Datos de remisión y manejo de una población oncológica a una unidad de dolor. ¿Qué podemos mejorar? / Review of the remission and management of a cancer related pain population to a pain unit. What can we improve?

Objetivos: Determinar las características demográficas, clínicas y de manejo analgésico de una población con dolor oncológico remitida a nuestra unidad de dolor (UD). Descripción de su manejo clínico una vez recibidos en la unidad. Detectar aspectos de mejora.Material y métodos: Estudio retrospectivo y descriptivo, realizado durante un periodo de 23 meses, entre noviembre de 2019 y diciembre de 2021, de todos los pacientes oncológicos derivados a la UD, cuya causa de derivación fuera dolor de origen oncológico.Resultados: Se analizaron 78 pacientes, el 63,2 % hombres y el 46,8 % mujeres. La edad media poblacional fue de 64,84 ± 12,623 años. El 44,7 % fueron remitidos por servicios quirúrgicos. El 75 % presentaba dolor moderado o severo. Los tumores más frecuentes fueron los abdominales (31,6 %), y cabeza y cuello (22,4 %). La causa del dolor fue en 48,7 % de los casos de la infiltración tumoral y en un 60,5 % un dolor de origen de mixto. En el momento de la remisión el 60 % de los pacientes recibía opioides mayores, con una dosis de equivalentes diarios de morfina (EDM) de 163,57 ± 167,10 mg y el 38 % recibía antineuropáticos. El tiempo medio para atender a estos pacientes desde el momento de solicitarla fue de 9,18 ± 9,73 días. Se realizó intervencionismo menor en el 56,6 % (43) de los pacientes y mayor en el 2,6 % (2). Se inició en la UD el tratamiento con fármacos antineuropáticos en el 68,4 % de los casos. Tras el manejo en la UD, un 72,4 % de los pacientes refirieron mejoría del dolor.Conclusiones: Mejorar la tasa de remisión de pacientes desde servicios como Oncología médica y Atención primaria. Mejorar los tiempos de remisión a las unidades de dolor. Ajustar mejor los tratamientos analgésicos antes de la remisión. Generar un protocolo de remisión sencillo de pacientes que incluyan pautas básicas de manejo del dolor. Mejorar el diagnóstico de dolor neuropático. Aumentar la cartera de servicios de intervencionismos de la UD....(AU)

Aim: Studying the demographic profile, clinical characteristics and analgesic management of an oncologic population sent to our pain unit. To describe the pain management in our unit. To detect management aspects to be improved.Methodology: Retrospective and descriptive study, performed in a period of 23 months, between November 2019 and December 2021, of all patients sent to our pain unit for cancer pain management.Results: A total of 78 patients were analyzed, 63,2 % men and 46,8 % women. The average age was 64,84 ± 12,623 years. 44,7 % were sent by surgical services. In 75% the pain was moderate or severe. The main cancer location was abdominal (31,6 %), and head and neck (22,4 %). In 48,7 % the pain was originated by tumoral infiltration and in 60,5 % the pain was judged to be mixed. At the moment of the arrival 60 % of patients were on opioids, with an average dose of 163,57 ± 167,10 mg EDM and 38 % were on antineurophatic drugs. The average time to attend the patients from the moment or request was 9,18 ± 9,73 days. A minor interventional procedure was performed in 56,6 % (43) of the patients, and a major intervention in 2,6 % (2). We started antineurophatic drugs in 68,4 % of the cases. During the period of pain management in our unit a 72,4% of the patients referred an improvement of their cancer related pain.Conclusions: It is necessary to improve the rate of remission from medical oncology departments and primary care physicians. To reduce the remission time to our unit from the referral services. To improve analgesic management before referral. To create an easy protocol for remission of patients that includes basic pain management instructions. To improve the rate of neuropathic pain diagnosis before referral. To expand our interventional technics portfolio. Pain units can improve cancer related pain management. To create multidisciplinary cancer pain comities.(AU)

Plan Universitario de Formación en Dolor de la Sociedad Española del Dolor / No disponible

No disponible

Rotura de aneurisma ilíaco durante el precondicionamiento con levosimendán previo a cirugía de revascularización coronaria / Iliac aneurysm rupture during preconditioning with levosimendan for coronary artery bypass graft

