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Non-tuberculous mycobacterial infection has increased significantly in recent years, especially in emerging countries. We present the case of a 25-year-old male patient, immunocompetent, with cervical lymphadenopathy, identifying Mycobacterium kumamotonense, a rare species in extrapulmonary forms and with a high drug resistance index.

Background: We have observed that patients with descending necrotizing mediastinitis show bilateral lower lobes atelectasis before pleural effusion that finally forms empyema. Successful treatment of mediastinitis emphasizes optimal early drainage of neck, mediastinum, and antibiotic therapy. Methods: Exploratory study to determine the presence of segmental atelectasis as incipient sign of mediastinitis. We studied patients from August 2018 to July 2019 with tomographies. Results: We evaluated 25 patients operated due to Mediastinitis at our hospital, from August 2018 to July 2019. Ten (40%) were females and 15 (60%) were male patients. Twenty-one (84%) patients showed atelectasis and 4 (16%) did not have atelectasis. Of the patients that showed atelectasis, 17 (81%) were bilateral, 2 (9.5%) were right sided, and 2 (9.5%) were left sided. We also analyzed the occurrence of pleural effusion in this group. Fifteen (60%) patients had pleural effusion and 10 (40%) did not. Of the total patients with pleural effusion 11 (73.3%) were bilateral, 3 (20%) of the right side, and 1 (6.6%) of the left side. Conclusions: Atelectasis is a sign that we can find in most patients that will develop empyema and we assume that it is associated with lymph nodes inflammation, but it is necessary to develop other protocols to confirm that hilar lymph congestion is the cause of atelectasis. As atelectasis of lower lobes is a sign of imminent sepsis, we always decide to do mediastinal drainage when we find them associated with neck abscess. We are proposing a modification of the endo classification to decide surgery.

Introduction: The sputum smear or the culture are the definitive diagnosis of pulmonary tuberculosis. Only a fraction of clinical patients are culture-confirmed. Methodology: A total of 24 clinical cases (40 ± 14 years old) with positive smear and negative co-morbidity were studied. Cases were selected from 600 patients who attended the pneumology service over two years. A sputum sample was cultured in Löwenstein-Jensen medium with consequent amplification of the rrnA V2 promoter, the differentiation region 4, and the IS6110 insertion sequence of Mycobacterium tuberculosis. After the culture result, the patients were divided into negative (n = 14) or positive (n = 10) culture groups. In addition, 30 samples from healthy donors (45 ± 10 years) were studied. The numbers of CD4, CD8 and CD19 lymphocytes were determined by flow cytometry. Levels of IgA and IgG to M. tuberculosis were measured by ELISA. Results: IgG and IgA levels were detected in patients with positive culture, while only IgA was found in patients with negative cultures. The lymphocyte populations in the two groups were similar. The presence of a pleural apical cap was found more frequently in patients with negative- (57%) than with positive cultures (10%). Conclusions: The isotype profile in patients with positive cultures was both IgA and IgG positive, while in patients with negative culture, only IgA was found. The results will contribute to improve the diagnostic algorithm and appropriate treatment of patients with clinical tuberculosis. Further studies are needed to determine if this profile is predictive of the outcome of isolation.

Background: The superior vena cava syndrome (SVCS) is a rare pathological process caused by the superior vena cava obstruction (SVCO). Aim: To know the main causes of SVCS in a third level hospital. Material and methods: Observational, prospective and descriptive study in 31 patients with SVCS treated between June 2013 and December 2014. Yale, Stanford scores and tumour biopsy were obtained at diagnosis. Results: The main causes of SVCS were malignant tumours: lung cancer (22.5%) and lymphoma (16.1%). For lung cancer, the most common was non small cells (57.1%) and lymphoma was non-Hodgkin (80%). Conclusions: The main causes of SVCS are advanced malignant tumours like lung cancer and lymphomas, benign obstruction causes are relatively rare. Resumen: Antecedentes: El síndrome de vena cava superior (SVCS) es un proceso patológico poco frecuente causado por la obstrucción de la vena cava superior (VCS). Objetivo: Conocer las principales causas de SVCS en un hospital de tercer nivel. Material y método: Estudio observacional, prospectivo y descriptivo en 31 pacientes con SVCS atendidos durante junio de 2013 a diciembre de 2014. Se utilizó la escala de Yale, Stanford y biopsia de tumour al momento del diagnóstico. Resultados: La principal causa de SVCS fue por tumores malignos: cáncer broncogénico (22.5%) y linfoma (16.1%). Del cáncer pulmonar, el más común fue el de células no pequeñas (57.1%) y para el linfoma fue el no Hodgkin (80%). Conclusiones: El SVCS es principalmente ocasionado por tumores malignos avanzados como el cáncer de pulmón y los linfomas, los casos debidos a una obstrucción benigna son relativamente raros. Keywords: Superior vena cava syndrome, Superior vena cava obstruction, Claude Bernard–Horner syndrome, Palabras clave: Síndrome de vena cava superior, Obstrucción de la vena cava superior, Síndrome de Claude Bernard–Horner

