis. However, the findings from x-rays and study of the bronchoalveolar lavage fluid were consistent with bronchiolitis obliterans, possibly caused by the AIDS virus. In addition, the transbronchial biopsy findings were consistent with a diagnosis of bronchioloalveolar adenoma with radiographic evidence of multiple nodules.

Adenoma bronquioloalveolar asociado a bronquiolitis obliterante y leishmaniasis pulmonar en el sida / Bronchioloalveolar adenoma associated with bronchiolitis obliterans and leishmaniasis with lung involvement in acquired immunodeficiency syndrome

La leishmaniasis visceral no es inusual en pacientes con síndrome de inmunodeficiencia adquirida (sida), pero su afectación pulmonar es infrecuente. La leishmaniasis pulmonar a menudo se presenta como neumonitis intersticial. Describimos un caso en el cual el hallazgo de amastigotes en la biopsia transbronquial permitió el diagnóstico de leishmaniasis pulmonar. Sin embargo, los hallazgos radiológicos y del lavado broncoalveolar eran compatibles con una bronquiolitis obliterante que podría deberse al virus del sida. Además, la biopsia transbronquial permitió diagnosticar un adenoma bronquioloalveolar con la presencia radiológica de múltiples nódulos

Visceral leishmaniasis is not unusual in patients with acquired immunodeficiency syndrome (AIDS), but lung infiltration is uncommon. Leishmaniasis involving the lung often manifests as interstitial pneumonitis. We report a case in which the discovery of amastigotes in the transbronchial biopsy led to a diagnosis of leishmaniasis. However, the findings from x-rays and study of the bronchoalveolar lavage fluid were consistent with bronchiolitis obliterans, possibly caused by the AIDS virus. In addition, the transbronchial biopsy findings were consistent with a diagnosis of bronchioloalveolar adenoma with radiographic evidence of multiple nodules

Diagnóstico y tratamiento de las enfermedades pulmonares intersticiales difusas / Diagnosis and treatment of diffuse interstitial lung diseases

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Clinical characteristics and response to newer quinolones in Legionella pneumonia: a report of 28 cases.

Twenty-eight (11.6%) out of 241 Spanish patients enrolled in an international phase III clinical trial of mild to moderate community-acquired pneumonia (CAP) comparing gemifloxacin vs. trovafloxacin were diagnosed of Legionnaires' disease. A definite diagnosis was established by seroconversion in 13 patients of whom only 2 had a positive Legionella urinary antigen. The remaining 15 patients were possible Legionella infections based on a single elevated IgG titer (> or = 1:512). All patients had a radiologically confirmed diagnosis of pneumonia, 5 (19%) patients were older than 65, comorbidity was present in 9 (33%), and 10 (36%) had to be hospitalized. Fifteen patients were treated with oral gemifloxacin (320 mg/day) and 13 with oral trovafloxacin (200 mg/day). Overall, clinical success occurred in 25 (89.3%) patients after 7 days of treatment and only 1 patient needed a 14-day treatment. There were only one adverse event withdrawal and one clinical failure, and no patients died. In light of the favorable clinical outcome, the use of newer fluoroquinolones seems adequate for the treatment of suspected or proven Legionella pneumonia.

Community-acquired pneumonia in the elderly: Spanish multicentre study.

Community-acquired pneumonia (CAP) in the elderly has increased as a consequence of an overall increase of the elderly population. A controversy about the aetiology and outcome of CAP in this population still exists and more epidemiological studies are needed. A prospective, 12-month, multicentre study was carried out to assess the clinical characteristics, aetiology, evolution and prognostic factors of elderly patients (> or = 65 yrs) admitted to hospital for CAP. The study included 503 patients (age 76 +/- 7 yrs). The clinical picture lasted < or = 5 days in 318 (63%) and the main clinical features were cough (n = 407, 81%) and fever (n = 380, 76%). Aetiological diagnosis was achieved in 199 (40%) cases, with a definite diagnosis obtained in 164 (33%). Of the 223 microorganisms isolated the main agents found were Streptococcus pneumoniae in 98 (49%) and Haemophilus influenzae in 27 (14%). A total of 53 patients died (11%) and the multivariate analysis showed the following factors of bad prognosis: previous bed confinement, alteration in mental status, absence of chills, plasma creatinine > or = 1.4 mg x dL(-1), oxygen tension in arterial blood/inspiratorv oxygen fraction ratio < 200 at the time of admission, and shock and renal failure during the evolution. The results of this study may aid in the management of empiric antibiotic treatment in elderly patients with community-acquired pneumonia and the patients who have a greater probability of bad evolution may be identified based on the risk factors.

Necesidad del tratamiento directamente observado en la tuberculosis / the need for directly observed treatment of tuberculosis

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Serological response (Western blot) to fractions of Mycobacterium tuberculosis sonicate antigen in tuberculosis patients and contacts.