Presentamos el caso de un paciente de 77 años programado para cirugía de revascularización coronaria. Coincidiendo con la infusión de levosimendán como precondicionamiento previo a la cirugía, se produjo la rotura de un aneurisma ilíaco derecho, lo que obligó a suspender la intervención y realizar un bypass aortobifemoral urgente. Creemos que esta rotura pudo verse precipitada por el incremento de la presión transmural debida al efecto inotrópico del levosimendán sobre un vaso dilatado y aterosclerótico. Por lo que sabemos, no existe ningún caso de rotura de aneurisma como complicación durante la infusión de levosimendán, pero la coincidencia de acontecimientos en el tiempo nos hace pensar en cierta relación causa-efecto (AU)

We present the case of a 77-year-old patient scheduled for coronary artery bypass. During the infusion of levosimendan as preconditioning for surgery, the break of an aneurysm took place iliac rightly, which forced to suspend the intervention and to fulfil an urgent bypass aortobyfemoral. We believe that this break could turn precipitated by the increase of the pressure transmural owed to the effect inotropic of the levosimendan on an extensive glass and aterosclerotic. For what we know, there does not exist any case of break of aneurysm as complication during the infusion of levosimendan, but the coincidence of events in the time makes us think about certain cause and effect relationship (AU)

[Iliac aneurysm rupture during preconditioning with levosimendan for coronary artery bypass graft]. / Rotura de aneurisma ilíaco durante el precondicionamiento con levosimendán previo a cirugía de revascularización coronaria.

We present the case of a 77 year-old patient scheduled for coronary artery bypass. During the infusion of levosimendan as preconditioning for surgery, a rupture of right common iliac artery occurred. Surgery was delayed and an urgent aorto-bifemoral bypass was performed. We believe that the rupture of the artery was triggered by an increase in transmural pressure due to the inotropic effects of levosimendan in a dilated diseased vessel. To our knowledge, there are no cases of aneurysm rupture as a complication during levosimendan infusion, but the coincidence of events in time strongly suggests some kind of causal relationship.

Dolor en el suelo pélvico. Aproximación analgésica / No disponible

No disponible

[Evaluation of 2 invasive techniques for treating myofascial pain]. / Evaluación de dos técnicas invasivas en el tratamiento del dolor miofascial.

OBJECTIVE: To assess the efficacy of 2 invasive techniques for treating myofascial pain: trigger point acupuncture and 1% lidocaine infiltration of trigger points. MATERIAL AND METHODS: Patients who met the inclusion criteria were randomized to 2 groups for evaluation at our pain clinic over a period of 7 months. Each patient had 4 treatment sessions. Response was evaluated on a visual analog scale (VAS) and by means of the Lattinen test. RESULTS: Twenty-one patients were enrolled. Eleven underwent acupuncture and 10 received lidocaine infiltrations. When post-treatment pain was assessed, the mean (SD) VAS scores fell from 5.50 (2.08) to 2.45 (2.05) in the acupuncture group and from 4.8 (2.03) to 2.2 (1.91) in the lidocaine group. Lattinen test scores also fell, from 10.63 (2.69) to 8.54 (3.14) in the acupuncture group and from 10.9 (1.59) to 8.60 (2.63) in the lidocaine group. There were no statistically significant differences between the 2 treatment groups. CONCLUSION: Both acupuncture and lidocaine infiltration of trigger points were effective in reducing pain intensity after treatment and in improving quality of life. One method could not be shown to be better than the other for treating myofascial pain.

Réplica a la carta de V.L. Villanueva / No disponible

No disponible

Evaluación de dos técnicas invasivas en el tratamiento del dolor miofascial / Evaluation of 2 invasive techniques for treating myofascial pain

