Toxicidad pulmonar aguda grave secundaria al uso de infliximab biosimilar en un paciente con enfermedad de Crohn / Acute severe pulmonary toxicity due to biosimilar infliximab in a Crohn's disease patient

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Tromboembolismo pulmonar no sospechado en el Servicio de Urgencias / Unsuspected pulmonary thromboembolism in the Emergency Department

Antecedentes y objetivos. El tromboembolismo pulmonar (TEP) es una enfermedad que en ocasiones, se diagnostica con un elevado retraso, lo que puede provocar una mayor morbimortalidad. Hemos definido el perfil clínico de los pacientes con TEP no sospechado en el Servicio de Urgencias, y los factores que influyen en el retraso para establecer el diagnóstico de TEP. Pacientes y métodos. Se analizaron retrospectivamente 148 pacientes ingresados con diagnóstico de TEP confirmado mediante TAC (n=133) o gammagrafía de ventilación/perfusión de alta probabilidad (n=15). Fueron divididos en dos grupos: los que no tenían sospecha diagnóstica de la enfermedad en el Servicio de Urgencias (TEP no sospechado) y aquellos en los que sí se sospechó este proceso (TEP sospechado). Se estudiaron las características clínicas, los factores de riesgo, los signos y los síntomas a su llegada a Urgencias; las pruebas complementarias realizadas, los días de ingreso hospitalario y la mortalidad. Resultados. De los 148 enfermos con TEP, el diagnóstico no se sospechó en el Servicio de Urgencias en 63 pacientes (42,6%). La disnea y el dolor torácico fueron las manifestaciones clínicas más comunes y se identificaron con mayor frecuencia entre los enfermos con TEP sospechado, que entre los pacientes con TEP no sospechado, con diferencias significativas (OR=0,4 [0,2-0,9] para la disnea y OR=0,3 [0,2-0,7], para el dolor torácico). Sin embargo, la presencia asociada de trombopenia (OR=3,4 [1,1-10,2], p<0,05), un electrocardiograma (ECG) normal (OR=3,4 [1,1-10,2], p<0,05), y la localización del TEP en pulmón derecho (OR=4,7 [2-11,3], p<0,001), fueron factores asociados a la no sospecha de la enfermedad. Los días de ingreso y de duración de los síntomas, así como la mortalidad, no fueron estadísticamente diferentes entre ambos grupos. Conclusiones. La proporción de enfermos con TEP confirmado pero no sospechado en el Servicio de Urgencias fue elevada (cerca del 40%). La presencia de disnea y dolor torácico se asociaron a la sospecha de TEP. Por el contrario, la presencia de trombopenia, un ECG normal, y la localización del TEP en el pulmón derecho se asociaron a la no sospecha de TEP en urgencias(AU)

Background and objectives. Pulmonary embolism (PE) is a disease that sometimes has a significant delay in diagnosis. This situation may lead to an increase in morbidity and mortality in patients who have it. The aim of our study has been to define the clinical profile of patients with unsuspected PE in the emergency department and the factors that influence the delayed diagnosis. Patients and methods. A total of 148 patients admitted with diagnosis of PE confirmed by CT (n=133) or by high-probability ventilation-perfusion scintigraphy scan (n=15) were retrospectively analyzed. They were divided into two groups: those with unsuspected disease in the emergency department (USPE) and those who it was suspected (SPE). Baseline characteristics of the patients, risk factors, signs and symptoms in the emergency department, complementary test, days of hospitalization and mortality were studied. Results. The USPE was found in 63/148 patients (42.6%) in the emergency department. Dyspnea and chest pain were the most frequent clinical manifestations of this disease, this being more commonly identified in the SPE group than in the USPE group, with significant differences (OR=0.4 [0.2-0.9] for dyspnea and OR=0.3 [0.2-0.7] for chest pain). However, However, the presence of thrombocytopenia (OR=3.4 [1.1-10.2], P<.05), normal electrocardiogram (EC) (OR=3.4 [1.1-10.2], P<.05), and localization of PE in right lung (OR=4.7 [2-11.3], P<.001) were risk factors for not suspect it. Days of hospitalization, days of symptoms and mortality were not statistically different between groups. Conclusions. According to the results, the proportion of unsuspected PE in the emergency department was high (close to 40%). The presence of dyspnea and chest pain was associated to suspicion of SPE. On the contrary, the presence of thrombocytopenia, normal EC and right localization of PE were associated to the non-suspicion of SPE in the emergency department(AU)

