Rendimiento diagnóstico de la broncoscopia con biopsia transbronquial en el estudio de lesiones sugerentes de cáncer pulmonar / Bronchoscopy with transbronchial biopsy for the diagnosis of potentially malignant pulmonary lesions: experience in 261 patients

Background: Bronchoscopy is a minimally invasive procedure used for the diagnosis of lung cancer. Aim: To report our experience with bronchoscopy and transbronchial biopsies for the diagnosis of potentially malignant pulmonary lesions. Material and Methods: Revision of electronic records from patients who underwent transbronchial biopsies seeking for lung cancer. The diagnostic yield of the procedure was evaluated using pathology reports or a 24 months follow up. Results: 261 patients were included. Bronchoscopy was diagnostic in 65% of cases. Lesions mean diameter was 51 mm (range 9-120 mm). Diagnostic yield for lesions less than 30 mm was 59%, for lesions less than 35 mm was 61%, and for lesions over 40 mm was 69%. The presence of malignant lesions and their location in the superior or middle lobe were associated with a better predictive value of the procedure. TNM staging was IIIB/IV in 80% of the patient at the time of diagnosis. Conclusions: The diagnostic yield of bronchoscopy is influenced by the etiology and location of lung lesions.

Coagulase-negative staphylococcal prosthetic valve endocarditis--a contemporary update based on the International Collaboration on Endocarditis: prospective cohort study.

OBJECTIVE: To describe the contemporary features of coagulase-negative staphylococcal (CoNS) prosthetic valve endocarditis (PVE). DESIGN: Observational study of prospectively collected data from a multinational cohort of patients with infective endocarditis. Patients with CoNS PVE were compared to patients with Staphylococcus aureus and viridans streptococcal (VGS) PVE. SETTING: The International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) is a contemporary cohort of patients with infective endocarditis from 61 centres in 28 countries. PATIENTS: Adult patients in the ICE-PCS with definite PVE and no history of injecting drug use from June 2000 to August 2005 were included. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Heart failure, intracardiac abscess, death. RESULTS: CoNS caused 16% (n = 86) of 537 cases of definite non-injecting drug use-associated PVE. Nearly one-half (n = 33/69, 48%) of patients with CoNS PVE presented between 60 days and 365 days of valve implantation. The rate of intracardiac abscess was significantly higher in patients with CoNS PVE (38%) than in patients with either S aureus (23%, p = 0.03) or VGS (20%, p = 0.05) PVE. The rate of abscess was particularly high in early (50%) and intermediate (52%) CoNS PVE. In-hospital mortality was 24% for CoNS PVE, 36% for S aureus PVE (p = 0.09) and 9.1% for VGS PVE (p = 0.08). Meticillin resistance was present in 68% of CoNS strains. CONCLUSIONS: Nearly one-half of CoNS PVE cases occur between 60 days and 365 days of prosthetic valve implantation. CoNS PVE is associated with a high rate of meticillin resistance and significant valvular complications.

Lesiones cutáneas en una paciente con linfoma no Hodgkin / Skin lesions in a patient with non-Hodgkin lymphoma

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Resultados clínicos de la resincronización ventricular en pacientes con insuficiencia cardíaca severa / Results of intraventricular resynchronization in patients with severe cardiac failure

BACKGROUND: Intraventricular resynchronization with pacemakers is a promising therapy for patients with refractory cardiac failure and intraventricular conductions delay. However its long term effects are not well known. AIM: To report the results of this therapy in patients with cardiac failure. PATIENTS AND METHODS: Fourteen patients (11 male), whose mean age was 68 years, with a severe and refractory cardiac failure, have been treated in our unit using intraventricular resynchronization with pacemakers. Eight had a coronary heart disease and six a dilated myocardiopathy. The pacemaker was implanted transvenously, with conventional stimulation in atrium and right ventricle. The left ventricle was stimulated through an epicardial vein, accessed through the coronary sinus. RESULTS: In one patient the high thresholds did not allow a left ventricular stimulation. In the other 13 patients, a clinical improvement was observed in 11 (85 per cent), that has been sustained for a mean of 8.2 months. The ejection fraction improved form 23.5 to 32.4 per cent (p < 0.001), the 6 min walking test improved from 347 to 437 m (p = 0.003) and the functional capacity changes from 3.3 to 2.7 (p < 0.001). Three patients died during follow up. One was the patient in whom the stimulation failed and two had a sudden death. No complications of the procedure were observed. CONCLUSIONS: In this series, intraventricular resynchronization with pacemakers was effective in 11 of 13 patients, improving functional capacity and ejection fraction. Sudden death could be avoided adding a defibrillator to the pacemaker system.