Background: Mediastinitis is a potentially fatal condition. In addition to timely diagnosis, its prognosis depends on an early and systematic approach. Objective: To describe the results of mediastinitis treatment over a period of 34 years in a teaching hospital, its evolution and the current model of care. Materials and methods: Cross-sectional, retrospective and descriptive study of patients with mediastinitis admitted from 1 June 1982 to 30 July 2016. The analysed variables were demographic, classification and aetiology of mediastinitis, comorbidities, complications, length of hospital and intensive care unit stay and mortality. Results: 1880 patients were included of which 1496 (79.6%) were men. The mean age was 39.4 ± 17.8 years. According to the classification of Endo, 603 (32.1%) corresponded to type I and 1277 (67.9%) to types IIA and IIB. According to the aetiology, in 910 cases the origin was odontogenic (48.4%), 526 due to retropharyngeal abscess (28%), 147 secondary to submandibular abscess (7.8%), 49 due to cervical lymphadenectomy (2.6%), 36 due to pharyngeal trauma (1.9%), 14 due to post-intubation tracheal rupture (0.7%) and 198 were of undetermined origin (10.6%). Mediastinotomy with right thoracotomy was performed in 86% and mediastinotomy with left thoracotomy was performed in 14%. Simultaneous tracheostomy was performed in 83% of cases, standardising this procedure since 2005. Mortality varied between periods and was 50% in 1982â1992, 41% in 1992â2001, 35% in 2002â2011 and 17% in 2012â2016. Conclusion: Along with the standardisation of the management of mediastinitis, a fall in mortality from this cause has been observed over the years. The maturity of the proposed model of care is a result of, among other things, medical and scientific advances and the experience gained in this pathology over more than three decades. Resumen: Antecedente: La mediastinitis es un padecimiento potencialmente fatal. Además del diagnóstico oportuno el pronóstico dependerá de un abordaje sistemático temprano. Objetivo: Describir los resultados del tratamiento de la mediastinitis en un periodo de 34 años en un hospital escuela, su evolución y el modelo de atención vigente. Material y métodos: Estudio retrospectivo, descriptivo y transversal de pacientes con mediastinitis ingresados del 1 de junio de 1982 al 30 de julio de 2016. Las variables que se analizan son demográficas, clasificación y etiología de la mediastinitis, comorbilidades, complicaciones, días de estancia en hospital y en terapia intensiva y mortalidad. Resultados: Se incluye a 1880 pacientes de los cuales 1496 (79.6%) fueron hombres. La edad promedio fue de 39.4 ± 17.8 años. Según la clasificación de Endo, 603 (32.1%) correspondieron al tipo I y 1277 (67.9%) a los tipos IIA y IIB. Según la etiología, en 910 casos fue de origen ondotogénico (48.4%), 526 por absceso retrofaríngeo (28%), 147 secundarios a absceso submandibular (7.8%), 49 a linfadenectomía cervical (2.6%), 36 a trauma faríngeo (1.9%), 14 a ruptura traqueal postintubación (0.7%) y 198 de origen indeterminado (10.6%). Se realizó mediastinotomía con toracotomía derecha en 86% y con toracotomia izquierda en 14%. La traqueostomía simultánea se realizó en el 83% de los casos, estandarizándose desde el año 2005. La mortalidad varió por periodos siendo de 50% en 1982 a 1992, de 41% en 1992 a 2001, de 35% en 2002 a 2011 y de 17% en 2012 a 2016. Conclusión: A la par de una estandarización en el manejo de la mediastinitis, se observa un descenso en la mortalidad por esta causa con el pasar de los años. La madurez del modelo de atención que se propone responde entre otros a avances médico-científicos y a la experiencia acumulada en esta patología en más de tres décadas. Keywords: Mediastinitis, Thoracic surgery, Emergency surgery, Neck abscess, Palabras clave: Mediastinitis, Cirugía de tórax, Cirugía de urgencia, Absceso de cuello

