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Introduction: The magnitude of current resistance to antituberculosis drugs in Spain is unknown. The objective of this study is to describe resistance to first-line antituberculosis drugs and determine the associated factors., Methods: Prospective multicenter study of adult tuberculosis patients with positive Mycobacterium tuberculosis culture and antibiogram including first-line drugs in 32 hospitals and one out-patient center of the Spanish Health System between 2010 and 2011., Results: A total of 519 patients, 342 Spanish nationals and 177 (34.1%) foreigners were studied. Drug resistance was found in 48 (9.2%), of which 35 (6.7%) were isoniazid-resistant. There were 10 (1.9%) multiresistant cases and no strain was extremely resistant. Initial isoniazid resistance was detected in 28 of the 487 (5.7%) antituberulosis-naïve patients, most of whom were foreigners (P<.01). Acquired resistance was seen in 7 (22.6%) previously treated cases. Multiresistance was initial in 6 cases (1.2%) and acquired in another 4 (12.9%). Factors associated with initial isoniazid resistance were immigrant status and group cohabitation OR=2.3; 95%CI: .98-5.67 and OR=2.2; 95%CI: 1.05-7.07 respectively). The factor associated with acquired resistance to isoniazid was age below 50 years (P=.03)., Conclusions: The rate of initial isoniazid resistance is greater than estimated, probably due to the increase in immigration during recent years, suggesting that systematic national monitoring is required. Immigrants and those who cohabit in groups have a higher risk of isoniazid resistance., (Copyright © 2014. Published by Elsevier Espana.)

Objectives: To determine predictive factors for changes in standard anti-tuberculosis chemotherapy at the time of diagnosis., Methods: A prospective study was performed among tuberculosis (TB) patients treated at specialised centres during 2008-2009. Treatment outcome was monitored per standard guidelines. Treatment was considered successful if the patient was cured or completed treatment. Factors associated with treatment modification were analysed at the bivariate and multivariate levels using logistic regression., Results: A total of 427 patients were included in the study. The initial standard treatment regimen was retained for 249 patients (58.3%), extended to 9 months for 36 (8.4%) and changed for 142 (33.3%). Factors associated with a change of regimen at the multivariate level were female sex, age ≥ 50 years, human immunodeficiency virus infection, comorbidities, alcoholism, hospitalisation and culture-positive sputum. Drug resistance and toxicity were analysed independently. Treatment outcome was successful in 97.2% of cases without a regimen change and in 87.3% of those with a changed regimen (P < 0.001)., Conclusion: Factors associated with changes in the initial anti-tuberculosis regimen should be considered for rigorous follow-up. Results obtained through individualised treatment provided by specialists were good despite the complexity of the cases treated.

Introduction: Community acquired pneumonia (CAP) is a highly prevalent pathology whose etiology is determined by the characteristics of the geographic region, and the patient. The study of these features is essential for a proper therapeutic approach. Our aim was to study the changes of the causative agent of CAP brought about by the influence of seasonal and climatic changes in our geographic area., Patients and Method: A prospective and longitudinal study of patients admitted with CAP was done from January 2006 to December 2009. We analyzed demographic data, comorbidities, severity, etiologic agent, complications and mortality. We correlated mean temperature and mean cumulative rainfall for each season with Streptococcus pneumoniae and Legionella pneumophila. Statistical analyses included: Chi squared test, Student's t test for independent samples, variance analysis and Spearman's correlation., Results: We included 243 patients, 64.6% men and 54.7% over the age of 65. The highest incidence of CAP was in the winter. Streptococcus pneumoniae was the most common causative agent for all seasons except in summer when the main agent was Legionella pneumophila. We observed a significant correlation between the lowest seasonal average temperature and pneumococcal etiology of CAP; inversely, with higher temperatures, Legionella pneumophila was more common. No etiological differences were found by season when related with environmental humidity., Conclusions: In our area, Streptococcus pneumoniae was the most common etiological agent in winter with low temperatures; in summer, with high temperatures, the most frequent was Legionella pneumophila., (Copyright © 2012 SEPAR. Published by Elsevier España, S.L. All rights reserved.)

The association of systemic sarcoidosis with malignant neoplasms has been reported by several publications although there is controversy as to whether sarcoidosis predisposes patients to certain types of tumors or whether it is the tumors that cause a sarcoid reaction. The relationship between endobronchial carcinoid tumor and sarcoidosis is uncommon. We report the case of a 43-year-old male who was hospitalized due to hemoptysis. Thoracic CT revealed a pulmonary mass in the right upper lobe (RUL) as well as hypermetabolic lymphadenopathies seen with PET-CT. The endobronchial biopsies were compatible with carcinoid tumor. The patient underwent lobectomy of the RUL with mediastinal lymphadenectomy. Histology demonstrated type I endobronchial carcinoid tumor and sarcoid granulomas, both in the RUL surgical piece as well as in the mediastinal lymph nodes., (Copyright © 2011 SEPAR. Published by Elsevier Espana. All rights reserved.)

Introduction: The objective of the present study was to validate the Spanish version of the SAQLI, which is a health-related quality of life (HRQL) questionnaire specific for sleep apnea-hypopnea syndrome (SAHS), and to assess its sensitivity to change., Material and Methods: A multicenter study performed in a group of patients with SAHS (apnea-hypopnea index [AHI] ≥5) who had been referred to the centers' Sleep Units. All patients completed the following questionnaires: SF-36, FOSQ, SAQLI and Epworth scale. The psychometric properties (internal consistency, construct validity, concurrent validity, predictive value, repeatability and responsiveness to change) of the SAQLI were assessed (four domains: daily function, social interactions, emotional function and symptoms; an optional fifth domain is treatment-related symptoms)., Results: One hundred sixty-two patients were included for study (mean age: 58±12; Epworth: 10±4; BMI: 33±5.9kg m(-2); AHI: 37±15hour(-1)). The factorial analysis showed a construct of four factors with similar distribution to the original questionnaire domains. Internal consistency (Cronbach's alpha between 0.78 and 0.82 for the different domains), concurrent validity for SF-36, Epworth scale and FOSQ, and test-retest reliability were appropriate. The predictive validity of the questionnaire showed no significant correlations with the severity of SAHS. SAQLI showed good sensitivity to change in all the domains of the questionnaire (p<0,01)., Conclusions: The Spanish version of the SAQLI is a valid HRQL measurement with appropriate psychometric properties for use in patients with SAHS and it is sensitive to change., (Copyright © 2012 SEPAR. Published by Elsevier Espana. All rights reserved.)