[Unsuspected pulmonary thromboembolism in the Emergency Department]. / Tromboembolismo pulmonar no sospechado en el Servicio de Urgencias.

BACKGROUND AND OBJECTIVES: Pulmonary embolism (PE) is a disease that sometimes has a significant delay in diagnosis. This situation may lead to an increase in morbidity and mortality in patients who have it. The aim of our study has been to define the clinical profile of patients with unsuspected PE in the emergency department and the factors that influence the delayed diagnosis. PATIENTS AND METHODS: A total of 148 patients admitted with diagnosis of PE confirmed by CT (n=133) or by high-probability ventilation-perfusion scintigraphy scan (n=15) were retrospectively analyzed. They were divided into two groups: those with unsuspected disease in the emergency department (USPE) and those who it was suspected (SPE). Baseline characteristics of the patients, risk factors, signs and symptoms in the emergency department, complementary test, days of hospitalization and mortality were studied. RESULTS: The USPE was found in 63/148 patients (42.6%) in the emergency department. Dyspnea and chest pain were the most frequent clinical manifestations of this disease, this being more commonly identified in the SPE group than in the USPE group, with significant differences (OR=0.4 [0.2-0.9] for dyspnea and OR=0.3 [0.2-0.7] for chest pain). However, However, the presence of thrombocytopenia (OR=3.4 [1.1-10.2], P<.05), normal electrocardiogram (EC) (OR=3.4 [1.1-10.2], P<.05), and localization of PE in right lung (OR=4.7 [2-11.3], P<.001) were risk factors for not suspect it. Days of hospitalization, days of symptoms and mortality were not statistically different between groups. CONCLUSIONS: According to the results, the proportion of unsuspected PE in the emergency department was high (close to 40%). The presence of dyspnea and chest pain was associated to suspicion of SPE. On the contrary, the presence of thrombocytopenia, normal EC and right localization of PE were associated to the non-suspicion of SPE in the emergency department.

The shock index and the simplified PESI for identification of low-risk patients with acute pulmonary embolism.

We compared the test characteristics of the shock index (SI) and the simplified pulmonary embolism severity index (sPESI) for predicting 30-day outcomes in a cohort of 1,206 patients with objectively confirmed pulmonary embolism (PE). The primary outcome of the study was all-cause mortality. The secondary outcome was nonfatal symptomatic recurrent venous thromboembolism (VTE) or nonfatal major bleeding. Overall, 119 (9.9%) out of 1,206 patients died (95% CI 8.2-11.5%) during the first month of follow-up. The sPESI classified fewer patients as low-risk (369 (31%) out of 1,206 patients, 95% CI 28-33%) compared to the SI (1,024 (85%) out of 1,206 patients, 95% CI 83-87%) (p<0.001). Low-risk patients based on the sPESI had a lower 30-day mortality than those based on the SI (1.6% (95% CI 0.3-2.9%) versus 8.3% (95% CI 6.6-10.0%)), while the 30-day rate of nonfatal recurrent VTE or major bleeding was similar (2.2% (95%CI 0.7-3.6%) versus 3.3% (95%CI 2.2-4.4%)). The net reclassification improvement with the sPESI was 13.4% (p = 0.07). The integrated discrimination improvement was estimated as 1.8% (p<0.001). The sPESI quantified the prognosis of patients with PE better than the SI.