OBJETIVO: Evaluar la eficacia de dos técnicas invasivasen el tratamiento del dolor miofascial: punción depuntos gatillo con aguja de acupuntura e infiltración delos mismos con lidocaína al 1%.MATERIAL Y MÉTODOS: Se distribuyó a los pacientesaleatoriamente en ambos grupos, de los evaluados duranteun periodo de 7 meses en la Unidad del Dolor y quecumplían los criterios de inclusión. Se practicaron cuatrosesiones por paciente, evaluando la respuesta mediante laEscala Visual Analógica (EVA) y el test de Lattinen.RESULTADOS: Se incluyeron 21 pacientes. Once fueronpinchados con aguja de acupuntura y 10 se infiltraroncon lidocaína. Se objetivó una disminución en la puntuaciónen la EVA al final de ambos tratamientos. Los valoresfueron 5,50 ± 2,08 disminuyendo a 2,45 ± 2,05 en elgrupo acupuntura, y 4,8 ± 2,03 disminuyendo a 2,20 ±1,91 en el grupo lidocaína. También se redujo la puntuaciónen el test de Lattinen de 10,63 ± 2,69 a 8,54 ± 3,14con aguja de acupuntura y de 10,9 ± 1,59 a 8,60 ± 2,63con lidocaína. No hubo diferencias estadísticamente significativaen ambas escalas (visual analógica y test deLattinen) entre ambas técnicas.CONCLUSIÓN: Tanto la punción con aguja de acupunturacomo la infiltración con lidocaína demostraron sereficaces en la disminución de la intensidad del dolor alfinal del tratamiento, así como en su influencia en lacalidad de vida, no pudiendo determinar en este grupode pacientes que un método sea superior a otro en el tratamientodel dolor miofascial(AU)

OBJETIVE: To assess the efficacy of 2 invasivetechniques for treating myofascial pain: trigger pointacupuncture and 1% lidocaine infiltration of triggerpoints.MATERIAL AND METHODS: Patients who met theinclusion criteria were randomized to 2 groups forevaluation at our pain clinic over a period of 7 months.Each patient had 4 treatment sessions. Response wasevaluated on a visual analog scale (VAS) and by meansof the Lattinen test.RESULTS: Twenty-one patients were enrolled. Elevenunderwent acupuncture and 10 received lidocaineinfiltrations. When post-treatment pain was assessed,the mean (SD) VAS scores fell from 5.50 (2.08) to 2.45(2.05) in the acupuncture group and from 4.8 (2.03) to2.2 (1.91) in the lidocaine group. Lattinen test scoresalso fell, from 10.63 (2.69) to 8.54 (3.14) in theacupuncture group and from 10.9 (1.59) to 8.60 (2.63) inthe lidocaine group. There were no statisticallysignificant differences between the 2 treatment groups.CONCLUSION: Both acupuncture and lidocaineinfiltration of trigger points were effective in reducingpain intensity after treatment and in improving qualityof life. One method could not be shown to be better thanthe other for treating myofascial pain(AU)

Ketamina en el dolor del miembro fantasma / Ketamine and phantom limb pain

El dolor en miembro fantasma es una de las principales complicaciones a largo plazo tras la amputación de un miembro. Entre las opciones disponibles y que cuentan con respaldo bibliográfico de casos puntuales, se encuentra el uso de la ketamina. Se presenta el caso de un varón de 65 años, con dolor en miembro fantasma desde hacia10 años, con respuesta parcial a los anticonvulsionantes y antidepresivos. El paciente refería un dolor basal de 4, medido con la escala visual analógica, y episodios frecuentes de dolor lancinante de 10. El índice de Lattinen tenía un valor de 12 y, además, el paciente estaba deprimido y con afectación de su vida familiar. Ante esta situación decidimos, tras revisar la bibliografía, citarlo para perfusión continua intravenosa de ketamina. Evaluamos al paciente a la semana, a los 3 y a los 6 meses con un EVA a los 6 meses de 0en reposo y con disminución de los episodios de dolor lancinante menos de 2 a la semana, con un EVA en estos episodios de 6, Lattinen de 5 y mejoría del estado de ánimo (AU)

Phantom limb pain is one of the main long-term complications of amputation. Among the available options that have been reported in sporadic cases in the literature is the use of ketamine. We present the case of a 65-year-old man with phantom limb pain for 10 years and partial response to anticonvulsants and antidepressants. The patient reported a baseline visual analog scale (VAS) pain score of 4 and frequent episodes of lancinating pain with a score of 10. The Lattinen index was 12. The patient was depressed with repercussions on his family life. After reviewing the literature, we decided to administer continuous intravenous ketamine perfusion. The patient was evaluated at 1 week, at 3 months and at 6 months. VAS score at 6 months was 0 with the patient at rest and the number of episodes of lancinating pain was reduced to two per week, with a VAS score of 6, Lattinen index of 5, and improvement in the patient’s mood (AU)

