Gemma Rubinos Cuadrado

Age, comorbidity, treatment decision and prognosis in lung cancer

Fluid (ml) ‘Usual’ thickener 785 202 (701–903) 0.47 Pre-thickened 795 346 (745–1091) Protein (g) ‘Usual’ thickener 7 3 (4–7) 0.001 Pre-thickened 15 7 (10–17) Energy (kCal) ‘Usual’ thickener 267 50 (254–304) 0.0001 Pre-thickened 583 241 (543–784) Calcium (mg) ‘Usual’ thickener 25 8 (22–30) 0.0001 Pre-thickened 544 156 (467–623) Vitamin C (mg) ‘Usual’ thickener 35 48 (13–61) 0.001 Pre-thickened 170 134 (128–262) Vitamin D (μg) ‘Usual’ thickener 0 0 0.00001 Pre-thickened 5 2 (4–6)

Neumonía adquirida en la comunidad por gérmenes atípicos: tratamiento y evolución

Objetivo Estudiar la evolucion de un grupo de neumonias extrahospitalarias causadas por germenes atipicos ( Mycoplasma pneumoniae, Legionella spp., Coxiella burnetii y Chlamydophila pneumoniae ) en funcion del tratamiento empirico recibido. Pacientes y metodos Entre enero de 1996 y febrero de 2001 ingresaron en nuestra unidad 390 casos de neumonia, de los que 89 estaban causados por germenes atipicos. Los pacientes se dividieron retrospectivamente en 2 grupos segun el tratamiento empirico pautado: grupo A, al que se habia proporcionado cobertura frente a germenes atipicos (quinolonas o macrolidos), y grupo B, al que no se habia proporcionado dicha cobertura. Se estudio la evolucion segun las diferencias entre ambos grupos en la estancia hospitalaria, la resolucion radiologica, el reingreso en el primer mes tras el alta y la mortalidad. Resultados El grupo de estudio lo constituyeron 89 pacientes con neumonia causada por germenes atipicos (39 en el grupo A y 50 en el B). Las variables estudiadas no mostraron diferencias significativas entre ambos grupos. Conclusiones En nuestra serie de neumonias extrahospitalarias la cobertura antibiotica frente a germenes atipicos no mejoro la evolucion clinica y radiologica de los pacientes.

Home Mechanical Ventilation through Mask: Monitoring Leakage and Nocturnal Oxygenation at Home

Background: Leakage is common in patients receiving home mechanical ventilation (HMV) via a face mask. Although pressure ventilators have partial compensatory capacity, excessive leakage can compromise the effectiveness of treatment. Home ventilators are equipped with built-in software which provides information on leakage. However, the values of leakage and their effects in routine clinical practice are currently little known. Objective: To measure leakage in stable patients on nocturnal HMV and its impact on treatment effectiveness. Methods: Consecutive outpatients on HMV were recruited. Nocturnal pulse oximetry was performed at home and leakage was measured using the ventilator’s built-in software. We measured: mean SpO2, percentage of time with SpO2 <90% (T90), mean leakage (meanL), maximum leakage (maxL), and minimum leakage (minL) during the ventilation session. We estimated ventilator capacity to compensate for leakage according to inspiratory positive airway pressure and divided the patients into two groups: those with leak compensation and those without. Results: The study included 41 patients [mean age, 64 years (SD 11.9); 23 (56%) women]. Nocturnal pulse oximetry showed an SpO2 of 94% (±2.9) and a T90 of 10% (±21.7). Leakage (in l/min) was: meanL, 32.2 (±15.3); maxL, 64.8 (±28.5), and minL, 18.8 (±10.6). Seven cases (17%) had leakage greater than the ventilator compensatory capacity, but no significant difference in SpO2 or T90 was observed between patients with or without leak compensation. Conclusions: A wide variation between maxL and minL was observed in our series; 17% of cases had higher leakage values than the compensatory capacity of the ventilator, but this did not affect nocturnal oxygenation.Background: Leakage is common in patients receiving home mechanical ventilation (HMV) via a face mask. Although pressure ventilators have partial compensatory capacity, excessive leakage can compromise the effectiveness of treatment. Home ventilators are equipped with built-in software which provides information on leakage. However, the values of leakage and their effects in routine clinical practice are currently little known. Objective: To measure leakage in stable patients on nocturnal HMV and its impact on treatment effectiveness. Methods: Consecutive outpatients on HMV were recruited. Nocturnal pulse oximetry was performed at home and leakage was measured using the ventilator’s built-in software. We measured: mean Sp O 2 , percentage of time with Sp O 2 ! 90% (T90), mean leakage (meanL), maximum leakage (maxL), and minimum leakage (minL) during the ventilation session. We estimated ventilator capacity to compensate for leakage according to inspiratory positive airway pressure and divided the patients into