OBJECTIVE: To assess the serological response to fractions of Mycobacterium tuberculosis sonicate antigen by Western blot analysis in patients with tuberculosis and contacts. METHODS: We studied 71 individuals including 43 patients with active tuberculosis, 16 contacts and 12 healthy blood donors. For Western blot analysis, M. tuberculosis (H37Rv strain) sonicate antigen extract was fractionated by electrophoresis on polyacrylamide gel (SDS-PAGE). RESULTS: We obtained antibody responses directed against four antigenic fractions with molecular weights of 71, 65, 26-38 and 19 kDa. Sixty per cent of pleural tuberculosis and 52.4% of smear-positive pulmonary tuberculosis had whole responses against all four fractions; there were no partial responses in these groups. For patients with smear-negative pulmonary tuberculosis whole responses were 17.6% and partial responses 41.2%. All contacts whose tuberculin tests converted from negative to positive (three cases) reacted exclusively against the 19 kDa fraction. CONCLUSIONS: Western blot-positive results in patients with pleural and smear-positive pulmonary tuberculosis were characterised by a whole pattern against all four antigenic fractions, whereas patients with smear-negative pulmonary tuberculosis showed heterogeneous results. The exclusive response against the 19 kDa fraction observed in contacts with tuberculin conversion could help to identify candidates for preventive therapy.

[Lobar emphysema due to bronchial atresia associated with a bronchogenic cyst]. / Enfisema lobar por atresia bronquial asociada a quiste broncogénico.

We report a case of bronchial atresia in the apical segment of right down lobule associated to subcarinal bronchogenic cyst in an eighteen years old patient who consults by long time bronchitis. The thorax X-ray shows an image suggested of mucoid impaction. The respiratory function tests are not essential for the diagnostic. The fiber bronchoscopy is normal and the diagnostic is established by mean image technics (thoracic HR-TC and MR).

Enfisema lobar por atresia bronquial asociada a quiste broncogénico / Lobar emphysema by bronchail atresia associated in bronchogenic cyst

Presentamos un caso de atresia bronquial en el segmento apical de lóbulo inferior derecho asociada a quiste broncogénico subcarinal en un paciente de 18 años que consulta por bronquitis de larga duración. La radiografía simple de tórax muestra una imagen sugestiva de impacto mucoso. La exploración funcional respiratoria no aporta datos para el diagnóstico. La fibrobroncoscopia es normal y el diagnóstico se establece mediante técnicas de imagen (TC-AR y RM torácicas) (AU)

Mortality from tuberculosis in Spain from 1970 to 1993: changes in epidemiological trends during the acquired immune-deficiency syndrome epidemic.

SETTING: Spain has the highest rates in Europe of the acquired immune-deficiency syndrome (AIDS), and probably a high rate of dual human immunodeficiency virus (HIV)/tuberculosis infection. OBJECTIVE: To determine the trends of tuberculosis mortality in Spain from 1970 to 1993, and to draw conclusions about the effects of the AIDS epidemic on these trends. DESIGN: Official population figures and data on deaths from tuberculosis were used to calculate specific tuberculosis mortality rates by age and sex (per 100000 population). Causes of death from tuberculosis were grouped according to the International Classification of Diseases. RESULTS: The crude death rate decreased from 10.28 to 1.84, with an annual mean decrease of 8.1% (95% confidence interval 7.5% to 8.7%). No changes in mortality from tuberculosis of the central nervous system (CNS) have been recorded since 1982, and none in mortality from other tuberculosis and in the age group 20-49 years since 1986. Mortality was higher among males and in the older age groups. The peak observed in the 1970s, due to the excess of deaths from CNS tuberculosis in children under the age of 5 years, has disappeared. CONCLUSION: Between 1970 and 1993, tuberculosis mortality in Spain decreased, although an excess of deaths occurred in young adults and from extra-pulmonary tuberculosis, coinciding with the AIDS epidemic.

[Tuberculosis in AIDS patients: the contribution of an analysis of the restriction fragment length polymorphism of Mycobacterium tuberculosis isolates]. / Tuberculosis en pacientes con SIDA: aportación del análisis de los fragmentos de restricción de longitud polimórfica aislados de Mycobacterium tuberculosis.

BACKGROUND: In this report we study tuberculosis transmission in HIV infected patients using molecular epidemiological methods. PATIENTS AND METHODS: We have studied 60 M. tuberculosis isolates from 30 HIV infected cases, and their clinical-epidemiological data. Susceptibility to tuberculostatic agents and electrophoretic patterns using RFLPs (restriction fragment length polymorphisms) method were evaluated. Dice's coefficient was used for the similarity analysis. RESULTS: Over 73% studied patients were included in clusters using RFLPs analysis. This data show that nearly 60% of the tuberculosis cases in our area have a recent transmission. Forty per cent of these cases were included in the main cluster. The frequency of tuberculostatic-resistant strains in HIV infected patients was similar to the that of observed in other patients. We did not find correlation between RFLPs clusters and clinical-epidemiological data. CONCLUSIONS: Tuberculosis transmission in HIV-positive patients using RFLPs as molecular marker shows that 60% of the cases are caused by recently acquired strains. We did not find multi-drug resistant strains in our isolates. However due to the high transmissibility of these circulating clones, control disease measures in this group of risk population are required.