Usos clínicos de la metadona / Clinical uses of methadone

La metadona es un opioide sintético agonista total en receptores micro, y antagonista de los receptores NMDA. Es altamente liposoluble, con una vida media de unas 23 horas, pudiendo variar entre 13 y 54 horas. Es un isómero óptico, cuya forma L es la responsable de la mayor actividad analgésica. Este fármaco ha sido utilizado satisfactoriamente desde hace años para el tratamiento sustitutivo de pacientes drogodependientes, sin embargo, su utilización como analgésico es menos generalizada, a pesar de su perfil farmacológico que podría ser beneficioso en este aspecto. Teniendo esto en cuenta, hemos revisado las principales aplicaciones terapéuticas de la metadona, y su implicación tanto en el dolor agudo como en el dolor crónico. La metadona es una alternativa atractiva para el tratamiento del dolor oncológico y neuropático, dada su buena disponibilidad oral, su larga vida media con escasas dosis diarias y su bajo coste. Las vías intravenosa, intradural, y epidural, se han mostrado eficaces y seguras para el tratamiento del dolor posoperatorio

Methadone is a synthetic opioid that is primarily a micro-opioid agonist, but also a NMDA-antagonist. It is highly liposoluble and has an average lifee in blood of approximately 23 hours, although it can vary from 13 to 54 hours. It is an optical isomer, where l-methadone is the primarily responsible factor for the analgesic effect. Methadone has successfully been used for many years for the treatment of dependence on opioid drugs. However, it has been less used as an analgesic, in spite of its useful pharmacolog ic profile. Bearing this in mind, we have reviewed the main therapeutic uses of methadone, and its effectiveness in treating both acute and chronic pain. Methadone is an attractive alternative for the treating cancer and neuropathic pain, because of its good oral bioavailability, its long average lHe at low daily doses and its oral bioavailability, its long average life at low daily doses and its low cost. Intravenous, intrathecal and epidural viae have shown to be effective and safe for the treatment of postoperative pain

Inflammatory response associated with pulmonary complications in non-HIV immunocompromised patients.

BACKGROUND: A study was undertaken to evaluate the local and systemic inflammatory response associated with pulmonary complications in immunocompromised patients and potential implications regarding severity and prognosis. METHODS: Levels of different inflammatory mediators were measured in the bronchoalveolar lavage (BAL) fluid and serum on days 1 and 4 after the identification of the pulmonary complication in 127 patients with different immunosuppressive conditions. RESULTS: Pulmonary complications were characterised by a high percentage of neutrophils and increased levels of tumour necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-8 and IL-10 in the BAL fluid and high serum levels of TNF-alpha, IL-6, and plasma C-reactive protein (CRP). The inflammatory response was similar in the different groups of immunocompromised patients evaluated. The levels of proinflammatory cytokines were higher in patients with pulmonary infections, particularly those of bacterial aetiology. Patients with a more severe pulmonary infection had a more intense local and systemic inflammatory response. A BAL fluid IL-6 level of >40 pg/ml was an independent predictor of mortality (OR 4.65, 95% CI 1.3 to 16.1), together with a need for mechanical ventilation (OR 13.5, 95% CI 3.2 to 57.3). Patients who died had persistently high levels of CRP on day 4. CONCLUSIONS: The evaluation of the inflammatory response, particularly the determination of IL-6 levels in the BAL fluid and CRP in the serum, may be useful for deciding the appropriate management of pulmonary complications in immunocompromised patients.

Factors associated with unknown aetiology in patients with community-acquired pneumonia.

Despite comprehensive diagnostic work-up, the aetiology of community-acquired pneumonia (CAP) remains undetermined in 30-60% of cases. The authors studied factors associated with undiagnosed pneumonia. Patients hospitalised with CAP and being evaluated by two blood cultures, at least one valid lower respiratory tract sample, and serology on admission were prospectively recorded. Patients who had received antimicrobial pretreatment were excluded. Patients with definite or probable aetiology were compared to those with undetermined aetiology by uni- and multivariable analysis. A total 204 patients were eligible for the study. The aetiology remained undetermined in 82 (40%) patients, whereas a definite aetiology could be established in 89 (44%) and a probable one in 33 (16%). In multivariable analysis, factors associated with undetermined aetiology included age >70 yrs, renal and cardiac comorbidity, and nonalveolar infiltrates on the chest radiograph. There was no association of undiagnosed pneumonia with mortality. Age and host factors were associated with unknown aetiology of community-acquired pneumonia. Some of these cases may also represent fluid volume overload mimicking pneumonia.