espanolIntroduccion: En Mexico existe un incremento alarmante de casos de infeccion pulmonar y extrapulmonar por Mycobacterium bovis. La falta de identificacion oportuna deriva en complicaciones y eleva la mortalidad. Objetivo: Conocer la frecuencia de infecciones por Mycobacterium bovis en muestras clinicas de pacientes con tuberculosis, identificadas en el laboratorio de micobacterias en un hospital de concentracion de la Ciudad de Mexico. Metodo: Estudio prospectivo, descriptivo. Se estu- diaron cepas aisladas de material biologico en cultivos Lowestein-Jensen y MGITI960. La identificacion de Mycobacterium bovis se realizo mediante la amplificacion del fragmento RD9 por PCR punto final. Resultados: Se incluyeron 850 pacientes con diagnostico de tuberculosis, en 441 casos se confirmo Mycobacterium tuberculosis por cultivo positivo (250 casos pulmo- nares, 65 ganglionares, 39 renales, 34 meningeos, 25 miliares, 14 pleurales, ocho peritoneales, cuatro oseos y dos pericardi- cos). Se tipificaron 48 cepas (10.8 %) como Mycobacterium bovis por amplificacion del fragmento RD9 por PCR punto final. Conclusiones: Actualmente no se piensa en Mycobacterium bovis como agente causal de tuberculosis, lo que pudiera ser la causa del fracaso del tratamiento farmacologico. En este estudio se observo que la principal forma extrapulmonar es la linfadenopatia cervical. EnglishIntroduction: In Mexico, there is an alarming increase in the number of cases of Mycobacterium bovis infection on pulmonary and extrapulmonary presentations. The lack of timely identification triggers complications and increases mortality. Objective: To know the frequency of M. bovis infections in clinical samples of patients with tuberculosis in the mycobacteria laboratory of a reference hospital in Mexico City. Method: Prospective, descriptive study. Strains isolated from biological material were stud- ied in Lowestein-Jensen and MGITI960 cultures. M. bovis was identified by amplifying the RD9 fragment with end-point poly- merase chain reaction (PCR). Results: Eight-hundred and fifty tuberculosis-diagnosed patients were included; in 441 cases, Mycobacterium tuberculosis was confirmed by positive culture (250 pulmonary, 65 ganglionic, 39 renal, 34 meningeal, 25 miliary, 14 pleural, 8 peritoneal, 4 bone and 2 pericardial cases). Forty-eight strains (10.8%) were typified as M. bovis by amplification of the RD9 fragment with end-point PCR. Conclusions: M. bovis is not currently thought of a causative agent of tuberculosis, which could be the cause of pharmacological treatment failure. In this study, the main extrapulmonary form was observed to be cervical lymphadenopathy.