Background: Adherence to tuberculosis (TB) treatment is troublesome, due to long therapy duration, quick therapeutic response which allows the patient to disregard about the rest of their treatment and the lack of motivation on behalf of the patient for improved. The objective of this study was to develop and validate a scoring system to predict the probability of lost to follow-up outcome in TB patients as a way to identify patients suitable for directly observed treatments (DOT) and other interventions to improve adherence., Methods: Two prospective cohorts, were used to develop and validate a logistic regression model. A scoring system was constructed, based on the coefficients of factors associated with a lost to follow-up outcome. The probability of lost to follow-up outcome associated with each score was calculated. Predictions in both cohorts were tested using receiver operating characteristic curves (ROC)., Results: The best model to predict lost to follow-up outcome included the following characteristics: immigration (1 point value), living alone (1 point) or in an institution (2 points), previous anti-TB treatment (2 points), poor patient understanding (2 points), intravenous drugs use (IDU) (4 points) or unknown IDU status (1 point). Scores of 0, 1, 2, 3, 4 and 5 points were associated with a lost to follow-up probability of 2,2% 5,4% 9,9%, 16,4%, 15%, and 28%, respectively. The ROC curve for the validation group demonstrated a good fit (AUC: 0,67 [95% CI; 0,65-0,70])., Conclusion: This model has a good capacity to predict a lost to follow-up outcome. Its use could help TB Programs to determine which patients are good candidates for DOT and other strategies to improve TB treatment adherence.

Background and Objective: The objective of this study was to translate and adapt to Spanish the Québec Sleep Questionnaire (QSQ)., Methods: For QSQ tran-cultural adaptation, the back-translation technique was used. A psychologist and a pneumonologist made a first translation of the questionnaire. Naturalness-correctness of items and conceptual equivalence were evaluated by external researchers and a group of patients. A back-translation was finally remitted to author., Results: Most of the items had minimal difficulty in translation. The difficulty was moderate in only 4 of them (items 2, 7, 8, 30). Naturalness-correctness was maximal in most items and excellent in 4 (8 to 9 points). The conceptual equivalence was complete in all the items, except item 2 that showed a partial equivalence., Conclusions: The first translation and adaptation to Spanish language of the quality of life questionnaire QSQ has been done. The translation has minimal difficulty and the conceptual equivalence is almost complete., (Copyright © 2011 Elsevier España, S.L. All rights reserved.)

Introduction: There is no specific health-related quality of life (HRQL) questionnaire that has been validated in Spanish for its use in patients with sleep apnea-hypopnea syndrome (SAHS). The objective of the present study was to validate the Spanish version of the Quebec Sleep Questionnaire (QSQ)., Patients and Methods: A multi-center study including a group of patients with SAHS (AHI≥5) referred to the Sleep Unit. All patients completed the following questionnaires: SF-36, FOSQ, QSQ and Epworth scale. Internal consistency, construct validity, concurrent validity, predictive validity, repeatability and responsiveness to change of the QSQ (32 items in five domains: daytime sleepiness, diurnal symptoms, nocturnal symptoms, emotions, and social interactions) were assessed., Results: A hundred twenty one patients were included in the study (mean age: 57 ± 13; mean Epworth: 9 ± 4; mean Body Mass Index (BMI): 28 ± 3 kg·m(-2) and mean AHI: 36 ± 20 hour(-1)). The factorial analysis showed a construct of five factors with similar distribution to the original questionnaire domains. Internal consistency (Cranach's alpha between 0.78 and 0.93 for the different domains), concurrent validity (compared to SF-36, Epworth scale and FOSQ), predictive validity of SAHS severity and test-retest reliability were appropriate. The test showed good responsiveness to change in diurnal (P=.003) and nocturnal symptoms domains (P=.02)., Conclusions: The Spanish version of the QSQ is a valid HRQL measure with appropriate psychometric properties for use in patients with SAHS and is responsive to change in symptoms domains., (Copyright © 2011 SEPAR. Published by Elsevier Espana. All rights reserved.)

Background and Objective: Weight loss in patients with severe chronic obstructive pulmonary disease (COPD) is a prognostic bad factor. The objective of this study is to analyze the effectively of megestrol acetate (MA) to increase appetite of these patients., Patients and Methods: Randomized double blind placebo controlled trial to study the effect of 160 mg/bid of MA, for 8 weeks, on nutritional, functional, analytical and quality of life parameters, in 38 patients with severe COPD and body mass index (BMI) < 21 kg/m(2), or between 21-25 with involuntary weight loss of 5% in the last 3 months., Results: At 8 weeks, in the MA group the body weight increased (2.3 kg) with respect to the control group (0.1 kg) (p<0.04). MA improved significantly the triceps skin-fold thickness (p < 0.04), prealbumin (p<0.004), lymphocytes (p<0.0006), C3 (p<0.04), PCO(2) (p<0.007) and bicarbonate levels (p<0.008). MA did not increase the MRC and SGRQ scales, the distance of 6 MWT nor BODE index. The IL-6 and TNF alpha levels were not modified in the MA group, but leptin did increase (p<0.043). MA improved the sense of wellbeing (p<0.02) and the appetite (p<0.008), compared to the control group. Adverse effects were similar in both groups., Conclusions: MA safely increases the body weight and the appetite in severe COPD patients with weight loss. MA improves blood gases and nutritional parameters and the sense of wellbeing, but it does not improve the respiratory muscular function or exercise tolerance., (Copyright © 2010 Elsevier España, S.L. All rights reserved.)

Background: To identify the differential tuberculosis (TB) characteristics within the immigrant population with respect to natives in Spain., Methodology/principal Findings: A prospective cohort study design was implemented to examine the TB cases diagnosed and starting standard antituberculous treatment in Spain, between January 1st 2006 and March 31st 2007. A logistic regression analysis was performed to determine differential characteristics. 1,490 patients were included in the study population, 1,048 natives and 442 (29.7%) immigrants. According to the multivariate analysis, the following variables were significantly associated with immigrant TB cases: younger age (OR = 3.79; CI:2.16-6.62), living in group situation (OR = 7.61; CI:3.38-12.12), lower frequency of disabled (OR:0.08; CI:0.02-0.26) and retired (OR:0.21; CI:0.09-0.48) employment status, lower frequency of pulmonary disease presentation (OR = 0.47; CI:0.24-0.92), primary or emergency care admission (OR = 1.80; CI:1.05-3.06 and OR = 2.16; CI:1.36-3.45), drug resistance (OR = 1.86; CI:1.01-3.46), treatment default (OR:2.12; CI:1.18-3.81), lower frequency of alcohol and cigarette consumption (OR = 2.10; CI:1.42-3.11 and OR = 2.85; CI:2.10-3.87 respectively), more directly observed treatment (OR = 1.68; CI:1.04-2.69), and poor understanding of TB disease and its treatment (OR = 3.11; CI:1.86-5.20). The low percentage of primary MDR-TB in the native population (0.1% vs. 2.2% of immigrants) should be noted., Conclusions/significance: The differences show the need to introduce specific strategies in the management of TB within the immigrant population, including the improvement of social and work conditions.

