A predictive score at admission for respiratory failure among hospitalized patients with confirmed 2019 Coronavirus Disease: a simple tool for a complex problem.

Coronavirus Disease 2019 (COVID-19) pandemic has implacably stricken on the wellness of many countries and their health-care systems. The aim of the present study is to analyze the clinical characteristics of the initial wave of patients with COVID-19 attended in our center, and to identify the key variables predicting the development of respiratory failure. Prospective design study with concurrent data retrieval from automated medical records of all hospitalized adult patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rRT-PCR assay performed on respiratory samples from March 2nd to 18th, 2020. Patients were followed up to May 1st, 2020 or death. Respiratory failure was defined as a PaO2/FiO2 ratio ≤ 200 mm Hg or the need for mechanical ventilation (either non-invasive positive pressure ventilation or invasive mechanical ventilation). We included 521 patients of whom 416 (81%) had abnormal Chest X-ray on admission. Median age was 64.6 ± 18.2 years. One hundred eighty-one (34.7%) developed respiratory failure after a median time from onset of symptoms of 9 days (IQR 6-11). In-hospital mortality was 23.8% (124/521). The modeling process concluded into a logistic regression multivariable analysis and a predictive score at admission. Age, peripheral pulse oximetry, lymphocyte count, lactate dehydrogenase and C-reactive protein were the selected variables. The model has a good discriminative capacity with an area under the ROC curve of 0.85 (0.82-0.88). The application of a simple and reliable score at admission seems to be a useful tool to predict respiratory failure in hospitalized COVID-19 patients.

Non-alcoholic fatty liver disease in patients with intestinal, pulmonary or skin diseases: Inflammatory cross-talk that needs a multidisciplinary approach.

Non-alcoholic fatty liver disease (NAFLD) is currently considered the most common cause of liver disease. Its prevalence is increasing in parallel with the obesity and type 2 diabetes mellitus (DM2) epidemics in developed countries. Several recent studies have suggested that NAFLD may be the hepatic manifestation of a systemic inflammatory metabolic disease that also affects other organs, such as intestine, lungs, skin and vascular endothelium. It appears that local and systemic proinflammatory/anti-inflammatory cytokine imbalance, together with insulin resistance and changes in the intestinal microbiota, are pathogenic mechanisms shared by NAFLD and other comorbidities. NAFLD is more common in patients with extrahepatic diseases such as inflammatory bowel disease (IBD), obstructive syndrome apnea (OSA) and psoriasis than in the general population. Furthermore, there is evidence that this association has a negative impact on the severity of liver lesions. Specific risk characteristics for NAFLD have been identified in populations with IBD (i.e. age, obesity, DM2, previous bowel surgery, IBD evolution time, methotrexate treatment), OSA (i.e. obesity, DM2, OSA severity, increased transaminases) and psoriasis (i.e. age, metabolic factors, severe psoriasis, arthropathy, elevated transaminases, methotrexate treatment). These specific phenotypes might be used by gastroenterologists, pneumologists and dermatologists to create screening algorithms for NAFLD. Such algorithms should include non-invasive markers of fibrosis used in NAFLD to select subjects for referral to the hepatologist. Prospective, controlled studies in NAFLD patients with extrahepatic comorbidities are required to demonstrate a causal relationship and also that appropriate multidisciplinary management improves these patients' prognosis and survival.

La enseñanza de la práctica clínica en la Facultad de Medicina de la Universidad Complutense de Madrid / Teaching of clinical practice in the Faculty of Medicine of the Complutense University of Madrid

Se describe la metodología de instrucción y evaluación en práctica clínica y el grado de implicación del profesorado en esta tarea en la Unidad Docente del Hospital 12 de Octubre (Facultad de Medicina, Universidad Complutense de Madrid). A pesar de algunas disfunciones curriculares, nuestros estudiantes alcanzan un buen nivel de competencia clínica al final del grado. Algunos profesores tienen un conocimiento limitado de los roles docentes que pueden asumir, por lo que deberían recibir formación específica. Idealmente, la enseñanza clínica ha de implicar a todos los profesionales que cuidan del paciente en el contexto extra- e intrahospitalario

We describe the methodology for instruction and assessment of clinical practice and analyze the profile and teaching roles of faculty at the Teaching Unit of the Hospital 12 de Octubre (Faculty of Medicine, Complutense University of Madrid). Despite some structural limitations in curriculum development our students reach a good final level of clinical competence. The need for trainers to understand the different roles they can assume, improving faculty development and involving all the professionals taking care of the patient in the teaching process are emphasized

Development of Aspergillosis in a cohort of non-neutropenic, non-transplant patients colonised by Aspergillus spp.