[Comparative study of coronary angioplasty in diabetic patients. Immediate clinical and angiographic results and clinical evolution in the first year of follow up]. / Estudio comparativo de la angioplastia coronaria en pacientes con diabetes. Resultados clínicos y angiográficos inmediatos y evolución clínica en el primer año.

BACKGROUND: The success of revascularization procedures for coronary artery disease could be lower in diabetic patients. AIM: To report the results of coronary angioplasty in diabetic and non diabetic patients. PATIENTS AND METHODS: All angioplasty procedures performed between 1996 and 1999 were recorded. Demographic data, procedure details, hospital outcome and evolution at one year of follow up were analyzed. RESULTS: During the study period, 358 patients were treated; of these, 79 were diabetics. Despite the greater severity of coronary lesions among diabetic patients the clinical success of the procedure was 92.4% in diabetics and 91.8% in non diabetics. Hospital mortality was 1.3% in diabetics and 0.7% in non diabetics. Major complications occurred in 3.8% of diabetics and 3.2% in non diabetics. One year survival was 95.9% for diabetics and 98% in non diabetics. There were five late cardiac deaths among non diabetics and 3 among diabetics during the year of follow up. The frequency of new revascularization procedures was 4.3% in diabetics and 8.3% in non diabetics. Event-free survival was 95.6% in diabetics and 89.2% in non diabetics. CONCLUSIONS: Results of angioplasty were similar in diabetic and non diabetic patients in terms of hospital outcome and late follow-up.

[The classification of coronary lesion from Society for Cardiac Angiography and Intervention predicts better results of coronary angioplasty than the one from American College of Cardiology/American Heart Association Coronary Disease]. / La clasificación de lesiones coronarias de la Society for Cardiac Angiography and Interventions predice mejor el éxito de la angioplastia coronaria que la del American College of Cardiology/American Heart Association.

BACKGROUND: The classification of coronary lesion complexity, using the American College of Cardiology/American Heart Association (ACC/AHA) is a predictor of balloon angioplasty success. Stents have improved results even in complex lesions. AIM: To compare the ACC/AHA and the new Society for Cardiac Angiography (SCA&I) coronary lesion scores as predictors of angioplasty success. PATIENTS AND METHODS: Ali consecutive angioplasty procedures (n = 346, 456 lesions, 47% stents) were prospectively analyzed from August 1996 to March 1999. Coronary lesions were classified using the ACC/AHA and SCA&I scores. Angiographic success was assessed and its multivariate predictors determined with logistic regression analysis. RESULTS: According to the ACC/AHA score, angiographic success was 97, 92.7, 93.3, and 82.3% in A, Bl, B2 and C lesions respectively (p = 0.013). There only were significant differences in success between C and A, Bl or B2 lesions. According to the SCA&I score success was achieved in 97.3, 97.9, 75.8 and 33.3% in nonCP, CP, nonCO and CO lesions respectively (P < 0.001). With the SCA&I score statistically significant differences in angiographic success were found for all lesion score comparisons, except between nonCP and CP lesions. No other variables had predictive value for angiographic success. CONCLUSIONS: Coronary angioplasty angiographic success is better predicted by the new SCA&l lesion score than with the ACC/AHA lesion classification in a group of patients with frequent use of stents.

[Endovascular stent implantation in the treatment of coronary artery disease: angiographic, and immediate and late clinical results]. / Implante de prótesis endovasculares (stents) en el tratamiento de la cardiopatía coronaria: resultados angiográficos, clínicos inmediatos y tardíos.

BACKGROUND: Coronary revascularization allows a better survival and quality of life in high risk patients with coronary artery disease. AIM: To report the experience in stent placement as treatment for obstructive atherosclerotic coronary artery disease. PATIENTS AND METHODS: A prospective analysis of 105 stent placements. A morphological and quantitative analysis of coronary angiograms, using an electronic caliper, was performed. Patients were followed during their hospital stay and after discharge. RESULTS: In four of 112 coronary lesions, it was not possible to liberate the stent and in 108, it was successfully placed (48 in anterior descending, 19 in circumflex, 36 in right coronary arteries and 5 in saphenous aortocoronary by-pass. Lesions with stent implantation were type A in 11%, B1 in 30%, B2 in 44% and C in 15%. Reference diameter was 3.13 +/- 0.58 mm. After placement, luminal diameter increased from 0.95 +/- 0.43 to 2.99 +/- 0.46 mm, with a final stenosis of 7.2 +/- 10.1%. Angiographic success was obtained in 99% and procedure success in 98%. Hospital mortality was 0.98%. After a mean of eight months follow up, 91% of patients is free of major cardiac events. In 17% angina recurred and 5% required a new revascularization. There were no late cardiac deaths, acute stent thrombosis or infarction in relation to the treated lesion. CONCLUSIONS: In these patients, stent placement has had excellent immediate and late results.