Pulmonary TB should be suspected in patients with respiratory symptoms longer than 2-3 weeks. Immunosuppression may modify clinical and radiological presentation. Chest x-ray shows very suggestive, albeit sometimes atypical, signs of TB. Complex radiological tests (CT scan, MR) are more useful in extrapulmonary TB. At least 3 serial representative samples of the clinical location are used for diagnosis whenever possible. Bacilloscopy and liquid medium cultures are indicated in all cases. Genetic amplification techniques are coadjuvant in moderate or high TB suspicion. Administration of isoniazid, rifampicin, ethambutol and pyrazinamide (HREZ) for 2 months and HR for 4 additional months is recommended in new cases of TB, except in cases of meningitis in which treatment should continue for up to 12 months and up to 9 months in spinal TB with neurological involvement, and in silicosis. Appropriate adjustments with antiretroviral treatment should be made in HIV patients. Combined therapy is recommended to avoid development of resistance. An antibiogram to first line drugs should be performed in all the initial isolations of new patients. Treatment control is one of the most important activities in TB management. The Tuberculin Skin Test (TST) is positive in TB infection when >or=5mm, and Interferon-Gamma Release Assays (IGRA) are recommended in combination with TT. The standard treatment schedule for infection is 6 months with isoniazid. In pulmonary TB, respiratory isolation is applied for 3 weeks or until 3 negative bacilloscopy samples are obtained., ((c) 2010 Elsevier España, S.L. All rights reserved.)

Pulmonary TB should be suspected in patients with respiratory symptoms longer than 2-3 weeks. Immunosuppression may modify clinical and radiological presentation. Chest X-ray shows very suggestive, albeit sometimes atypical, signs of TB. Complex radiological tests (CT scan, MR) are more useful in extrapulmonary TB. At least 3 serial representative samples of the clinical location are used for diagnosis whenever possible. Bacilloscopy and liquid medium cultures are indicated in all cases. Genetic amplification techniques are coadjuvant in moderate or high TB suspicion. Administration of isoniazid, rifampicin, ethambutol and pyrazinamide (HREZ) for 2 months and HR for 4 additional months is recommended in new cases of TB, except in cases of meningitis in which treatment should continue for up to 12 months and up to 9 months in spinal TB with neurological involvement, and in silicosis. Appropriate adjustments with antiretroviral treatment should be made in HIV patients. Combined therapy is recommended to avoid development of resistance. An antibiogram to first line drugs should be performed in all the initial isolations of new patients. Treatment control is one of the most important activities in TB management. The Tuberculin Skin Test (TST) is positive in TB infection when >or=5mm, and Interferon-Gamma Release Assays (IGRA) are recommended in combination with TT. The standard treatment schedule for infection is 6 months with isoniazid. In pulmonary TB, respiratory isolation is applied for 3 weeks or until 3 negative bacilloscopy samples are obtained., (Copyright 2010 SEPAR. Published by Elsevier Espana. All rights reserved.)

Varicella-zoster virus (VZV) pneumonia is one of the most serious complications of this infection in adults. The objective of this study was to analyze the epidemiological and clinical characteristics in a large sample of patients with VZV pneumonia. This was a 10-y retrospective, descriptive, observational study. We studied 46 patients with VZV pneumonia, 21 men and 25 women, with a mean age 36 +/-11 y. A contact with an index case was observed in 57%, 76 were active smokers, 6.5% consumed drugs and 2 women were pregnant. The symptoms were: fever (83%), cough (83%), dyspnoea (63%), pleuritic pain (70%), and haemoptysis (6%) and started 3-5 days after the onset of blisters, except in 11% in whom respiratory symptoms appeared first. Arterial blood gases showed a mean PO(2)/FiO(2) of 308 +/-101 and 30 patients had a PO(2) of <55 mmHg--11 of these (4%) were admitted to the ICU, 8 required mechanical ventilation. Comparison of patients in the ICU with those on the general ward showed differences in the duration of fever (6.1 +/- 4.2 vs 3.2 +/- 1.1 days, p <0.001), mean stay (16.8+/-9.3 vs 7.2+/-2.4 days, p <0.001) and complications such as acute renal failure (p = 0.01) and acute respiratory failure (p < 0.001). Despite the severity of disease, no patient died. Once diagnosed, 98% were treated with acyclovir, combined with steroids in 6 and with antibiotics in 3 complicated with bacterial pneumonia. The prevalence for the period was 0.33 cases/100,000 inhabitants/y. In conclusion, VZV pneumonia has a severe course and accounts for a high percentage of admissions to the intensive care unit. The absence of mortality may be related to early treatment with acyclovir. Smoking was a risk factor for VZV pneumonia.

Usually, mortality due to mild community-acquired pneumonias (CAP) (Pneumonia severity index (PSI) classes I-III) is low (<3%), but the appearance of hypoxemia significantly increases mortality. Our aim was to determine the clinical parameters associated with risk factors of developing hypoxemia in subjects with mild CAP (PSI I-III) and the clinical outcomes of the hypoxemic group. We analyzed clinical characteristics and the outcomes of patients with mild CAP and hypoxemia (PaO2/FiO2<300), in a prospective, multicenter cohort study of 1195 patients. Mild pneumonias (PSI I-III) were found in 645 cases (53.9%), of which 217 (33.6%) presented hypoxemia according to a PaO2/FiO2<300. Patients with PaO2/FiO2<300 required more ICU admissions, mechanical ventilation, and developed septic shock than other PSI I-III patients. The clinical parameters associated with hypoxemia were: COPD, bilateral chest X-ray involvement, and hypoalbuminemia. We conclude that patients with COPD, those with bilateral chest X-ray involvement, or hypoalbuminemia were significantly more likely to have hypoxemia in mild CAP. Hypoxemic patients with low-risk pneumonia have worse clinical outcomes, including more ICU admission, need for mechanical ventilation and presence of septic shock than non-hypoxemic low-risk patients.