BACKGROUND: A previous study explored factors discriminating colonization and true infection among non-transplant, non-neutropenic patients with repeated Aspergillus spp. isolation from lower respiratory samples. The present study explored the evolution of patients with Aspergillus colonization in that study to determine the percentage of cases progressing to aspergillosis and time to development. METHODS: Clinical records were retrospectively reviewed (for each patient from his end date in the past study) and data from all respiratory processes suffered by patients up to April 2015 were recorded. Comparisons of variables were performed between colonized patients that developed aspergillosis and those that did not. A Kaplan-Meier curve was used to describe time to development of aspergillosis in chronic obstructive pulmonary disease (COPD) patients for II-IV stages of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification. RESULTS: Sixty seven colonized patients were followed, 12 of them (17.9%) developed aspergillosis. Diagnoses included six tracheobronchitis (4 invasive, 2 simple tracheobronchitis), four pulmonary disease (2 invasive pulmonary aspergillosis, 2 chronic pulmonary aspergillosis), one allergic bronchopulmonary aspergillosis and one pulmonary aspergilloma. Up to 47 (70.4%) of the study patients presented COPD. Among patients developing aspergillosis COPD was more frequent (100%) than among those that did not develop aspergillosis (35 out of 55; 63.6%) (p = 0.012), as well as GOLD IV patients were more frequent among COPD patients developing aspergillosis than among COPD patients that did not (50.0 vs. 26.1%, p = 0.046). Mean time to development of aspergillosis was 18.4 months (median: 8.5) with a wide range (1-58). Overtime, the percentage of patients developing aspergillosis was significantly higher among GOLD IV patients than among GOLD II-III patients (p = 0.032). CONCLUSIONS: The high percentage of cases progressing to aspergillosis among colonized patients, especially among those with COPD (25.5%), stresses the importance of colonization as risk factor, and creates awareness of the possible change from colonization to invasive disease in GOLD IV patients.

El método de selección de los residentes en España. Análisis del examen MIR y propuesta de una nueva metodología / The method of selection of the residents in Spain. Analysis of the examination MIR and offer of a new methodology

Introducción: El método para seleccionar a los graduados que acceden a los puestos de residencia condiciona decisivamente el funcionamiento curricular en las escuelas de medicina, incluyendo la manera de estudiar y aprender del estudiante y la actitud docente del profesorado. La metodología usada actualmente en España puede ser fácilmente mejorada, por lo que tomando como referencia las metodologías multicriterio empleadas en el Reino Unido y los EE. UU. proponemos una similar para ser aplicada en nuestro país. Objetivos del estudio: Analizar las limitaciones del método para la selección de los residentes utilizado en España y proponer uno nuevo que mejore el ordenamiento de los candidatos y evite la distorsión producida por el actual sobre la dinámica curricular. Aparte de proponer la modificación del examen MIR, se comenta la necesidad de mejorar las enseñanzas prácticas y evaluar el nivel de competencia clínica de los estudiantes. Conclusiones: El método de selección aplicado en España, basado fundamentalmente en un test teórico, resulta inapropiado y debería ser sustituido por otro que evalúe mejor la capacidad la contextualización clínica de los conocimientos y el nivel de competencia clínica y que tenga en cuenta el rendimiento global del estudiante a lo largo del grado de forma ponderada

Introduction: The method for selecting medical graduates for residency positions has a strong influence on teaching and learning strategies in medical schools. The methodology currently used in Spain does not seem appropriate for ranking the candidates or improving curriculum development. Thus, and taking into account the most consistent methodologies used in the United Kingdom and USA, we have designed a new method to be used in our country. Objectives: To analyze the limitations of the methodology used in Spain, and propose a new one aimed to improve the accuracy of selection itself and avoiding the negative influence of the current method on curricular development. In addition, we emphasize the necessity of improving teaching and learning in the clinical context to assure that graduating students reach an adequate level of clinical competence. Conclusions: The method for selecting candidates to residency post currently used in Spain, which relies mainly on testing theoretical knowledge, should be changed for an alternative methodology taking into account student’s performance through the course and assessing his/her ability for clinical contextualization of knowledge and level of clinical competence

[The method of selection of the residents in Spain. Analysis of the examination MIR and offer of a new methodology]. / El método de selección de los residentes en España. Análisis del examen MIR y propuesta de una nueva metodología.

INTRODUCTION: The method for selecting medical graduates for residency positions has a strong influence on teaching and learning strategies in medical schools. The methodology currently used in Spain does not seem appropriate for ranking the candidates or improving curriculum development. Thus, and taking into account the most consistent methodologies used in the United Kingdom and USA, we have designed a new method to be used in our country. OBJECTIVES: To analyze the limitations of the methodology used in Spain, and propose a new one aimed to improve the accuracy of selection itself and avoiding the negative influence of the current method on curricular development. In addition, we emphasize the necessity of improving teaching and learning in the clinical context to assure that graduating students reach an adequate level of clinical competence. CONCLUSIONS: The method for selecting candidates to residency post currently used in Spain, which relies mainly on testing theoretical knowledge, should be changed for an alternative methodology taking into account student,s performance through the course and assessing his/her ability for clínical contextualization of knowledge and level of clinical competence.