Avances terapéuticos en la tromboembolia de pulmón / Therapeutic advances in pulmonary thromboembolism

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Identificación de pacientes con un tromboembolismo pulmonar de bajo riesgo / Identification of patients with low risk pulmonary thromboembolism

Objetivo. Determinar las características de los pacientes diagnosticados de tromboembolismo pulmonar (TEP) en el Servicio de Urgencias del Hospital Gregorio Marañón, para valorar la aplicabilidad de un modelo basado en criterios clínicos que permite identificar a pacientes con bajo riesgo de complicaciones. Material y métodos. Se evaluaron todos los pacientes que ingresaron por urgencias con el diagnóstico de TEP agudo. Se recogieron las siguientes variables: edad, sexo, comorbilidad (antecedentes personales de insuficiencia cardiaca, enfermedad pulmonar crónica, enfermedad renal crónica, enfermedad cerebrovascular y cáncer), tensión arterial, frecuencia cardiaca, saturación arterial de oxígeno y estado mental. También se recogió el tratamiento recibido y la presencia de complicaciones durante su estancia en el hospital. Se identificó como enfermos con TEP de bajo riesgo a aquellos pacientes que no presentaban ninguna de estas características en la evaluación inicial. Resultados. Se incluyeron en el estudio 101 pacientes, de los que 16 cumplían todos los criterios para ser considerados de bajo riesgo (15,8%). Al comparar este subgrupo con el resto de los enfermos, se detectaron diferencias en la edad, que fue significativamente menor en los pacientes de bajo riesgo. También se apreciaron diferencias estadísticamente significativas en la frecuencia cardiaca y en la saturación arterial de oxígeno. Todos los pacientes, excepto 1 que se encontraba en situación terminal, recibieron tratamiento anticoagulante. La evolución de los enfermos durante el ingreso fue satisfactoria en el 100% de los individuos del grupo de bajo riesgo frente al 88,1% en el de pacientes de no bajo riesgo. En este último grupo 7 enfermos (6,93%) presentaron complicaciones durante el ingreso y se produjeron 5 fallecimientos (4,95%). Conclusiones. La aplicación de un modelo basado en criterios clínicos permite identificar a un subgrupo de pacientes con TEP con bajo riesgo de complicaciones. Dicho subgrupo de enfermos no se beneficia por tanto de un ingreso hospitalario, con la ventaja del confort que proporciona al paciente el tratamiento ambulatorio y de la disminución de costes que dicha estrategia supone (AU)

Objective. Determine the characteristics of the patients diagnosed of pulmonary thromoembolism (PTE) in the Emergency Service of the Hospital Gregorio Marañón, in order to evaluate the applicability of a clinical-criteria based model that makes it possible to identify patients at low risk of complications. Material and methods. All the patients who were admitted to emergency with the diagnosis of acute PTE were evaluated. The following variables were collected: age, gender, comorbidity (personal background of heart failure, chronic pulmonary disease, chronic renal disease, cerebrovascular disease and cancer), blood pressure, heart rate, arterial oxygen saturation and mental condition. The treatment received and the presence of complications during the patient’s stay in the hospital were also collected. Those patients with PTE who did not present any of these characteristics in the initial evaluation were identified as being at low risk. Results. A total of 101 patients, 16 of whom fulfilled all the criteria to be considers at low risk (15.8%), were included in the study. When this subgroup was compared with the rest of the patients, differences in age that were significantly lower in the low risk patients were detected. Statistically significant differences in heart rate and in arterial oxygen saturation were also observed. All the patient, except for one who was in end-state condition, received anticoagulant treatment. The evolution of the patients during admission was satisfactory in 100% of the low risk group individuals versus 88.1% of the non-low risk patients. In the latter group, 7 patients (6.93%) presented complications during admission and there were 5 deaths (4.95%). Conclusions: Application of the clinical-criteria based model makes it possible to identify a subgroup of patients with PTE at low risk of complications. Thus, this subgroup of patients does not benefit from hospitalization, with the advantage of the comfort provided to the patient of by out-patient treatment and of the decrease in costs obtained from this strategy (AU)

Pleural fluid parameters identifying complicated parapneumonic effusions.