Background: The adherence to long tuberculosis (TB) treatment is a key factor in TB control programs. Always some patients abandon the treatment or die. The objective of this study is to identify factors associated with defaulting from or dying during antituberculosis treatment., Methods: Prospective study of a large cohort of TB cases diagnosed during 2006-2007 by 61 members of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR). Predictive factors of completion outcome (cured plus completed treatment vs. defaulters plus lost to follow-up) and fatality (died vs. the rest of patients) were based on logistic regression, calculating odds ratios (OR) and 95% confidence intervals (CI)., Results: Of the 1490 patients included, 29.7% were foreign-born. The treatment outcomes were: cured 792 (53.2%), completed treatment 540 (36.2%), failure 2 (0.1%), transfer-out 33 (2.2%), default 27 (1.8%), death 27 (1.8%), lost to follow-up 65 (4.4%), other 4 (0.3%). Completion outcome reached 93.5% and poor adherence was associated with: being an immigrant (OR = 2.03; CI:1.06-3.88), living alone (OR = 2.35; CI:1.05-5.26), residents of confined institutions (OR = 4.79; CI:1.74-13.14), previous treatment (OR = 2.93; CI:1.44-5.98), being an injecting drug user (IDU) (OR = 9.51; CI:2.70-33.47) and treatment comprehension difficulties (OR = 2.93; CI:1.44-5.98). Case fatality was 1.8% and it was associated with the following variables: age 50 or over (OR = 10.88; CI:1.12-105.01), retired (OR = 12.26;CI:1.74-86.04), HIV-infected (OR = 9.93; CI:1.48-66.34), comprehension difficulties (OR = 4.07; CI:1.24-13.29), IDU (OR = 23.59; CI:2.46-225.99) and Directly Observed Therapy (DOT) (OR = 3.54; CI:1.07-11.77)., Conclusion: Immigrants, those living alone, residents of confined institutions, patients treated previously, those with treatment comprehension difficulties, and IDU patients have poor adherence and should be targeted for DOT. To reduce fatality rates, stricter monitoring is required for patients who are retired, HIV-infected, IDU, and those with treatment comprehension difficulties.

Introduction and Objective: When sleep apnea-hypopnea syndrome (SAHS) and cardiovascular disease occur concurrently, prognosis is affected. Echocardiography can detect structural cardiac abnormalities but using this technique in all patients would place a heavy burden on resources. The objective of this study was to investigate whether the N-terminal fraction of brain natriuretic peptide (NT-proBNP) can be used as a marker for silent heart disease., Patients and Methods: NT-proBNP concentration was measured in the 114 consecutive patients with SAHS who underwent echocardiography before starting treatment. Left and right ventricular systolic and diastolic function, as well as structural abnormalities, were studied. Correlations between NT-proBNP concentration and the abnormalities detected were investigated. A receiver operating characteristics (ROC) curve was plotted for NT-proBNP concentration and cardiac abnormalities., Results: Data for 98 patients were finally analyzed. NT-proBNP concentration was significantly correlated with ventricular septal thickness (r=0.63), posterior wall thickness (r=0.45), and left ventricular end-diastolic diameter (r=0.51) (P<.0001 for all correlations). The area under the ROC curve was significant (0.870; 95% confidence interval, 0.801-0.939; P<.0001). Assuming that specificity would be more useful for clinical practice, we calculated that NT-proBNP concentrations below 100 and 200 pg/mL could rule out structural abnormalities with a reliability of 90% and 100%, respectively., Conclusions: NT-proBNP concentration was strongly correlated with echocardiographic abnormalities and so could be a useful tool for identifying patients who should be referred to the cardiologist.

Introduction: Sleep apnea-hypopnea syndrome (SAHS) is an emerging disease with high prevalence. There is controversy as to whether cardiac abnormalities are due to the disease itself or to the arterial hypertension frequently associated with this disease., Objectives: To analyze echocardiographic abnormalities in a population of SAHS patients depending on the presence or absence of hypertension at the time of diagnosis and after six months of treatment with continuous positive airway pressure (CPAP)., Methods: We studied 85 consecutive patients diagnosed with SAHS who required treatment with CPAP (Hypertensive: 43, nonhypertensive: 42). We performed a baseline echocardiogram after six months of treatment. We analyzed morphological (wall thickness, diameters, ejection fraction) and functional (peak E- and A-wave velocities, deceleration time, Tei index) parameters of the left and right ventricles., Results: Hypertensive patients were older and had higher blood pressure values, but there were no differences between groups in other clinical parameters. The hypertensive group had greater septal thickness (hypertensive: 12.1+/-2.3; nonhypertensive: 10.8+/-2.1mm; p=0.01). There were also differences in impairment of left (hypertensiveHT: 92.9%, nonhypertensive: 65%, p=0.002) and right (hypertensive: 74.4%, nonhypertensive: 42.1%, p=0.006) ventricular filling. After six months of treatment, an improvement of the myocardial performance index was noted in nonhypertensive patients (baseline Tei: 0.55+/-0.1 vs. 6-month Tei: 0.49+/-0.1; p=0.01), whereas no significant change was observed in hypertensive patients., Conclusions: Cardiac abnormalities in SAHS patients are increased in the presence of associated hypertension. Treatment with CPAP for six months improves cardiac abnormalities in nonhypertensive patients but not in hypertensive patients.

Objective: Sleep apnea-hypopnea syndrome (SAHS) is an emerging disease with considerable cardiovascular impact. The myocardial performance index (MPI) is an echocardiographic parameter that is useful in the assessment of global myocardial function. The purpose of this study was to identify any differences in the MPI between patients with and without SAHS., Patients and Methods: We studied 120 consecutive patients referred to our department for suspected SAHS. Following the overnight sleep study and after excluding all patients with hypertension, heart disease, or invalid recordings, 54 patients with SAHS and 13 patients without the disease matched for age and body mass were analyzed. A blinded cardiologist performed Doppler echocardiography, measuring parameters related to ventricular hypertrophy, systolic function, diastolic function, and the MPI. The data were compared by chi(2) and analysis of variance., Results: Mean (SD) ventricular mass was greater in patients with SAHS (183.17 [40.5] g) than in those without that diagnosis (149 [26] g) (P=.005). No differences were observed in systolic function (78.5% [8.95%] vs 81.6% [7%]) (P=.2), although a higher percentage of patients with SAHS had abnormal diastolic function (71.2% vs 38.5%) (P=.049). The MPI was significantly higher in SAHS patients (0.54 [0.12] vs 0.46 [0.07]) (P=.028)., Conclusions: On its own, SAHS leads to left ventricular hypertrophy. Diastolic involvement is common in these patients, although a large number of healthy individuals who are obese also present it. The MPI is higher in SAHS and could be a useful parameter to identify patients with silent heart disease before it progresses.