Bacterial colonisation in patients with bronchiectasis: microbiological pattern and risk factors.

BACKGROUND: A study was undertaken to investigate the incidence, diagnostic yield of non-invasive and bronchoscopic techniques, and risk factors of airway colonisation in patients with bronchiectasis in a stable clinical situation. METHODS: A 2 year prospective study of 77 patients with bronchiectasis in a stable clinical condition was performed in an 800 bed tertiary university hospital. The interventions used were pharyngeal swabs, sputum cultures and quantitative protected specimen brush (PSB) bacterial cultures (cut off point > or =10(2) cfu/ml) and bronchoalveolar lavage (BAL) (cut off point > or =10(3) cfu/ml). RESULTS: The incidence of bronchial colonisation with potential pathogenic microorganisms (PPMs) was 64%. The most frequent PPMs isolated were Haemophilus influenzae (55%) and Pseudomonas spp (26%). Resistance to antibiotics was found in 30% of the isolated pathogens. When the sample was appropriate, the operative characteristics of the sputum cultures were similar to those obtained with the PSB taken as a gold standard. Risk factors associated with bronchial colonisation by PPMs in the multivariate analysis were: (1) diagnosis of bronchiectasis before the age of 14 years (odds ratio (OR)=3.92, 95% CI 1.29 to 11.95), (2) forced expiratory volume in 1 second (FEV1) <80% predicted (OR=3.91, 95% CI 1.30 to 11.78), and (3) presence of varicose or cystic bronchiectasis (OR=4.80, 95% CI 1.11 to 21.46). CONCLUSIONS: Clinically stable patients with bronchiectasis have a high prevalence of bronchial colonisation by PPMs. Sputum culture is a good alternative to bronchoscopic procedures for evaluation of this colonisation. Early diagnosis of bronchiectasis, presence of varicose-cystic bronchiectasis, and FEV1 <80% predicted appear to be risk factors for bronchial colonisation with PPMs.

Bronchial inflammation and colonization in patients with clinically stable bronchiectasis.

To evaluate the bronchial inflammatory response and its relationship to bacterial colonization in bronchiectasis, we performed a bronchoalveolar lavage (BAL) in 49 patients in stable clinical condition and in nine control subjects. BAL was processed for differential cell count, quantitative bacteriologic cultures, and measurement of inflammatory mediators. An increase was observed in the percentage of neutrophils (37 [0 to 98]) (median[range]) versus 1[0 to 4]%, p = 0.01), in the concentration of elastase (90.5 [8 to 2,930] versus 34 [9 to 44], p = 0.03), myeloperoxidase (9.1 [0 to 376] versus 0.3 [0.1 to 1.4], p = 0.01), and in the levels of TNF-alpha (4 [0 to 186] versus 0 [0 to 7], p = 0.03), IL-8 (195 [0 to 5,520] versus 3 [0 to 31], p = 0.001), and IL-6 (6 [0 to 115] versus 0 [0 to 3], p = 0.001) in patients with bronchiectasis compared with control subjects. Noncolonized patients showed a more intense bronchial inflammatory reaction than did control subjects. This inflammatory reaction was exaggerated in patients colonized by microorganisms with potential pathogenicity (MPP), with a clear relationship with the bronchial bacterial load. Patients with bronchiectasis showed a slight systemic inflammatory response, with poor correlations between systemic and bronchial inflammatory mediators, suggesting that the inflammatory process was mostly compartmentalized. We conclude that patients with bronchiectasis in a stable clinical condition present an active neutrophilic inflammation in the airways that is exaggerated by the presence of MPP, and the higher the bacterial load the more intense the inflammation.