espanolIntroduccion: Nuevos hospitales estan reemplazando a instalaciones antiguas. Existe poca informacion del desempeno de una unidad de cuidados intensivos (UCI) cuando es reubicada en un area nueva y equipada. Objetivo: Analizar el impacto del cambio de instalaciones de un ambiente compartido a camas individuales en la ocurrencia de eventos adversos en la UCI. Metodo: Estudio transversal, comparativo, con datos prospectivos de pacientes ingresados del 1 de marzo de 2014 al 28 de febrero de 2017 a la antigua UCI (aUCI) y del 17 de julio de 2017 al 17 de enero de 2019 a la nueva UCI (nUCI) de un hospital-escuela publico. La tasa de eventos adversos se midio en eventos por 1000 dias-paciente. Resultados: En 1188 pacientes (aUCI, n = 681 versus nUCI, n = 507) se observo reduccion en la tasa de paro cardiaco no previsto (razon de tasas 0.31, IC 95 % = 0.12-0.80) e incremento en la tasa de extubacion no planeada (razon de tasas 2.49, IC 95 % = 1.24-5.01), estadisticamente significativos; los otros nueve eventos adversos monitoreados no mostraron cambios. Conclusiones: Com- parada con la aUCI, la mayor parte de eventos adversos monitoreados no se modificaron significativamente en los 18 meses de inicio de actividades de la nUCI. EnglishIntroduction: New hospitals are replacing old facilities. There is little information on the performance of an intensive care unit (ICU) when it is relocated in a new and equipped area. Objective: To analyze the impact of the change of ICU facilities from a shared environment to individual beds on the occurrence of adverse events. Method: Cross-sectional, comparative study, with prospectively collected data from patients admitted from March 01, 2014 to February 28, 2017 to the former ICU (f-ICU) and from July 17, 2017 to January 17, 2019 to the new ICU (n-ICU) of a public teaching hospital. The rate of adverse events was measured in events per 1,000 patient-days. Results: Among 1,188 patients (f-ICU, n = 681 vs. n-ICU, n = 507), a reduc- tion in the rate of unforeseen cardiac arrest (rate ratio: 0.31; 95% confidence interval [CI] = 0.12–0.80) and an increase in the rate of unplanned extubation (rate ratio: 2.49; 95% CI = 1.24–5.01) were observed, with both being statistically significant. The other nine monitored adverse events showed no changes. Conclusions: In comparison with the f-ICU, most of the monitored adverse events did not significantly change within the first 18 months of activities at the n-ICU.

Lung cancer is the leading cause of cancer death in both sexes, accounting for nearly a third of all cancer deaths. It causes more deaths than breast, colon, prostate and pancreatic cancer combined. Their overall 5-year survival rate is 15%, however, if caught in early stages it can reach up to 60–70%. Unfortunately, over 70% of lung cancers occur in advanced stages. For early clinical stages of non-small cell tumours, surgical treatment is usually recommended. Recently, the video-assisted thoracic surgery approach has proven to be at least equivalent to open surgery regarding oncologic principles, also showing the advantages of a minimally invasive procedure. In this occasion we present the case of a patient with lung cancer IIB on whom a lobectomy was performed using a minimally invasive approach. The patient was discharged three days after surgery.

Background: Improving intensive care unit (ICU) performance is a primary goal in quality of care management; for this purpose, measuring with tools that enable us to make comparisons with proposed standards is necessary. Objective: To describe the clinical performance and resource utilisation of a respiratory ICU (RICU) over a 5-year period. Material and methods: A cross-sectional, retrospective, comparative study was conducted in the RICU of a teaching hospital. Using the revised Rapoport–Teres method, the standardised clinical performance index (SCPI) and the standardised resource utilisation index (SRUI) were calculated annually and for the entire study period. The results were compared with those obtained by the ICUs participating in Project IMPACT (in standard deviations) in a four-quadrant coordinate graph designed for this purpose. SCPI and SRUI values greater than zero indicate better survival and a lower resource utilisation than expected. Values below zero indicate a mortality and resource utilisation higher than expected. Results: In the study period, 1177 patients were admitted to the RICU. Readmissions (n = 34) and patients

The appearance of new anti-tuberculosis drugs such as bedaquiline and delamanid makes it impossible not to remember that the first strictly controlled medical trials of tuberculosis treatment were published in two rigorously researched outstanding articles that can be qualified as historical. In 1948, streptomycin was formally studied as an efficacious anti-tuberculosis drug. In 1952, another trial compared streptomycin-paramino salicylic acid with isoniazid, by means of which the first bases of pharmacological tuberculosis treatment were established.La aparición de nuevos fármacos antituberculosos, como la bedaquilina y el delaminid, hace inevitable recordar que los primeros ensayos estrictamente controlados del tratamiento médico de la tuberculosis se publicaron en dos artículos de excelente y rigurosa investigación científica que pueden calificarse como históricos. En 1948 se estudió formalmente la estreptomicina como medicamento antituberculoso eficaz. En 1952, en otro ensayo se comparó estreptomicina-ácido paraaminosalicílico con isoniacida, con lo que se establecieron las primeras bases del tratamiento farmacológico de la tuberculosis.