[Infectious endocarditis: prognostic factors of mortality in 131 cases]. / Endocarditis infecciosa: factores pronósticos de mortalidad en 131 casos.

BACKGROUND: Global hospital mortality for infective endocarditis ranges from 13 to 40%. AIM: To compare clinical, microbiological, echocardiographic factors and complications between patients that died during an episode of infective endocarditis and those who survived. PATIENTS AND METHODS: We followed during their hospital stay, 129 patients, aged 14 to 74 years old, who had 131 episodes of infective endocarditis. Clinical assessment, echocardiography and microbiological study was done to all patients. Surgical indications were those derived from complications. RESULTS: Thirty three patients died during hospital stay (25.2%). There were no differences between survivors and deceased patients in the lapse between onset of symptoms and hospital admission, presence of fever, dyspnea or heart murmurs. Skin and mucosal septic manifestations occurred with higher frequency in deceased patients (57.1 and 24.3% respectively). Blood cultures were positive in 55% in survivors and 48% in those who died. The most frequent infecting organisms were staphilococci and streptococci. Vegetations were found with greater frequency in aortic position in both groups of patients. Deceased patients had a higher frequency of cardiac failure (84 and 65% respectively) and embolic episodes (77 and 46% respectively) than survivors. Antimicrobial treatment was successful in 94% of survivors and 15% of those who died. Forty percent of survivors and 54% of deceased patients were subjected to surgical procedures. CONCLUSIONS: The most important predictor of hospital mortality in this series of patients with infective endocarditis was antimicrobial treatment failure.

[Medical subspecialties in Chile: current status]. / Las subespecialidades médicas en Chile: situación actual.

There is no reliable registry of medical subspecialists in Chile According to the records of the Autonomous National Corporation for Certification of Medical Specialties (CONACEM), the largest number of certifications is in internal medicine (n = 681), followed by cardiology (n = 153), respiratory medicine (n = 106), gastroenterology (n = 93), endocrinology (n = 77), rheumatology (n = 55), hematology (n = 50) nephrology (n = 50), and infections diseases (n = 31). Over 55% of those certified in internal medicine and 70% of those certified in medical subspecialties (except nephrology) live in the metropolitan area of Santiago. Almost 80% of university-trained internists have received their training at the University of Chile (1952-1995), whereas 52% of university-trained subspecialists have been trained at the Catholic University of Chile. A sizeable number of nonofficial specialist-training programs are conducted at some universities at variance with their own official training policies. In internal medicine, a larger number of specialists have been trained by the universities than are certified by CONACEM, whereas the converse is true for medical subspecialists. More than 80% of the internists in Chile work for the Ministry of Health, who cares for 70% of the country's population. The best internist: population ratio is in Arica and Valdivia, and the poorest one in Arauco and in Viña del Mar/Quillota. According to estimations done by the Santiago Medical Society (Chilean Society of Internal Medicine) and its subspecialty affiliate societies, an adequate proportion of internists would be 1 for every 10,000 inhabitants, and for subspecialists, 1 for every 100,000 inhabitants. More information is needed about the ideal number of specialists and subspecialists required, and about their ideal distribution throughout the country. CONACEM needs to be strengthened, the universities should be able to certify non-university training centers, and the migration of subspecialists out of Santiago should be encouraged.

Ventricular mass in hypertensive and normotensive obese subjects.

Two-dimensional echocardiography was performed in 29 normotensive obese subjects and 21 hypertensive obese subjects representative of the Chilean population. The left ventricular mass (LVM) did not correlate with height or body surface area (BSA) in these patients, but positively correlated with body mass index (BMI), tricipital skinfold thickness and blood pressure (BP). The LVM/BSA ratio was significantly higher in the hypertensive subjects and was correlated with BP only. Left ventricular hypertrophy (LVM/BSA > 120 or 150 g/m2 in women or men, respectively) was found in 28% of normotensive and 58% of hypertensive subjects (P = 0.036). No statistical differences were found in relative wall thickness (RWT) between both groups. Posterior wall thickness was independently associated with BP while interventricular septum thickness was positively associated with the waist/hip ratio. Systolic function, evaluated through fractional shortening and end systolic diameters, was negatively and independently associated with body fat area. Left ventricular hypertrophy is a prevalent condition in these obese subjects. Hypertension seems to exert an additive effect, mainly increasing posterior wall thickness. Fat accumulation was negatively related to systolic function in this sample, irrespective of blood pressure.