Neumonía adquirida en la comunidad. Pautas de tratamiento

Al iniciar el tratamiento de una neumonía adquirida en la comunidad (NAC) debemos tener en cuenta los siguientes factores: a) necesidad de hospitalización; b) edad y presencia de comorbilidad, y c) gravedad de la NAC en el momento de establecer el diagnóstico. Una vez definidos estos puntos, se iniciará un tratamiento antibiótico empírico basado en las recomendaciones descritas. Se seguirá el curso evolutivo de estos pacientes con el fin de detectar de forma temprana a aquellos pacientes que sufran un deterioro o que no mejoren con el tratamiento antibiótico administrado.Este último grupo de pacientes debe ser sometido a una profunda revaluación con el objetivo de definir conductas y pautas antibióticas de segunda línea.Por ahora, cada país debe adecuar las normas de la American Thoracic Society (ATS) de acuerdo a su realidad epidemiológica y efectuar estudios que validen prospectivamente la eficacia de aquéllas. (AU)

Pulmonary infiltrates in HIV-infected patients in the highly active antiretroviral therapy era in Spain.

OBJECTIVE: To study the incidence, etiology, and outcome of pulmonary infiltrates (PIs) in HIV-infected patients and to evaluate the yield of diagnostic procedures. DESIGN: Prospective observational study of consecutive hospital admissions. SETTING: Tertiary hospital. PATIENTS: HIV-infected patients with new-onset radiologic PIs from April 1998 to March 1999. METHODS: The study protocol included chest radiography, blood and sputum cultures, serologic testing for "atypical" causes of pneumonia, testing for Legionella urinary antigen, testing for cytomegalovirus antigenemia, and bronchoscopy in case of diffuse or progressive PIs. RESULTS: One hundred two episodes in 92 patients were recorded. The incidence of PIs was 18 episodes per 100 hospital admission-years (95% confidence interval [CI]: 15-21). An etiologic diagnosis was achieved in 62 cases (61%). Bacterial pneumonia (BP), Pneumocystis carinii pneumonia (PCP), and mycobacteriosis were the main diagnoses. The incidences of BP and mycobacteriosis were not statistically different in highly active antiretroviral therapy (HAART) versus non-HAART patients. The incidence of PCP was lower in those receiving HAART (p =.011), however. Nine patients died (10%). Independent factors associated with higher mortality were mechanical ventilation (odds ratio [OR] = 83; CI: 4.2-1,682), age >50 years (OR = 23; CI: 2-283), and not having an etiologic diagnosis (OR = 22; CI: 1.6-293). CONCLUSIONS: Pulmonary infiltrates are still a frequent cause of hospital admission in the HAART era, and BP is the main etiology. There was no difference in the rate of BP and mycobacteriosis in HAART and non-HAART patients. Not having an etiologic diagnosis is an independent factor associated with mortality.

Pulmonary infiltrates in non-HIV immunocompromised patients: a diagnostic approach using non-invasive and bronchoscopic procedures.

BACKGROUND: The development of pulmonary infiltrates is a frequent life threatening complication in immunocompromised patients, requiring early diagnosis and specific treatment. In the present study non-invasive and bronchoscopic diagnostic techniques were applied in patients with different non-HIV immunocompromised conditions to determine the aetiology of the pulmonary infiltrates and to evaluate the impact of these methods on therapeutic decisions and outcome in this population. METHODS: The non-invasive diagnostic methods included serological tests, blood antigen detection, and blood, nasopharyngeal wash (NPW), sputum and tracheobronchial aspirate (TBAS) cultures. Bronchoscopic techniques included fibrobronchial aspirate (FBAS), protected specimen brush (PSB), and bronchoalveolar lavage (BAL). Two hundred consecutive episodes of pulmonary infiltrates were prospectively evaluated during a 30 month period in 52 solid organ transplant recipients, 53 haematopoietic stem cell transplant (HSCT) recipients, 68 patients with haematological malignancies, and 27 patients requiring chronic treatment with corticosteroids and/or immunosuppressive drugs. RESULTS: An aetiological diagnosis was obtained in 162 (81%) of the 200 patients. The aetiology of the pulmonary infiltrates was infectious in 125 (77%) and non-infectious in 37 (23%); 38 (19%) remained undiagnosed. The main infectious aetiologies were bacterial (48/125, 24%), fungal (33/125, 17%), and viral (20/125, 10%), and the most frequent pathogens were Aspergillus fumigatus (n=29), Staphylococcus aureus (n=17), and Pseudomonas aeruginosa (n=12). Among the non-infectious aetiologies, pulmonary oedema (16/37, 43%) and diffuse alveolar haemorrhage (10/37, 27%) were the most common causes. Non-invasive techniques led to the diagnosis of pulmonary infiltrates in 41% of the cases in which they were used; specifically, the diagnostic yield of blood cultures was 30/191 (16%); sputum cultures 27/88 (31%); NPW 9/50 (18%); and TBAS 35/55 (65%). Bronchoscopic techniques led to the diagnosis of pulmonary infiltrates in 59% of the cases in which they were used: FBAS 16/28 (57%), BAL 68/135 (51%), and PSB 30/125 (24%). The results obtained with the different techniques led to a change in antibiotic treatment in 93 cases (46%). Although changes in treatment did not have an impact on the overall mortality, patients with pulmonary infiltrates of an infectious aetiology in whom the change was made during the first 7 days had a better outcome (29% mortality) than those in whom treatment was changed later (71% mortality; p=0.001). CONCLUSIONS: Non-invasive and bronchoscopic procedures are useful techniques for the diagnosis of pulmonary infiltrates in immunocompromised patients. Bronchial aspirates (FBAS and TBAS) and BAL have the highest diagnostic yield and impact on therapeutic decisions.