La selección de los graduados en Medicina para los puestos de residencia. Estudio comparativo de los métodos usados en diferentes países / Selection of medical graduates for residency posts. A comparative study of the methodologies used in different countries

Introducción: El diseño de una metodología apropiada para la selección de los graduados que acceden a los puestos de residencia tiene gran importancia porque, aparte de su eficiencia en la elección de los candidatos, condiciona decisivamente el funcionamiento curricular en las escuelas de medicina, incluyendo la manera de estudiar y aprender del estudiante y la actitud docente del profesorado y su motivación para perseguir la innovación curricular. En la actualidad existe una gran dispersión en los métodos de selección de los residentes en diferentes países, evidenciando que no hay ninguno perfecto. El uso aislado de criterios tales como el peso del expediente académico, los test de conocimiento teórico, determinadas pruebas prácticas de la competencia clínica, o las entrevistas tienen un valor limitado para predecir qué candidatos van a ser más competentes durante la residencia o la práctica autónoma. Objetivos: Describir las metodologías utilizadas para la selección de los residentes en los países de nuestro entorno prestando especial atención a las empleadas en el Reino Unido y los EE. UU. donde se analiza de manera sistemática el funcionamiento de los currícula en las escuelas de medicina. Se comentan las ventajas y desventajas de los exámenes de ámbito nacional para otorgar el grado y/o construir el listado de acceso a la residencia, y su utilidad para favorecer el proceso de convergencia y armonización de los grados y los programas de residencia a nivel transnacional europeo o internacional. El presente análisis se utiliza para establecer una comparación con la metodología de selección aplicada actualmente en España en un intento de diseñar un nuevo método multicriterio más eficiente que se describirá en otro artículo publicado en el próximo número de esta revista Conclusiones: Los métodos multicriterio para la selección de los residentes en el Reino Unido y los EE. UU. parecen los más consistentes por lo que serán utilizados para construir el nuevo método que podría ser aplicado en España. Aunque muchos expertos en docencia médica rechazan los exámenes de ámbito nacional para otorgar el grado y/o establecer el orden de acceso a los puestos de residencia porque limitan la diversidad y la innovación curriculares, cuando están bien diseñados sirven para verificar el alcance del nivel mínimo aceptable de competencia clínica del graduado sin distorsionar el buen funcionamiento y la mejora progresiva del currículum

Introduction: The design of an appropriate method for the selection of medical graduates for residency posts is extremely important, not only for the efficiency of the method itself (accurate identification of most competent candidates), but also for its influence on the study and teaching methodologies operating in medical schools. Currently, there is a great variation in the criteria used in different countries and there is no definitively appropriate method. The use of isolated or combined criteria, such as the marks obtained by students in medical schools, their performance in tests of theoretical knowledge and evaluations of clinical competence, or personal interviews, have a limited value for identifying those candidates who will perform better during the residency and later on during independent practice. Objectives: To analyse the variability in the methodologies used for the selection of residents employed in different countries, in particular those used in the United Kingdom and USA, where external agencies and medical schools make systematic analyses of curriculum development. The advantages and disadvantages of national or transnational licensing examinations on the process of convergence and harmonization of medical degrees and residency programmes through Europe are discussed. The present analysis is used to design a new and more efficient multi-criteria methodology for resident selection in Spain, which will be published in the next issue of this journal. Conclusions: Since the multi-criteria methods used in UK and USA appear to be most consistent, these have been employed for designing the new methodology that could be applied in Spain. Although many experts in medical education reject national examinations for awarding medical degrees or ranking candidates for residency posts, it seems that, when appropriately designed, they can be used to verify the level of competence of graduating students without necessarily distorting curriculum implementation or improvement

[Selection of medical graduates for residency posts. A comparative study of the methodologies used in different countries]. / La selección de los graduados en Medicina para los puestos de residencia. Estudio comparativo de los métodos usados en diferentes países.