Objective To evaluate the occurrence of adverse events during a multifaceted program implementation. Design Cross-sectional secondary analysis. Setting The respiratory-ICU of a large tertiary care center. Participants Retrospectively collected data of patients admitted from 1 March 2010 to 28 February 2014 (usual care period) and from 1 March 2014 to 1 March 2017 (multifaceted program period) were used. Interventions The program integrated three components: (1) strategic planning and organizational culture imprint; (2) training and practice and (3) implementation of care bundles. Strategic planning redefined the respiratory-ICU Mission and Vision, its SWOT matrix (strengths, weaknesses, opportunities, threats) as well as its medium to long-term aims and planned actions. A ‘Wear the Institution's T-shirt’ monthly conference was given in order to foster organizational culture in healthcare personnel. Training was conducted on hand hygiene and projects ‘Pneumonia Zero’ and ‘Bacteremia Zero’. Finally, actions of both projects were implemented. Main outcome measures Rates of adverse events (episodes per 1000 patient/days). Results Out of 1662 patients (usual care, n = 981; multifaceted program, n = 681) there was a statistically significant reduction during the multifaceted program in episodes of accidental extubation ([Rate ratio, 95% CI] 0.31, 0.17–0.55), pneumothorax (0.48, 0.26–0.87), change of endotracheal tube (0.17, 0.07–0.44), atelectasis (0.37, 0.20–0.68) and death in the ICU (0.82, 0.69–0.97). Conclusions A multifaceted program including strategic planning, organizational culture imprint and care protocols was associated with a significant reduction of adverse events in the respiratory-ICU.

Background and Aims Nontuberculous mycobacteria (NTM) are mainly distributed as important emerging pathogens in patients with chronic or immunosuppressive diseases. Accurate identification of causative species is crucial for proper treatment and patient follow-up. However, several difficulties are associated with phenotypic and molecular diagnostic methods for precise identification at the species level due to shared metabolic and genetic characteristics. We undertook this study to evaluate the application of the phylogenetic method based on hsp65 gene into Telenti's PCR-restriction enzyme analysis (PRA) for molecular identification of NTM. Methods The study population was comprised of 1646 Mycobacterium clinical isolates (AFB positive) collected from 2008–2011, of which 537 (32.6%) were MNT identified by PRA analysis. DNA sequencing of hsp65 in 53 isolates (10%) was performed. Sequence identification through NCBI-Basic Local Alignment Search Tool (BLAST) achieved correct identification in 23 isolates. Phylogenetic trees including hsp65 available GenBank sequences for all described genres of NTM and hsp65 obtained sequences were constructed using Mega 5.05 software. We compared sequence identification based on phylogenetic clustering and BLAST similarity search. Results Phylogenetic clustering allowed more specific differentiation of closely related species and clearer identification in comparison with BLAST; 30 Mycobacterium species (this is the first report of isolation of some of these from clinical samples in Mexico) were identified in this way. Conclusions The proposed 440 bp hsp65 phylogenetic method allows a better identification tool to differentiate Mycobacterium species and is useful to complement diagnosis and epidemiological surveillance of NTM.

Introduction: The present study aimed to establish the frequency and clinical characteristics of cutaneous tuberculosis among Mexican adult patients. Methodology: Ninety-five patients with clinically compatible lesions to cutaneous tuberculosis participated in the study. All patients were HIV negative and none of them had previous anti-TB treatment. A skin biopsy was taken from every patient suspected of having tuberculosis, and a histopathologic examination was performed as follows: Ziehl-Neelsen staining; culturing of mycobacteria by Löwenstein-Jensen (L-J) medium; Mycobacteria Growth Indicator Tube detection via BACTEC (MGIT-360); and polymerase chain reaction (PCR) with the sequence of insertion IS6110 for Mycobacterium tuberculosis complex. Results: Tuberculosis was confirmed in 65 out of 95cases (68.4%). Identified lesions were scrofuloderma (42 cases, 64.6%); lupus vulgaris (12 cases, 18.4%); warty tuberculosis (six cases, 9.2%); and papulonecrotic tuberculoid (five cases; 7.7%). The Ziehl-Neelsen staining was positive for acid fast bacilli in nine cases (13.8%) and 48 patients were positive for the PCR amplification (73.8%). All skin biopsies resulted positive for tuberculosis. A positive clinical response to the specific treatment was considered a confirmation for tuberculosis. The noninfectious etiology corresponded to 30 cases (31.6%). Conclusions: Tuberculosis in developing countries is still an important cause of skin lesions which must be studied via histopathological examination and culture due to their low bacillary load. A PCR test is necessary to obtain faster confirmation of the disease and to establish an early, specific and effective treatment.