Niveles elevados de carboxihemoglobina: fuentes de exposición a monóxido de carbono

INTRODUCTION Inhalation of carbon monoxide (CO) can result in poisoning, with symptoms ranging from mild and nonspecific to severe, or even death. CO poisoning is often underdiagnosed because exposure to low concentrations goes unnoticed, and threshold values for normal carboxyhemoglobin vary according to different authors. The aim of our study was to analyze carboxyhemoglobin (COHb) levels in an unselected population and detect sources of CO exposure METHODS In a cross-sectional descriptive study, we analyzed consecutive arterial blood gas levels processed in our laboratory. We selected those with COHb≥2.5% in nonsmokers and ≥5% in smokers. In these cases a structured telephone interview was conducted. RESULTS Elevated levels of COHb were found in 64 (20%) of 306 initial determinations. Of these, data from 51 subjects aged 65±12 years, 31 (60%) of which were men, were obtained. Mean COHb was 4.0%. Forty patients (78%) were non-smokers with mean COHb of 3.2%, and 11 were smokers with COHb of 6.7%. In 45 patients (88.2%) we detected exposure to at least one source of ambient CO other than cigarette smoke. CONCLUSIONS A significant proportion of individuals from an unselected sample had elevated levels of COHb. The main sources of CO exposure were probably the home, so this possibility should be explored. The population should be warned about the risks and encouraged to take preventive measures.

Monitoring Noninvasive Ventilation in Patients with Obesity Hypoventilation Syndrome: Comparison between Ventilator Built-in Software and Respiratory Polygraphy

Background: Polygraphy (PG) remains the standard method of assessing noninvasive ventilation (NIV) effectiveness. Built-in software (BIS) of recent NIV equipment provides estimates of some ventilator parameters, but their usefulness is unclear. Objectives: To assess the reliability of BIS compared with PG in a cohort of obesity hypoventilation syndrome (OHS) patients on NIV. Methods: Thirty stable OHS patients on NIV were evaluated in an outpatient setting with simultaneous PG and BIS recordings. The automated apnea-hypopnea event index (EIAUT) provided by Rescan and manual scoring based on available traces obtained from the software (EIBIS) were compared with manual PG scoring (EIPG). Each manual scoring was separately performed by 2 trained operators. Agreement between the 2 operators was assessed using the kappa coefficient. Pearson correlation and Bland-Altman plots were used to evaluate agreement between EIAUT, EIBIS, and EIPG. Results: Twenty-six cases were valid for analysis (age ±61 years, 17 men). All patients were ventilated in the spontaneous/timed mode (mean inspiratory positive airway pressure 17 ± 3 cm H2O, mean expiratory positive airway pressure 10 ± 3 cm H2O). Cohens kappa agreement between the operators was 0.7 for EIBIS and 0.84 for EIPG. EIBIS showed good correlation with EIPG (r2 = 0.79 p < 0.001), better than scoring provided by the automated analysis (r2 = 0.71, p < 0.006 for EIAUT vs. EIPG). Conclusions: In stable OHS patients on NIV, unattended home-based monitoring using Rescan is reproducible and reliable to assess quality of ventilation when compared with PG. In addition, manual scoring of events using data obtained with this device is more consistent than software-based automated analysis.

Neumonía adquirida en la comunidad: adenosindesaminasa plasmática como marcador etiolÓgico

Fundamento La adenosindesaminasa (ADA) es una enzima intracitoplasmatica cuya elevacionha sido demostrada tanto en procesos infecciosos que estimulan la inmunidad celular como enotro tipo de enfermedades (diabetes y hepatopatias, entre otras). El objetivo de este estudio esdeterminar la capacidad del ADA plasmatico (ADAp) para predecir el tipo de germen causanteen la neumonia adquirida en la comunidad (NAC) y poder guiar el tratamiento antibiotico empirico. Pacientes y metodo Estudio de cohortes (245 casos y 49 controles) para contrastar las diferenciasen el valor de ADAp estudiando tanto variables microbiologicas (tipo de germen) como factoresde comorbilidad y complicaciones. Se practico una regresion logistica. Resultados Las NAC causadas por germenes atipicos elevan significativamente el valor delADAp, que se normaliza en la convalecencia. Las variables con capacidad independiente paraelevar dicho valor fueron la presencia de germen «atipico» (odds ratio [OR] = 5,9), hepatopatia(OR = 5,8), diabetes (OR = 1,9) y toma previa de antibioticos (OR = 1,7). Conclusiones La ADAp puede ser utilizada como marcador etiologico para guiar el tratamientoantibiotico empirico en la NAC, en ausencia de diabetes, hepatopatia y toma de antibioticosprevia a la determinacion.