INTRODUCTION: The design of an appropriate method for the selection of medical graduates for residency posts is extremely important, not only for the efficiency of the method itself (accurate identification of most competent candidates), but also for its influence on the study and teaching methodologies operating in medical schools. Currently, there is a great variation in the criteria used in different countries and there is no definitively appropriate method. The use of isolated or combined criteria, such as the marks obtained by students in medical schools, their performance in tests of theoretical knowledge and evaluations of clinical competence, or personal interviews, have a limited value for identifying those candidates who will perform better during the residency and later on during independent practice. OBJECTIVES: To analyse the variability in the methodologies used for the selection of residents employed in different countries, in particular those used in the United Kingdom and USA, where external agencies and medical schools make systematic analyses of curriculum development. The advantages and disadvantages of national or transnational licensing examinations on the process of convergence and harmonization of medical degrees and residency programmes through Europe are discussed. The present analysis is used to design a new and more efficient multi-criteria methodology for resident selection in Spain, which will be published in the next issue of this journal. CONCLUSIONS: Since the multi-criteria methods used in UK and USA appear to be most consistent, these have been employed for designing the new methodology that could be applied in Spain. Although many experts in medical education reject national examinations for awarding medical degrees or ranking candidates for residency posts, it seems that, when appropriately designed, they can be used to verify the level of competence of graduating students without necessarily distorting curriculum implementation or improvement.

Examen clínico objetivo y estructurado formativo tras inmersión clínica precoz empleando estudiantes de sexto curso como observadores y administradores de retroalimentación / Formative objective structured clinical examination following early clerkships using sixth-year students as examiners and feed-back providers

Introducción: En este artículo se describen la logística y los resultados de un examen clínico objetivo y estructurado (ECOE) formativo pasado a estudiantes de tercero expuestos a un curso de transición del periodo básico al clínico y a rotaciones clínicas precoces, en el que utilizamos estudiantes de sexto curso como observadores y administradores de la retroalimentación. Materiales y métodos: Se analizan el rendimiento de los candidatos, la correlación de las puntuaciones otorgadas con listados de ítems y una escala global de la competencia usados por el paciente estandarizado y el estudiante observador, así como el grado de aceptación de la prueba por parte de todos los participantes. Resultados: Los estudiantes observadores se sintieron altamente satisfechos con su tarea de observación y administración de la retroalimentación. Los profesores valoraron con puntuaciones altas la tarea de los estudiantes observadores, y los alumnos candidatos otorgaron igualmente puntuaciones altas a la actuación de los estudiantes observadores, la calidad de la retroalimentación recibida y la logística del ECOE. El rendimiento global en el ECOE superó el 70,1%. Se observó una buena correlación entre las puntuaciones otorgadas por los dos observadores (enfermo y estudiante) con los dos instrumentos de medida (listados y escala global). Conclusiones: Los estudiantes del último curso del grado son capaces de usar de manera fiable los listados de ítems y una escala global de la competencia, y de proporcionar retroalimentación adecuada en un ECOE formativo. La exposición clínica precoz al inicio del tercer curso en un currículo 3 + 3 motiva y prepara a los estudiantes para el aprendizaje posterior en las rotaciones del periodo clínico

Introduction: We describe the logistic and results of a formative objective structured clinical examination (OSCE) designed with the double aim of providing feedback to third-year students given by senior students, and assessing clinical skills of the candidates who were exposed to a short transition course and early clerkships. Materials and methods:Candidates performance, the correlation between the scores given by standardized patients and students examiners using checklists and a global rating scale, as well as the acceptance of the OSCE by all participants were analyzed. Results: Faculty members considered excellent the action of student examiners including the feedback they gave to candidates. Student examiners felt much satisfied observing and giving feedback to candidates. Candidates valued highly the action of student examiners, the quality of the feedback they received, and the logistic of the OSCE. Global performance in the OSCE was 70.1%. The correlation between the scores given by the two examiners using checklists and the global rating scale was good. Conclusions: Senior students are able to use checklists and a global rating scale in a reliable manner and to provide appropriate feedback at a formative OSCE. A transition course followed by an early clinical immersion motivate and prepare students for learning during the clinical period in our 3 + 3 curriculum

Repeated Aspergillus isolation in respiratory samples from non-immunocompromised patients not selected based on clinical diagnoses: colonisation or infection?