Introduction and Objectives: Sleep apnea-hypopnea syndrome (SAHS) is associated with significant effects on the heart, which can be assessed using noninvasive methods such as transthoracic echocardiography. However, it is not clear whether these effects are due to the condition itself or are influenced by associated factors, such as high blood pressure (HBP). The objective of this study was to investigate the echocardiographic alterations observed in SAHS patients and how they are affected by the presence of concomitant HBP., Methods: The study involved 103 consecutive patients (49 with HBP and 54 without) with SAHS and an indication for continuous positive airways pressure treatment and 24 controls matched for age and body mass index. Doppler echocardiography was performed in a blinded manner. Both morphology (i.e., wall thickness, and diameters) and function (i.e., ejection fraction, peak E and A wave velocities, mitral deceleration time, and Tei index) were assessed. Results were compared using ANOVA and Bonferroni's test., Results: Hypertensive patients had larger morphological changes characteristic of left ventricular hypertrophy (i.e., increased septal and posterior wall thicknesses) than nonhypertensive patients, who in turn had larger changes than controls (septal thickness: HBP-SAHS, 12 [2] mm; non-HBP SAHS, 11 [2] mm, and controls, 9.5 [5] mm; 1 vs. 2, P=.038; 1 vs. 3, P=.0001, 2 vs. 3, P=.034) (posterior wall thickness: HBP-SAHS, 11 [2] mm; non-HBP SAHS, 10 [1] mm, and controls, 9 [1.5] mm; 1 vs. 2, P=.5; 1 vs. 3, P=.0001; 2 vs. 3, P=.001). In addition, there were also greater changes in ventricular filling patterns on the left (HBP-SAHS, 92%; non-HBP SAHS, 72%, controls, 29%; P=.0001) and on the right (HBP-SAHS, 72%; non-HBP SAHS, 58%; controls, 25%; P=.001). There was a trend towards a larger left ventricular Tei index (HBP-SAHS, 0.56 [0.2]; non-HBP SAHS, 0.54 [0.12]; controls, 0.5 [0.1]; 1 vs. 2, P=.8; 1 vs. 3, P=.09; 2 vs. 3, P=.7)., Conclusions: From the time of diagnosis, SAHS was associated with left ventricular hypertrophy and impaired biventricular filling, even in the absence of concomitant HBP. The abnormalities observed were more severe when HBP was present.

Introduction and Objectives: Sleep apnea-hypopnea syndrome (SAHS) is a prevalent condition that has well-known cardiovascular repercussions. However, few published echocardiographic studies have investigated the abnormalities present at SAHS diagnosis or their relationship with syndrome severity. Our objective was to evaluate myocardial structural, functional and performance parameters in these patients., Methods: In total, 110 consecutive patients diagnosed with SAHS between June 2005 and 2006 who required treatment with continuous positive airway pressure were divided into two groups according to SAHS severity. Baseline echocardiography was carried out to evaluate structural and functional variables. Findings in the two groups were compared by univariate and multivariate analysis., Results: The patients' mean age was 54 (13) years, their body mass index was 32 (6), 51% had comorbidities, and 74% were male. Patients with severe SAHS (i.e., apnea-hypopnea index [AHI] > or = 30) smoked and drank alcohol more and had larger neck circumferences. There was no significant difference in any structural parameter between the two groups. Functionally, patients with severe SAHS had shorter aortic (AHI<30 277 [4] ms vs AHIé30 263 [4] ms; P=.02) and pulmonary (AHI < 30 287 +/- 5 ms vs. AHI > or = 30 268 +/- 5 ms; P=.01) ejection times, and a higher Tei index (Left: AHI<30 0.51 [0.01] vs AHIé30 0.57 [0.02] [P=.04]; Right: AHI<30 0.38 [0.02] vs AHIé30 0.49 [0.03] [P=.02]). There were correlations between SAHS severity and the right Tei index, and aortic and pulmonary ejection times (P=.0001, P=.01, and P=.0001, respectively). The pulmonary ejection time was an independent predictor of SAHS severity (odds ratio: 0.98, 95% confidence interval, 0.97-0.99; P=.01)., Conclusions: Myocardial performance is poorer in patients with SAHS. The Tei index and ejection times are all associated with SAHS severity. The pulmonary ejection time is an independent predictor of disease severity.

Objective: To evaluate the usefulness of transcutaneous carbon dioxide pressure (TcPCO2) monitoring in patients hospitalized for respiratory disease., Patients and Methods: We used a SenTec TcPCO2 monitor that also determines transcutaneous oxygen saturation (SpO2) by means of a sensor placed behind the ear lobe at a temperature of 42 degrees C. We compared arterial blood gas measurements--PaCO2 and arterial oxygen saturation (SaO2)--with transcutaneous measurements and analyzed the correlation, regression line, and agreement between the 2 methods., Results: Thirty patients (20 men and 10 women) with various respiratory diseases and a mean (SD) age of 71 (13) years were included in the study. The median TcPCO2 was 43.25 mm Hg and the median PaCO2 was 42.6 mm Hg with no significant differences between the 2 measurements. The correlation was significant (rho=0.979; P< .0001) and the corresponding regression equation was TcPCO2=-2.475+1.058 PaCO2. The mean difference was 0.16 mm Hg (95% confidence interval [CI], --0.74 to 1.06). The lower limit of agreement (mean -1.96 SD) was -4.64 mm Hg, and the upper limit (mean +1.96 SD) was 4.96 mm Hg. For SaO2, the median was 94% and for SpO2, 95%. The difference between the 2 medians was significant (P< .004). The correlation was also significant (rho=0.822; P< .0001) with SpO2=4.427+0.97 SaO2. The mean difference was 1.14% (95% CI, 0.381% to 1.899%). The lower limit of agreement (mean -1.96 SD) was --2.93% and the upper limit (mean +1.96 SD) was 5.21%, Conclusions: Transcutaneous determination of carbon dioxide pressure and oxygen saturation is useful for patients hospitalized for respiratory disease in view of its good correlation and agreement, although SpO2 does tend to overestimate SaO2.

Intimal sarcoma of the pulmonary artery is a rare tumor that is usually diagnosed during surgery or autopsy. Such tumors are characterized by local growth, with only slight ability to metastasize. Diagnosis is difficult and often delayed owing to the nonspecific nature of the symptoms. Since intimal sarcoma of the pulmonary artery is so rare and insidious it is often confused with pulmonary thromboembolism and is therefore treated inappropriately with prolonged anticoagulation or thrombolysis. With a mean survival of 12 months from the onset of symptoms, the prognosis is poor. We present the case of a woman who was preoperatively diagnosed with intimal sarcoma of the pulmonary artery and who underwent surgical resection with no apparent recurrence at long term follow-up. A review of the literature is also included.

Question of the Study: The aim of our study was to examine the relationship between health-related quality of life (HRQL), lung function parameters and intensity of dyspnea in order to determinate what variables influence the HRQL in patients with pulmonary emphysema., Patients and Methods: Forty (mean aged 66+/-9) consecutive male patients with pulmonary emphysema were evaluated. All patients underwent spirometry, measurement of lung volumes, inspiratory and expiratory respiratory pressure (MIP and MEP), measurement of corrected carbon monoxide diffusing capacity (KCO), and 6-min walking test (6MWT). The scale of dyspnea by the baseline dyspnea index (BDI) and British Medical Council Research (MCR), and the quality of life by Chronic Respiratory Question Disease (CRQD) were also assessed., Results: FEV1, FVC, 6MWT, KCO, MEP, MIP, BDI and MCR were correlated with dimensions of CRQD. Factor analysis reduced these variables to four factors, which accounted for 86.2% of the total variance: (1) airway obstruction, (2) dyspnea, (3) capacity of effort, (4) maximum static respiratory pressure. In the multiple regression model BDI and MEP explained the 64% of the total variance of CRQD., Conclusions: Quality of life measured by CRQD in patients with emphysema is predominantly determined by dyspnea, and in minor degree by expiratory muscle strength. Our results underscore the usefulness of dyspnea scales and MEP in the evaluation of HRQL in patients with emphysema.