BACKGROUND: Controversy exists regarding the clinical utility of pleural fluid parameters as prognosticators of complicated parapneumonic effusions that require drainage. OBJECTIVES: The purpose of this prospective study is to further assess the utility of these parameters in the management of a larger series of parapneumonic effusions and to determine appropriate binary decision thresholds. METHODS: We studied 238 consecutive patients with parapneumonic effusions who underwent diagnostic thoracentesis. RESULTS: We found that pleural fluid pH had the highest diagnostic accuracy (area under the curve, AUC: 0.928; 95% confidence interval, CI: 0.894-0.963) compared with pleural fluid glucose (AUC: 0.835; 95% CI: 0.773-0.897), LDH (AUC: 0.824; 95% CI: 0.761-0.887) or pleural fluid volume (AUC: 0.706; 95% CI: 0.634-0.777). The optimal binary decision threshold for pleural fluid pH identifying complicated effusions requiring drainage was 7.15. Binary, multilevel and continuous likelihood ratios (LRs) for pH were calculated to estimate the likelihood of complication of the pleural effusion. Values for the LRs were compared for each of the three strategies, and relative clinical and statistical significances were assessed. Binary LRs provided significantly less information than continuous strategies. CONCLUSION: The pH has the highest diagnostic accuracy for identifying complicated parapneumonic pleural effusions. The binary decision threshold determining the need for chest drainage is 7.15 in our patient series. We recommend continuous LRs to estimate the post-test probability of the complication as they provide the most information compared with binary LRs. Our results do not support the use of pleural fluid LDH as independent predictor of complicated parapneumonic effusions.

Prognostic features of residual pleural thickening in parapneumonic pleural effusions.

The objective of the study was the identification of predictive factors for the development of residual pleural thickening (RPT) in patients with parapneumonic effusion. The design of the prospective study involved investigating patients with parapneumonic pleural effusions diagnosed between March 1991 and December 2000 in the respiratory department of Hospital Ramón y Cajal (Madrid, Spain) which is a 1,500 tertiary-care hospital. The clinical and radiological characteristics and measurements of microbiological and biochemical variables in the pleural fluid taken from the patients were studied. RPT was defined in a posteroanterior chest radiograph as pleural thickening of > or = 10 mm measured at the lateral chest wall at the level of an imaginary line, tangent to the diaphragmatic dome. A total of 48 of the 348 patients studied (13.79%) were found to have RPT. Among the factors studied, only presence of pus in the pleural space, Fine classes IV and V, temperature > or = 38 degrees C and delayed resolution of pleural effusions after diagnosis (> 15 days) were independently associated with the risk of RPT. This study showed that significant residual pleural thickening was not a common complication of parapneumonic pleural effusions. There are certain risk factors for the development of residual pleural thickening. However, this complication was not associated with long-term functional repercussions in the series of patients involved in this study.

Diagnostic value of adenosine deaminase in nontuberculous lymphocytic pleural effusions.

Adenosine deaminase (ADA) can aid in the diagnosis of tuberculous pleural effusions, but false-positive findings from lymphocytic effusions have been reported. The purpose of this study is to assess the ADA levels in nontuberculous lymphocytic pleural effusions (lymphocyte count > 50%) of different aetiologies. Altogether, 410 nontuberculous lymphocytic pleural fluid samples were consecutively selected. These included malignant effusions (n = 221), idiopathic effusions (n = 76), parapneumonic effusions (n = 35), postcoronary artery bypass graft surgery effusions (n = 6), miscellaneous exudative effusions (n = 21) and transudative effusions (n = 51). The ADA level reached the diagnostic cut-off for tuberculosis (40 U x L(-1)) in seven of the 410 cases (1.71%). The negative predictive value of ADA for the diagnosis of pleural tuberculosis was 99% (403 of 407 cases) in the group of lymphocytic pleural effusions. In five of these seven patients ADA1 and ADA2 were measured, and in all these cases (100%) ADA1/ADA(p) correctly classified these lymphocytic effusions as nontuberculous (ratio < 0.42). This prospective study provides additional evidence that adenosine deaminase levels in nontuberculous lymphocytic pleural effusions seldom exceed the cut-off set for tuberculous effusions. The pleural fluid adenosine deaminase levels were significantly higher in different types of exudative effusions than in transudates. An adenosine deaminase level < 40 IU x L(-1) virtually excluded a diagnosis of tuberculosis in lymphocytic pleural effusions. Adenosine deaminase1/adenosine deaminase(p) correctly classified all nontuberculous lymphocytic pleural effusions with high adenosine deaminase levels.