BACKGROUND: Isolation of Aspergillus from lower respiratory samples is associated with colonisation in high percentage of cases, making it of unclear significance. This study explored factors associated with diagnosis (infection vs. colonisation), treatment (administration or not of antifungals) and prognosis (mortality) in non-transplant/non-neutropenic patients showing repeated isolation of Aspergillus from lower respiratory samples. METHODS: Records of adult patients (29 Spanish hospitals) presenting ≥ 2 respiratory cultures yielding Aspergillus were retrospectively reviewed and categorised as proven (histopathological confirmation) or probable aspergillosis (new respiratory signs/symptoms with suggestive chest imaging) or colonisation (symptoms not attributable to Aspergillus without dyspnoea exacerbation, bronchospasm or new infiltrates). Logistic regression models (step-wise) were performed using Aspergillosis (probable + proven), antifungal treatment and mortality as dependent variables. Significant (p < 0.001) models showing the highest R2 were considered. RESULTS: A total of 245 patients were identified, 139 (56.7%) with Aspergillosis. Aspergillosis was associated (R2 = 0.291) with ICU admission (OR = 2.82), congestive heart failure (OR = 2.39) and steroids pre-admission (OR = 2.19) as well as with cavitations in X-ray/CT scan (OR = 10.68), radiological worsening (OR = 5.22) and COPD exacerbations/need for O2 interaction (OR = 3.52). Antifungals were administered to 79.1% patients with Aspergillosis (100% proven, 76.8% probable) and 29.2% colonised, with 69.5% patients receiving voriconazole alone or in combination. In colonised patients, administration of antifungals was associated with ICU admission at hospitalisation (OR = 12.38). In Aspergillosis patients its administration was positively associated (R(2) = 0.312) with bronchospasm (OR = 9.21) and days in ICU (OR = 1.82) and negatively with Gold III + IV (OR = 0.26), stroke (OR = 0.024) and quinolone treatment (OR = 0.29). Mortality was 78.6% in proven, 41.6% in probable and 12.3% in colonised patients, and was positively associated in Aspergillosis patients (R2 = 0.290) with radiological worsening (OR = 3.04), APACHE-II (OR = 1.09) and number of antibiotics for treatment (OR = 1.51) and negatively with species other than A. fumigatus (OR = 0.14) and aspergillar tracheobronchitis (OR = 0.27). CONCLUSIONS: Administration of antifungals was not always closely linked to the diagnostic categorisation (colonisation vs. Aspergillosis), being negatively associated with severe COPD (GOLD III + IV) and concomitant treatment with quinolones in patients with Aspergillosis, probably due to the similarity of signs/symptoms between this entity and pulmonary bacterial infections.

Registros de enfermedades respiratorias en España: fundamentos y organización / Respiratory disease registries in Spain: fundamentals and organization

En el presente trabajo se describen las características generales, objetivos y aspectos organizativos de losregistros de enfermedades respiratorias existentes en España con el objetivo de dar a conocer su actividade incrementar su difusión.Se recoge información sobre los siguientes registros: Registro Español de Pacientes con Déficit de Alfa-1antitripsina, Registro Español de Bronquiectasias, Registro Internacional de Enfermedad Tromboembólica,Registro Español de Enfermedades de Origen Laboral, Registro Español de Hipertensión ArterialPulmonar, Registro de Mesotilioma Pleural, Registro Español de Tuberculosis y Estudio multicéntricoEspañol de Tumores Pulmonares Neuroendocrinos.Nuestro trabajo aporta información de cada uno de los citados registros.Cada registro ha recogido información clínica específica que aporta datos en situaciones reales, y completalos resultados obtenidos de los ensayos clínicos. Dicha información se ha difundido en publicacionestanto nacionales como internacionales y ha permitido la elaboración de varias normativas. Por tanto,las actividades llevadas a cabo por los profesionales vinculados a los registros han conseguido difundirel conocimiento sobre las enfermedades estudiadas propiciando el intercambio de información entregrupos(AU)

This present paper describes the general characteristics, objectives and organizational aspects of therespiratory disease registries in Spain with the aim to report their activities and increase their diffusion.The document compiles information on the following registries: the Spanish Registry of Patients withAlpha-1 Antitrypsin Deficiency, Spanish Registry of Bronchiectasis, International Registry of ThromboembolicDisease, Spanish Registry of Occupational Diseases, Spanish Registry of Pulmonary Artery Hypertension, Registry of Pleural Mesothelioma, Spanish Registry of Tuberculosis and Spanish MulticenterStudy of Neuroendocrine Pulmonary Tumors.Our paper provides information on each of the registries cited.Each registry has compiled specific clinical information providing data in real situations, and completesthe results obtained from clinical assays. Said information has been published both in national as well asinternational publications and has lead to the creation of various guidelines. Therefore, the activities of theprofessionals involved in the registries have spread the knowledge about the diseases studied, promotingthe exchange of information among workgroups(AU)

[Respiratory disease registries in Spain: fundamentals and organization]. / Registros de enfermedades respiratorias en España: fundamentos y organización.

This present paper describes the general characteristics, objectives and organizational aspects of the respiratory disease registries in Spain with the aim to report their activities and increase their diffusion. The document compiles information on the following registries: the Spanish Registry of Patients with Alpha-1 Antitrypsin Deficiency, Spanish Registry of Bronchiectasis, International Registry of Thromboembolic Disease, Spanish Registry of Occupational Diseases, Spanish Registry of Pulmonary Artery Hypertension, Registry of Pleural Mesothelioma, Spanish Registry of Tuberculosis and Spanish Multi-center Study of Neuroendocrine Pulmonary Tumors. Our paper provides information on each of the registries cited. Each registry has compiled specific clinical information providing data in real situations, and completes the results obtained from clinical assays. Said information has been published both in national as well as international publications and has lead to the creation of various guidelines. Therefore, the activities of the professionals involved in the registries have spread the knowledge about the diseases studied, promoting the exchange of information among workgroups.