Visceral leishmaniasis is not unusual in patients with acquired immunodeficiency syndrome (AIDS), but lung infiltration is uncommon. Leishmaniasis involving the lung often manifests as interstitial pneumonitis. We report a case in which the discovery of amastigotes in the transbronchial biopsy led to a diagnosis of leishmaniasis. However, the findings from x-rays and study of the bronchoalveolar lavage fluid were consistent with bronchiolitis obliterans, possibly caused by the AIDS virus. In addition, the transbronchial biopsy findings were consistent with a diagnosis of bronchioloalveolar adenoma with radiographic evidence of multiple nodules.

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.

Context: Pulmonary tuberculosis with negative sputum bacilloscopy involves diagnostic difficulties when there are not available liquid culture media due to the slow growth of Mycobacterium tuberculosis in the traditional culture media, and also due to the need for carrying out invasive examinations., Objective: Evaluate the high resolution computerized tomography findings (HRCT) in patients with pulmonary tuberculosis and negative bacilloscopy of sputum., Method: Prospectively 28 patients (12 with active tuberculosis and 16 with inactive tuberculosis) were evaluated through HRCT, assessing the following findings: centrolobular nodules, multiple branched linear structures, macronodules, cavitation, consolidation, enlargement of interlobular septums, ground-glass change, bronchiectases, emphysema, broncovascular distortion, fibrotic changes, calcified mediastinal adenopathies, parenchymous calcification, pleural enlargement, and pleural effusion., Results: The findings that were associated significantly to the active disease were: consolidation (67%), macronodules (67%) and centrolobular nodules (67%). The presence of centrolobular nodules and/or consolidation had a sensitivity of 83% and a specificity of 87%. The findings significantly associated to inactive disease were bronchiectases (87%) and broncovascular distortion (62%)., Conclusion: Our results support the value of HRCT in patients with pulmonary tuberculosis and negative sputum bacilloscopy, since the finding of centrolobular nodules and/or consolidation has good sensitivity and specificity for the diagnosis of active pulmonary disease.

Twenty-eight (11.6%) out of 241 Spanish patients enrolled in an international phase III clinical trial of mild to moderate community-acquired pneumonia (CAP) comparing gemifloxacin vs. trovafloxacin were diagnosed of Legionnaires' disease. A definite diagnosis was established by seroconversion in 13 patients of whom only 2 had a positive Legionella urinary antigen. The remaining 15 patients were possible Legionella infections based on a single elevated IgG titer (> or = 1:512). All patients had a radiologically confirmed diagnosis of pneumonia, 5 (19%) patients were older than 65, comorbidity was present in 9 (33%), and 10 (36%) had to be hospitalized. Fifteen patients were treated with oral gemifloxacin (320 mg/day) and 13 with oral trovafloxacin (200 mg/day). Overall, clinical success occurred in 25 (89.3%) patients after 7 days of treatment and only 1 patient needed a 14-day treatment. There were only one adverse event withdrawal and one clinical failure, and no patients died. In light of the favorable clinical outcome, the use of newer fluoroquinolones seems adequate for the treatment of suspected or proven Legionella pneumonia.

Community-acquired pneumonia (CAP) in the elderly has increased as a consequence of an overall increase of the elderly population. A controversy about the aetiology and outcome of CAP in this population still exists and more epidemiological studies are needed. A prospective, 12-month, multicentre study was carried out to assess the clinical characteristics, aetiology, evolution and prognostic factors of elderly patients (> or = 65 yrs) admitted to hospital for CAP. The study included 503 patients (age 76 +/- 7 yrs). The clinical picture lasted < or = 5 days in 318 (63%) and the main clinical features were cough (n = 407, 81%) and fever (n = 380, 76%). Aetiological diagnosis was achieved in 199 (40%) cases, with a definite diagnosis obtained in 164 (33%). Of the 223 microorganisms isolated the main agents found were Streptococcus pneumoniae in 98 (49%) and Haemophilus influenzae in 27 (14%). A total of 53 patients died (11%) and the multivariate analysis showed the following factors of bad prognosis: previous bed confinement, alteration in mental status, absence of chills, plasma creatinine > or = 1.4 mg x dL(-1), oxygen tension in arterial blood/inspiratorv oxygen fraction ratio < 200 at the time of admission, and shock and renal failure during the evolution. The results of this study may aid in the management of empiric antibiotic treatment in elderly patients with community-acquired pneumonia and the patients who have a greater probability of bad evolution may be identified based on the risk factors.

Background: Community-acquired pneumonia (CAP) is one of the most frequent infectious disease conditions. With the aim of knowing the diagnostic and therapeutic strategies of CAP in Spanish hospitals we performed a prospective, observational and multicenter study., Patients and Method: Observational study of 468 patients with CAP consecutively evaluated in 21 Spanish hospitals. Clinical, diagnostic, therapeutic and evolutive variables were recorded., Results: We included 468 patients with a mean age of 63 (18) years; 75% of them had some comorbidity. 380 (81%) patients required hospitalization in a conventional ward while 19 (4%) were admitted in an Intensive Care Unit (ICU). 69 patients (15%) required ICU admission. During the first 24 h of admission, biochemical determinations were performed in 98% of cases, blood gas measurements in 88%, blood cultures in 265 (58%), sputum cultures in 149 (41%) and an invasive diagnostic technique was carried out in 17 cases. In 62 cases (14%), a microbiological diagnosis was achieved. Streptococcus pneumoniae (28 cases) was the most frequent isolate followed by Legionella pneumophila (6 cases). Clarithromycin was the most frequent antibiotic prescribed (38%), either as monotherapy (28) or in combination (148), followed by amoxicillin-clavulanate (124 cases). Nine percent of patients were considered non-responders to initial empirical antibiotic tretament. Overall mortality was 6% (25%) and it was significanty higher in non-responders., Conclusions: In most patients with CAP admitted in Spanish hospitals, a systematic diagnostic approach is lacking. There is an important variability in the administration of antimicrobials, the association of a betalactam plus clarithromycin being the most frequent strategy. Overall mortality is low and significantly higher in those patients with a lack of response to initial antibiotic treatment.