Treatment and Course of Community-Acquired Pneumonia Caused by Atypical Pathogens

Objective To study the course of disease and outcomes in a group of patients with community-acquired pneumonia caused by atypical pathogens (Mycoplasma pneumoniae, Legionella species, Coxiella burnetii, and Chlamydophila pneumoniae) according to the empiric treatment received. Patients and methods Of a total of 390 patients admitted to our hospital with pneumonia between January 1996 and February 2001, the causative microorganism was an atypical pathogen in 89 cases. Patients were divided retrospectively into 2 groups according to the empiric treatment they received: group A, who had received an antibiotic regimen (quinolones or macrolides) that provided coverage for atypical pathogens; and group B, who had received treatment that did not provide such coverage. Clinical course was assessed in terms of the differences between the 2 groups in length of hospital stay, radiographic resolution, readmission at 30 days after discharge, and mortality. Results A total of 89 patients with pneumonia caused by atypical pathogens (39 in group A and 50 in group B) were studied. No significant between-group differences in the variables were found. Conclusions In this group of patients hospitalized for community-acquired pneumonia, antibiotic regimens providing coverage for atypical pathogens did not improve either clinical or radiographic evolution.

Chemotherapy and Survival in Advanced Non-Small Cell Lung Carcinoma: Is Pneumologists' Skepticism Justified?

Objective Few studies have assessed whether the advantage chemotherapy has been shown to have in treating advanced non-small lung carcinoma in clinical trials is transferrable to normal health care activity. This could explain the skepticism of a large number of pneumologists towards this treatment. The objective of our study was to analyze prognostic factors related to survival and to see whether cytostatic treatment was an independent predictor. Patients and methods Patients enrolled in the study had been diagnosed with non-small cell carcinoma in stages IV or IIIB with pleural or N2-N3 involvement and with [a performance status of 2 or below according to the Eastern Cooperative Oncology Group (ECOG). Survival was analyzed with regard to the following variables: age, sex, comorbidity, weight loss, laboratory test results, histological type, ECOG score, TNM staging, and treatment. The Student t test, the χ2 test, the Kaplan-Meier method, the log-rank test, and Cox regression analysis were used in the statistical analysis. Results We enrolled 190 patients (157 men and 33 women) with a mean (SD) age of 61.75 (10.85) years (range, 33–85 years). Of these patients, 144 received cytostatic treatment and 46 palliative treatment. The median survival was 31 weeks and was related to absence of weight loss (hazard ratio [HR], 1.73; 95% confidence interval [CI], 1.26–2.39; P=.001), cytostatic treatment (HR, 1.85; 95% CI, 1.25–2.76; P=.002), and ECOG score of 0 to 1 (HR, 2.84; 95% CI, 1.62–5.00; P=.0001). In patients with ECOG scores of 0 to 1, weight loss and treatment were significant prognostic factors. Survival in the ECOG 2 group was 15 weeks for patients undergoing cytostatic treatment and 11 weeks for patients with symptomatic treatment. Conclusions In normal clinical practice, chemotherapy significantly prolongs survival in patients with performance status of less than 2, more time being gained if there is no associated weight loss. We conclude that the reluctance shown by many pneumologists toward using this treatment is not entirely justified.

Respuesta a la hipercapnia en pacientes con síndrome obesidad-hipoventilación en tratamiento con ventilación no invasiva en domicilio

INTRODUCTION Respiratory center (RC) dysfunction has been implicated in the pathogenesis of obesity-hypoventilation syndrome (OHS), and often requires treatment with home non-invasive ventilation (NIV). Our objective was to measure the effect of NIV on RC function in patients with OHS, and the factors that determine such an effect. METHODS We performed a prospective, repeated measures study to evaluate hypercapnia response (HR) by determining the p01/pEtCO2 ratio slope at baseline and after 6months of treatment with NIV in a group of OHS patients. A threshold of 0.22cmH2O/mmHg had previously been established in a control group, in order to differentiate optimal RC response from suboptimal RC response. RESULTS A total of 36 cases were included, 19 men (52%) aged 65 (SD 9) years, 63% of whom had p01/pEtCO2 below the reference value. Baseline p01/pEtCO2 was 0.17 (SD: 0.14) cmH2O/mmHg and, after 6 months of NIV, 0.30 (SD: 0.22) cmH2O/mmHg (p=0.011). After 6months of treatment with NIV, depressed RC function persisted in 12 cases (33%). CONCLUSION In total, 63% of OHS patients had RC dysfunction. The application of NIV improves RC function but not in all cases.