Horizontes en la neumología española: algunas reflexiones / Horizons for spanish respiratory medicine: reflections

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[Bronchioloalveolar carcinoma in Spain: a rare and different form of lung cancer]. / Carcinoma bronquioloalveolar en España. Un cáncer de pulmón infrecuente y diferente.

OBJECTIVE: To describe a series of cases of bronchioloalveolar carcinoma (BAC) treated surgically between 1993 and 1997 in the 19 hospitals that make up the Bronchogenic Carcinoma Cooperative Group of the Spanish Society of Pulmonology and Thoracic Surgery (GCCB-S). PATIENTS AND METHODS: From a total of 2,944 cases of non-small cell lung cancer (NSCLC), 82 (3%) were BAC. The clinical characteristics and prognosis of patients with BAC were compared with those of the remaining 2,862 patients with NSCLC. RESULTS: The percentage of men was lower for BAC than for other types of NSCLC (64.6% compared with 93.5%; P< .001) and BAC was associated with less comorbidity (50% vs 62%; P< .05), particularly in terms of chronic obstructive pulmonary disease (33% vs 47.2%; P< .05). Other characteristics showing significant differences were the higher frequency of BAC as a chance finding and the lower likelihood of weight loss or reduced performance status at the time of diagnosis. Classification as stage cI was significantly more common in patients with BAC (87% vs 75%; P.001), and this difference between groups was more pronounced for stage pI (68.5% vs 47%; P< .01). Only taking into account patients classified as stage pI with complete resection of NSCLC and following exclusion of operative mortality, patients with BAC presented an overall 5-year survival of 65% (95% confidence interval [CI], 51%-79%), compared with a significantly lower survival of 53% (95% CI, 50%-56%; P< .05) in patients with other forms of NSCLC. CONCLUSIONS: In Spain, among cases of lung cancer treated by surgery, BAC is very rare (3%) and displays clinical characteristics that are different from other forms of NSCLC. Controlling for the most basic prognostic factors (stage pI and complete resection), survival is significantly higher for BAC.

Carcinoma bronquioloalveolar en España. Un cáncer de pulmón infrecuente y diferente / Bronchioloalveolar carcinoma in Spain: a rare and different form of lung cancer

Objetivo: Describir una serie de casos de carcinoma bronquioloalveolar (CBA) tratados quirúrgicamente por los 19 hospitales del Grupo Cooperativo de Carcinoma Broncogénico de la Sociedad Española de Neumología y Cirugía Torácica (GCCB-S) entre 1993 y 1997. Pacientes y métodos: Del total de 2.944 casos de carcinoma broncogénico no microcítico (CBNM), 82 (3%) eran CBA. Se compararon las características clínicas y el pronóstico de los CBA con los de los restantes 2.862 CBNM. Resultados: Los CBA ocurren menos frecuentemente en varones (el 64,6 frente al 93,5%; p = 0,001), tienen menos comorbilidad en general (el 50 frente al 62%; p < 0,05) y enfermedad pulmonar obstructiva crónica en particular (el 33 frente al 47,2%; p < 0,05). Otras características con diferencias significativas son la mayor frecuencia de que el CBA sea un hallazgo casual y la menor probabilidad de que en el momento del diagnóstico exista historia de pérdida de peso o peor estado clínico. Por estadios clínicos, la clasificación Ic es significativamente más frecuente en los CBA (el 87 frente al 75%; p = 0,001), diferencia que se incrementa en la estadificación Ip (el 68,5 frente al 47%; p < 0,01). Considerando la población de CBNM con resección completa en estadio Ip, y una vez excluida la mortalidad operatoria, los CBA presentan una supervivencia global a los 5 años del 65% (intervalo de confianza [IC] del 95%, 51-79%), significativamente superior al resto de CBNM no CBA, en que es del 53% (IC del 95%, 50-56%) (p < 0,05). Conclusiones: En España, entre los casos de cáncer de pulmón operado, el CBA es muy infrecuente (3%) y presenta características clínicas diferentes del resto de los CBNM. Controlando con los factores pronósticos más básicos (estadio Ip y resección completa), la supervivencia del CBA es significativamente superior