A possible relationship between Takayasu arteritis (TA) and Tuberculosis (Tb) has been suggested. Both diseases present similar chronic inflammatory lesions and occasionally granulomas on the arterial walls. The genetic relationship between these two diseases has not been explored before, however, both diseases have been associated with human leukocyte antigen (HLA) alleles. Therefore, the aim of the present study was to analyze the distribution of HLA-B alleles in TA (n = 40) and Tb (n = 34) patients and healthy controls (72 exposed and 99 nonexposed). HLA-B alleles were determined by reverse dot blot. The statistical methods used included the Chi(2), and odds ratio (OR) with 95% confidence intervals. In spite of the loose clinical relationship between TA and Tb, we did not detected any genetic relationship between them when the HLA-B alleles were analyzed in these groups of patients. On the contrary, we detected distinct specific HLA-B alleles for each disease. TA was characterized by HLA-B39, -B44, and -B52, pulmonary Tb by HL-B35 and extrapulmonary Tb by HLA-B39 and -B40. This preliminary study suggests a difference in the distribution of HLA-B alleles in patients with TA and Tb.

Background Coccidioidomycosis is a reemerging fungal disease seen mainly in the states located at the Mexican-U.S. border. The finding of advanced cases of the disease are now more frequent. Methods A cross-sectional study was conducted to determine the prevalence of skin reactivity to coccidioidin in the city of Torreon, Coahuila, Mexico, located in the northern region of the country. A multifactorial association of environmental, social, and health conditions was analyzed. A total of 1,653 coccidioidin skin tests was applied in male and female subjects older than 8 years of age. Results The overall rate of positive reactivity in this city was 40.2%, with a 95% confidence interval of 37.8–42.5. This was related to time/life exposure risk and to the habitat of unpaved streets. No statistically significant difference regarding gender, socioeconomic level, and working activities was found. The highest reactivity was observed in subjects between 30 and 65 years of age. Conclusions Positive results were related to exposure risk and habitat, principally in the southeast region of the city. These results were applied both to residents and outsiders with no differences between the groups. Of the total, 87.5% were considered high-risk subjects. It is recommended that future surveys be carried out in other northern cities of Mexico to obtain more useful data concerning the extent of the infection and mainly to establish preventive measures, such as appropriate reforestation and urbanization procedures.

Takayasu's arteritis (TA) and tuberculosis (TB) have been associated with major histocompatibility complex genes, especially HLA-B alleles. However, different HLA-B alleles have been detected in these diseases. The aim of the study was to compare the distribution of the residues 63 and 67 on the HLA-B molecule in patients with TA and TB in order to establish a genetic relationship between these two diseases. HLA-B sequences obtained in 30 patients with TB were compared to those previously reported in TA and healthy controls. 8 out of 30 TB patients studied (26.6%) presented at least one allele with glutamic acid at position 63 and serine at position 67. This was observed in 73% of the TA patients (p = 0.0005). Ten TB (10/30 = 33.3%) and two TA patients (2/26 = 7.7%) did not show similarity at the mentioned positions (p = 0.019). This preliminary study suggests a difference in the distribution of the residues 63 and 67 of the HLA-B alleles in patients with TA and TB.

Transthoracic needle biopsy (TNB) was performed in 344 cases of intrathoracic pathology. In 60 of them, the material obtained was inadequate. In the remaining 284, the possibilities of TNB to identify malignant cells were evaluated. Of them, 202 had neoplastic lesions and 82 had nonneoplastic processes. Among the neoplastic cases, malignant cells were found in 188, (true positive), and in 14 the results were false negative. In the group of nonneoplastic processes, there were 80 without malignant cells (true negative), and two were diagnosed as malignant, (false positive). In these 284 cases with cytologic diagnosis, the global sensitivity was 0.93, and the specificity was 0.97; however, including all cases and the inadequate samples as false negatives, the sensitivity is lower--0.71. TNB required some skill, the use of fine needles, and the collaboration of an expert cytopathologist. TNB is an important method with which to explore intrathoracic pathology.