In order to assess factors associated with spontaneous pneumothorax (SP), mainly climatic changes, a prospective study was undertaken of 62 SP episodes among patients admitted to our hospital during a two-year period, from January 1994 to January 1996. Atmospheric pressure (AP) changes were analyzed, with daily recording of the number of unusual changes in AP (increases above 95th percentile and decreases below 5th percentile) and how many of these changes were followed by some episode of spontaneous pneumothorax during the following five days. To measure the degree of this association between the emergence of pneumothorax and exposure to unusual changes I AP, the relative risk (RR) was calculated. A total of 77 unusual AP changes were observed, 17 of which concurred with the emergence of 8 episodes of SP during the following five days, with a RR of 2.7 (1.6-4.4). Although the etiology of SP is unknown and probably of multifactorial origin, these data suggest that unusual changes in AP may play a relevant role in triggering this condition.

Background: We aimed to evaluate the differences in pulmonary function, quality of life (CVRS) and dyspnea in patients with chronic obstructive pulmonary disese (COPD) and emphysema according to the body mass index (BMI). Moreover, we analyzed the relation between BMI, pulmonary function, CVRS and dyspnea., Patients and Method: This was a prospective, 12-months study including 20 patients with COPD and emphysema. They were classified in group A (BMI < 21 kg/m(2) group B (BMI >= 21 kg/m(2)). We performed pulmonary function tests and determined the levels of dyspnea and CVRS according to a scale of dyspnea and a CVRS questionnaire., Results: Seven patients had a BMI < 21 kg/m(2) and it was >=21 kg/m(2) in 13 patients. DLCO in group A patients was lower than in group B. After a multiple regression analysis, the FVC accounted for 52% of dyspnea variability. Both PEM and dyspnea were the parameters that better predicted the CVRS., Conclusions: Patients with COPD and emphysema with a VMI < 21 kg/m(2) have a lower DLCO than patients with a BMI >= 21 kg/m(2). In our patients, dyspnea sensation depended on the FVC. In addition,the CVRS depended on dyspnea sensation and PEM.

Objective: To assess the serological response to fractions of Mycobacterium tuberculosis sonicate antigen by Western blot analysis in patients with tuberculosis and contacts., Methods: We studied 71 individuals including 43 patients with active tuberculosis, 16 contacts and 12 healthy blood donors. For Western blot analysis, M. tuberculosis (H37Rv strain) sonicate antigen extract was fractionated by electrophoresis on polyacrylamide gel (SDS-PAGE)., Results: We obtained antibody responses directed against four antigenic fractions with molecular weights of 71, 65, 26-38 and 19 kDa. Sixty per cent of pleural tuberculosis and 52.4% of smear-positive pulmonary tuberculosis had whole responses against all four fractions; there were no partial responses in these groups. For patients with smear-negative pulmonary tuberculosis whole responses were 17.6% and partial responses 41.2%. All contacts whose tuberculin tests converted from negative to positive (three cases) reacted exclusively against the 19 kDa fraction., Conclusions: Western blot-positive results in patients with pleural and smear-positive pulmonary tuberculosis were characterised by a whole pattern against all four antigenic fractions, whereas patients with smear-negative pulmonary tuberculosis showed heterogeneous results. The exclusive response against the 19 kDa fraction observed in contacts with tuberculin conversion could help to identify candidates for preventive therapy.

A 42-year-old man was admitted to the hospital with fever, abdominal pain and miliary radiological pattern. The amylase and lipase in serum, and the amylase in urine were increased. The tuberculin skin test was negative. The thoracic and abdominal CT scan showed costal affectation, multiple focal hepatic lesions and large necrosing peripancreatic lymphadenopathies. The transbronchial biopsy and the pancreatic punction demonstrated granulomatous necrotic lesions, and M. tuberculosis grew in the bronchial washing culture. The specific treatment normalized the pulmonary, costal and pancreatic lesions.

We report a case of bronchial atresia in the apical segment of right down lobule associated to subcarinal bronchogenic cyst in an eighteen years old patient who consults by long time bronchitis. The thorax X-ray shows an image suggested of mucoid impaction. The respiratory function tests are not essential for the diagnostic. The fiber bronchoscopy is normal and the diagnostic is established by mean image technics (thoracic HR-TC and MR).

Objective: To determine clinical features and outcome in hospitalized patients with acute lung injury secondary to diffuse pulmonary hemorrhage (DPH)., Patients and Method: Eight adult patients suffering DPH and acute lung injury were undergone to diagnosis procedure and following., Results: Two cases of idiopathic pulmonary hemosiderosis, two cases of systemic lupus erythematous, two cases of Goodpasture's syndrome, one case of idiopathic rapidly progressive glomerulonephritis and one of periarteritis nodosa were diagnosed. Treatment was methylprednisolone in all cases; besides, three cases required ventilatory support, and one immunosuppressive therapy, plasmapheresis and hemodialysis. One patient died and three of them suffered relapse with satisfactory outcome., Conclusion: We remark the presence of acute lung injury as an initial feature of DPH in our experience and the importance of a prompt diagnosis of the underlying disease.

Background: Cellular immunity disorder, showed by a decreased blood level of lymphocytes T CD4, is the main indicator of progression in HIV infection. The diminished level of these lymphocytes and CD4/CD8 ratio in pulmonary samples obtained by bronchoalveolar lavage (BAL) is known, so as the enhanced level of lymphocytes T CD8, while the pulmonary diseases high incidence in these patients could be due to a local immunity disorder or systemic one remains unknown. The aim of this study is to compare systemic immunity disorders, studied in blood samples, with local immunity replay, showed by BAL samples, in patients with HIV infection., Methods: 74 HIV patients were studied, all of them hospitalized due to acute respiratory disease, and undergone to fiberoptic bronchoscopy for diagnosing. Cellular and lymphocytic populations are compared and measured by flow cytometry in blood and BAL samples., Results: Percentage of total lymphocytes and CD4+ population were decreased in BAL samples, above all in patients with CD4 level minor than 25%., Conclusions: Cellular immunity disorder of patients with HIV infection is bigger in lung than in blood. It's possible to foresee the lymphocytes T CD4+ pulmonary depletion from their blood levels.

Background: In this report we study tuberculosis transmission in HIV infected patients using molecular epidemiological methods., Patients and Methods: We have studied 60 M. tuberculosis isolates from 30 HIV infected cases, and their clinical-epidemiological data. Susceptibility to tuberculostatic agents and electrophoretic patterns using RFLPs (restriction fragment length polymorphisms) method were evaluated. Dice's coefficient was used for the similarity analysis., Results: Over 73% studied patients were included in clusters using RFLPs analysis. This data show that nearly 60% of the tuberculosis cases in our area have a recent transmission. Forty per cent of these cases were included in the main cluster. The frequency of tuberculostatic-resistant strains in HIV infected patients was similar to the that of observed in other patients. We did not find correlation between RFLPs clusters and clinical-epidemiological data., Conclusions: Tuberculosis transmission in HIV-positive patients using RFLPs as molecular marker shows that 60% of the cases are caused by recently acquired strains. We did not find multi-drug resistant strains in our isolates. However due to the high transmissibility of these circulating clones, control disease measures in this group of risk population are required.