[Infective endocarditis: clinical aspects and necropsy study in 20 cases]. / Endocarditis infecciosa: aspectos clínicos y estudio necropsico en 20 casos.

Aiming to know the principal anatomo-pathological findings in patients that died with a diagnosis of infective endocarditis, the clinical histories and necropsy protocols of such patients that died between 1984 and 1989 were reviewed. Twenty patients (11 male) aged 43.2 +/- 16.1 years were studied. In nine, the endocarditis was subacute, and 80% had a history of valvular or congenital heart disease. The principal clinical complication was sepsis followed by neurological, nephrological and cardiac complications. The necropsy disclosed cardiac, nephrological and abdominal lesions in 100, 80 and 65% of patients respectively. In 65% of necropsies, neurological injuries were found (cerebral edema in 7 patients and hemorrhagic complications in 11). It is concluded that extra cardiac lesions are frequent in patients dying with a diagnosis of infective endocarditis.

[Fatal infectious endocarditis in a patient with annulo-aortic ectasia and predominant bicuspid valve aortic stenosis. Anatomoclinical case]. / Endocarditis infecciosa mortal en portadora de anuloectasia aortica asociada a estenosis aortica biscuspide predominante. Caso anatómo clínico.

A 25 year old female with bicuspid aortic valve and aortic stenosis developed infectious endocarditis due to beta hemolytic streptococcus. Specific antibiotic therapy was not successful, the patient developed multiple embolic episodes and platelet dysfunction that prevented surgery. The patient died 5 weeks after admission. Necropsy showed aortic annulo-ectasia, cystic medial necrosis and localized dissection of the proximal aorta. There were multiple aortic valve vegetations and evidence of inflammatory myocardial involvement, coronary embolization and myocardial infarction. Aortic annulo-ectasia should be investigated in patients with aortic valve endocarditis and early surgery would be advised to prevent aortic dissection.

[The echocardiographic evolution of left ventricular hypertrophy in treated hypertensive patients. A long-term follow-up]. / Evolución ecocardiográfica de la hipertrofia ventricular izquierda en hipertensos tratados. Seguimiento a largo plazo.

In order to study the possible regressive changes of left ventricular hypertrophy in treated hypertensive patients and to correlate them either with the drugs they received and/or the blood pressure reduction obtained, a long-term (6 years) echocardiographic follow-up study was performed in 61 patients. B and M mode echocardiographic septum and posterior wall thickness and left ventricular mass index were measured yearly and the type of ventricular hypertrophy, asymmetric septal or concentric (symmetric), were compared before and after the follow-up. Sixteen patients received only diuretics; 14, only propranolol, and associated therapy was used in the remaining 31 patients. Average blood pressure was significantly reduced in the whole group of patients, but, individually, 30 of them achieved normal levels for the diastolic (90 mmHg), remaining it over this value in the other, although all of them experienced an average reduction 10 mmHg with therapy. Those patients with concentric hypertrophy at entry showed a significant septal, posterior wall thickness and total ventricular mass reduction during the follow-up, those with initial asymmetric septal hypertrophy, a significant septal thickness and ventricular mass reduction, and those without hypertrophy on admission, showed an average paradoxical increase in septal thickness. We conclude that left ventricular hypertrophy disappeared or decreased in 48% of the patients and that treatment seems to prevent its progression or development in the 43% of all patients. The regressive or favorable changes were significantly more frequent among patients with normal blood pressure after treatment as well as among patients treated only with propranolol in comparison to those treated only with diuretics.

[Infectious endocarditis: clinical and echocardiographic initial follow-up]. / Endocarditis infecciosa: seguimiento inicial clínico-ecocardiográfico.

We analyzed the clinical and echocardiographic features of 24 patients with infective endocarditis followed for a mean of 20.2 month (range 3-84) after discharge. Mean age was 38 years, male to female ratio was 2:1 and 87% of cases had a subacute clinical course; 17% of patients had late prosthetic endocarditis. Positive blood cultures were obtained in only 50% of patients. Vegetations were detected by echocardiography in 88%, 66% of them located at the aortic valve. Heart failure (62%) was the main complication, leading to valve replacement in 4 patients. Four patients died during follow up, 3 males due to heart failure and a female from systemic emboli. Twenty patients survive at the end of follow up (84%), 50% of them in FC I or II, 40% in FC III or IV (2 lost to follow up). Eleven patients had a late echocardiogram at a mean of 12 months after discharge: 6 of them showed persistence of vegetations (55%).