Neumotórax masivo bilateral / Bilateral massive pneumothorax

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Empiema bacteriano espontáneo / Spontaneous bacterial empyema

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[Comparative analysis of Light's criteria and other biochemical parameters to distinguish exudates from transudates]. / Análisis comparativo de los criterios de Light y otros parámetros bioquímicos para distinguir entre exudados y trasudados.

Light's criteria have classically been used to differentiate exudates from transudates. Nevertheless, a number of studies have attempted to identify more efficient parameters. The objective of our study was to determine the usefulness of biochemical parameters to differentiate transudates from exudates, and to compare them with the so far best studied criteria: the Light's criteria. We prospectively analysed 850 non selected cases of pleural effusion, with closed final diagnosis after its confirmation, therapeutic response and follow-up, collected consecutively at the Pleura Unit of our hospital. The parameters evaluated as potentially discriminatory between transudates and exudates included: glucose, proteins, albumin, lactate-dehydrogenase (LDH), cholesterol, triglycerides, bilirubin, alkaline phosphatase and adenosin-deaminase (ADA), both separately and in combination to obtain the highest yield. The highest diagnostic yield was observed with the combination of pleural cholesterol, pleural LDH, and the pleural fluid/serum protein ratio, but without significant differences between combinations of pleural cholesterol and LDH, pleaural LDH and pleural proteins, Light's criteria or modified Light's criteria. We recommend the use of pleural cholesterol higher than 47 mg/dl and pleural LDH higher than 222 IU/l to offer the same yield as the combination of three parameters, due to its lower cost and because the necessity of serum determinations is avoided.

Análisis comparativo de los criterios de Light y otros parámetros bioquímicos para distinguir entre exudados y trasudados / Comparative analysis of Light criteria and other biochemical parameters to distinguish exudates from transudates

Los criterios de Light han sido empleados clásicamente para diferenciar entre exudados y trasudados pleurales. No obstante, son muchos los estudios que han tratado de identificar parámetros más eficaces. El objetivo de nuestro trabajo fue determinar la utilidad de distintos parámetros bioquímicos para diferenciar entre trasudados y exudados y compararlos con los criterios mejor estudiados hasta el momento: los criterios de Light. Analizamos prospectivamente 850 casos de derrame pleural no seleccionados, con diagnóstico final cerrado tras su confirmación, respuesta terapéutica y seguimiento, recogidos de forma consecutiva en la Unidad de Pleura de nuestro hospital. Los parámetros que valoramos como potencialmente discriminantes entre trasudados y exudados fueron: glucosa, proteínas, albúmina, lactato deshidrogenasa (LDH), colesterol, triglicéridos, bilirrubina, fosfatasa alcalina y adenosín de aminasa (ADA), tanto individualmente como combinados entre sí para obtener el máximo rendimiento. El mayor rendimiento diagnóstico lo ofrece la combinación del colesterol pleural, la LDH pleural y la relación proteínas pleura/suero, pero sin diferencias significativas con las combinaciones del colesterol y LDH pleurales, la LDH y proteínas pleurales, los criterios de Light o los criterios de Light modificados. Recomendamos el empleo de colesterol pleural mayor de 47 mg/dl y LDH pleural mayor de 222 UI/l por ofrecer el mismo rendimiento que la combinación de tres parámetros, por su menor coste y porque evita la necesidad de determinaciones séricas (AU)

Factores predictivos de engrosamiento pleural en la pleuritis tuberculosa / Factors predictive of pleural thickening in tuberculous pleuritis

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