Setting: Spain has the highest rates in Europe of the acquired immune-deficiency syndrome (AIDS), and probably a high rate of dual human immunodeficiency virus (HIV)/tuberculosis infection., Objective: To determine the trends of tuberculosis mortality in Spain from 1970 to 1993, and to draw conclusions about the effects of the AIDS epidemic on these trends., Design: Official population figures and data on deaths from tuberculosis were used to calculate specific tuberculosis mortality rates by age and sex (per 100000 population). Causes of death from tuberculosis were grouped according to the International Classification of Diseases., Results: The crude death rate decreased from 10.28 to 1.84, with an annual mean decrease of 8.1% (95% confidence interval 7.5% to 8.7%). No changes in mortality from tuberculosis of the central nervous system (CNS) have been recorded since 1982, and none in mortality from other tuberculosis and in the age group 20-49 years since 1986. Mortality was higher among males and in the older age groups. The peak observed in the 1970s, due to the excess of deaths from CNS tuberculosis in children under the age of 5 years, has disappeared., Conclusion: Between 1970 and 1993, tuberculosis mortality in Spain decreased, although an excess of deaths occurred in young adults and from extra-pulmonary tuberculosis, coinciding with the AIDS epidemic.

Swyer-James syndrome, unilateral hyperlucent lung with air entrapment, generally occurs after severe infections during childhood. It is usually diagnosed by its characteristic chest radiographic image film or computed tomography, in patients who are almost asymptomatic. We report a case of Swyer-James syndrome, diagnosed from the study of severe pulmonary hypertension and with a fatal outcome.

To analyze the situations that make chemoprophylaxis for tuberculosis difficult. One hundred twenty-eight patients consecutive (106 HIV negative and 22 HIV positive) diagnosed of tuberculosis (TB) were studied. The patients were interviewed and a questionnaire was filled out in order to identify risk groups and determine what steps had been taken to prevent TB. In the HIV negative group, 63 (57.8%) had at least one risk factor. The most common were contact with persons with active TB (31.1%), former TB (15.1%), rapid weight loss or chronic malnutrition (13.2%) and residence in closed institutions (5.6%). Of the 51 (48.1%) for whom evaluation of chemoprophylaxis was indicated, 43 (84.3%) had been examined by a physician within the past five years; only 10 (23.3%) of them, however, had been checked for TB and isoniazide had been prescribed for only 4 (9.3%). In the HIV positive group, 13 (72.2%) of those for whom evaluation of chemoprophylaxis was indicated had been seen by a physician; 12 (97.7%) of them were given tuberculin tests checked for TB and isoniazide was prescribed for 4 (30.7%). None of the patients in either group who were prescribed a full course of prophylaxis actually took the drug enough. Most HIV negative patients for whom evaluation of chemoprophylaxis was indicated had been examined by a physician in the five years before disease was detected; less than a quarter of them were checked for TB, however. This situation is probably a consequence of the structure of health care in Spain as it affects TB control. Nearly all the HIV positive patients were checked for the disease, as they benefited from protocolized health care.

Objective: To identify the situations that influence in the delayed diagnosis of tuberculosis., Patients and Method: We studied 109 patients (87 non HIV-infected and 22 HIV-infected) who were diagnosed of tuberculosis in one year consecutively, using a questionnaire to obtain time intervals in which the whole diagnostic delay (WD) was divided., Results: WD was higher than 1 month in 90 % of non HIV-infected patients. The delay due to the health system (SD) was higher (71% > 1 month) than the delay due to patient (PD; 30% > 1 month) and there was a negative correlation between both (R-0.73). In HIV+ group, WD was lower (59.1% > month) and, although PD was higher (40.9% > 1 month), the time that the system delayed the suspicion of the diagnosis was lower (5.5% > 1 month). In HIV-group there were the following significant differences: higher delay in the suspicion of diagnosis (DSD) (61.4% and 60.8% > 1 month) and shorter time to make the diagnosis (12.3% and 21.6% > 1 month) in sputum smear-positive patients and who had cavitary lesions; PD was higher (67.1% > 1 month) in patients with general symptoms and nearly none in patients with upper airways symptoms; and higher DSD in presence of nonspecific symptoms like cough or/and expectoration (68.6% > 1 month) or upper airways symptoms (100% > 1 month). As these clinical symptoms were consulted in primary care mainly, there was a higher SD (75.75 > 1 month) and DSD (58.1% > 1 month), and were increased when a promptly chest X-ray was not performed (87.1 and 68.7% > 1 month)., Conclusions: Delayed diagnosis of tuberculosis is common. In non HIV-infected patients, it occurs mainly in the health system. Diagnostic delays contribute to raise advanced disease with more contagious potential.

Changes in cell immunity made manifest by decreases in blood levels of CD4 T cells is the main indicator of progressing HIV infection. The decrease in these lymphocytes, as well as in the CD4/CD8 index and increases in suppressant or cytotoxic CD8 cells can be detected in bronchoalveolar (BAL) lung samples. It is not clear whether the high incidence of respiratory system diseases in HIV patients stems from local or systemic immune changes. The aim of this study was to compare changes in the systemic cell immunity studied in samples of peripheral blood with changes detected in BAL samples from HIV patients with acute respiratory disease. We studied 42 patients in the advanced stages of AIDS (C3 by Centers for Disease Control classification) who were hospitalized for acute respiratory disease and who underwent diagnostic fiberoptic bronchoscopy and BAL. Cell counts and lymphocyte populations were analyzed by flow cytometry in samples of peripheral blood and BAL. The percentage of CD4 lymphocytes and the CD4/CD8 index were lower in BAL, particularly in patients with blood CD4 levels below 12% of the total T cell population, or at a level of 20 CD4 cells/microliters. Changes in cell immunity in patients with advanced HIV infection (C3 classification) and acute respiratory disease are more manifest locally in the lung than peripherally in blood. Lung depletion of CD4 T cells in the lung can be predicted based on blood levels.

Bronchioloalveolar carcinoma is an infrequent malignant lung tumor, specially in patients younger than 50. Diagnosis is difficult and usually late, because its clinical and radiologic features are similar to other lung diseases and because its poor histopathologic differentiation from other primitive o metastatic adenocarcinoma. We report a case of multinodular, diffuse and bilateral bronchioloalveolar carcinoma in a young woman without previous lung disease which suspected diagnosis was by broncho-aspirated cytology and open lung biopsy was necessary for its confirmation.