Objective: To describe a series of cases of bronchioloalveolar carcinoma (BAC) treated surgically between 1993 and 1997 in the 19 hospitals that make up the Bronchogenic Carcinoma Cooperative Group of the Spanish Society of Pulmonology and Thoracic Surgery (GCCB-S). Patients and methods: From a total of 2944 cases of non-small cell lung cancer (NSCLC), 82 (3%) were BAC. The clinical characteristics and prognosis of patients with BAC were compared with those of the remaining 2862 patients with NSCLC. Results: The percentage of men was lower for BAC than for other types of NSCLC (64.6% compared with 93.5%; P<.001) and BAC was associated with less comorbidity (50% vs 62%; P<.05), particularly in terms of chronic obstructive pulmonary disease (33% vs 47.2%; P<.05). Other characteristics showing significant differences were the higher frequency of BAC as a chance finding and the lower likelihood of weight loss or reduced performance status at the time of diagnosis. Classification as stage cI was significantly more common in patients with BAC (87% vs 75%; P<.001), and this difference between groups was more pronounced for stage pI (68.5% vs 47%; P<.01). Only taking into account patients classified as stage pI with complete resection of NSCLC and following exclusion of operative mortality, patients with BAC presented an overall 5-year survival of 65% (95% confidence interval [CI], 51%-79%), compared with a significantly lower survival of 53% (95% CI, 50%-56%; P<.05) in patients with other forms of NSCLC. Conclusions: In Spain, among cases of lung cancer treated by surgery, BAC is very rare (3%) and displays clinical characteristics that are different from other forms of NSCLC. Controlling for the most basic prognostic factors (stage pI and complete resection), survival is significantly higher for BAC

[Failure of levofloxacin therapy in two cases of community-acquired pneumonia caused by fluoroquinolone-resistant Streptococcus pneumoniae and complicated with empyema]. / Fracaso terapéutico de levofloxacino en dos casos de neumonía adquirida en la comunidad complicada con empiema causados por Streptococcus pneumoniae resistente a fluoroquinolonas.

BACKGROUND: Community acquired pneumonia (CAP) due to Streptococcus pneumoniae is a frequent cause of morbidity and mortality. We communicate two cases of CAP with complications. In both cases levofloxacin-resistant S. pneumoniae was isolated in pleural effusion. Patient 1: A 51-year-old man who had not received previous treatment with quinolones was admitted to the hospital for CAP and initially treated with levofloxacin (500 mg/24h iv). Four days later pleural effusion developed and fluid culture isolated levofloxacin-resistant S. pneumoniae (MIC > 32 .g/ml). The outcome was favorable following chest tube placement and treatment with beta-lactam antibiotics. Patient 2: A 73-year-old man with a history of chronic obstructive pulmonary disease was admitted due to CAP and was initially treated with levofloxacin (500 mg/24 h iv). He was transferred to our hospital after 10 days of treatment with this antibiotic, following the development of pleural effusion with isolation of levofloxacin-resistant S. pneumoniae (MIC = 12 .g/ml). The patient was treated with chest tube placement and beta-lactam antibiotics with a favorable outcome. CONCLUSIONS: Patients with CAP treated empirically must be closely followed, both clinically and radiologically, to facilitate early detection of complications due to bacterial resistance to the prescribed antibiotic. Patients with CAP who have received quinolones in the weeks before the development of pneumonia should not been treated empirically with these antibiotics because of the risk of resistance development.

Fracaso terapéutico de levofloxacino en dos casos de neumonía adquirida en la comunidad complicada con empiema causados por Streptococcus pneumoniae resistente a fluoroquinolonas / Failure of levofloxacin therapy in two cases of community-acquired pneumonia caused by fluoroquinolone-resistant Streptococcus pneumoniae and complicated with empyema

Antecedentes. La neumonía adquirida en la comunidad (NAC) por Streptococcus pneumoniae es una causa frecuente de mortalidad y morbilidad. Se describen 2 casos de NAC tratadas con levofloxacino que se complicaron. En ambos casos se aisló en líquido pleural S. pneumoniae resistente al antibiótico empleado. El primer caso correspondía a un varón de 51 años, no tratado previamente con quinolonas. Ingresó en el hospital por NAC tratada inicialmente con levofloxacino (500 mg/24 h i.v.). A los 4 días aparece un derrame pleural en el que se aísla S. pneumoniae resistente a levofloxacino (concentración inhibitoria mínima [CIM] > 32 µg/ml). El paciente evolucionó favorablemente mediante drenaje del derrame y tratamiento con antibiótico betalactámico. El segundo caso era un varón de 73 años con antecedentes de enfermedad pulmonar obstructiva crónica. Ingresa por NAC tratada inicialmente con levofloxacino (500 mg/24 h i.v.). Fue remitido a nuestro hospital por presencia de derrame pleural en el que creció S. pneumoniae resistente a levofloxacino (CIM = 12 µg/ml) tras 10 días de tratamiento antibiótico. El paciente evolucionó de manera favorable mediante drenaje del derrame y tratamiento con antibiótico betalactámico. Conclusiones. Los pacientes con NAC en los que se inicia tratamiento antibiótico empírico deben vigilarse estrechamente desde el punto de vista clínico y radiológico, para la detección precoz de complicaciones por resistencia bacteriana al antibiótico empleado. En los pacientes con NAC que hayan recibido quinolonas en las semanas previas al desarrollo de la neumonía no es recomendable iniciar tratamiento empírico con estos antibióticos dado el riesgo de desarrollo de resistencias (AU)