Reappraisal of the aetiology and prognostic factors of severe acute respiratory failure in HIV patients.

The introduction of highly active antiretroviral therapy with protease inhibitors in 1996 has changed the morbidity and mortality of acquired immune deficiency syndrome patients. Therefore, the aetiologies and prognostic factors of human immunodeficiency virus (HIV)-infected patients with life-threatening respiratory failure requiring intensive care unit (ICU) admission need to be reassessed. From 1993 to 1998, we prospectively evaluated 57 HIV patients (mean+/-SEM age 36.5+/-1.3 yrs) admitted to the ICU showing pulmonary infiltrates and acute respiratory failure. A total of 21 and 30 patients were diagnosed as having Pneumocystis carinii and bacterial pneumonia, respectively, of whom 13 and eight died during their ICU stay (p=0.01). Both groups of patients had similar age, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and severity in respiratory failure. The number of cases with bacterial pneumonia admitted to ICU decreased after 1996 (p=0.05). Logistic regression analysis showed that (APACHE) II score >17, serum albumin level <25 g.(-1), and diagnosis of P. carinii pneumonia were the only factors at entry associated with ICU mortality (p=0.02). Patients with bacterial pneumonia are less frequently admitted to the intensive care unit after the introduction of highly active antiretroviral therapy with protease inhibitors in 1996. Compared to the previous series, it was observed that the few Pneumocystis carinii pneumonia patients that need intensive care still have a bad prognosis.

Role of glucocorticoids on inflammatory response in nonimmunosuppressed patients with pneumonia: a pilot study.

The aim of the study was to assess the potential role of glucocorticoids (GC) in modulating systemic and pulmonary inflammatory responses in mechanically ventilated patients with severe pneumonia. Twenty mechanically ventilated patients with pneumonia treated at a respiratory intensive care unit (RICU) of a 1,000-bed teaching hospital were prospectively studied. All patients had received prior antimicrobial treatment. Eleven patients received GC (mean+/-SD dose of i.v. methylprednisolone 677+/-508 mg for 9+/-7 days), mainly for bronchial dilatation. Serum and bronchoalveolar lavage fluid (BALF) tumour necrosis factor (TNF)-alpha, interleukin (IL)-1beta, IL-6 and C-reactive protein levels were measured in all patients. The inflammatory response was attenuated in patients receiving GC, both systemically (IL-6 1,089+/-342 versus 630+/-385 pg x mL(-1), p=0.03; C-reactive protein 34+/-5 versus 19+/-5 mg x L(-1), p=0.04) and locally in BALF (TNF-alpha 118+/-50 versus 24+/-5 pg x mL(-1), p= 0.05; neutrophil count: 2.4+/-1.1 x 10(9) cells x L(-1) (93+/-3%) versus 1.9+/-1.8 x 10(9) cells x L(-1) (57+/-16%), p=0.03). Four of the 11 (36%) patients receiving GC died compared to six (67%) who were not receiving GC (p=0.37). The present pilot study suggests that glucocorticoids decrease systemic and lung inflammatory responses in mechanically ventilated patients with severe pneumonia receiving antimicrobial treatment.