[Management of chronic cough in high volume medical offices: efficacy of a sequential protocol]. / Manejo de la tos crónica en consultas de alta demanda: eficacia de un protocolo secuencial.

INTRODUCTION: Chronic cough is one of the main causes of medical consultation. There is not however an homogeneous attitude regarding its management. A prospective evaluation was performed of a simple therapeutic protocol based on the anatomical approach of the cough reflex. METHODS: A total of 110 patients with chronic cough for longer than four weeks were studied. The exclusion criteria were: non-smoking during the last year, not to have diseases compromising the immune system and not to have received inhibitors of the angiotensing converting enzyme. A three-visit stepwise approach was performed with specific diagnostic tests ordered and a specific therapy instituted according to the clinical suspicion. RESULTS: At the third visit, 97% of patients were free from cough or had improved markedly. Cough causes were identified in 105 cases (95%) and the most common were: asthma (33%), postnasal dripping (29%), gastroesophageal reflux (10%), and asthma with associated gastroesophageal reflux (16%). Patients with asthma had a longer duration of tos compared with those who had postnasal dripping (p < 0.05) as the only differential feature. CONCLUSIONS: The diagnostic-therapeutic diagram based on the anatomic reflex of cough is useful for the management of chronic cough in a highly demanded medical office. With this protocol, the cause of cough can be identified and treated successfully in almost every patient with a small number of diagnostic tests and medical visits.

Manejo de la tos crónica en consultas de alta demanda: eficacia de un protocolo secuencial / Management of chronic cough in highly demanded medical offices: efficacy of a sequential protocol

Introducción. La tos crónica es una de las principales causas de consulta médica; no existe, sin embargo, una actitud homogénea respecto a su manejo. Evaluamos de forma prospectiva un sencillo protocolo de tratamiento basado en la aproximación anatómica del reflejo de la tos. Métodos. Se estudiaron 110 pacientes que padecían tos crónica por más de cuatro semanas y los siguientes criterios de exclusión: no fumar en el último año, no padecer enfermedades que comprometen la inmunidad y no recibir inhibidores de la enzima de conversión de la angiotensina. Se realizó una aproximación 'paso a paso' consistente en tres visitas en las que se solicitaron pruebas diagnósticas y se instituyó un tratamiento específico de acuerdo con la sospecha clínica. Resultados. A la tercera visita el 97 por ciento de los pacientes estaba sin tos o había mejorado de forma notable. Las causas de la tos se identificaron en 105 casos (95 por ciento), siendo las más comunes: asma (33 por ciento), síndrome de goteo postnasal (29 por ciento), reflujo gastroesofágico (10 por ciento) y asma con reflujo gastroesofágico asociado (16 por ciento). Los pacientes con asma presentaron una mayor duración de la tos en comparación con los que presentaron goteo postnasal (p < 0,05) como única característica diferencial. Conclusiones. El diagrama diagnóstico-terapéutico basado en la anatomía del reflejo de la tos es útil para el manejo de la tos crónica en una consulta de alta demanda. Con este protocolo la causa de la tos puede ser identificada y tratada con éxito en casi todos los pacientes con un reducido número de pruebas diagnósticas y visitas médicas (AU)

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[Fulminant pneumonia caused by Streptococcus milleri: rare or not diagnosed?]. / Neumonía de curso fulminante causada por Streptococcus milleri: infrecuente o no diagnosticada?

Streptococcus milleri is increasingly isolated in laboratory samples and is worthy of consideration as a differential diagnosis in pyogenic infections, particularly in adults with underlying infections. We describe a well-documented case of pleuropulmonary infection in a young man with no known risk factors. We analyze the diversity of microbiological features of these bacteria in culture, as well as their clinical importance as pathogens.

[Alveolar recruitment under high-pressure transpulmonary inflation. An experimental morphometric study]. / Reclutamiento alveolar por insuflación transpulmonar a alta presión. Estudio morfométrico experimental.

We describe an experimental study in which morphometric techniques are used to question traditional conceptions about the behavior of the alveolus under changes in pressure. An increase in inflation pressure in the lung results in alveolar recruitment (an increase in distal air spaces) due to stretching of its walls. To test this hypothesis, the lungs of rats were filled to 25 to 35 cm water pressure. Lungs filled to a higher pressure were expected to present a decrease in alveolar size along with thinning of its walls, and an increase of internal perimeter of the alveolus with no change in amount of tissue. Morphometric data were processed by computer and results were analyzed by statistical tests. The lungs of 10 Wistar rats were examined under light microscope. The following variables were recorded: mean linear intersection (Lm), alveolar cord, wall thickness, internal alveolar perimeter and tissue percentage. Lower Lm in lungs filled to 35 cm water pressure allows us to consider that the number of alveoli increased; lower Lm and alveolar cord indicate that alveolar size is smaller; alveolar wall thickness decreased; internal alveolar perimeter increased. All these differences were statistically significant (p < 0.001), tissue percentage being the only variable that did not change significantly. All results lead us to consider that an increase in lung inflation pressure leads to alveolar recruitment and stretching of its walls.

[Isolation of M. tuberculosis in abdominal specimens]. / Aislamiento de M. tuberculosis en muestras de origen abdominal.

The isolation of mycobacteria in abdominal specimens during a 10 years period is presented. Twenty-three clinical cases have been reviewed; patients were divided in three groups: 1) Peritoneal and intestinal tuberculosis. 2) Pulmonary tuberculosis with isolation of M. tuberculosis in feces, and 3) Miliary tuberculosis. We emphasize the low yielding of bacilloscopy, the low number of colonies in cultures and the importance of the microbiological study of abdominal specimens in the confirmatory diagnosis. The predominant symptoms of peritoneal tuberculosis were abdominal pain and distention and fever. The study of the ascitic fluid showed in most of the cases lymphocytic exudate and the pathological study of biopsies showed granulomas with caseous necrosis. Three patients had another associated abdominal disease. Isolation of M. tuberculosis in feces does not invariably mean the presence of intestinal tuberculosis. We confirm the frequent association of disseminated tuberculosis and HIV1 infection.