Background. Community acquired pneumonia (CAP) due to Streptococcus pneumoniae is a frequent cause of morbidity and mortality. We communicate two cases of CAP with complications. In both cases levofloxacin-resistant S. pneumoniae was isolated in pleural effusion. Patient 1: A 51-year-old man who had not received previous treatment with quinolones was admitted to the hospital for CAP and initially treated with levofloxacin (500 mg/24h iv). Four days later pleural effusion developed and fluid culture isolated levofloxacin-resistant S. pneumoniae (MIC > 32 µg/ml). The outcome was favorable following chest tube placement and treatment with beta-lactam antibiotics. Patient 2: A 73-year-old man with a history of chronic obstructive pulmonary disease was admitted due to CAP and was initially treated with levofloxacin (500 mg/24 h iv). He was transferred to our hospital after 10 days of treatment with this antibiotic, following the development of pleural effusion with isolation of levofloxacin-resistant S. pneumoniae (MIC = 12 µg/ml). The patient was treated with chest tube placement and beta-lactam antibiotics with a favorable outcome. Conclusions. Patients with CAP treated empirically must be closely followed, both clinically and radiologically, to facilitate early detection of complications due to bacterial resistance to the prescribed antibiotic. Patients with CAP who have received quinolones in the weeks before the development of pneumonia should not been treated empirically with these antibiotics because of the risk of resistance development (AU)

Primary pulmonary lymphoma: diagnosis and follow-up of 6 cases and review of an uncommon entity.

AIMS AND BACKGROUND: Primary pulmonary lymphoma is an uncommon disease with a poorly defined management. We reviewed and followed the cases of primary pulmonary lymphoma in our institution to gather an estimation of this entity in our population. DESIGN AND METHODS: We reviewed the records of all patients with biopsy-proven lymphoma of the lung. The main diagnostic criterion for primary pulmonary lymphoma was the absence of extrapulmonary involvement. RESULTS: We identified 6 cases of primary pulmonary lymphoma among 33 patients with biopsy-proven lymphoma of the lung evaluated in our center in a 12-year period. A radiological abnormality in an asymptomatic patient was the most common clinical presentation. Four cases were low-grade and two cases high-grade non-Hodgkin PPL. Histopathologic analyses of lung specimens obtained by transbronchial biopsy were sufficient for a diagnosis in 5 of the 6 cases and avoided invasive surgical maneuvers. Most patients followed an indolent course, but with a tendency to relapse. CONCLUSIONS: Although clinical management of this entity is undefined, we feel bronchoscopic study, which is less aggressive than surgery, may be an adequate procedure for a diagnosis. Mono-chemotherapy using alkylating agents and careful clinical observation may be the best therapeutic approach for these patients, since most of them have favorable outcomes, whatever the treatment modalities.

Report on the incidence of interstitial lung diseases in Spain.

BACKGROUND AND AIM OF THE WORK: Almost no epidemiological data are available on a worldwide basis on the prevalence, incidence or relative frequency of interstitial lung diseases (ILD). We report the results of a registration of ILD by 23 centers of pulmonary medicine in Spain over one year (from October 2000 to September 2001). METHODS: A standardized questionnaire was sent to the centers, together with guidelines for classification and diagnostic evaluation. This questionnaire included questions about the explorations performed to establish the diagnosis. RESULTS: A total of 511 cases were registered. The mean age of the patients was 61 +/- 0.7 (x +/- SEM) yrs. The male to female ratio was 1.2:1. The estimated incidence of ILD was 7.6 per 100,000/year. The most frequent disease was idiopathic pulmonary fibrosis (38.6%), followed in decreasing order by sarcoidosis (14.9%), cryptogenic organizing pneumonia (10.4%), ILD associated with collagen vascular diseases (9.9%) and hypersensitivity pneumonitis (6.6%). In 5.1% of cases ILD was unclassified. HRCT scan was performed in 91.9% of cases, bronchoalveolar lavage in 67.9%, transbronchial lung biopsy in 59.9%, and surgical lung biopsy in 22.7%. CONCLUSIONS: This registration provides interesting information on the occurrence of ILD in Spain and on the procedures used to establish the diagnosis.